KUESIONER IDENTIFIKASI POTENSI WILAYAH

Petunjuk pengisian:
Mohon setiap kader untuk melakukan interview kepada 10 orang warga sasaran di sekitar
lingkungan tempat tinggal, kemudian dilakukan Focus Group Discussion (FGD) dalam
kelompok yang terdiri dari Kader, perangkat desa, TOMA dan TOGA

I. DATA KELUARGA
1. Nama : ………………………………...........................................
2. Umur : ……………………...........................................................
3. Jenis Kelamin :L/P
4. Agama : ...........................................................................................
5. Pendidikan : ...........................................................................................
6. Pekerjaan : ...........................................................................................
7. No BPJS : ...........................................................................................
8. Alamat : ...........................................................................................
9. Tanggal : ...........................................................................................

II. IDENTIFIKASI MASALAH KESEHATAN

1. Bagaimana bila anda atau keluarga anda ada yang hamil sampai dengan
Melahirkan?
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2. Bagaimana anda memantau perkembangan dan pertumbuhan bila ada anggota

keluarga masih bayi atau balita (0-59 bln)?
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3. Bagaimana cara pemberian makanan pada bayi atau balita di keluarga anda ( 0- 24
bulan)?
............................................................................................................................... ............................
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4. Bagaimana pelaksanaan pemberian imunisasi pada bayi atau balita di keluarga

anda?
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5. Bagaimana menurut anda pelaksanaan posyandu di tempat anda?

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 KUESIONER IDENTIFIKASI POTENSI WILAYAH

Petunjuk pengisian:
Mohon diisi sesuai dengan yang anda ketahui, hasil rekap data akan digunakan untuk rapat
FKD, kemudian dilakukan Focus Group Discussion (FGD) dalam kelompok yang terdiri dari
Kader, perangkat desa, TOMA dan TOGA

I. DATA KELUARGA
1. Nama : ………………………………...........................................
2. Umur : ……………………...........................................................
3. Jenis Kelamin :L/P
4. Agama : ...........................................................................................
5. Pendidikan : ...........................................................................................
6. Pekerjaan : ...........................................................................................
7. No BPJS : ...........................................................................................
8. Alamat : ...........................................................................................
9. Tanggal : ...........................................................................................

II. IDENTIFIKASI MASALAH KESEHATAN

1. Menurut anda, apa yang dimaksud dengan pernikahan?

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2. Bagaimana menurut anda mengenai pernikahan dini?

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3. Menurut anda, apa risiko dari pernikahan dini?

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4. Menurut anda apa yang dimaksud dengan kontrasepsi? Apa saja jenisnya?
.............................................................................................................................. ............................
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5. Menurut anda, apa yang dimaksud dengan kesehatan reproduksi?

...........................................................................................................................................................
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 KUESIONER IDENTIFIKASI POTENSI WILAYAH

Petunjuk pengisian:
Mohon setiap kader untuk melakukan interview kepada 10 orang warga sasaran di sekitar
lingkungan tempat tinggal, kemudian dilakukan Focus Group Discussion (FGD) dalam
kelompok yang terdiri dari Kader, perangkat desa, TOMA dan TOGA

I. DATA KELUARGA
1. Nama : ………………………………...........................................
2. Umur : ……………………...........................................................
3. Jenis Kelamin :L/P
4. Agama : ...........................................................................................
5. Pendidikan : ...........................................................................................
6. Pekerjaan : ...........................................................................................
7. No BPJS : ...........................................................................................
8. Alamat : ...........................................................................................
9. Tanggal : ...........................................................................................

II. IDENTIFIKASI MASALAH KESEHATAN

1. Apakah di keluarga anda ada yang mempunyai riwayat penyakit degeneratif

(jantung, stroke, diabetes, tekanan darh tinggi, asam urat atau lainnya)?
..............................................................................................................................................................
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2. Bagaimana kebiasaan pola makan anda dan keluarga?

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3. Bagaimana anda melakukan cek kesehatan secara berkala?

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4. Bagaimana pelaksanaan posyandu lansia atau posbindu PTM di tempat

saudara?
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5. Menurut anda manfaat apa yang diperoleh dengan pelaksanaan posbindu

PTM atau posyandu lansia?
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