Format Pengkajian Daerah Binaan
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Transcript of Format Pengkajian Daerah Binaan
FORMULIR PENGKAJIAN
DAERAH BINAAN
STIKES HANG TUAH SURABAYA
I. DATA DEMOGRAFI DAERAH BINAANKabupaten : .........................................Kecamatan : .........................................Desa / Kelurahan : .........................................RW / RT : .........................................Luas Wilayah : .........................................Peta wilayah daerah binaan (dilampirkan)
Batas Wilayah : Sebelah utara : ...................................... Sebelah selatan : ...................................... Sebelah timur : ...................................... Sebelah barat : ......................................
A. Pemanfaatan Wilayah1. Perumahan : .....................................................................................................................2. Sawah : .....................................................................................................................3. Tambak : .....................................................................................................................4. Perkebunan : .....................................................................................................................5. Lapangan : .....................................................................................................................6. Hutan : .....................................................................................................................7. Lain-lain : .....................................................................................................................
B. Sarana Transportasi1. Jalan Kaki : ( ) ............... %2. Sepeda Motor : ( ) ............... %3. Mobil : ( ) ............... %4. Lain-lain : ( ) ............... %
C. Pembagian Wilayah1. Jumlah RT : .....................................................................................................................2. Jumlah RW : .....................................................................................................................
D. Tipe Masyarakat1. Agamis : ( ) ............... %2. Industri : ( ) ............... %3. Perniagaan : ( ) ............... %4. Lain-lain : ( ) ............... %
E. Struktur Pemerintahan1. Swadaya ( )2. Swakarsa ( )3. Swasembada ( )
F. Organisasi Sosial Masyarakat1. PKK : ( ) ............... kelompok2. Kontak Tani : ( ) ............... kelompok3. LKMD / BPD : ( ) ............... kelompok4. Karang Taruna : ( ) ............... kelompok5. Kelompencapir : ( ) ............... kelompok
II. PELAYANAN KESEHATAN DAN SOSIALA. Kader Kesehatan
1. Apakah dalam wilayah RT/RW ada kader kesehatan ?...................................................................................................................................................
2. Bila ada berapa jumlahnya ?...................................................................................................................................................
3. Berapa orang kader yang telah dilatih aktif ?...................................................................................................................................................
4. Materi apa yang pernah diberikan pada pelatihan kader?...................................................................................................................................................
5. Bentuk kegiatan apa yang dilakukan kader ?...................................................................................................................................................
B. Dana Kesehatan1. Apakah diwilayah saudara terdapat dana sehat ?
...................................................................................................................................................2. Kalau ada dalam bentuk apa ?
...................................................................................................................................................C. Fasilitas Kesehatan
1. Rumah sakit : .................... buah2. Puskesmas : .................... buah3. Dokter praktik : .................... buah4. Bidan praktik : .................... buah5. Praktik keperawatan : .................... buah
D. Fasilitas Lainnya1. Fasilitas Agama
a. Apakah diwilayah saudara ada fasilitas agama ?.............................................................................................................................................
b. Apakah jenis kegiatannya ?.............................................................................................................................................
2. Fasilitas Pendidikana. Apakah diwilayah saudara terdapat fasilitas pendidikan (formal / informal)?
.............................................................................................................................................b. Apakah fasilitas tersebut dimanfaatkan ?
.............................................................................................................................................c. Jenis bahasa yang digunakan?
.............................................................................................................................................E. Fasilitas Umum
1. Panti asuhan : ( ) .................... buah2. Panti Jompo : ( ) .................... buah3. Apakah ada bak sampah (TPS) : .............................................................................................4. Apakah ada hidran air : .............................................................................................5. Apakah ada WC umum : .............................................................................................6. Apakah ada pasar : .............................................................................................7. Apakah ada pengrajin : .............................................................................................
F. Keamanan1. Apakah Sistem keamanan lingkungan (Siskamling) ?
...................................................................................................................................................2. Apakah di daerah saudara terdapat pos polisi?
...................................................................................................................................................3. Apakah ada pemadam kebakaran ?
...................................................................................................................................................4. Apakah ada Penanggulangan Bencana (SAR)?
...................................................................................................................................................G. Rekreasi
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CATATAN :..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... .....................................................................................................................................................................
Mahasiswa
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