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7/24/2019 1.1.1.d kerangka acuan survey edit.doc
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PEMERINTAH KABUPATEN BOJONEGORODINAS KESEHATAN
UPTD PUSKESMAS KANOR
Bojonegoro, Oktober 201
Ke!"#"
No$or % &&0' '&12(&)'201 *t+( S#r( Se$" K"r-"."n #"n
S/"t % Pent/ng K"r-"."t/ Pke$" K"nor
"$!/r"n % 3 #/3
Per/+"4 % Un#"ng"n K a n o r
Meng+"r"! #eng"n +or$"t "t" ke+"#/r"nn-" ntk #"!"t
$eng/kt/ !erte$"n beok !"#" 5
H"r/ ' T"ngg"4 %
J"$ % 11(00 6IB '# Se4e"/(
Te$!"t % R"ng !erte$"n Pke$" K"nor
A7"r" % Perte$"n $/n/4ok"r-"(
Pe$b"+""n % Ko$/t$en $"-"r"k"t ter+"#"! !e4"-"n"n #/
Pke$" K"nor
De$/k/"n "t" !er+"t/"n #"n ke+"#/r"n-" #/"$!"/k"n ter/$" k"/+(
Koor#/n"tor A#$en Sekret"r/
N"$" N"$"NIP( NIP(
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PEMERINTAH KABUPATEN BOJONEGORO
DINAS KESEHATAN
UPTD PUSKESMAS KANOR
Not4enPerte$"n
N"$" Perte$"n % Pe$b"t"n K//oner Kebt+"n #"nH"r"!"n M"-"r"k"t(
T"ngg"4 % Pk4 %
Sn"n A7"r"1( Pe$bk""n2( Pe$b"+""n$"ter/!erte$"n)( Pent!
Not4en Sebe4$n-" Me$b"+" 7"r" ko$n/k"/ #eng"n !e4"ngg"n
Pe$b"+""n
Pe$b"t"n k//oner kebt+"n #"n +"r"!"n $"-"r"k"t /n/"k"n #/!ergn"k"n eb"g"/ b"+"n ntk $eng$!4k"n/nor$"/ ter+"#"! kebt+"n #"n +"r"!"n $"-"r"k"t, A#"!nbentk #"r/ K//oner te4"+ #/e!"k"t/ #eng"n bentk tertt!
#"n ntk e$" !e4"-"n"n #eng"n !ert"n-"n"n -"ng berk/"r$engen"/ !en#"!"t $"-"r"k"t tent"ng !e4"-"n"n -"ng#/ber/k"n o4e+ !etg" ert" eg"4" "/4/t"n-" 8 BentkK/eoner Ter4"$!/r 9
Ke/$!4"n K//oner te4"+ #/b"t #"n te4"+ #/e!"k"t/ ber"$"
Reko$en#"/ Keb/j"k"n Ke!"4" UPTD Pke$" B4"nkD"t"r H"#/r
No N"$" T"n#" t"ng"n(1 1
2 2
) )
& &
: :; ;
< 4"k/ 2 Pere$!"n
Pen#/#/k"nTer"k+/r
% 1 SD Keb"."+ S 1
% 2 S T P : S 2 Ke"t"% ) S T A ; T/#"keko4"+
% & D13D)3D& K"$/ % Pk4 0;()0 > 1&(00 6IB(- J$?"t % Pk4 0;()0 > 11(00 6IB(- S"bt % Pk4 0;()0 > 12(00 6IB(
Jen/ Pe4"-"n"n -"/t %
Pe4"-"n"n R"."t J"4"n
1( oket !en#"t"r"n(
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2( K4/n/k U$$(
)( K4/n/k G/g/(
&( K4/n/k Kee+"t"n Ib #"n An"k 8KIA9(
( K4/n/k G/@/(
:( K4/n/k Ber+ent/ Merokok(
;( I$$n/"/(
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NIP ' D"t" "/n %
! HARAPAN RESPONDEN TENTAN# PELAYANAN PUBLIK NILAI
1 B"g"/$"n" +"r"!"n "#"r" tent"ng ke$#"+"n !roe#r !e4"-"n"n #/ UPTDPke$" B4"nk(
" T/#"k $#"+ 1
b Kr"ng $#"+ 2
7 M#"+ )# S"ng"t $#"+ &
2 B"g"/$"n" +"r"!"n "#"r" tent"ng kee"/"n !er-"r"t"n !e4"-"n"n#eng"n jen/ !e4"-"n"nn-"
" T/#"k e"/ 1
b Kr"ng e"/ 2
7 Se"/ )
# S"ng"t e"/ &
) B"g"/$"n" +"r"!"n "#"r" tent"ng keje4""n #"n ke!"t/"n !etg" -"ng$e4"-"n/
A T/#"k je4" 1B Kr"ng je4" 2
C Je4" )
D S"ng"t je4" &
& B"g"/$"n" +"r"!"n "#"r" tent"ng ke#//!4/n"n !etg" #"4"$ $e$ber/k"n!e4"-"n"n
A T/#"k #//!4/n 1
B Kr"ng #//!4/n 2
C D//!4/n )
D S"ng"t #//!4/n &
B"g"/$"n" +"r"!"n "#"r" tent"ng t"nggng j"."b !etg" #"4"$$e$ber/k"n !e4"-"n"n
A T/#"k bert"nggng j"."b 1
B Kr"ng bert"nggng j"."b 2
C Bert"nggng j"."b )D S"ng"t bert"nggng j"."b &
: B"g"/$"n" +"r"!"n "#"r" tent"ng ke$"$!"n !etg" #"4"$ $e$ber/k"n!e4"-"n"n
A T/#"k $"$! 1
B Kr"ng $"$! 2
C M"$! )
D S"ng"t $"$! &
; B"g"/$"n" +"r"!"n "#"r" tent"ng ke7e!"t"n !e4"-"n"n #/ !ke$" /n/ NIAI
A T/#"k 7e!"t 1
B Kr"ng 7e!"t 2
C Ce!"t )
D S"ng"t 7e!"t &
< B"g"/$"n" +"r"!"n "#"r" tent"ng ke"#/4"n ntk $en#"!"tk"n !e4"-"n"n
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#/ !ke$" /n/
A T/#"k "#/4 1B Kr"ng "#/4 2
C A#/4 )
D S"ng"t "#/4 &
= B"g"/$"n" +"r"!"n "#"r" tent"ng keo!"n"n #"n ker"$"+"n !etg"#"4"$ $e$ber/k"n !e4"-"n"n
A T/#"k o!"n #"n r"$"+ 1B Kr"ng o!"n #"n r"$"+ 2
C So!"n #"n r"$"+ )D S"ng"t o!"n #"n r"$"+ &
10 B"g"/$"n" +"r"!"n "#"r" tent"ng ke."j"r"n b/"-" ntk $en#"!"tk"n!e4"-"n"n #/ !ke$" /n/
A Se4"4 ."j"r 1
B Kr"ng ."j"r 2C 6"j"r )
D S"ng"t ."j"r &
11 B"g"/$"n" +"r"!"n "#"r" tent"ng kee"/"n "nt"r" b/"-" -"ng#/b"-"rk"n #eng"n b/"-" -"ng te4"+ #/tet"!k"n
A Se4"4 t/#"k e"/ 1B K"#"ng > k"#"ng e"/ 2
C B"n-"k e"/n-" )D S"ng"t e"/ &
12 B"g"/$"n" +"r"!"n "#"r" tent"ng kete!"t"n !e4"k"n""n !e4"-"n"nter+"#"! j"#."4 ."kt !e4"-"n"n #/ !ke$" /n/
A Se4"4 t/#"k te!"t 1
B K"#"ng > k"#"ng te!"t 2C B"n-"k te!"tn-" )
D Se4"4 te!"t &
1) B"g"/$"n" +"r"!"n "#"r" tent"ng ken-"$"n"n !e4"-"n"n #/ 4/ngkng"nn/t !e4"-"n"n /n/
A T/#"k n-"$"n 1B Kr"ng n-"$"n 2
C N-"$"n )D S"ng"t n-"$"n &
1& B"g"/$"n" +"r"!"n "#"r" tent"ng ke"$"n"n !e4"-"n"n #/ 4/ngkng"n n/t!e4"-"n"n
A T/#"k "$"n 1
B Kr"ng "$"n 2
C A$"n )
D S"ng"t "$"n &
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Ter/$" k"/+ "t" !"rt//!"/ "n#" #"4"$ "+" !en/ngk"t"n k/nerj" !ke$"
k"$/, e$" kr/t/k #"n "r"n "k"n #/"+"k"n ntk #/t/n#"k4"njt/(
PEMERINTAH KABUPATEN BOJONEGORODINAS KESEHATAN
UPTD PUSKESMAS KANORA4"$"t Pke$" B4"nk
Te4!( Pke$" B4"nk E$"/4 Pke$" B4"nk
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Rek"!"n K"j/"n H"r"!"n Pe4"-"n"n #/ Pke$" B4"nk
No( T"ngg"4S$ber
Inor$"/I/ Inor$"/ Tj"n Keter"ng"n
1 1)3:3201& K//oner
M"-"r"k"t $eng/ng/nk"nke$#"+"n !roe#r!e4"-"n"n -"ng "ng"t$#"+
Ag"r $"-"r"k"t$#"+$en#"!"tk"n!e4"-"n"n
2 1)3:3201&
M"-"r"k"t $eng/ng/nk"nkee"/"n !er-"r"t"n#eng"n jen/ !e4"-"n"n-"ng "ng"t e"/
Ag"r !e4"ngg"n$#"+$en#"!"tk"n!e4"-"n"n e"/#eng"n!er-"r"t"n-"
) 1)3:3201&
M"-"r"k"t $eng/ng/nk"nkeje4""n #"n ke!"t/"n!etg" -"ng $e4"-"n/"ng"t je4"
Ag"r $"-"r"k"t$en#"!"tk"nkeje4""n #"nke!"t/"n!etg" -"ng$e4"-"n/
& 1)3:3201&
M"-"r"k"t $eng/ng/nk"nke#//!4/n"n ."kt !etg"-"ng #/+"r"!k"n "ng"t#//!4/n
Ag"r Petg"#"t"ng #"n!4"ng te!"t."kt
1)3:3201&M"-"r"k"t $eng/ng/nk"nt"nggng j"."b !etg""ng"t bert"nggng j"."b
Ag"r !etg"$enj"4"nk"ntg"n-" e"/#eng"n t"nggng
j"."bn-"
: 1)3:3201&M"-"r"k"t $eng/ng/nk"nke$"$!"n !etg""ng"t $"$!
Ag"r !etg"#"4"$$e$ber/k"n!e4"-"n"n e"/#eng"nko$!eten/n-"
; 1)3:3201&M"-"r"k"t $eng/ng/nk"nke7e!"t"n !e4"-"n"n"ng"t 7e!"t
Ag"r !etg"7e!"t #"4"$$e$ber/k"n!e4"-"n"n
< 1=3:3201&
M"-"r"k"t $eng/ng/nk"nke"#/4"n ntk
$en#"!"tk"n !e4"-"n"n"ng"t "#/4
Ag"r !etg"t/#"k$e$be#"k"nt"t ekono$/!e4"ngg"n #"4"$$e$ber/k"n!e4"-"n"n
= 1=3:3201&
M"-"r"k"t $eng/ng/nk"nkeo!"n"n #"n ker"$"+"n!etg" "ng"t o!"n #"nr"$"+
Ag"r !etg"ber/k"! o!"n#"n $r"+en-$
10 1=3:3201& M"-"r"k"t $eng/ng/nk"nke."j"r"n b/"-" "ng"t."j"r
M"-"r"k"t$en#"!"tk"nke."j"r"n b/"-"
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e"/ #eng"n!e4"-"n"n -"ng#/ter/$"
11 1=3:3201&
M"-"r"k"t $eng/ng/nk"nkee"/"n "nt"r" b/"-"-"ng b"-"rk"n #eng"n
-"ng #/tet"!k"n
B/"-" !e4"-"n"n!e4"ngg"n #//rber#""rk"nk4"//k"/!e4"-"n"n -"ng#/ter/$"!e4"ngg"n
12 1=3:3201&
M"-"r"k"t Meng/ng/nk"nkete!"t"n !e4"k"n""n!e4"-"n"n ter+"#"! j"#"4e4"4 te!"t
Petg" $ene!"t/."kt !e4"-"n"ne"/ #eng"n
j"#"4 -"ng"#"
1) 1=3:3201&M"-"r"k"t Meng/ng/nk"nKen-"$"n"n !e4"-"n"n"ng"t n-"$"n(
M"-"r"k"t$en#"!"tk"nken-"$"n"n#"4"$ !e4"-"n"n
1& 1=3:3201&M"-"r"k"t $eng/ng/nk"nke"$"n"n "ng"t "$"n
M"-"r"k"t$en#"!"tk"n
j"$/n"nke"$"n"ne4"$" #/Pke$"
Ke!"4" UPTD Pke$" B4"nk Koor#/n"tor A#$en
#r( er" Agt/n" N"$"
NIP( NIP(
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