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FORMULIR PENILAIAN RUMAH SEHAT
NAMA ......................... ALAMAT KK: KELURAHAN : .....................................................
1. .............................. 1 .....................................................
2. .............................. 2 ..................................................... KECAMATAN : .....................................................
3. .............................. 3 .....................................................
4. .............................. 4 ..................................................... KOTA : .....................................................
5. .............................. 5 .....................................................
6. .............................. 6 ..................................................... PROPINSI : .....................................................
7. .............................. 7 .....................................................
8. .............................. 8 ..................................................... TANGGAL : .....................................................
9. .............................. 9 .....................................................
10. .............................. 10 ..................................................... NAMA PETUGAS : .....................................................
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NOKOMPONEN RUMAH
YANG DINILAI KRITERIA NILAI BOBOTHASIL PENILAIAN
(NO. KK)
I KOMPONEN RUMAH
1
2
3
4
5
6
7
8
II SARANA SANITASI
1
2
3
4
III PERILAKU PENGHUNI
1
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CARA MENILAI HASIL PENILAIAN = Nilai x bobot