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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