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 : .....................................................

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

CARA MENILAI HASIL PENILAIAN = Nilai x bobot