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PEMERINTAH KABUPATEN WONOSOBO

PUSKESMAS ..................................................

Nomor :Lampiran : 1 (satu berkas)Perihal : Sertifikasi Hasil Pemicuan Perubahan Perilaku Masyarakat Kegiatan

Pamsimas Komponen !i "esa#Kel $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Kepa!a %th

Kepala "inas Kesehatan Kabupaten &onosobo

"i

'empat

"alam rangka pelaksanaan kegiatan Pamsimas komponen !i ilayah kera

Puskesmas $$$$$$$$$$$$$$$$$$$$$$$$$$$ Kecamatan$$$$$$$$$$$$$$$$$$$$$$$$$$* khususnya pelaksanaan

kegiatan perubahan higienis masyarakat !engan pen!ekatan S'+M#,L'S* terlampir 

kami sampaikan Sertifikasi sanitarian atas Hasil Pemicuan Perubahan Perilaku

Higienis Masyarakat yang telah !ilaksanakan pa!a :

Hari#tanggal : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$"usun#"esa : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

"emikian !isampaikan !an mohon !itin!aklanuti hasil sertifikasi ini kepa!a Kepala

"inas P- Kabupaten sebagai kelengkapan !okumen .encana Kera Masyarakat

(.KM)

 /tas bantuan +apak#0bu* !isampaikan terima kasih

Kepala Puskesmas arung

N0P

'embusan:

Kepala "inas P- Kabupaten arung

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SERTIFIKASI

HASIL PEMICUAN PERUBAHAN PERILAKU HIGINENIS MASYARAKAT

DENGAN PENDEKATAN CLTS

Nomor :$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

'anggal : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$"esa#Kelurahan : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Kecamatan : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Puskesmas : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Kabupaten : &onosobo

%ang bertan!a tangan !ibaah ini :

Nama : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$N0P : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

2abatan : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

+er!asarkan hasil pemicuan perubahan perilaku higienis yang !ilakukan !enganpen!ekatan ,L'S yang kami ha!iri* !i "usun#"esa $$$$$$$$$$$$$$$$$ Kecamatan $$$$$$$$$$$$$$$$$sertalaporan proses pemicuan pleh 'im Pemicun pa!a tanggal $$$$$$$$$$$$$$$$$$$* !engan ini kaminyatakan baha :

1$ Proses pelaksanaan pemicuan !ilaksanakan sesuai !engan ketentuan3ketentuan !alamPe!oman Pelaksanaan Pamsimas !i tingkat Masyarakat

$ 'elah terbentuk komite#relaan sanitasi#natural lea!er S'+M#,L'S4$ /!anya kesepakatan arga untuk berubah perilaku higienis secara bertahap !an

berkesinambungan pa!a pemicuan tahap pertama

"emikian Sertifikasi Hasil Pemicuan Perubahan Perilaku Masyarakat ini kami buat !engansebenarnya !an kami bertanggungaab bila kemu!ian hari tera!i kesalahan ataupenyimpangan !alam proses tersebut$

555555555* 5555555$$

Sanitarian#Petugas Sertifikasi

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

N0P $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$