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Lampitan 1
Laporan Bulanan Eradikasi Frambusia Puskesmas
Nama/Kode Puskesmas c
G
c
o o
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o c
o
Nama Kabupaten/Kota
Tahun dan Bulan Laporan
€o o
C
o
C
o
C co
E
o
(L
= = = =
A. Laporan Kasus Frambusia (termasuk kasus pd B. Dan C.) .9 .a '6 '6
6
Jum ah Kasus Suspek Frambusia yang
1.
dtemukan
E
G oo oo oo oo
Jumlah Kas!s Suspek Frambusia
J
2
diperiksa RDT
J!m ah kasus Frambusia RDT
3. (+)
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Kode Jml Seko ah E E 6 E E
Sekolah
Nama
Seko ah
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Jumlah
D per ksa
Jml
Kasus
Jml
Suspek
Kasus
RDT
d per ksa "g o
o- o o
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tahun ini E= g
E
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Mon tor Keg aran Pemer ksaan tuambusia di Seko ah
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Montor (egiatan Puskesmas Keli ing dan X!njungan Rumah
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Kepada Yth.
1. Direktur Jenderal PP&PL, Kementerian Kesehatan \- lnqord%oq €ur'useusarnad

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Laporan Bulanan Eradikasi Frambusia uiaquupqepisBderqeroras%rorrou{!nuqpuffipmp4ov+}uqEqasi}srioqrorenqprro)ruo4,
Dinas Kesehatan Provinsi
Provinsi
Periode Laporan (Tahun/Bulan)
'1. Kinerla Pelaporan .\:
a. Jumlah Puskesmas Yang Ada
b. Jml Puskesmas Melapor Bulan ini
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2. Data Kasus Frambusia
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d. Jml Desa ditemukan kasus frambusia tahun ini *)
e. Jml Puskesmas telah melaksanakan PK&KR semua desa tahun lni
') Januari sampai bulan laporan
Demikian laporan ini dibuat untuk dimanfaatkan sebagaimana mestinya
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