From Survey Kebutuhan Sarana.docx

PEMERINTAH KABUPATEN BONE DINAS KESEHATAN UPTD PUSKESMAS KECAMATAN KAJUARA Alamat : Jln.Poros Bone-Sinjai,Kel Awang Tangka Kec.Kajuara,Kab.Bone,Kode Pos 92776 Email : [email protected] HP. 082 346 875 446

FORM SURVEY KEBUTUHAN SARANA PERAWATAN PASIEN NAMA : UMUR :

ALAMAT TGL

: :

1. Kebutuhan mobilisasi pasien, Ya/Tidak: a. Kursi roda. b. Brankar. c. Tongkat. Alasan:.................................................................................................................................. ............................................................................................................................................... 2. Kebutuhan pengatur suhu ruangan, Ya/Tidak: a. Kipas angin. b. A C. c. Jendela. Alasan:.................................................................................................................................. ............................................................................................................................................... 3. Kebutuhan sarana ibadah, Ya/Tidak: a. Tempat sholat. b. Mukena/ Sajadah. c. Al- Quran. Alasan:.................................................................................................................................. ............................................................................................................................................... 4. Kebutuhan sarana untuk buang air besar, Ya/Tidak: a. DPCloset jongkok. b. Closek duduk. c. Pispot. Alasan:.................................................................................................................................. ............................................................................................................................................... 5. Kebutuhan pada sarana ruang tunggu pasien Rawat Inap, Ya/Tidak: a. Fasilitas bacaan. b. Fasilitas permainan bagi anak. c. Ayunan bagi anak-anak. Alasan:.................................................................................................................................. ............................................................................................................................................... 6. Kebutuhan untuk sarana cuci pakaian, Ya/Tidak: a. Tempat cuci pakaian. b. Mesin cuci pakaian. c. Tempat jemuran pakaian. Alasan:.................................................................................................................................. ............................................................................................................................................... Kajuara,........................................ Responden

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