CHECKLIST KEBERSIHAN KAMAR MANDI U

BULAN TA

RUANG:

NO KEGIATAN
1 2 3 4 5 6 7
1 Kamar mandi dalam keadaan bersih*
2 Tersedia cukup air bersih*
3 Tersedia sabun*
4 Bak mandi tidak menjadi perindukan vektor*
5 Pengosongan tempat sampah setiap hari (1 x 24 jam)*
6 Ventilasi berhubungan langsung dengan udara luar*
7 Ada himbauan atau slogan untuk memelihara kesehatan*
8 Wastafel dalam keadaan bersih*
9 Wastafel tersedia sabun atau antiseptik*
10 Wastafel tersedia lap pengering*
*PMK RI Nomor 75 Tahun 2014
*KMK RI Nomor 1428/MENKES/SK/XII/2006

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Catatan:
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Mengetahui
Kepala Puskesmas Sukaraya

NIP.
HAN KAMAR MANDI UPTD PUSKESMAS
TAHUN

PETUGAS KEBERSIHAN : .................................

TANGGAL
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Keterangan:
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√ = Ya
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X = Tidak
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- = Tdk relevan
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Bekasi, ……………………………….
Petugas Kesehatan Lingkungan

NIP.