Lampiran 1

REGISTER PELA

PUSKESMAS ……………………………………………..
KABUPATEN/KOTA PROVINSI :

Bulan : Tahun

Nomor Family Kasus

No Tanggal Kunjungan Folder/Rekam Nama Lengkap Alamat Lengkap (Baru/Lama/Rujukan Umur /Tanggal Lahir
Medik ) Jenis Kelamin
(tgl/bulan/thn)

(1) (2) (3) (4) (5) (6) (7) (8)

ICD X
T76 Adult and child abuse, neglect and other maltreatment, suspect
T76.0Neglect or abandonment, suspect
T76.01Adult neglect or abandonment suspected
T76.02Child neglect or abandonment suspect

T76.1Physical abuse, suspected

T76.11
Adult physical abuse, suspected
T76.12
Child Physical abuse, suspect

T76.2Sexual abuse, suspected

T76.21
Adult sexual abuse, suspected
T76.22
Child sexual abuse, suspected

T76.3Psychological abuse, suspected

T76.31
Adult psychological abuse, suspected
T76.32
Child psychological abuse, suspected

T76.9unspecified maltreatment, suspected

T76.91
unspecified adult maltreatment, suspected
T76.92
unspecified child maltreatment, suspected

T09.A : Sexual abuse complicating pregnancy, childbirth and the puerperium

 REGISTER PELAYANAN KORBAN TINDAK KEKERASAN TERHADAP PEREMPUAN, ANAK DAN KDRT
DI PUSKESMAS ……………………………………………….

KORBAN

Disabilitas Tindak Kekerasan

Pendidikan Pekerjaan Status Perkawinan (Fisik/Intelektual/Se (Fisik/Psikis/Seksual/Pe Kode ICD X TKP
nsorik/Mental/ nelantaran, dll)
Ganda)

(9) (10) (11) (12) (13) (14) (15)

T74
T74.0
T74.01
T74.01XA
T74.01XD …… subsequent encounter
T74.01XS …… sequela

T74.02 Child neglect or abandonment, confirmed

T74.02XA …… initial encounter
T74.02XD …… subsequent encounter
T74.02XS …… sequela

T74.1 Physical abuse, confirmed

T74.11 Adult physical abuse, confirmed
T74.11XA …… initial encounter
T74.11XD …… subsequent encounter
T74.11XS …… sequela

T74.12 Child physical abuse, confirmed

T74.12XA …… initial encounter
T74.12XD …… subsequent encounter
T74.12XS …… sequela

T74.2 Sexual abuse, confirmed

T74.21 Adult sexual abuse, confirmed
T74.21XA …… initial encounter
T74.21XD …… subsequent encounter
T74.21XS …… sequela

T74.22 Child sexual abuse, confirmed

T74.22XA …… initial encounter
T74.22XD …… subsequent encounter
T74.22XS …… sequela

T74.3 Psychological abuse, confirmed

T74.31 Adult psychological abuse, confirmed
T74.31XA …… initial encounter
T74.31XD …… subsequent encounter
T74.31XS …… sequela

T74.32 Child psychological abuse, confirmed

T74.32XA …… initial encounter
T74.32XD …… subsequent encounter
T74.32XS …… sequela
T74.4 Shaken infant syndrome
T74.4XXA …… initial encounter
T74.4XXD …… subsequent encounter
T74.4XXS …… sequela

T74.9 Unspecified maltreatment, confirmed

T74.91 Unspecified adult maltreatment, confirmed
T74.91XA …… initial encounter
T74.91XD …… subsequent encounter
T74.91XS …… sequela

T74.92 Unspecified child maltreatment, confirmed

T74.92XA …… initial encounter
T74.92XD …… subsequent encounter
T74.92XS …… sequela
 Format 1-P

Pelayanan yang Keterangan

Waktu Kejadian Dampak kesehatan Rujuk ke Kebangsaan
diberikan

(16) (17) (18) (19) (20) (21)

`
 Lampiran 2
REGISTER PE

RUMAH SAKIT ……………………………………………..

KABUPATEN/KOTA PROVINSI :

Bulan : Tahun

Nomor Family Kasus

No Tanggal Kunjungan Folder/Rekam Nama Lengkap Alamat Lengkap (Baru/Lama/Rujukan Umur /Tanggal Lahir
Medik ) Jenis Kelamin
(tgl/bulan/thn)

(1) (2) (3) (4) (5) (6) (7) (8)

ICD X
T76 Adult and child abuse, neglect and other maltreatment, suspect
T76.0 : Neglect or abandonment, suspect
T76.01 : Adult neglect or abandonment suspected
T76.02 : Child neglect or abandonment suspect

T76.1 : Physical abuse, suspected

T76.11 : Adult physical abuse, suspected
T76.12 : Child Physical abuse, suspect

T76.2 : Sexual abuse, suspected

T76.21 : Adult sexual abuse, suspected
T76.22 : Child sexual abuse, suspected

T76.3 : Psychological abuse, suspected

T76.31 : Adult psychological abuse, suspected
T76.32 : Child psychological abuse, suspected
T76.9 : unspecified maltreatment, suspected
T76.91 : unspecified adult maltreatment, suspected
T76.92 : unspecified child maltreatment, suspected

T09.A : Sexual abuse complicating pregnancy, childbirth and the puerperium

 REGISTER PELAYANAN KORBAN TINDAK KEKERASAN TERHADAP PEREMPUAN, ANAK DAN KDRT
DI RUMAH SAKIT ……………………………………………….

KORBAN

Disabilitas Tindak Kekerasan

Pendidikan Pekerjaan Status Perkawinan (Fisik/Intelektual/Se (Fisik/Psikis/Seksual/Pe Kode ICD X TKP
nsorik/Mental/ nelantaran, dll)
Ganda)

(9) (10) (11) (12) (13) (14) (15)

T74
T74.0
T74.01
T74.01XA
T74.01XD …… subsequent encounter
T74.01XS …… sequela

T74.02 Child neglect or abandonment, confirmed

T74.02XA …… initial encounter
T74.02XD …… subsequent encounter
T74.02XS …… sequela

T74.1 Physical abuse, confirmed

T74.11 Adult physical abuse, confirmed
T74.11XA …… initial encounter
T74.11XD …… subsequent encounter
T74.11XS …… sequela
T74.12 Child physical abuse, confirmed
T74.12XA …… initial encounter
T74.12XD …… subsequent encounter
T74.12XS …… sequela

T74.2 Sexual abuse, confirmed

T74.21 Adult sexual abuse, confirmed
T74.21XA …… initial encounter
T74.21XD …… subsequent encounter
T74.21XS …… sequela

T74.22 Child sexual abuse, confirmed

T74.22XA …… initial encounter
T74.22XD …… subsequent encounter
T74.22XS …… sequela

T74.3 Psychological abuse, confirmed

T74.31 Adult psychological abuse, confirmed
T74.31XA …… initial encounter
T74.31XD …… subsequent encounter
T74.31XS …… sequela

T74.32 Child psychological abuse, confirmed

T74.32XA …… initial encounter
T74.32XD …… subsequent encounter
T74.32XS …… sequela

T74.4 Shaken infant syndrome

T74.4XXA …… initial encounter
T74.4XXD …… subsequent encounter
T74.4XXS …… sequela

T74.9 Unspecified maltreatment, confirmed

T74.91 Unspecified adult maltreatment, confirmed
T74.91XA …… initial encounter
T74.91XD …… subsequent encounter
T74.91XS …… sequela

T74.92 Unspecified child maltreatment, confirmed

T74.92XA …… initial encounter
T74.92XD …… subsequent encounter
T74.92XS …… sequela
 Format 1-RS

Pelayanan yang Keterangan

Waktu Kejadian Dampak kesehatan Rujuk ke Kebangsaan
diberikan

(16) (17) (18) (19) (20) (21)

`
 Lampiran 3

PUSKESMAS ……………………
Kabupaten/kota ………………. Provinsi ………………………

Bulan : …………….. Tahun ………………………..

Kasus
Kelurahan/Desa

Kekerasan Fisik Kekerasan Psikis

No
0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn
Rujukan
Lama
Baru

L P L P L P L P L P L P L P L P L P L P L
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Total
 Kekerasan Seksual
Kekerasan Psikis
Perkosaan Pelecehan

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn

P L P L P L P L P L P L P L P L P L P L P L P L P L P L
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

`
 LAPORAN PELAYANAN KORBAN TINDAK KEKERASAN TERHADAP PEREMPUAN, A
DI PUSKESMAS ………………………..

KORBAN
UMUR DAN JENIS KEKERASAN
Eksploitasi
Pelecehan Seksual Ekonomi

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn

P L P L P L P L P L P L P L P L P L P L P L P L P L P
55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81
 TERHADAP PEREMPUAN, ANAK DAN KDRT
………………..

ORBAN

Penelantaran Dugaan TPPO

Ekonomi

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn

L P L P L P L P L P L P L P L P L P L P L P L P L P L P
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109
 Status
Pendidikan Pekerjaan Disabilita
Perkawinan
Dugaan TPPO
Swasta

Belum Sekolah

Putus Sekolah
Tidak Sekolah

Tidak Bekerja

Belum kawin
Pra Sekolah

Perguruan

Lain-lain
BUMN

Kawin
Tinggi

POLRI
13-15 thn 16-17 thn 18-60 thn >60 thn

Informal

Cerai
SMA
SMP

Fisik
PNS

Formal
TNI
SD
L P L P L P L P
110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 ### 128 129 130 131 132 133 134 135 136 137
 Format 2-P

Disabilitas Dampak TKP Pelayanan Yang Diberikan

Rumah Tangga

Tempat Kerja
Intelektual

Keterangan

Konseling
Sensorik

Lain-lain

Lain-lain
Abortus

Sekolah
Mental

Ganda

Visum
Medis
Hamil

Rujuk
Cacat

TTU
138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155
 Lampiran 4

RUMAH SAKIT ……………………

Kabupaten/kota ………………. Provinsi ………………………

Bulan : …………….. Tahun ………………………..

Kasus
Kelurahan/Desa

Kekerasan Fisik Kekerasan Psikis

No
0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn
Rujukan
Lama
Baru

L P L P L P L P L P L P L P L P L P L P L
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Total
 Kekerasan Seksual
Kekerasan Psikis
Perkosaan Pelecehan

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn

P L P L P L P L P L P L P L P L P L P L P L P L P L P L
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

`
 LAPORAN PELAYANAN KORBAN TINDAK KEKERASAN TERHADAP PEREMPUAN, A
DI RUMAH SAKIT ………………………..

KORBAN
UMUR DAN JENIS KEKERASAN
Eksploitasi
Pelecehan Seksual Ekonomi

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn

P L P L P L P L P L P L P L P L P L P L P L P L P L P
55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81
TERHADAP PEREMPUAN, ANAK DAN KDRT
………………..

ORBAN

Penelantaran Dugaan TPPO

Ekonomi

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn

L P L P L P L P L P L P L P L P L P L P L P L P L P L P
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109
 Status
Pendidikan Pekerjaan Disabilita
Perkawinan
Dugaan TPPO
Swasta

Belum Sekolah

Putus Sekolah
Tidak Sekolah

Tidak Bekerja

Belum kawin
Pra Sekolah

Perguruan

Lain-lain
BUMN

Kawin
Tinggi

POLRI
13-15 thn 16-17 thn 18-60 thn >60 thn

Informal

Cerai
SMA
SMP

Fisik
PNS

Formal
TNI
SD
L P L P L P L P
110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 ### 128 129 130 131 132 133 134 135 136 137
 Format 2-RS

Disabilitas Dampak TKP Pelayanan Yang Diberikan

Rumah Tangga

Tempat Kerja
Intelektual

Keterangan

Konseling
Sensorik

Lain-lain

Lain-lain
Abortus

Sekolah
Mental

Ganda

Visum
Medis
Hamil

Rujuk
Cacat

TTU
138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155
 Lampiran 5

Kabupaten/kota ………………. Provinsi ………………………

Bulan : …………….. Tahun ………………………..

Kasus
Puskesmas

Kekerasan Fisik Kekerasan Psikis

No
0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn
Rujukan
Lama
Baru

L P L P L P L P L P L P L P L P L P L P L
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Total
 Kekerasan Seksual
Kekerasan Psikis
Perkosaan Pelecehan

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn

P L P L P L P L P L P L P L P L P L P L P L P L P L P L
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

`
 LAPORAN PELAYANAN KORBAN TINDAK KEKERASAN TERHADAP PEREMPUAN, A
DI DINAS KESEHATAN KABUPATEN/KOTA......................................

KORBAN
UMUR DAN JENIS KEKERASAN
Eksploitasi
Pelecehan Seksual Ekonomi

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn

P L P L P L P L P L P L P L P L P L P L P L P L P L P
55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81
 TERHADAP PEREMPUAN, ANAK DAN KDRT
TA.........................................

ORBAN

Penelantaran Dugaan TPPO

Ekonomi

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn

L P L P L P L P L P L P L P L P L P L P L P L P L P L P
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109
 Status
Pendidikan Pekerjaan Disabilita
Perkawinan
Dugaan TPPO
Swasta

Belum Sekolah

Putus Sekolah
Tidak Sekolah

Tidak Bekerja

Belum kawin
Pra Sekolah

Perguruan

Lain-lain
BUMN

Kawin
Tinggi

POLRI
13-15 thn 16-17 thn 18-60 thn >60 thn

Informal

Cerai
SMA
SMP

Fisik
PNS

Formal
TNI
SD
L P L P L P L P
110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 ### 128 129 130 131 132 133 134 135 136 137
 Format 3

Disabilitas Dampak TKP Pelayanan Yang Diberikan

Rumah Tangga

Tempat Kerja
Intelektual

Keterangan

Konseling
Sensorik

Lain-lain

Lain-lain
Abortus

Sekolah
Mental

Ganda

Visum
Medis
Hamil

Rujuk
Cacat

TTU
138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155
 Lampiran 6

Provinsi ………………………

Tahun ………………………..

Kasus
Kekerasan Fisik Kekerasan Psikis
Kab/Kota

No
0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn
Rujukan
Lama
Baru

L P L P L P L P L P L P L P L P L P L P L
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Total
 Kekerasan Seksual
Kekerasan Psikis
Perkosaan Pelecehan

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn

P L P L P L P L P L P L P L P L P L P L P L P L P L P L
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

`
 LAPORAN PELAYANAN KORBAN TINDAK KEKERASAN TERHADAP PEREMPUAN, A
DI DINAS KESEHATAN PROVINSI.........................................

KORBAN
UMUR DAN JENIS KEKERASAN
Eksploitasi
Pelecehan Seksual Ekonomi

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn

P L P L P L P L P L P L P L P L P L P L P L P L P L P
55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81
TERHADAP PEREMPUAN, ANAK DAN KDRT
.....................................

ORBAN

Penelantaran Dugaan TPPO

Ekonomi

13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn 13-15 thn 16-17 thn 18-60 thn >60 thn 0-11 bln 1-6 thn 7-12 thn

L P L P L P L P L P L P L P L P L P L P L P L P L P L P
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109
 Status
Pendidikan Pekerjaan Disabilita
Perkawinan
Dugaan TPPO
Swasta

Belum Sekolah

Putus Sekolah
Tidak Sekolah

Tidak Bekerja

Belum kawin
Pra Sekolah

Perguruan

Lain-lain
BUMN

Kawin
Tinggi

POLRI
13-15 thn 16-17 thn 18-60 thn >60 thn

Informal

Cerai
SMA
SMP

Fisik
PNS

Formal
TNI
SD
L P L P L P L P
110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 ### 128 129 130 131 132 133 134 135 136 137
 Format 4

Disabilitas Dampak TKP Pelayanan Yang Diberikan

Rumah Tangga

Tempat Kerja
Intelektual

Keterangan

Konseling
Sensorik

Lain-lain

Lain-lain
Abortus

Sekolah
Mental

Ganda

Visum
Medis
Hamil

Rujuk
Cacat

TTU
138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155