PEMERINTAH KABUPATEN BONDOWOSO

DINAS KESEHATAN
PUSKESMAS KOTAKULON
JL Diponegoro No. 176 Telp. (0332) 427087 Kode Pos 68213
E-mail : puskesmas_kotakulon@yahoo.com
Website : puskesmaskotakulon.blogspot.com
KECAMATAN BONDOWOSO
BONDOWOSO

NO. .........................................
KERANGKA ACUAN KEGIATAN
(JUDUL KEGIATAN)
PUSKESMAS KOTAKULON

I. PENDAHULUAN
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II. LATAR BELAKANG

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III. TUJUAN
- Tujuan Umum :
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- Tujuan Khusus :
1. ...................................................................................................................
2. ............................................................................................................dst

IV. KEGIATAN POKOK DAN RINCIAN KEGIATAN

- Kegiatan Pokok
: ................................................................................................................
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- Rincian Kegiatan :
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V. CARA MELAKSANAKAN KEGIATAN
- ........................
- .........................

VI. SASARAN
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VII. JADWAL PELAKSANAAN KEGIATAN

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NO KEGIATAN JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOP DES
1
2

VIII. EVALUASI PELAKSANAAN KEGIATAN & PELAPORAN

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IX. PENCATATAN, PELAPORAN & EVALUASI KEGIATAN

1. Pencatatan : ..............................................
2. Pelaporan : ................................................
3. Evaluasi : ................................................

Mengetahui Pembuat
Plt. Kepala Puskesmas Kotakulon Kerangka Acuan Kegiatan

dr. Indah Yuli Hartatik .............................

NIP. 19780708 200604 2 020 NIP. .....................................