kartu jentik rumah
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KARTU JENTIK RUMAH/BANGUNAN*
Nama KK/Pengelola Bangunan/Instansi : …………………………………………………………………………………..
Alamat : ................................................................................................................................
Desa/Kelurahan : ..................................................................................................................
Kecamatan : .........................................................................................................................
Kabupaten/Kota : .................................................................................................................
BULAN Hasil pemeriksaan jentik nyamuk penular DBD ( + )/ (-)Tahun
2005 2006 2007 2008 2009 2010Minggu Minggu Minggu Minggu Minggu Minggu
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4JANUARI
FEBRUARIMARETAPRILMEIJUNI JULI
AGUSTUSSEPTEMBER
OKTOBERNOVEMBERDESEMBER
*gantungkan pada meteran listrik rumah/bangunan
Petugas pemeriksa jentik
(.....................................................................)
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Formulir JPJ-1
HASIL PEMERIKSAAN JENTIK
RT/ RW : ..................................................................................................
DESA/ KELURAHAN : ...............................................................................
KECAMATAN : .........................................................................................
KABUPATEN/KOTA : ...............................................................................
NO NAMA KK /JENIS/NAMA TTU
ALAMAT (RT/RW)
JENTIK KETERANGAN (+) (-)
Petugas pemeriksa jentik
(............................................................)