LAPORAN PELAKSANAAN PEMICUAN DI MASYARAKAT

DESA TG PUNAK KEC. RUPAT UTARA KAB. BENGKALIS

PROVINSI RIAU TAHUN 2011

1. LOKASI PEMICUAN
a. Desa : Tanjung Punak
b. Kecamatan : Rupat Utara
2. GAMBARAN UMUM
a. Keadaan Georgrafis
b. Jumlah KK
c. Data Sarana Sanitasi
d. Pencaharian
3. PROSES PEMICUAN
a. Elemen pemicuan yang digunakan
b. Faktor pendukung
c. Faktor penghambat
d. Pembelajaran yang didapat
4. HASIL PEMICUAN
a. Jumlah peserta yang hadir
b. Jumlah KK yang tidak ada jamban/WC
c. Jumlah KK yang mempunyai Jamban/WC
d. Jumlah KK yang mempunyai komitmen perubahan
e. RTL
5. KESIMPULAN DAN SARAN
a. Kesimpulan
b. Saran
 LAPORAN
PEMICUAN DI MASYARAKAT KAB. BENGKALIS
PROVINSI RIAU TAHUN 2011

1. LOKASI PRAKTEK
- DUSUN :
- DESA :
- KECAMATAN :
2. GAMBARAN UMUM
a. Keadaan Geografis
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b. Jumlah Penduduk : ...........................Jiwa
c. Jumlah KK : ............................
d. Data Sarana Air Bersih dan Jamban :

Jumlah (buah)
NO JENIS
Perorangan Komunal (umum)
1 Sumur Gali (SGL)
2 Sumur Pompa Tangan (SPT)
Penampungan Air Hujan
3
(PAH)
4 Perlindungan Mata Air (PMA)
5 Perpipaan
6 Jamban/WC

e. Kemana kebiasaan BAB Mayoritas penduduk :

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f. Kemana kebiasaan mandi mayoritas penduduk :

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g. Kemana kebiasaan mencuci pakaian/alat masak mayoritas penduduk

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h. Mata pencaharian
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3. PROSES PEMICUAN
a. Elemen Pemicuan Yang digunakan
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b. Faktor Pendukung
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c. Faktor penghambat
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d. Pembelajaran yang didapat

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4. Hasil Pemicuan
a. Jumlah peserta yang hadir :....................... jiwa
- Jml Laki-laki : ................................... orang
- Jml Perempuan : ................................... orang
b. Jumlah KK yang tidak punya Jamban/WC : .....................
c. Jumlah KK yang mempunyai Jamban/WC : .....................
d. Jumlah KK mempunyai komitmen untuk berubah : .....................
e. RTL
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5. KESIMPULAN DAN SARAN
Kesimpulan
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 Tanjung Punak,...............................2011

Nama Tanda Tangan

Ketua
Sekretaris
Anggota
 DAFTAR HADIR MASYARAKAT
DALAM RANGKA PROSES PEMICUAN CLTS/STBM
DESA TANJUNG PUNAK KEC. RUPAT UTARA KAB. BENGKALIS
TANGGAL : ................................................2011

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KEPALA DESA TG PUNAK

ISMAIL. Z
 KONTRAK SOSIAL
KESEPAKATAN MASYARAKAT UNTUK MEMBUAT JAMBAN
DESA TANJUNG PUNAK KECAMATAN RUPAT UTARA KAB. BENGKALIS
TANGGAL : ......................................2011

NO NAMA ALAMAT TGL MULAI TGL SELESAI TANDA TANGAN

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KEPALA DESA TG PUNAK

ISMAIL. Z