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v Lampiran 1. Tabel penelitian
Karakteristik Usia BB saat datang BB setelah 2 bulan Persentil Growth velocity Jenis kelamin Laki-laki Perempuan Jenis PJB Non-sianotik Sianotik
Lamiran 2. Formulir persetujuan
FORMULIR PERSETUJUAN MENGIKUTI PENELITIAN DAN TINDAKAN MEDIS
Yang bertandatangan dibawah ini:
Nama : ……….
Umur : ……….
Alamat : ……….
Telepon : ………..
Pekerjaan : ………..
Adalah orang tua/wali : Nama : ……….
Umur : ……….. Jenis kelamin : L/P
Menerangkan bahwa setelah mendapatkan keterangan yang jelas dan lengkap tentang tujuan penelitian, menyatakan bersedia mengikuti penelitian dan tidak keberatan untuk dilakukan pemeriksaan fisis.
Surakarta,
Orang tua/wali peserta penelitian Peneliti
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v Lampiran 3. Formulir isian penelitian
FORMULIR ISIAN PENELITIAN
Nama : ………. Tanggal lahir/umur : ………. Jenis kelamin : ………. Alamat : ……….. No. HP : ……….. BB saat awal : ……… BB setelah 2 bulan : ………
Presentil growth velocity: ……….
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Lampiran 6. Perencanaan anggaran penelitian 1. Pembuatan dan penggandaan
proposal
Rp. 500.000,00 2. Penggadaan formulir penelitian Rp. 100.000,00 3. Presentasi hasil penelitian Rp. 500.000,00
4. Lain-lain Rp. 500.000,00
61 v No Nama Jenis kelamin usia (bulan) FTT Penyakit penyerta Diagnosis 1 An. AT L 6-8 FTT ISPA TOF 2 An. NJ P 18-20 - ISPA TOF 3 An. BT L 11-13 - ISPA TOF 4 An. HR P 21-23 - ISPA TOF 5 An. RY L 4-6 FTT ISPA TOF 6 An. AN P 9-11 - ISPA TOF 7 An. AS P 13-15 - - TOF 8 An. NN P 22-24 - ISPA TOF 9 An. Av L 2-4 FTT - TOF 10 An. Nz L 16-18 - - TOF 11 An. NF P 22-24 - - TOF 12 An. AA L 7-9 - - TOF 13 An. FR L 10-12 - - TOF 14 An. AF L 6-8 - - TOF 15 An. DY P 7-9 - - TGA, pulmonal atresia 16 An. DF L 20-22 - ISPA single atrium, single ventrikel 17 An. NT P 4-6 - ISPA Trikuspid atresia 18 An. BL P 1-3 FTT - DORV 19 An. Az P 1-3 FTT ISPA Trunkus arteriosus tipe A 20 An. Af P 2-4 FTT - Truncus arteriosus 21 An. Ar P 3-5 - - TAPVD 22 An. Al L 0-2 FTT TGA 23 An. MA L 0-2 FTT TGA
Penyakit Jantung Bawaan non sianotik No Nama
Jenis kelamin
usia
(bulan) FTT ISPA Diagnosis 1 An. DM P 14-16 - - VSD L to R shunt 2 An. RN P 17-19 - - VSD PMO 3 An. SY P 10-12 - - VSD 4 An. AR L 15-17 - - VSD 5 An. RS L 7-9 - - VSD 6 An. RY L 6-8 - - VSD 7 An. NF P 10-12 - - VSD SADC L to R shunt
8 An. AZ P 9-11 - ISPA PDA 9 An. AF L 8-10 - - PDA 10 An. SF P 7-9 - - PDA 11 An. NF P 8-10 - - PDA 12 An. FH L 6-8 ` - - PDA 13 An. NJ P 14-16 - - PDA 14 An. MR P 18-20 - - ASD 15 An. JS P 3-5 - - ASD 16 An. FT P 2-4 FTT ISPA ASD 17 An. AF P 4-6 FTT ISPA ASD 18 An. KZ L 5-7 - ISPA ASD
19 An. ZH P 7-9 - - ASD II L to R shunt 20 An. EL L 5-7 - ISPA ASD II
21 An. HY L 2-4 - - ASD primum 22 AN. FZ P 17-19 - - AVSD
23 An. Af L 8-10 - ISPA PS severe Lampiran 7. Data Dasar Subjek Penelitian
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