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62 LAMPIRAN
Lampiran 2. Persetujuan Setelah Pemberitahuan
JUDUL PENELITIAN : HUBUNGAN ANTARA KADAR ASETILKOLINESTERASE DENGAN GAMBARAN EKG PADA PETANI YANG TERPAPAR KRONIK ORGANOFOSFAT
INSTANSI PELAKSANA: BAGIAN FISIOLOGI FK UNDIP
Persetujuan Setelah Penjelasan (INFORMED CONSENT)
Penelitian ini merupakan penelitian yang bertujuan mengetahui faktor-faktor yang berpengaruh terhadap terjadinya kelainan gambaran EKG pada petani yang mengalami keracunan kronik organofosfat.
Pada penelitian ini akan dilakukan wawancara, pemeriksaan fisik, elektrokardiografi dan pengambilan sampel darah. Kemungkinan terjadinya komplikasi akibat penelitian ini sangat kecil karena dilakukan oleh tenaga terlatih. Bapak/ Ibu/ Saudara bisa menolak apabila tidak setuju ikut serta dalam penelitian ini. Apabila setuju untuk menjadi subjek penelitian, maka identitas Bapak/ Ibu/ Saudara akan kami rahasiakan. Seluruh biaya penelitian ditanggung oleh peneliti. Peneliti juga akan memberikan imbalan sesuai dengan kemampuan peneliti.
Penanggung jawab penelitian adalah dr. Saekhol, dosen Bagian Ilmu Kesehatan Masyarakat FK Undip. Alamat kantor: Jl. Prof. Dr. Soedarto, Tembalang, Semarang.
Terima kasih atas kerjasama Bapak/ Ibu/ Saudara.
Setelah mendengar dan memahami penjelasan peneltian, dengan ini saya menyatakan
SETUJU / TIDAK SETUJU Untuk menjadi subjek penelitian
Semarang, 15 Maret 2014 Saksi
NamaTerang : NamaTerang :
64
Lampiran 3. Kuesioner
No. :
Nama Pewawancara :
PENELITIAN HUBUNGAN ANTARA KADAR ASETILKOLINESTERASE DENGAN GAMBARAN EKG PADA PETANI YANG TERPAPAR KRONIK ORGANOFOSFAT
(Isi atau lingkari nomor jawaban)
Sabtu, 15 Maret 2014
Lama tinggal di Kepakisan : ………. tahun
Petani : 1. Ya
2. Bukan
Lama jadi petani : ………. tahun
Menggunakan pestisida semprot?
: 1. Ya 2. Tidak Alat pelindung diri yang dipakai
saat menyemprot (bisa lebih dari 1 jawaban)
: 1. Topi/ penutup kepala 2. Kacamata
3. Masker wajah
4. Sarung tangan plastik/ karet 5. Baju lengan panjang 6. Celana panjang 7. Sepatu boot Bila pernah terkena tumpahan
pestisida, tindakan yang dilakukan?
: 1. Mencuci dengan air
2. Mencuci dengan air dan sabun 3. Tidak melakukan apa-apa
Bila ada, apa pengobatan yang didapatkan
: 1. Dirawat di RS
2. Diobati di Puskesmas 3. Tidak berobat
4. Lainnya Apakah saat terkena tumpahan,
7. Badan lemah
Apakah saat ini terdapat gejala berikut (bisa lebih dari 1 jawaban)
Penyakit yang pernah atau sedang diderita
: 1. Sakit kuning/ sakit lever (hati) 2. Sakit ginjal
3. Sakit kencing manis 4. Tumor/ kanker
5. Lainnya………. Adakah gejala berikut : 1. Kulit, kuku, matakuning
2. Perut bengkak 3. Kaki bengkak
4. Badan lemas sering kesemutan 5. Lainnya………. Apakah minum alkohol : 1. Ya
2. Dulu ya, sekarang tidak
Terakhir minum…… bulan/ tahun yang lalu 3. Tidak pernah
Apakah minum obat berikut (bisa lebih dari 1 jawaban)
2. Dulu ya, sekarang tidak.
66
Lampiran 6. Dokumentasi Penelitian
Gambar 10. Pencatatan biodata responden dan pengukuran tekanan darah
72
Lampiran 7. Biodata Mahasiswa
Identitas
Nama : Daisy Syakhsiatusy Syahiqoh
NIM : 22010110120011
Tempat, tanggal lahir : Rembang, 26 Desember 1992
Jenis kelamin : Perempuan
Alamat : Bukit Cemara Residence 9L, Jl. Bulusan Selatan VII
No. HP : 085229857060
e-mail : [email protected]
Riwayat Pendidikan
SD : MI An-Nashriyyah Lulus tahun 2004
SMP : SMP N 1 Lasem Lulus tahun 2007
SMA : SMA N 1 Rembang Lulus tahun 2010
