Form Kuisioner
Form Kuisioner
Form Kuisioner
Data Demografi
1. Jenis kelamin
3. Suku Bangsa
8. Lama Terdiagnosis :
11 Benar: 1
Salah: 0
4 Benar: 1
Salah: 0
7 Benar: 1
Salah: 0
9 Benar: 1
Salah: 0
2 Pengetahuan perawatan 10 Benar: 1
diri gagal jantung Salah: 0
12 Benar: 0
Salah: 1
13 Benar: 1
Salah: 0
15 Benar: 0
Salah: 1
3 Benar: 1
Salah: 0
5 Benar: 1
Salah: 0
3 Pengetahuan tanda dan 8 Benar: 1
gejala gagal jantung Salah: 0
14 Benar: 0
Salah: 1
Lampiran 4 : Kuesioner Kualitas Hidup (WHOQOL-BREFF) Versi Indonesia
WHOQOL-BREF
Pertanyaan berikut ini menyangkut perasaan anda terhadap kualitas hidup, kesehatan dan hal-hal
lain dalam hidup anda. Saya akan membacakan setiap pertanyaan kepada anda, bersamaan
dengan pilihan jawaban. Pilihlah jawaban yang menurut anda paling sesuai. Jika anda tidak
yakin tentang jawaban yang akan anda berikan terhadap pertanyaan yang diberikan, pikiran
pertama yang muncul pada benak anda seringkali merupakan jawaban yang terbaik.
Camkanlah dalam pikiran anda segala standar hidup, harapan, kesenangan dan perhatian
anda. Kami akan bertanya apa yang anda pikirkan tentang kehidupan anda pada empat
minggu terakhir.
Sangat
Sangat buruk Buruk Biasa-biasa saja Baik
baik
1. Bagaimana menurut anda kualitas
hidup anda? 1 2 3 4 5
Sangat
Sangat tdk Tdk Memuas- memuas-
Biasa-biasa saja
memuaskan memuaskan Kan kan
2. Seberapa puas anda terhadap kesehatan
anda? 1 2 3 4 5
Pertanyaan berikut adalah tentang seberapa sering anda telah mengalami hal-hal berikut
ini dalam empat minggu terakhir.
Tdk sama Dlm jumlah Sangat Dlm jumlah
sekali Sedikit sedang sering berlebihan
3. Seberapa jauh rasa sakit fisik anda
mencegah anda dalam beraktivitas sesuai 5 4 3 2 1
kebutuhan anda?
4. Seberapa sering anda membutuhkan terapi
medis untuk dpt berfungsi dlm kehidupan 5 4 3 2 1
sehari-hari anda?
5. Seberapa jauh anda menikmati hidup anda? 1 2 3 4 5
6. Seberapa jauh anda merasa hidup anda
berarti? 1 2 3 4 5
7. Seberapa jauh anda mampu berkonsentrasi? 1 2 3 4 5
8. Secara umum, seberapa aman anda rasakan
dlm kehidupan anda sehari-hari? 1 2 3 4 5
9. Seberapa sehat lingkungan dimana anda
tinggal (berkaitan dgn sarana dan prasarana) 1 2 3 4 5
Pertanyaan berikut ini adalah tentang seberapa penuh anda alami hal-hal berikut ini dalam
4 minggu terakhir?
Tdk sama Sepenuhnya
sekali Sedikit Sedang Seringkali dialami
10. Apakah anda memiliki vitalitas yg
2
cukup untuk beraktivitas sehari ? 1 2 3 4 5
11. Apakah anda dapat menerima
penampilan tubuh anda? 1 2 3 4 5
12. Apakah anda memiliki cukup uang
utk memenuhi kebutuhan anda? 1 2 3 4 5
13. Seberapa jauh ketersediaan
informasi bagi kehidupan anda dari 1 2 3 4 5
hari ke hari?
14. Seberapa sering anda memiliki
kesempatan untuk bersenang- 1 2 3 4 5
senang /rekreasi?
Biasa-biasa
Sangat buruk Buruk saja Baik Sangat baik
15. Seberapa baik kemampuan anda
dalam bergaul? 1 2 3 4 5
Pertanyaan berikut merujuk pada seberapa sering anda merasakan atau mengalami hal-hal
berikut dalam empat minggu terakhir.
Transformed scores*
Equations for computing domain scores Raw score
4-20 0-100
27. Domain 1 (6-Q3) + (6-Q4) + Q10 + Q15 + Q16 + Q17 + Q18
†+ †+ †+†+†+†+† a. = b: c:
28. Domain 2 Q5 + Q6 + Q7 + Q11 + Q19 + (6-Q26)
a. = b: c:
†+†+†+†+ †+ †
29. Domain 3 Q20 + Q21 + Q22
a. = b: c:
†+†+†
30. Domain 4 Q8 + Q9 + Q12 + Q13 + Q14 + Q23 + Q24 + Q25
†+†+†+†+†+†+†+† a. = b: c:
Lampiran 5 : WHOQOL-BREFF
WHO/MSA/MNH/PSF/97.4
English only
Distr.: Limited
WHOQOL-BREF
Domain 1 (6-Q3) + (6-Q4) + Q10 + Q15 + Q16 + Q17 + Q18 4-20 0-100
d+ d+ d+d+d+d+d =
* Please see Table 4 on page 10 of the manual, for converting raw scores to transformed scores.
This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). The
document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written
permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means -
electronic, mechanical or other - without the prior written permission of WHO.
MSA/MNH/PSF/97.6 I.D. number
Page 16
ABOUT YOU
Before you begin we would like to ask you to answer a few general questions about yourself: by circling the
correct answer or by filling in the space provided.
Instructions
This assessment asks how you feel about your quality of life, health, or other areas of your life. Please answer all
the questions. If you are unsure about which response to give to a question, please choose the one that appears
most appropriate. This can often be your first response.
Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the
last two weeks. For example, thinking about the last two weeks, a question might ask:
You should circle the number that best fits how much support you got from others over the last two weeks. So
you would circle the number 4 if you got a great deal of support from others as follows.
You would circle number 1 if you did not get any of the support that you needed from others in the last two weeks.
MSA/MNH/PSF/97.6
Page 17
Please read each question, assess your feelings, and circle the number on the scale for each question
that gives the best answer for you.
Neither
Very poor Poor poor nor Good Very good
good
1(G1) How would you rate your quality of life? 1 2 3 4 5
The following questions ask about how much you have experienced certain things in the last two weeks.
Not at all A little A moderate Very much An extreme
amount amount
3 (F1.4) To what extent do you feel that physical 1 2 3 4 5
pain prevents you from doing what you
need to do?
4(F11.3) How much do you need any medical 1 2 3 4 5
treatment to function in your daily life?
5(F4.1) How much do you enjoy life? 1 2 3 4 5
6(F24.2) To what extent do you feel your life to 1 2 3 4 5
be meaningful?
The following questions ask about how completely you experience or were able to do certain things in the last two weeks.
poor nor
good
15 (F9.1) How well are you able to get around? 1 2 3 4 5
The following questions ask you to say how good or satisfied you have felt about various aspects of your
The following question refers to how often you have felt or experienced certain things in the last two weeks.
7 4 0 6 4 0 3 4 0 8 4 0
8 5 6 7 5 6 4 5 6 9 5 6
9 5 6 8 5 6 5 7 19 10 5 6
10 6 13 9 6 13 6 8 25 11 6 13
11 6 13 10 7 19 7 9 31 12 6 13
12 7 19 11 7 19 8 11 44 13 7 19
13 7 19 12 8 25 9 12 50 14 7 19
14 8 25 13 9 31 10 13 56 15 8 25
15 9 31 14 9 31 11 15 69 16 8 25
16 9 31 15 10 38 12 16 75 17 9 31
17 10 38 16 11 44 13 17 81 18 9 31
18 10 38 17 11 44 14 19 94 19 10 38
19 11 44 18 12 50 15 20 100 20 10 38
20 11 44 19 13 56 21 11 44
21 12 50 20 13 56 22 11 44
22 13 56 21 14 63 23 12 50
23 13 56 22 15 69 24 12 50
24 14 63 23 15 69 25 13 56
25 14 63 24 16 75 26 13 56
26 15 69 25 17 81 27 14 63
27 15 69 26 17 81 28 14 63
28 16 75 27 18 88 29 15 69
29 17 81 28 19 94 30 15 69
30 17 81 29 19 94 31 16 75
31 18 88 30 20 100 32 16 75
32 18 88 33 17 81
33 19 94 34 17 81
34 19 94 35 18 88
35 20 100 36 18 88
37 19 94
38 19 94
39 20 100
40 20 100
Lampiran 6 : Kontrak Bimbingan
Lampiran 7 : Kartu Bimbingan Skripsi
Lampiran 8 : Laporan Kemajuan Penelitian
Lampiran 9 : Permohonan Menempuh Seminar Usulan Penelitian
Lampiran 10 : Lembar Verifikasi Untuk Menempuh USSK
Lampiran 11 : Permohonan Menempuh USSK
Lampiran 12 : Surat Ijin Validitas Dan Reliabilitas di RSUD dr. Slamet Garut
Lampiran 13 : Surat Pengantar Penelitian Bangkesbangpol Kabupaten Garut
Lampiran 14 : Surat Izin Penelitian RSUD dr Slamet Garut
Lampiran 15 : Surat Ethical Approval
Lampiran 16 : Output Hasil SPSS Hasil Pengumpulan Data Responden
Jenis Kelamin
Usia
Frequenc Percent Valid Cumulative
y Percent Percent
Vali Dewasa Pertengahan 6 6.8 6.8 6.8
d Dewasa Akhir 20 22.7 22.7 29.5
Lanisa Awal 25 28.4 28.4 58.0
Lanisa Akhir 22 25.0 25.0 83.0
Manula 15 17.0 17.0 100.0
Total 88 100.0 100.0
Agama
Suku Bangsa
Status Pernikahan
Frequency Percent Valid Percent Cumulative
Percent
Valid Belum Menikah 2 2.3 2.3 2.3
Menikah 80 90.9 90.9 93.2
Bercerai 1 1.1 1.1 94.3
Janda Atau Duda 5 5,6 5,6 98.9
Total 88 100.0 100.0
Pekerjaan
Frequency Percent Valid Percent Cumulative
Percent
Tidak Bekerja atau IRT 50 56.8 56.8 56.8
Valid PNS atau ABRI 10 11.4 11.4 68.2
Wiraswasta 19 21.6 21.6 89.8
Lainnya 9 10.2 10.2 100.0
Total 88 100.0 100.0
Penghasilan
Frequency Percent Valid Percent Cumulative
Percent
Valid < UMR (Rp. 1.800.000) 52 59.1 59.1 59.1
> UMR (Rp. 1.800.000) 36 40,9 40,9 98.9
Total 88 100.0 100.0
SKOR PENGETAHUAN
Frequency Percent Valid Percent Cumulative
Percent
Valid 4 1 1.1 1.1 1.1
5 2 2.3 2.3 3.4
6 2 2.3 2.3 5.7
7 11 12.5 12.5 18.2
8 8 9.1 9.1 27.3
9 17 19.3 19.3 46.6
10 14 15.9 15.9 62.5
11 15 17.0 17.0 79.5
12 12 13.6 13.6 93.2
13 5 5.7 5.7 98.9
15 1 1.1 1.1 100.0
Total 88 100.0 100.0
KATEGORI PENGETAHUAN
Frequency Percent Valid Cumulative
Variabel
Percent Percent
Q1
Frequency Percent Valid Percent Cumulative
Percent
Valid SANGAT 7 8.0 8.0 8.0
BURUK
BURUK 21 23.9 23.9 31.8
SEDANG 45 51.1 51.1 83.0
BAIK 12 13.6 13.6 96.6
SANGAT BAIK 3 3.4 3.4 100.0
Total 88 100.0 100.0
Q2
Frequency Percent Valid Percent Cumulative
Percent
Valid SANGAT 7 8.0 8.0 8.0
BURUK
BURUK 48 54.5 54.5 62.5
SEDANG 28 31.8 31.8 94.3
BAIK 4 4.5 4.5 98.9
SANGAT BAIK 1 1.1 1.1 100.0
Total 88 100.0 100.0
Chi-Square Tests
Value df Asymptotic
Significance
(2-sided)
Pearson Chi-Square 15.795a 8 0.045
Likelihood Ratio 13.875 8 0.085
Linear-by-Linear .443 1 0.506
Association
N of Valid Cases 88
Lampiran 17: Uji Validitas dan Realiabilitias Kuesioner Pengetahuan
P1 P2 P3 P4 P5 P6 P7
Pertanyaan 1 Pearson Correlation 1 1.000** .934** -0.279 1.000** 0.172 .934**
30 30 30 30 30 30 30 30 30
.451* .935** 0.247 0.110 1.000** 0.110 1.000** 1.000** .985**
30 30 30 30 30 30 30 30 30
-0.347 -0.321 -0.238 0.059 -0.279 -0.238 -0.279 -0.279 -0.248
30 30 30 30 30 30 30 30 30
.451* .935** 0.247 0.110 1.000** 0.110 1.000** 1.000** .985**
0.012 0.000 0.188 0.563 0.000 0.563 0.000 0.000 0.000
30 30 30 30 30 30 30 30 30
0.282 0.120 -0.339 0.085 0.172 0.085 0.172 0.172 0.190
0.131 0.527 0.067 0.656 0.363 0.656 0.363 0.363 0.315
30 30 30 30 30 30 30 30 30
P8 P9 P10 P11 P12 P13 P14 P15 .985**
N 30 30 30 30 30 30 30
Pertanyaan 8 Pearson Correlation .451* .451* .367* -0.347 .451* 0.282 .508**
Sig. (2-tailed) 0.012 0.012 0.046 0.060 0.012 0.131 0.004
N 30 30 30 30 30 30 30
Pertanyaan 9 Pearson Correlation .935** .935** .873** -0.321 .935** 0.120 .873**
N 30 30 30 30 30 30 30
Pertanyaan 10 Pearson Correlation 0.247 0.247 0.167 -0.238 0.247 -0.339 0.167
N 30 30 30 30 30 30 30
Pertanyaan 11 Pearson Correlation 0.110 0.110 0.028 0.059 0.110 0.085 0.167
N 30 30 30 30 30 30 30
P8 P9 P10 P11 P12 P13 P14 P15 skor
30 30 30 30 30 30 30 30 30
1 .536** 0.085 -0.056 .451* 0.226 .451* .451* .476**
30 30 30 30 30 30 30 30 30
.536** 1 0.191 0.055 .935** 0.055 .935** .935** .912**
30 30 30 30 30 30 30 30 30
0.085 0.191 1 -0.111 0.247 0.028 0.247 0.247 0.274
30 30 30 30 30 30 30 30 30
-0.056 0.055 -0.111 1 0.110 0.028 0.110 0.110 0.156
30 30 30 30 30 30 30 30 30
30 30 30 30 30 30 30 30 30
P1 P2 P3 P4 P5 P6 P7
Pertanyaan 13 Pearson Correlation 0.110 0.110 0.167 -0.238 0.110 0.085 0.167
N 30 30 30 30 30 30 30
Pertanyaan 14 Pearson Correlation 1.000** 1.000** .934** -0.279 1.000** 0.172 .934**
N 30 30 30 30 30 30 30
Pertanyaan 15 Pearson Correlation 1.000** 1.000** .934** -0.279 1.000** 0.172 .934**
N 30 30 30 30 30 30 30
Total Pearson Correlation .934** .934** .861** -0.238 .934** 0.085 .861**
N 30 30 30 30 30 30 30
P8 P9 P10 P11 P12 P13 P14 P15 skor
30 30 30 30 30 30 30 30 30
30 30 30 30 30 30 30 30 30
30 30 30 30 30 30 30 30 30
30 30 30 30 30 30 30 30 30
Reliability
Case Processing Summary
N %
Cases Valid 30 62.5 Statistics
Excluded a
18 37.5 Cronbach's Cronbach's Alpha N of
Total 48 100.0 Alpha Based on Items
a. Listwise deletion based on all variables in Standardized Items
the procedure. .984 .932 27
Lampiran 18 : Turnitin Report
Lampiran 19 : Biodata Peneliti
RIWAYAT HIDUP
Agama : Islam
Telepon 08978746608
Email : Rizkanr88@gmail.com
Riwayat Pendidikan