Ref. no.:

ASEAN Homestay Standard

BORANG PENILAIAN
PIAWAIAN HOMESTAY ASEAN
                                                          -  Organisasi Homestay   -

1

 / KANDUNGAN

No.	Contents / Kandungan	Page / Ms.	
				
i.	Profile	/ Profil  	3	
ii.	Checklist for Assessor / Senarai Semak untuk Penilai	4	
		
ASEAN Homestay Assessment Criteria / Kriteria Penilaian Homestay ASEAN		
			
1.0	Accommodation / Penginapan		
				
	1.1	The House / Rumah	5	
	1.2	The Bedroom / Bilik Tidur	6	
	1.3	The Toilet/Bathroom / Tandas/Bilik Air	7	
			
2.0	Hygiene and Cleanliness / Kebersihan dan Sanitasi		
				
	2.1	House (Kitchen, Bedroom & Toilet) / Rumah (Dapur, Bilik Tidur & Tandas)	9	
	2.2	Surrounding Compound / Kawasan Sekeliling	10	
	2.3	Food Preparation / Penyediaan Makanan	11	
			
3.0	Homestay Assessment Scorecard / Kad Skor Penilaian Homestay	13	
4.0	Appendix / Lampiran	14	

ASEAN Homestay Standard Assessment Form
-Homestay Provider	2

 / Profil

Name of Homestay 	:
Nama Homestay

Name of Provider
Nama Pengusaha	:

Identification Number	:
Nombor Pengenalan

Age	:
Umur

Year of Establishment	:
Tahun Penubuhan
Number of Household	:
Bilangan Isi Rumah
Address	:
Alamat

Telephone Number (H)
Nombor Telefon (Rumah)	:	
Handphone Number
Nombor Telefon Bimbit	:	
Email Address (if any)
Alamat E-mel (jika ada)	:	

Prerequisite Entry Requirements / Syarat Kemasukan Prasyarat:						
Homestay operator is free of criminal record / Pengusaha homestay bebas daripada rekod jenayah		Yes/Ya		No/Tidak		
						
Homestay operator is in good health / Pengusaha homestay berada dalam keadaan kesihatan yang baik		Yes/Ya		No/Tidak		

Name of Assessor/ Nama Penilai		:

Name of Organisation/ Nama Organisasi	:

Date of Assessment/ Tarikh Penilaian	:

ASEAN Homestay Standard Assessment Form
-Homestay Provider	3

 / Senarai Semak untuk Penilai

No.	Checklist Description / Perihal Senarai Semak	(ü)

1.	Attach one photocopy of the application form with the assessment form / Lampirkan satu salinan fotokopi borang permohonan bersama borang penilaian		
2.	Assessment form completely filled up / Borang penilaian telah diisi dengan lengkap		
3.	Homestay organization fulfills all prerequisite entry requirements / Organisasi homestay memenuhi semua syarat kemasukan prasyarat		
4.	The necessary photographs had been taken / Gambar-gambar yang diperlukan telah diambil		
5.	Photographs must be clear and viewable / Gambar mestilah jelas dan boleh dilihat		
6.	Attach photocopies of any relevant documents in the appendix / Lampirkan salinan fotokopi mana-mana dokumen berkaitan di bahagian lampiran		

______________________________________________________________________________
ASEAN Homestay Standard Assessment Form
-Homestay Provider	4

NO.	REQUIREMENTS/ KEPERLUAN		YES/YA		NO/TIDAK	*NA	
							
1.1	The House / Rumah						
					
1.1.1 Structure of house is in good and safe condition / Struktur rumah berada dalam keadaan baik dan selamat					
						
				REMARKS/ ULASAN:		
	Insert photographs here
Lampirkan gambar di sini					
					
1.1.2 Design and building materials reflect local architecture and identity / Reka bentuk dan bahan binaan mencerminkan seni bina dan identiti tempatan					
						
				REMARKS/ ULASAN:		
	Insert photographs here
Lampirkan gambar di sini					
						
1.1.3 Separate guest bedroom (s) /   Bilik 	tidur tetamu berasingan					
•	 Number of separate guest bedrooms	/ Bilangan bilik tidur tetamu berasingan :					
				REMARKS/ ULASAN:		
	Insert photographs here
Lampirkan gambar di sini					
					
1.1.4 Minimum one (1) bathroom/toilet for the guest / Minimum satu (1) bilik mandi/tandas untuk tetamu					
•	Number of bathroom/toilets / Bilangan	bilik mandi/tandas					
				REMARKS/ ULASAN:		
	Insert photographs here
Lampirkan gambar di sini					
						
* Not Applicable / Tidak Berkenaan						

 / Penginapan

ASEAN Homestay Standard Assessment Form
-Homestay Provider	5

/ PENGINAPAN

NO.	REQUIREMENTS/ KEPERLUAN	YES/YA	NO/TIDAK	*NA		
						
1.1	The House (cont..) / Rumah (samb..)					
					
1.1.5 Electricity supply in the house / Bekalan elektrik di rumah					
REMARKS/ ULASAN:					

1.1.6 Adequate clean water supply in the house / Bekalan air bersih yang mencukupi di rumah
	
        REMARKS/ ULASAN:

Insert photographs here
 Lampirkan gambar di sini

1.2	The Bedroom / Bilik Tidur					
					
1.2.1 Basic amenities such as fan, desk, mini cupboard, mirror, electric socket, mosquito net or coil, etc. / Kemudahan asas seperti kipas, meja, almari mini, cermin, soket elektrik, kelambu atau gegelung nyamuk, dsb.					

•	Amenities available   :

        REMARKS/ ULASAN:

Insert photographs here
 Lampirkan gambar di sini

* Not Applicable / Tidak Berkenaan

ASEAN Homestay Standard Assessment Form
-Homestay Provider	6

	NO.	REQUIREMENTS/ KEPERLUAN	YES/YA		NO/TIDAK	*NA	
							
1.2	The Bedroom (cont..) / Bilik Tidur (Samb..)					
						
	1.2.2 Maximum of four (4) bedrooms allocated for guests / Maksimum empat (4) bilik tidur diperuntukkan untuk tetamu					
	•	 Bedrooms available / Bilik tidur tersedia:					
				REMARKS/ ULASAN:		
		Insert photographs here
                                            Lampirkan gambar di sini					
						
	1.2.3 Standard beds with mattresses and pillows / Katil standard dengan tilam dan bantal					
						
				REMARKS/ ULASAN:		
		Insert photographs here
                                             Lampirkan gambar di sini					
						
	1.2.4 Windows are fitted with mesh frame / Tingkap dipasang dengan rangka jaring					
						
				REMARKS/ ULASAN:		
		Insert photographs here
   Lampirkan gambar di sini					
						
	1.2.5 Clean and fresh bed linen for every guest / Linen katil yang bersih dan segar disediakan untuk setiap tetamu					
						
				REMARKS/ ULASAN:		
		Insert photographs here
  Lampirkan gambar di sini					
						
	* Not Applicable / Tidak Berkenaan					

/ PENGINAPAN

ASEAN Homestay Standard Assessment Form
-Homestay Provider	7

NO.	REQUIREMENTS/ KEPERLUAN	YES/YA		NO/TIDAK	*NA	
						
1.3	The Toilet/Bathroom  /  Tandas / Bilik Air					
					
1.3.1 Sitting or squatting toilet inside or outside, but close the house / Tandas duduk atau mencangkung di dalam atau di luar rumah, tetapi berdekatan dengan rumah					
					
			REMARKS/ ULASAN:		
	Insert photographs here
  Lampirkan gambar di sini					
					
1.3.2 Basic toilet and bathroom facilities / Kemudahan asas tandas dan bilik mandi					
					
			REMARKS/ ULASAN:		
	Insert photographs here
  Lampirkan gambar di sini					
					
1.3.3 Adequate clean water provided at all times / Bekalan air bersih yang mencukupi sentiasa disediakan					
					
			REMARKS/ ULASAN:		
	Insert photographs here
  Lampirkan gambar di sini					
					
* Not Applicable / Tidak Berkenaan					

/ PENGINAPAN

ASEAN Homestay Standard Assessment Form
-Homestay Provider	8

NO.	REQUIREMENTS/ KEPERLUAN	YES/YA		NO/TIDAK	*NA		
							
2.1	House (Kitchen, Bathroom & Toilet) / Rumah (Dapur, Bilik Air & Tandas) 						
						
2.1.1 All rooms, kitchen and toilets are clean e.g free of malodour, dirt, dust						
	and cobwebs / Semua bilik, dapur dan tandas bersih contohnya: tiada bau busuk, kotoran, habuk dan sarang labah-labah						

			REMARKS/ ULASAN:			
	Insert photographs here
                                              Lampirkan gambar di sini						
						
2.1.2 Kitchen floor is clean / Lantai dapur bersih						
						
			REMARKS/ ULASAN:			
	Insert photographs here
 Lampirkan gambar di sini						
						
2.1.3 Toilet(s), shower tray(s), bath tub(s), well and sinks are clean e.g. Free						
	from dirt, stains and malodour / Tandas, dulang mandi, tab mandi, perigi 
dan sinki bersih contohnya: tiada kotoran, kesan noda atau bau busuk						

			REMARKS/ ULASAN:			
	Insert photographs here
                                             Lampirkan gambar di sini						
						
2.1.4 Disinfectants are used in toilets / Bahan pembasmi kuman digunakan di tandas						
						
			REMARKS/ ULASAN:			
	Insert photographs here
                                             Lampirkan gambar di sini						
						
* Not Applicable / Tidak Berkenaan						

/ KEBERSIHAN DAN KESIHATAN

ASEAN Homestay Standard Assessment Form
-Homestay Provider	9

	NO.	REQUIREMENTS/ KEPERLUAN	YES/YA		NO/TIDAK	*NA	
							
2.1	House (Kitchen, Bathroom & Toilet) (cont..) / Rumah (Dapur, Bilik Air & Tandas) (Samb..)					
						
	2.1.5 Soap, shampoo, toilet tissue and clean towels are provided / Sabun, syampu, tisu tandas dan tuala bersih disediakan					
						
				REMARKS/ ULASAN:		
		Insert photographs here
                                             Lampirkan gambar di sini					
							
2.2	Surrounding Compound / Kawasan Sekeliling					
						
	2.2.1 Surrounding compound is litter free / Kawasan sekeliling rumah bebas daripada sampah					
						
				REMARKS/ ULASAN:		
		Insert photographs here
                                             Lampirkan gambar di sini					
						
	2.2.2 No breeding grounds for mosquitoes / Tiada tempat pembiakan nyamuk					
						
				REMARKS/ ULASAN:		
		Insert photographs here
                                             Lampirkan gambar di sini 					
						
	2.2.3 Village beautification and landscaping using local plants / Pengindahan kampung dan landskap menggunakan tumbuhan tempatan					
						
				REMARKS/ ULASAN:		
		Insert photographs here
                                             Lampirkan gambar di sini					
						
	* Not Applicable / Tidak Berkenaan					

/ KEBERSIHAN DAN KESIHATAN

ASEAN Homestay Standard Assessment Form
-Homestay Provider	10

NO.	REQUIREMENTS/ KEPERLUAN	YES/YA		NO/TIDAK	*NA		
							
2.3	Food Preparation / Penyediaan Makanan						
						
2.3.1 Kitchen is in good, clean condition and well ventilated / Dapur dalam keadaan baik, bersih dan mempunyai pengudaraan yang baik						
						
			REMARKS/ ULASAN:			
	Insert photographs here
Lampirkan gambar di sini						
						
2.3.2 Kitchen utensils are in good condition, clean and kept in a dry place / Alat dapur dalam keadaan baik, bersih dan disimpan di tempat kering						
						
			REMARKS/ ULASAN:			
	Insert photographs here
 Lampirkan gambar di sini						
						
2.3.3 Presentable plates, glasses, mugs etc. are used in serving meals / Pinggan, gelas, cawan yang menarik digunakan semasa menyediakan makanan						
						
			REMARKS/ ULASAN:			
	Insert photographs here
 Lampirkan gambar di sini						
						
2.3.4 Individuals involved in food preparation have good personal hygiene and						
	properly attire / Individu yang terlibat dalam penyediaan makanan menjaga kebersihan diri dan berpakaian sesuai						

			REMARKS/ ULASAN:			
	Insert photographs here
 Lampirkan gambar di sini						
						
* Not Applicable / Tidak Berkenaan						

/ KEBERSIHAN DAN KESIHATAN

ASEAN Homestay Standard Assessment Form
-Homestay Provider	11

/ KEBERSIHAN DAN KESIHATAN

NO.	REQUIREMENTS/ KEPERLUAN	YES/YA	NO/TIDAK	*NA			
							
2.3	Food Preparation (cont..) / Penyediaan Makanan (Samb..)						
						
2.3.5 Fresh ingredients used in food preparation are sourced from local suppliers / Bahan segar yang digunakan dalam penyediaan makanan diperoleh daripada pembekal tempatan			

 REMARKS/ ULASAN:

2.3.6 Served food are properly covered / Makanan yang disediakan ditutup dengan       REMARKS/ ULASAN:
baik				

Insert photographs here
 				Lampirkan gambar di sini

2.3.7 Have safe drinking water / Terdapat air minum selamat

        REMARKS/ ULASAN:

Insert photographs here
 				Lampirkan gambar di sini

* Not Applicable / Tidak Berkenaan

ASEAN Homestay Standard Assessment Form
-Homestay Provider	12

No.	Assessment Criteria & Requirements / 
Kriteria Penilaian & Keperluan	Total YES /Jumlah YA 	Total NA / Jumlah NA	Total Requirements	Weightage / Pemberat	Result / Keputusan 		
				Jumlah Keperluan				
									
1.0	Accommodation / Penginapan							
	1.1	The House / Rumah (6)							
									
	1.2	The Bedroom / Bilik Tidur (5)			14	10%			
									
	1.3	The Toilet/Bathroom  /  Tandas/Bilik Mandi (3)							
									
2.0	Hygiene and Cleanliness / Kebersihan dan Kesihatan							
	2.1	House (Kitchen, Bedroom & Toilet)  / Rumah (Dapur, Bilik Tidur & Tandas) (5)							
									
	2.2	Surrounding Compound / Kawasan Sekitar (3)			15	15%			
									
	2.3	Food Preparation / Penyediaan Makanan (7)							
									
					TOTAL / JUMLAH	25%			
					(Passing Mark ≥ 18.75) / (Markah Lulus ≥ 18.75)		

/ KAD SKOR PENILAIAN HOMESTAY

Assessed by / Dinilai oleh:	Approved by / Diluluskan oleh:

Name / : 	Name / :
   Nama	Nama

Date / Tarikh :	Date / Tarikh :

ASEAN Homestay Standard Assessment Form
-Homestay Provider	13

  LAMPIRAN

ASEAN Homestay Standard Assessment Form
-Homestay Provider	14

Kriteria: Penginapan | Sub-Kriteria: Rumah

/ Bekalan elektrik di rumah

- Write details of interview findings here –
- Tulis butiran penemuan temuduga di sini -

/ Bahan segar digunakan dalam penyediaan makanan

        Kriteria: Kebersihan dan Kesihatan | Subkriteria: Penyediaan Makanan

- Write details of interview findings here –
- Tulis butiran penemuan temuduga di sini -

15

3. GENERAL COMMENTS / ULASAN UMUM 

RESULT (√) :
KEPUTUSAN		Pass / Lulus		Fail /
 Gagal 	

Approved by / Diluluskan oleh:

    (Signature & Stamped) / (Tandatangan & Cop)	Date/Tarikh (DD/MM/YYYY)

Chief Assessor
ASEAN Homestay Assessment Committee

        Ketua Penilai
Jawatankuasa Penilaian Homestay ASEAN

16

FORM D-2

ASEAN HOMESTAY STANDARD
ASSESSMENT RESULT FOR HOMESTAY PROVIDER

STANDARD HOMESTAY ASEAN
KEPUTUSAN PENILAIAN UNTUK PENYEDIA HOMESTAY

1. APPLICANT DETAILS / MAKLUMAT PEMOHON

	Name:
Nama																	
																		
	Identification Number:
Nombor Pengenalan		Name of Homestay:
Nama Homestay									

	References Number:
Nombor Rujukan		Region/State:
Wilayah/Negeri					Country:
Negara					

		(Similar with the Applicant’s Assessment Form)													
																			
	2. HOMESTAY ASSESSMENT SCORE / SKOR PENILAIAN HOMESTAY													
																			
	No.	Assessment Criteria & Requirements / Kriteria & Keperluan Penilaian	Total YES/ Jumlah YA		Total NA/ Jumlah NA 	Total Requirements	Weightage/ Pemberat	Result/ Keputusan		
						Jumlah Keperluan				
																
	1.0	Accommodation / Penginapan													
		1.1	The House / Rumah (6)													
																
		1.2	The Bedroom / Bilik Tidur (5)						14	10%				
		1.3	The Toilet/Bathroom  /  Tandas/Bilik Mandi (3)													
																
	2.0	Hygiene and Cleanliness / Kebersihan & Kesihatan													
		2.1	House (Kitchen, Bedroom & Toilet) / Rumah (Dapur, Bilik Tidur & Tandas) (5)													
																
		2.2	Surrounding Compound / Kawasan Sekitar (3)						15	15%				
		2.3	Food Preparation / Penyediaan Makanan (7)													
																			
													TOTAL / JUMLAH	25%				
												(Passing Mark ≥ 18.75) /
 (Markah Lulus ≥ 18.75)		

3. GENERAL COMMENTS / ULASAN UMUM

RESULT (√) :
KEPUTUSAN		Pass / Lulus		Fail /
 Gagal 	

Approved by / Diluluskan oleh:

          (Signature & Stamped) / (Tandatangan & Cop)                                                                         Date/ Tarikh (DD/MM/YYYY)

Chief Assessor
ASEAN Homestay Assessment Committee

            Ketua Penilai
Jawatankuasa Penilaian Homestay ASEAN