Permintaan Vaksin

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DAFTAR PERMINTAAN VAKSIN UNTUK PELAKSANAAN IMUNISASI

PUSKESMAS :
KECAMATAN :
KABUPATEN :
BULAN :
TAHUN :

SISA S/D PENERIMAAN JUMLAH PENERIMAAN NOMOR TANGGAL PERMINTAAN

NO JENIS VAKSIN SISA KET
BULAN….. BULAN….. BULAN….. BATCH KADARLUASA BULAN…..
1 BCG
2 PENTABIO
3 POLIO
4 TT
5 HEPATITIS B UNIJECK
6 CAMPAK
7 DT
8 TD
9 IPV
10
11
12

MENGETAHUI, TERANTANG MANUK, 2017

KEPALA BADAN LAYANAN UMUM DAERAH Pengelola Program Imunisasi Puskesmas Pangkalan Kuras II
PUSKESMAS PANGKALAN KURAS II

dr. BAMBANG HERMANTO HENDRA FRIANTO, AMK

NIP. 19790719 201001 1 010

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