Lampiran 3

FORMULIR PEMANTAUAN PERTUMBUHAN BALITA DI POSYANDU

Provinsi : Nama Posyandu

Kabupaten/Kota : Bulan
Puskesmas/Kecamatan : Tahun
Desa/Kelurahan :

Jenis
No Anak Ke Tanggal Lahir No Kartu Keluarga NIK (Nomor Induk Kependudukan)
Kelamin

(1) (2) (3) (4) (5) (6)

1 1 18-7-2017 P 0 1806095807170002
2 1 26-12-2017 P 0 1806096612170000
3 2 24-07-2017 p 0 1806096407170001
4 1 12/1/2018 L 0 1806091201180001
5 2 11/7/2017 L 0 1806091107120001
6 2 22-04-2018 L 0 1806092204180001
7 2 31-07-2017 P 0 18009107170001
8 2 11/10/2017 P 0 1806095110170001
9 3 26-02-2019 P 1806092210100009 1806096602190001
10 2 14-4-2017 P 1806092509120004 1806095404170001
11 1 8/5/2017 P 1806090506170002 1806094505170001
12 3 10/12/2017 P 180609270710004 1806096510170001
13 2 25-10-2017 P 1806092909150001 1806096510170001
14 3 11/10/2017 P 1806091105110109 1806095110170003
15 5 8/8/2016 P 1806090511090001 1806094808160002
16 1 7/2/2018 P 180609150810003 1806094702180002
17 1 8/5/2017 L 1806092905170001 180609080517001
18 2 17/5/2017 P 1806092304140003 1806095705170001
19 2 11/3/2017 P 1806091206120001 1806095103170001
20 2 7/11/2017 L 1806090502100002 1806096711170001
21 1 17/6/2018 L 0 1806091706180001
22 2 17/7/2015 P 1806092907150000 1806095707150001
23 2 10/11/2017 P 1806091301110008 1806095011170001
24 2 26/10/2017 P 1806090507120004 180096610180001
25 2 15/3/2018 P 1806092104110004 1806095503180001
26 2 4/5/2017 L 1806091912180002 1806090405170001
27 2 24/1/2017 P 180609011100011 1806096401170001
28 2 17/8/2017 P 1806092106130001 18060957081700001
29 2 14/1/2017 p 1806090403100012 1806095401170001
30 2 6/3/2016 P 1806091507100006 1806094603160002
31 1 4/4/2017 P 0 1806096104010001
32 1 3/4/2016 L 0 1806090304160002
33 2 16/6/2017 P 1'1806091105110295 1806095606170001
34 1 1/4/2015 P 1806092904150002 1806094104150001
35 1 23/6/2018 P 1806091009140003 1806096306180001
36 3 17/3/2017 L 0 180609563800003
37 2 4/1/2018 P 0 0
38
39
40
41
42
 :
:
:

Kepemilik
Berat an Buku IMD 1=YA,
Nama Anak Badan KIA/KMS 2=Tidak Nama Ayah NIK Ayah
(BB) Lahir 1=YA,
2=Tidak
(7) (8) (9) (10) (11) (12)
SHEZA NADIRA ANDIANI 3 1 1 ANIL JUNAIDI 1801182211920002
KANAYA DINAR ZULAIKHA 3 1 1 SUNARDI 1806096612170001
QAILLA ATIKA PUTRI 2.9 1 1 SUKARNO 1806090807880003
ALZAM ICHSANDIRA KURNIA3.4 1 1 JAMILA 3603186912920012
RASYA HAFIZH AL GHAZA 2.9 1 1 ISWANTO 1806092002820002
RIFAN AFANDI 3.5 1 1 GUSMAYANTO 180090809830001
ANGGUN AISILA 3 1 1 AMPRI 1806090507850008
ZIVANA ADELIA LIZA 2.9 1 1 NANTO 1806092602830001
NIFA SYAKAYLA 3 1 1 SITI SUTIHAT 1806090204760004
WIELDA NURHIDA 3 1 1 NURUR ROSYAD 180609107880002
NINDI WASI'AH PUTRI 3.1 1 1 WALUYO 1806092001950001
RIMA MAULIDA 3.8 1 1 RIDWAN 1806090808820002
NADIA NUR AVIVA 3.2 1 1 NOPIYANTO 180604121180001
RESVITA JOYA 2.7 1 1 ROBI SANDIKA 1806091912780002
AZIZAH 2.9 1 1 HAYUZA 1806091704640002
FEBI ZULYANTI 2.5 1 1 JAHURI 1805110303860001
FADLI AL FARIZKI 2.9 1 1 HANDOKO 1806091406940005
ARSYLA NADIRA 3.2 1 1 ADITYA 1806092305920001
MIYA RIYANTI 2.7 1 1 RIDWANTO 18060916037800004
AZKA ALFARIZI 3.4 1 1 RAJULI 0
ANDRIAN ZAKI ALPARIZI 3.2 1 1 JIPUL 0
FITRI NUR AISA 3.2 1 1 SUNANTO EFENDI 1806091505770008
HAFIZ H 3.5 1 1 SAHLAN 1806090609830001
ALIFIA V 2.6 1 1 ABDU MUIT 1806090505850003
SABRINA 2.9 1 1 SUKIRMAN 1806090708870002
M RISKI 3 1 1 SAHLANI 1809070705830001
AMIYATI 3.1 1 1 A SARIPUDIN 1806090209770002
GUSPITA 2.7 1 1 SUHARYADI 1806030202850004
IKA 3.2 1 1 MAGIANTO 1806091504840001
RAHMA IZZATUNISA 3.1 1 1 FARZAN 1806091211780001
SALMA 3.2 1 1 ROMZI 1806092909900002
NURUL FAHMI 2.8 1 1 ASEP 1806091012800004
URPIYAH ZAINATULIN 3.1 1 1 BAITUROZI 1806090310820001
HALWAHULASOH 2.8 1 1 HAIRUDDIN 1806090308890003
AZZRIA ALMAHIRA 2.4 1 1 ANTON NURDIAN 1806090207890001
ROSI SIADO MAHYUDIN 1806090310750001
KAIZA 3 1 1 HERMANTO 0
 Panjang
Badan/
No Tlp/ HP Ayah Alamat RT RW Tgl Pengukuran BB (kg) Tinggi
Badan
(cm)
(13) (14) (15) (16) (17) (18) (19)
08226774053 KACAMARGA 0 0 9.5 64
08226774053 KACAMARGA 0 0 9.3 63
08226774053 KACAMARGA 0 0 9 66
08226774053 KACAMARGA 0 0 7.5 62
08226774053 KACAMARGA 7 4 11 73
08226774053 KACAMARGA 0 0 7.3 62
08226774053 KACAMARGA 0 0 10 67
08226774053 KACAMARGA 0 0 10 67
08226774053 TANJUNG BETUAH 0 0 3/5/2019 4.6 53
082371145500 TANJUNG BETUAH 1 5 1/6/2019 8.8 78.3
085268726783 TANJUNG BETUAH 2 1 1/6/2019 10 81.9
085219215884 TANJUNG BETUAH 2 1 1/6/2019 8.3 73
085366840815 TANJUNG BETUAH 1 2 1/6/2019 9 79
085366840815 TANJUNG BETUAH 1 1 1/6/2019 9.5 74
82373476702 TANJUNG BETUAH 2 1 1/6/2019 8.1 81
082278259339 TANJUNG BETUAH 2 1 1/6/2019 8.5 72
081278033972 TANJUNG BETUAH 1 2 1/6/2019 8 77
082260292770 TANJUNG BETUAH 2 1 1/6/2019 9.3 79
0 GEDUNG 1 1 22/5/2019 10.2 75
0 GEDUNG 1 1 22/5/2019 9.4 67
0 GEDUNG 1 1 22/5/2019 7.8 42
0 KEJADIAN LOM 1 1 20/5/2019 13 94
0 BANJAR NEGERI 1 1 13/6/2019 10 75
0 BANJAR NEGERI 5 1 13/6/2019 7.9 68
0 BANJAR NEGERI 1 1 13/6/2019 9.2 78
081273115168 TENGOR 3 3 4/5/2019 10.2 74
081273115168 TENGOR 2 2 4/5/2019 10.7 79
081273115168 TENGOR 3 3 4/5/2019 8.2 76
081273115168 TENGOR 3 3 4/5/2019 11.2 80
085268298009 BANJAR MANIS 2 2 11/5/2019 10.5 87
0 PUTIH DOH 0 0 4/4/2019 9 81
0 PUTIH DOH 0 0 4/4/2019 11.3 88
0 PAMPANGAN 0 0 8/6/2019 10 80
0 PAMPANGAN 0 0 8/6/2019 12 92
0 PAMPANGAN 0 0 8/6/2019 8.6 67
KARANG BUAH 10.5 78
0 SUKAPADANG 1 1 16/5/2019 8.6 75
Cara Ukur ASI EksklusifF1=YA, 2=Tidak Vitamin A Vitamin A
1=Telenta Februari Agustus
ng umur 0 umur 1 umur 2 umur 3 umur 4 umur 5 1=YA 1=YA
2=Berdiri bln bln bln bln bln bln 2=Tidak 2=Tidak
(20) (21) (22) (23) (24) (25) (26) (27) (28)
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0
2 1
2 1
1 1
1 1
1 1
2 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
2 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
2 1 1 1 1 1 1 1 1
2 1 1 1 1 1 1 1 1
2 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
2 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
2 1 1 1 1 1 1
2 1 1
2 1 1

1 1 1