FORM

UPTD PU

Jenis No.
No Nama* Umur Kelamin Rekam
No. Telepon
(th/bln)* Medis
* (jika ada)

1 DEWI RATNA 25 P 085802599916

2 DWI SEPTIANI 20 P 081390575920

3 NURIL FATIHAH 27 P 085950832240

4 FEBIANA P 20 P 085727327717

5 WIWIK LISTIANI 27 P 085831386694

6 QURRATUN AINI 20 P 085608516165

7 NURUL FADILAH 30 P 085865262560

8 INDAH PURWANINGSIH 21 P 08561526319

9 ISTIYOWATI 30 P 085326277429

10 ERNAWATI 35 P 085848952683

11 KASEMI 34 P 085601664849

12 ETIK AL QORIAH 33 P 085201413615

13 ULFAH NUR 32 P 085880116879

14 MUTMAINAH 27 P 085713798063

15 KASENI 34 P

16 SRI MULYANI 42 P 0878346588212

17 IKA FATIMAH 30 P 085727542394

18 MUNADZIROH 35 P 082136579999

19 HANUNG S 30 P 085641723237

20 JUWARIYAH 27 P 081904839825

21 SITI AISYAH 20 P 08742136629

22 YATNI 38 P

23 DEWI LESTARI 27 P 081329576682

24 MISIYATI 38 P 0855591650141

25 DWI ASTUTI 32 P 085643895579

26 NUR KHARISATUL 25 P 085810017981

27 ROHAYATI 32 P 081332835142

28 RAHMAWATI 22 P 08816869859

29 MUNIROTUL FUADAH 26 P 0859160106571

30 PUJI ASTUTI 32 P 085640593693

31 SUTINI 23 P 085326376668

32 FATIN ZULAIKAH 26 P 085875295968

33 SABAR HARIANTI 23 P 081482905966

34 ROHAYATI 32 P 081332835142

35 SITI HASANAH 30 P 085647794669

36 RIFAH AULIA 21 P 081575679246

37 SITI NUR HIDAYAH 35 P 086974042252

38 MIA SUSANTI 20 P 083821541547

39 SUSILOWATI 30 P 085727229691
 FORM PERMINTAAN VTM IBU HAMIL
UPTD PUSKESMAS BANCAK KEC. BANCAK
KAB. SEMARANG

Kasus (Kontak Erat/Rapid

NIK* Tanggal Lahir* Alamat* Reaktif,dll)

3322036606950002 26/06/1995 Jetis 2/4 , Wonokerto HAMIL TM 3

3322164609000001 6/9/2000 MUNGKRUK 1/3 REJOSARI HAMIL TM 3

3322165309930002 3/9/1993 Gunung 4/1 , Bantal HAMIL TM 3

332213590200004 19/02/2000 Ngromo 4/8 , Rejosari HAMIL TM 3

3322166806930001 28/06/1993 Santren 2/2, Wonokerto HAMIL TM 3

3322166610000001 26/10/2000 BANJARSARI 01/08, BANCAK HAMIL TM 3

3322166501900001 25/1/1990 BANJARSARI 02/08, BANCAK HAMIL TM 3

3322165002990001 10/2/199 Beran 1/8 Rejosari HAMIL TM 3

3322165604900001 16/04/1990 Karangwuni 1/1 Plumutan HAMIL TM 3

3322015006820005 10/6/1982 Penggung, 2/5 Boto HAMIL TM 3

3309186012860001 10/12/1986 Legok 1/2 , Bantal HAMIL TM 3

3322164502870002 5/2/1987 Gayam 2/8 Bantal HAMIL TM 3

3674055401880004 14/1/1988 Dawung 2/4 Plumutan HAMIL TM 3

3322165201930002 12/1/1993 Kendel 3/3 Lembu HAMIL TM 3

3309186012860001 10/12/1986 Legok1/2 Bantal HAMIL TM 3

3322166706780001 27/6/1978 Kalisat 2/7 , Rejosari HAMIL TM 3

3322164710900001 7/10/1990 Wonokerto 1/1 HAMIL TM 3

3322165810850002 18/10/1985 Kalisari 2/1 , Plumutan HAMIL TM 3

3322166403900001 24/03/1990 Kalisari 2/1 , Plumutan HAMIL TM 3

3322164501930001 5/1/1993 Banjarsari 4/9 Bancak HAMIL TM 3

3322165512990001 5/12/1999 Krajan 2/1 Jlumpang HAMIL TM 3

3322165502820001 15/02/1982 Sembung 3/2 Boto HAMIL TM 3

3322165612930001 16/12/1993 Karangmojo 06/03 ,Bantal HAMIL TM 3

3322165504820001 15/04/1982 Wonokerto 3/1 HAMIL TM 3

332216506880001 17/06/1988 Galangan 1/6 , Rejosari HAMIL TM 3

3322164306950001 3/6/1985 Kalisat 3/7 , Rejosari HAMIL TM 3

3322165505880005 7/5/1988 Krempel , Lembu HAMIL TM 3

3322165111980001 11/11/1998 Ngentak HAMIL TM 3

3322164203940003 2/3/1994 Ngentak I 3/11 Bancak HAMIL TM 3

3322164404880001 4/4/1988 Gunung Jayan 12/3 Bancak HAMIL TM 3

3314148109700003 8/10/1997 Karet 1/4 Plumutan HAMIL TM 3

3315015005930003 10/5/1983 Krasak 1/1 Boto HAMIL TM 3

3322167008970002 30/08/1987 Krajan 2/2Lembu HAMIL TM 3

3322165505880005 7/5/1988 Krempel , Lembu HAMIL TM 3

3315175803900003 22/10/1980 Jatisari 7/2 Plumutan HAMIL TM 3

3322164101990001 11/2/1999 Krasak 3/1 Boto HAMIL TM 3

3322164506850002 5/6/1985 Gunung Tengis 2/6 ,Pucung HAMIL TM 3

3322164825000001 8/5/2000 Lego 3/3 , Bantal HAMIL TM 3

3322164610900003 6/10/1990 Krajan 1/1/ Bancak HAMIL TM 3

 Instansi Pengirim JUMLAH VTM Swab I Swab II HPL UMUR
(Puskesmas / RS)* Tgl Tgl KEHAMILAN

PUSKESMAS
16/12/2020 39 MGG
BANCAK
PUSKESMAS
21/12/2020 39 MGG
BANCAK
PUSKESMAS
18/12/2020 39 MGG
BANCAK
PUSKESMAS
17 /12/2020 39 MGG
BANCAK
PUSKESMAS
28/12/2020 38 MGG
BANCAK
PUSKESMAS
BANCAK 26/12/2020 38 MGG

PUSKESMAS
BANCAK 29/12/2020 38 MGG

PUSKESMAS
29/12/2020 38 MGG
BANCAK
PUSKESMAS
BANCAK 30/12/2020 38 MGG

PUSKESMAS
27/12/2020 38 MGG
BANCAK
PUSKESMAS
31/12/2020 38 MGG
BANCAK
PUSKESMAS
4/1/2021 37 MGG
BANCAK
PUSKESMAS
31/12/2020 37 MGG
BANCAK
PUSKESMAS
31/12/2020 37 MGG
BANCAK
PUSKESMAS
31/12/2020 37 MGG
BANCAK
PUSKESMAS
10/1/2021 36 MGG
BANCAK
PUSKESMAS
BANCAK 8/1/2021 36 MGG
PUSKESMAS
9/1/2021 36 MGG
BANCAK
PUSKESMAS 14/01/2021 36 MGG
BANCAK
PUSKESMAS
14/01/2021 36 MGG
BANCAK
PUSKESMAS
12/1/2021 36 MGG
BANCAK
PUSKESMAS 12/1/2021 36 MGG
BANCAK
PUSKESMAS
8/1/2021 36 MGG
BANCAK
PUSKESMAS
BANCAK 9/1/2021 36 MGG

PUSKESMAS
BANCAK 9/1/2021 36 MGG

PUSKESMAS
10/1/2021 36 MGG
BANCAK
PUSKESMAS
17/1/2021 35 MGG
BANCAK
PUSKESMAS
BANCAK 17/01/2021 35 MGG

PUSKESMAS
19/01/2021 35 MGG
BANCAK
PUSKESMAS 21/01/2021 35 MGG
BANCAK
PUSKESMAS
20/01/2021 35 MGG
BANCAK
PUSKESMAS
18/01/2021 35 MGG
BANCAK
PUSKESMAS
17/01/2021 35 MGG
BANCAK
PUSKESMAS
BANCAK 17/01/2021 35 MGG

PUSKESMAS
23/01/2021 34 MGG
BANCAK
PUSKESMAS
23/01/2021 34 MGG
BANCAK
PUSKESMAS
BANCAK 27/01/2021 34 MGG

PUSKESMAS
BANCAK 26/01/2021 34 MGG

PUSKESMAS
1/2/2021 33 MGG
BANCAK