PROGRAM IMS PESKESMAS WAJAGESENG

NO PELAPORAN BULANAN
PERMINTAAN BULANAN
KABUPATEN Lombok Tengah TERIMA TGL:
PROVINSI Nusa Tenggara Barat

STOK PENERIM PERSEDIA PEMAKAI SISA

NO NAMA OBAT/BAHAN ALAT SATUAN KEMASAN EXP.DATE PERMINTAAN
AWAL AAN AN AN STOK
OBAT
1 Acyclovir 200 mg Tablet 1 box/50 Tablet 58 0 58 58 0
2 Benzatin Penicillin 2.4 Jt IU/Vial 1 box/Vial 0 0 0 0 0
3 Ciproflolaxacin 500 mg 1 box/30 Tablet 170 600 770 78 692
4 Clindamycin 150 mg 1 box/30 Tablet 200 0 200 70 130
5 Clindamycin 300 mg 1 box/30 Tablet 0 0 0 0 0
6 Cotrimoxazole 400 mg 1 box/100 Tablet 760 0 760 0 760
7 Fluconazole 150 mg 1 box/10 Tablet 0 0 0 0 0
8 Ethambutol 250 mg 1 box/200 Tablet 0 0 0 0 0
9 Methylprednisolone 16 mg 1 box/10 Tablet 0 0 0 0 0
10 Metronidazole 500 mg 1 box/100 Tablet 381 500 881 426 455
11 Sulfadiazin 500 mg 1 Kaleng/1000 Tab 0 0 0 0 0
12 Combipak 1 box/ 10 amplop 19 0 19 0 19
13 Fehatrim Forte 1 box/ 100 Tablet 0 0 0 0 0
14 Ceftriaxone Injection 1 box/2 vial 0 0 0 0 0
15 Clarithromicin 500 mg 1 box/30 Tablet 0 0 0 0 0
16 Amoxilin + Clavulat PO 500mg/125mg 1 box/30 Tablet 0 0 0 0 0
17 Cefixime 400 mg + Azithromicin 1000 mg 1 paket/10 amplop 0 0 0 0 0
0
BAHAN DAN ALAT
1 TPHA Test 1 kit/100 pcs 0 0 0 0 0 0
2 VDRL Test 1 botol/ 5 ml 0 0 0 0 0 0
3 Ph Paper box 0 0 0 0 0 0
4 Cover Glass box 0 0 0 0 0 0
5 Slide box 0 0 0 0 0 0
6 Anuscopy Dissposible set 0 0 0 0 0
7 Lidi swap biji 0 0 0 0 0 0
8 Standar Diagnostik Reagen 1 200 500 700 500 200 300
9 Vikia Reagen 2 0 0 0 0 0 0
10 Focus Reagen 3 0 0 0 0 0 0
11 RPR Syphilis 0 0 0 0 0 0
12 Rapid Test Syphilis 100 300 400 400 0 300
13 Sarung Tangan 100 200 300 300 0 300
14 Alcohol Swap 0 500 500 500 0 300

Mengetahui Mengetahui Menyetujui

Kepala UPTD Puskesmas Wajageseng Kepala UPTK GFK Pengelola Prog.IMS.HIV Kab.

H. Muh. Yusuf, S.Sos

NIP:197207161992031002
PELAPORAN BULANAN : Maret 2020
PERMINTAAN BULANAN : April 2020
TERIMA TGL: VERIFIKASI TGL: PENYERAHAN TGL:

PEMBERIAN
PERSETUJUAN KET
I ED II ED

Yang Menerima
Pengelola Prog.IMS Puskesmas

Aspari S.Kep. Ns
PTT Dikes 2020