FORMAT PENDATAAN POSYANDU SASARAN BIAN

SASARAN IMUNISASI TAMBAHAN CAMPAK RUBELA ADALAH 9-59 BULAN DAN SASARAN IMUNISASI KEJAR

Provinsi : Banten Desa/Kelurahan : Belimbing

Kabupaten : Tangerang Posyandu : Kenanga 1
Puskesmas : Salembaran Jaya
Isilah kolom yang tidak berwarna!

No. Nama Anak Tanggal Lahir Umur (bulan) NIK

1 A. AKBAR 11/30/2019 31 3603143011192013 

3 A. LUTHFI 12/12/2019 30 3603141212190003 
4 A. NAHWAN 2/11/2021 16 3603101102214594 
5 A. NUR ALVARZIAT 8/15/2019 34 3603141508192108 
6 A. ZAINUN HAFIDZ 9/13/2020 21 3603141309200001 
8 ABIA ARSEN 2/11/2020 28 3603101102208540 
9 ABUYAZID BUSTOMI 4/21/2020 26 3603142104200002 
10 ADELIA 11/12/2019 31 3603141211190003 
11 AFIF AWAL 9/8/2018 46 3603140908182014 
12 AFIFAH 5/18/2019 37 3603141805192153 
13 AGNI 10/7/2018 45 3603140710182082 
14 AHMAD HAFID AHWAL 9/18/2018 45 3603101809186084 
15 AHMAD RAMZAN 9/5/2020 21 3603100509205296 
16 AINUR 10/7/2019 32 3603140710192063 
17 AIRA NAURA ZHAPIRA 9/21/2020 21 3603146109200002 
18 AISAH 9/5/2017 58 3603140509172058 
19 AISHWA 6/28/2020 24 3603106806202940 
20 AISYA AZ 6/24/2020 24 3603146406200001 
21 AJI 6/24/2018 48 3603142406182091 
22 ALESA 9/23/2019 33 3603106309187280 
23 ALESHA 6/23/2019 36 3603142306192078 
25 ALFAN AL AYYUBI 7/2/2021 11 3603100207214115 
26 ALFI 1/21/2019 41 3603142101192118 
27 ALVINO RADIKA RISKI 7/5/2020 23 3603140507200002 
28 ALWI 6/4/2019 37 3603140406192138 
29 ALYA 6/1/2018 49 3603140106182059 
30 AMAR FAHIM KURNIA 9/23/2020 21 3603102309205080 
32 ANDRA 1/12/2018 54 3603140112182021 
33 ANDRA 12/1/2018 43 3603100112189957 
34 ANJOYCE 2/9/2019 40 3603140902192128 
35 AQILA 7/21/2018 47 3603142107182085 
 ARDIKA CHANDRA
37 WIJAYA 11/11/2020 19 3603141111200001 
38 ARSAKA 6/16/2021 12 3603101606218803 
39 ARVINZA 3/20/2018 51 3603142003182062 
40 ARVINZA 3/20/2018 51 3603102003184462 
41 ASSAFA 10/9/2017 57 3603140910172130 
42 ASYIKA 6/15/2020 24 3603105506205389 
43 ATHAR 11/12/2017 56 3603141211172033 
44 ATHAYA 3/23/2018 51 3603142303182040 
45 ATHAYA 3/23/2018 51 3603102303182366 
47 AUREL 10/1/2017 57 3603140110172144 
48 AYU LESTARI 12/19/2019 30 3603141912192038 
49 AZIZAH 7/18/2019 35 3603141807192058 
50 AZIZAH 7/18/2019 35 3603141807192015 
51 AZIZAH ZAHRA SYAKIB 3/18/2020 27 3603145803200002 
52 AZKA 11/12/2019 31 3603141211192008 
53 AZKA MAULANA 9/9/2021 9 3603140909210004 
54 AZZAHRA 7/18/2018 47 3603141307182087 
55 AZZAL AL KAHFI 6/22/2019 36 3173062206190010 
56 AZZAM 6/22/2019 36 3603102206194157 
57 BALKIS 7/8/2019 35 3603140807192017 
58 BILA 5/3/2019 38 3603140305192079 
59 BILKIL 5/24/2021 13 3603106405213087 
60 CANTIKA 11/8/2017 56 3603140811172072 
61 CHANDANI FAIHA 2/26/2021 16 3603146602210002 
62 DAFA AL FALAH 7/26/2020 23 3603102607202193 
63 DAFFA 8/3/2019 35 3603100308194399 
64 DAHLAN 3/14/2021 15 3603101403217506 
65 DEA 9/13/2018 45 3603141309182051 
66 DELVIN 12/22/2018 42 3603140220122022 
67 DEVI 10/14/2017 57 3603141410172153 
68 DEVIN 8/29/2019 34 3603140290082019 
69 DEVIN 10/23/2017 56 3603142310172027 
70 DHAFITHA 12/30/2019 30 3603147612190001 
71 DILAN 10/22/2017 56 3603142210172052 
72 DILAN 11/18/2019 31 3603101811195073 
73 DINA 6/4/2018 49 3603140406182013 
74 EMASDAKA 12/21/2017 54 3603142112172067 
75 ERLI 10/14/2017 57 3603141410172149 
76 ERPINA 9/19/2019 33 3603145909190002 
77 ERVANSYAH 10/25/2018 44 3603142510182084 
78 EZA 11/23/2017 55 3603142311172034 
79 FADIL 7/17/2017 60 3603141707172041 
80 FAHMI 2/7/2018 53 3603140702182010 
81 FAHMI 2/7/2018 53 3603100702184791 
82 FAIHA 11/5/2018 44 3603140511182068 
FAIQ AL FATHAN
83 ROSYID 12/21/2020 18 3603102112209790 
84 FAISAL 7/5/2018 48 3603140507182055 
85 FAIZ AL ROSYID 6/7/2019 37 3603100706199822 
86 FAREL 11/26/2017 55 3603142611172078 
87 FAREL 12/4/2019 31 3603100412194127 
FARHANA KHAIRA
88 WAHYUDI 9/2/2021 9 3173064209210002 
89 FATAN 1/12/2020 29 3603101201204171 
90 FITRIA 9/19/2019 33 3603141909192083 
91 FITRIA 9/19/2018 45 3603141909182030 
92 HAEDAR 5/9/2018 50 3603100905182912 
93 HAIDAR 5/9/2018 50 3603140090052057 
94 HERDAN 11/24/2019 31 3603142411192032 
95 HILYA A 10/5/2020 20 3603104510202566 
96 IBNU BI SAIDAN 1/17/2021 17 3603101701214988 
97 IKSAN FADLI 1/7/2020 29 3603100701208232 
98 ILHAM 12/6/2018 43 3603140612182048 
99 ILHAM 1/6/2018 54 3603100601189097 
101 IRSAD 11/1/2018 44 3603140111182096 
102 ISYAD 11/1/2018 44 3603100111189354 
103 JAKIATUL 12/21/2019 30 3603142112192088 
104 JAKIATUL 8/13/2017 59 3603141408172080 
105 JAWES 2/9/2019 40 3603100902197161 
106 JESEN 12/24/2020 18 3603102412204982 
107 JONATAN 8/4/2019 35 3603140408192028 
108 KAISAH 12/6/2017 55 3603140612172119 
109 KEYSA ANIS PASYA 8/22/2021 10 3603106208211631 
110 KHAIRUDIN 3/7/2018 52 3603140070032076 
111 KHANZA PUTRI 4/19/2020 26 3603105904201502 
112 KHAVA 8/8/2020 22 3603144808200002 
113 KHOIRUDIN 10/27/2017 56 3603142710172020 
114 KHOLILAH 8/14/2019 34 3603141408192053 
115 KHOLILAH 10/4/2017 57 3603140410172060 
116 KIRAN 7/24/2019 35 3603142407192035 
117 LATISA 1/28/2019 41 3603106801198042 
118 LAURENA 12/29/2018 42 3603142912172088 
119 LINDA 8/24/2017 58 3603142408172092 
120 LOLITA 8/18/2018 46 3603105808184168 
121 M AZRUL 9/18/2018 45 3603141809180001 
122 M FAZRAN 7/20/2020 23 3603102007202605 
123 M. ADNAN 1/14/2019 41 3603140120112019 
124 M. ADNAN MAULANA 11/12/2019 31 3603101211194306 
125 M. AJI SANTOSO 6/24/2019 36 3603142406190006 
126 M. AJIS 6/24/2019 36 3603142406192113 
127 M. ALFORO 9/4/2021 9 3603100409219454 
128 M. ALI 8/18/2017 58 3603141808172064 
129 M. ATIP 1/21/2018 53 3603102101185305 
130 M. AZI 2019-06-24  36 3603102406191511 
131 M. AZKA 2019-06-20  36 3603142006192133 
132 M. AZKA 2018-08-09  47 3603140908182065 
133 M. AZZAM 2017-08-13  59 3603141308172054 
134 M. DAFFA 2019-08-03  35 3603100308191806 
135 M. DAFI 2019-10-31  32 3603103110195391 
136 M. DAFI ALFA RIZKI 2019-10-31  32 3603143110190001 
137 M. DAFI ALFARIZI 2019-10-31  32 3603140310102019 
138 M. DILAN 2019-11-18  31 3603141811192023 
139 M. FAJAR 2018-04-09  51 3603140904182071 
140 M. FAREL 2019-09-20  33 3603140020092019 
141 M. FAZAR 2018-04-09  51 3603100904181765 
142 M. FIKRI 2020-05-05  25 3603100505205374 
143 M. GIBRAN 2019-02-15  40 3603101502194378 
144 M. GILANG 2019-11-18  31 3603140180112019 
145 M. IKHSAN 2021-10-15  8 3603101510217745 
146 M. KAHAIRUL 2019-03-04  40 3603140403192103 
147 M. KHARUL 2021-10-29  7 3603102910215501 
148 M. KHOIRUL F 2019-01-04  42 3603140401192026 
149 M. KHOIRUL FAHRI 2019-01-04  42 3603100401196742 
150 M. KHOIRUL FAHRI 2019-01-04  42 3603100401198343 
151 M. MAULANA 2018-04-21  50 3603142104182009 
152 M. RAFIF 2019-05-27  37 3603102705193764 
153 M. RAFKA 2017-12-21  54 3603142112172056 
154 M. RIDHO AL HAFIDZ 2021-04-01  14 3603130104210002 
155 M.RAFANSYAH 2020-11-04  19 3603100411202917 
156 MAISAH 2020-03-29  27 3603106903202724 
157 MICA 2017-11-11  56 3603141111172116 
158 MIHAN 2017-08-24  58 3603142408172047 
MUHAMAD NURUL
159 SADIH 2020-03-09  27 3603100903201236 
160 MUTIA 2017-06-06  61 3603140606172126 
161 NABILA 2019-11-16  31 3603141611192043 
162 NABILA 2020-11-16  19 3603105611202677 
163 NABILA 2019-11-16  31 3603105611195770 
164 NABILA ZAFIRA PUTRI 2019-11-16  31 3603105611193314 
165 NADHIRA 2018-09-18  45 3603141809182011 
166 NADIN 2019-06-06  37 3603140606192063 
167 NADIRA 2020-03-21  27 3603106103205189 
168 NASAWA 2018-12-17  42 3603141712182081 
169 NASWA 2018-12-17  42 3603105712188985 
170 NAUFAL 2019-02-24  40 3603142402192093 
171 NAURA 2019-04-16  38 3603141604192028 
172 NAZWA 2018-04-18  50 3603141804182086 
173 NIA RAMADANI 2020-04-20  26 6004205083 
174 NOVAL 2019-02-24  40 3603102402193451 
175 NURADIBA SYAKILA 2021-11-11  7 3603105111219359 
176 NURASAN 2017-08-24  58 3603142408172109 
177 NURATIKA 2017-11-19  55 3603141911172133 
178 NURMA 2018-09-25  45 3603142509182012 
179 NURUL 2018-08-22  46 3603142208182016 
180 PARIS 2019-02-11  40 3603141102192123 
181 PUTRI 2020-12-17  18 3603105712208288 
182 PUTRI 2020-01-21  29 3603106101208592 
PUTRI MUTHIA
183 RAHAYU 2020-12-17  18 3603145712200004 
184 RADIT 2017-12-19  54 3603141912172042 
185 RAFA 2017-12-04  55 3603140412172025 
186 RAFI 2017-12-04  55 3603140412172029 
187 RAFKA 2019-12-12  30 3603141212192018 
188 RAIHAN 2019-09-07  33 3603140709192033 
189 RALINDIA 2019-02-27  40 3603106702191068 
190 RALINDYA 2019-02-27  40 3603142702192148 
191 RAMADHAN 2018-05-21  49 3603102105185785 
192 RANGGA MARDIKA 2020-03-14  27 3603101403202301 
193 RASYAD KAIRA MUDZKI 2020-09-14  21 3603101409204482 
194 RATU 2019-12-21  30 3603142112192068 
RATU KHORIYATUL
195 WASI 2019-12-02  31 3671104212190001 
RAYAN GALIH
196 ABDILLAH 2021-03-01  15 3603100103214438 
197 RAZANDRA 2021-10-22  8 3603102210219894 
198 RENATA 2018-07-04  48 3603140407182053 
199 RINA 2017-06-30  60 3603143006172089 
200 RISKI 2020-06-10  24 3603101006206841 
201 ROMADHAN 2018-11-02  44 3603140211182043 
202 SAFIRA 2017-08-13  59 3603141308172046 
203 SAFIRA 2017-08-13  59 3603141308172038 
204 SAKINAH 2018-12-01  43 3603104112186845 
205 SALWA 2019-04-02  39 3603140204192008 
206 SARAH JULIANTI 2018-05-07  50 3603140705182039 
207 SASMA 2021-11-01  7 3603106402216751 
208 SHAZIA 2019-04-20  38 3603142004192143 
209 SIARA ARUMI 2021-11-14  7 3603105411212799 
210 SITI ZAHRA 2017-12-19  54 3603141912172122 
211 SRI MULYANIH 2018-05-02  50 3603140205182019 
212 SRI MULYANIH 2018-05-02  50 3603144205180005 
213 SRI TABARANI 2017-11-23  55 3603142311172102 
214 SULTAN 2019-05-26  37 3603142605192098 
215 SYAHIDA 2017-10-09  57 3603140910172114 
216 SYAHLA ADIBA 2021-01-01  17 3603144101210001 
217 TANISHA 2019-12-05  30 3603140512192073 
TANISHAZA ARA
218 MOCCA 2019-12-05  30 3603144512190004 
219 TASYA 2020-01-11  29 3603141101202048 
220 TASYA RAHMAWATI 2021-06-15  12 3603105506215639 
221 TSAMARA 2021-01-30  16 3603147001210002 
222 USWATUN KHASANAH 2021-07-12  11 3603105207217390 
223 XHORDAN 2019-11-24  31 3603102411192199 
224 ZIBRAN 3/18/2021 15 3603101803213409 
AN SASARAN IMUNISASI KEJAR ADALAH 12-59 BULAN

Apakah anak Apakah anak sasaran Imun

Apakah anak merupakan mendapatkan ORI (Ya = 1, Tidak = 0
Nama Orang Tua Alamat sasaran Imunisasi Campak Rubela sejak
Tambahan Januari 2022
Campak Rubella (Ya=1, (Ya =1, Tidak=0) OPV
Tidak = 0)
DEPIH Belimbing 1 0
johan Belimbing 1
hasan Belimbing 1
WAWAN Belimbing 1
lebar Belimbing 1
suryanah hermawan Belimbing 1
anwar Belimbing 1
HENDRA Belimbing 1
NURHASAN Belimbing 1
YULI Belimbing 1
ANDIAR Belimbing 1
nurhayah Belimbing 1
soleh Belimbing 1
ENTONG Belimbing 1
alfian Belimbing 1
SRIWATI Belimbing 1
wulan Belimbing 1
rohmat Belimbing 1
Limah Belimbing 1
INDRIYANI Belimbing 1
INDRA Belimbing 1
muksobar Belimbing 1
SAIDI Belimbing 1
hendrik Belimbing 1
NANANG Belimbing 1
INTAN Belimbing 1
edi Belimbing 1
Santi Belimbing 1
novita Belimbing 1
ARIP Belimbing 1
MAHINDRA Belimbing 1
ulil Belimbing 1
rumyana Belimbing 1
M. RISKI Belimbing 1
ANA N Belimbing 1
ASEP Belimbing 1
marsin Belimbing 1
RIKI Belimbing 1
SHAKA Belimbing 1
IJAH Belimbing 1
DIRMAN Belimbing 1
LILIS TASLAH Belimbing 1
ANDI Belimbing 1
Ayu Belimbing 1
a. dahrul Belimbing 1
DEPIH Belimbing 1
suswandi Belimbing 1
HENI Belimbing 1
budiyanto Belimbing 1
ambiyan Belimbing 1
EKO Belimbing 1
USUP Belimbing 1
abdul hakim Belimbing 1
ROHADIS MUTRIA Belimbing 1
khasbani Belimbing 1
wawan Belimbing 1
saputra Belimbing 1
idah Belimbing 1
IFAH Belimbing 1
RIMAN Belimbing 1
YEYEN Belimbing 1
usen Belimbing 1
BEBY Belimbing 1
YULIANA Belimbing 1
MARSITA Belimbing 1
UMITA Belimbing 1
SAIFUL Belimbing 1
HENDRA Belimbing 1
JAYADI Belimbing 1
SUHERMANTO Belimbing 1
JOKO Belimbing 1
MUSA Belimbing 1
ADEK Belimbing 1
NUR Belimbing 1
lisnawati Belimbing 1
MINGSALIR Belimbing 1
a. rizal Belimbing 1
KUBIL Belimbing 1
laniska Belimbing 1
MAMAN Belimbing 1
yunita Belimbing 1
ade wahyudin Belimbing 1
laniska Belimbing 1
RUSDI Belimbing 1
TORO Belimbing 1
SUTIKNO Belimbing 1
MITA Belimbing 1
Rompiah Belimbing 1
eka nursafitri Belimbing 1
adam Belimbing 1
astri Belimbing 1
wahyudin Belimbing 1
FITRIAH Belimbing 1
SUKAR Belimbing 1
siti nur janah Belimbing 1
SAMSUDIN Belimbing 1
RAMLI Belimbing 1
yowel Belimbing 1
yowel Belimbing 1
TONI Belimbing 1
yusuf Belimbing 1
kasmin Belimbing 1
NARSIN Belimbing 1
mulyadi Belimbing 1
m hasanudin Belimbing 1
Mul Belimbing 1
ROHMAN Belimbing 1
KOKOM Belimbing 1
SOPIAN Belimbing 1
SANDI Belimbing 1
WAHYUDI Belimbing 1
FAJAR Belimbing 1
MAIL Belimbing 1
RALIM Belimbing 1
linah Belimbing 1
SIRNAWATI Belimbing 1
maulana sukron Belimbing 1
suharyanto Belimbing 1
HARIS Belimbing 1
sani Belimbing 1
ANTON HOLIYAH Belimbing 1
AMSIH Belimbing 1
YANTO Belimbing 1
SOPIAN Belimbing 1
ANDIAR Belimbing 1
Aulia Belimbing 1
RIO Belimbing 1
ROSITA Belimbing 1
kanda Belimbing 1
HAMDANI Belimbing 1
DAHLAN Belimbing 1
SARBINI Belimbing 1
NURMIN Belimbing 1
basri Belimbing 1
ASAN Belimbing 1
NANANG Belimbing 1
M. SOPIAN Belimbing 1
ralim dirga Belimbing 1
siti nasuha Belimbing 1
marif Belimbing 1
MAAN Belimbing 1
ISMAIL Belimbing 1
ISMAIL Belimbing 1
A. SUPYAN Belimbing 1
HAINUR ZARA Belimbing 1
SETIAWAN Belimbing 1
zainudin Belimbing 1
roby Belimbing 1
iyus Belimbing 1
LEO Belimbing 1
RONI Belimbing 1
adi Belimbing 1
KHAIRUL AMSYAH Belimbing 1
JOHAN Belimbing 1
melisa Belimbing 1
SRI RANI Belimbing 1
AGUS Belimbing 1
LISNAWATI Belimbing 1
DELTA Belimbing 1
yoga Belimbing 1
ACIM Belimbing 1
AHMAD HAKIM Belimbing 1
AGA JARRY Belimbing 1
SUHERI Belimbing 1
NASRUDIN Belimbing 1
SUPRYATNO Belimbing 1
HERU Belimbing 1
amsani Belimbing 1
AYANAH Belimbing 1
ANTON Belimbing 1
MAIDAH Belimbing 1
ROSITA Belimbing 1
M. BRATA Belimbing 1
fitri Belimbing 1
putra s Belimbing 1
muit Belimbing 1
NAGUN Belimbing 1
ASAN Belimbing 1
ERSIN Belimbing 1
M. JAENUDIN Belimbing 1
LILIS TASLAH Belimbing 1
MARSUDI Belimbing 1
ARIP Belimbing 1
JAYA NEGARA Belimbing 1
mantri Belimbing 1
maysaroh Belimbing 1
AMUNG Belimbing 1
M. BUKHORI Belimbing 1
listi Belimbing 1
ulfa Belimbing 1
Siyah Belimbing 1
Desi Belimbing 1
kubil Belimbing 1
OJI Belimbing 1
WAHYUDIN Belimbing 1
ROYADI Belimbing 1
ROMAH Belimbing 1
SANUDIN Belimbing 1
MANSYUR Belimbing 1
iis Belimbing 1
ASBAN Belimbing 1
enjel Belimbing 1
MUHAMMAD Belimbing 1
arip Belimbing 1
GUNAWAN Belimbing 1
HIDAYATUL NURUL Belimbing 1
ADUL Belimbing 1
RIKI Belimbing 1
jaka Belimbing 1
DONI Belimbing 1
EKO WARISMAN Belimbing 1
SLAMET Belimbing 1
elin Belimbing 1
ari Belimbing 1
ahmad Belimbing 1
NURAHYAH Belimbing 1
maria Belimbing 1
 Jumlah dosis yang dibutuhkan untuk
Apakah anak sasaran Imunisasi Kejar melengkapi status imunisasi
(Ya = 1, Tidak = 0)

IPV DPT-HB-Hib OPV IPV DPT-HB-Hib

FORMAT PENDATAAN SASARAN IMUNISASI CAMPAK RUBELLA USIA 1 - 5 TAHUN

Provinsi : Desa/Kelurahan :
Kabupaten : Nama Sekolah :
Puskemas :

Isilah kolom yang tidak berwarna!

Apakah anak Apakah anak merupakan

mendapatkan ORI Campak Rube
No. Nama Anak Nama Orang Tua Alamat Tanggal Lahir Umur (tahun) Campak Rubela
sejak Januari 2022 Usia 5 - <7 thn
(Ya =1, Tidak=0) (Ya=1, Tidak=0)

1 Beta 8/14/2016 6 0 1
2 Ratih 3/23/2014 8 0 1
3 Suci hh/bb/tttt #VALUE! 0 1
4 Iksan hh/bb/tttt #VALUE! 1 1
5 Tina hh/bb/tttt #VALUE! 1 1
6 Ridho hh/bb/tttt #VALUE! 1 1
7 Nisa hh/bb/tttt #VALUE! 0 1
8 Sari hh/bb/tttt #VALUE! 0 1
9 Putri hh/bb/tttt #VALUE! 1 1
10 hh/bb/tttt #VALUE! 1 0
11 hh/bb/tttt #VALUE! 0 0
12 hh/bb/tttt #VALUE! 0 0
13 hh/bb/tttt #VALUE! 0 0
14 hh/bb/tttt #VALUE! 0 0
15 hh/bb/tttt #VALUE! 0 0
16 hh/bb/tttt #VALUE! 0 0
17 hh/bb/tttt #VALUE! 0 0
18 hh/bb/tttt #VALUE! 0 0
19 hh/bb/tttt #VALUE! 0 0
20 hh/bb/tttt #VALUE! 0 0
 TOTAL 5 9
TOTAL VIAL VAKSIN (Jumlah Vial = Jumlah Total Sasaran/IP Vaksin) 2
Apakah anak merupakan sasaran Imunisasi Tambahan
Campak Rubella (Ya=1, Tidak = 0)

Usia 7-<12 thn Usia 12 -<15 thn

(Ya=1, Tidak=0) (bagi 5 Prov.)
(Ya=1, Tidak=0)
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 0
1 0
1 0
1 0
1 0
1 0
0 1
0 1
0 1
0 1
0 1
0 1
 6 6
2
FORMAT PENDATAAN KEBUTUHAN TENAGA DAN JADWAL PELAKSANAAN BULAN IMUNISASI ANAK NASIONAL
Provinsi : Puskesmas :
Kabupaten :

Jumlah Sasaran Imunisasi Kejar

Nama Tempat Pelaksanaan (Usia 12-59 bulan)
No. Nama Puskesmas Nama Kelurahan
Imunisasi
OPV IPV

1 Sarmi Dukuh Posyandu Mawar 9 9

SD N1 Sarmi 0 0
TK MUh Sarmi 3 7
SD Mulia Sarmi

TOTAL 12 16
MUNISASI ANAK NASIONAL

asaran Imunisasi Kejar Jumlah Sasaran Tambahan Campak Rubela

sia 12-59 bulan) Jumlah Total
Sasaran
Usia 12 -<15 thn
DPT-HB-Hib Usia 9-59 bln Usia 5 - <7 thn Usia 7-<12 thn
(bagi 5 Prov.)
8 15 41
0 0 9 6 6 21
6 30 10 1 57
2 80 90 75 247
0
0
0
0
0
0
0
0
14 47 99 97 81 366
 Jumlah Kebutuhan Tenaga Tanggal
Daftar Nama Tim Pelaksanaan
Pelaksana
Layanan
Vaksinator Nakes lainnya Guru/Kader Supervisor

1 1 3 1 Santi, kader Lita 9 May

1 1 3 1 Ani, Suci, Kader Cici 9 May
9 May
3 2 3 1 Brian, Mindo, Kader Suci 9 May
9 May
9 May
FORMAT PENDATAAN KEBUTUHAN LOGISTIK DAN COLD CHAIN

Nama Provinsi : Papua

Nama Kabupaten : Sarmi
Nama Puskesmas : Sarmi

Nama Nama Pos Jumlah Kebutuhan Vaksin (Vial)

No.
Desa/Kelurahan Pelayanan
OPV IPV DPT-HB-Hib Campak Rubela
1 Dukuh Posyandu Mawar 2 3 2 2
2 SD N1 Sarmi 2
3
4
5
6
7
8
9
10
11
12
13
14
TOTAL 2 3 2 4
 Jumlah Kebutuhan Logistik Jumlah Cold Chain Tersedia dan Berfungs

Dropper Pelarut MR ADS 5 ml ADS 0.5 ml Safety box Pen Marker Refrigerator
2 2 3 33 1 1 1
0 2 3 22 1 1

2 4 6 55 2 2
old Chain Tersedia dan Berfungsi Jumlah Kebutuhan
Vaccine Carrier
Vaccine Carrier
4 2
 FORMAT JADWAL KEGIATAN PENDUKUNG PELAKSANAAN BIAN

Nama Nama Waktu

No Kegiatan yang Akan Dilaksanakan Tempat Pelaksanaan
Puskesmas Desa/Kelurahan Pelaksanaan

1 Abadi Jaya Dukuh Pertemuan Kooridnasi dengan Kepala Sekolah 4 April Balai Dinas Pendidikan
Pertemuan dengan Kepala Desa, Kader

Orientasi Petugas Kesehatan

Monitoring kebutuhan logistik
Evaluasi Pelaksanaan BIAN
AAN BIAN

Penanggung
Sasaran Kegiatan Sumber Dana
Jawab Keg

Kepala Sekolah/Guru DAN Non Fisik Iman