FORMAT PELACAKAN / PENDATAAN SEKALIGUS FORMAT PELAYANAN IMUNISA

SASARAN ≥ 12 BULAN SD 59 BULAN UNTUK KEJAR IMUNISA

POSYANDU KRAJAN RT/RW :
DESA SUMBERAN PUSKESMAS :
KELURAHAN KAB/KO :
PROVINSI :

ALAMAT
lengkap RT RW TELP
NO NAMA SASARAN UMUR JK NAMA IBU
(RT/RW/DS
N/DESA) HBO BCG POL 1 DPT 1 POL 2 DPT 2 POL 3 DPT 3 POL 4

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 ALIKA NAYLA PUTRI 59 2 FIFIN KRAJAN 1 1
2 ATIKA ZAHRA R 59 2 JAMILATUN NKRAJAN 5 1 9/5/2017 8/7/2017 6/7/2017 9/9/2017 9/9/2017 11/10/2017 11/10/2017 18-11-2017 9/12/2017
3 M.HUSNI 59 1 KHOLILA KRAJAN 6 1 19-5-2017 8/7/2017 8/7/2017 8/2/2018 9/9/2017 7/3/2018 7/5/2018 6/11/2018 11/12/2018
4 M.IDAD ROBBANI 58 1 SITI MARYAMKRAJAN 1 1 8/7/2017 8/8/2017 8/9/2017 8/10/2017 8/11/2017 8/12/2017 8/1/2018 8/2/2018 8/3/2018
5 M.FAIZ 57 2 SUDARTI KRAJAN 2 1 17-7-2017 19-8-2017 19-8-2017 10/10/2017 10/10/2017 13-1-2018 9/12/2017 7/3/2018 13-1-2018
6 M IQBAL FARIS H 56 1 HOTIM KRAJAN 2 1 27-8-2017 13-10-2017 13-10-2017 9/12/2017 9/12/2017 13-1-2018 13-1-2018 7/3/2018 7/4/2018
7 AHMAD AL FARISI 55 2 ULFA KRAJAN 4 1 25-9-2017 25-10-2017 25-10-2017 13-1-2018 13-1-2018 7/3/2018 7/4/2018 7/4/2018 7/5/2018
8 AMMAR ARKHAN N R 64 2 ANIK KRAJAN 3 1
9 KHUSNUL KHOTIMAH 53 1 HOSNAWATI KRAJAN 3 1 12/11/2017 18-12-2017 7/4/2018 7/4/2018 11/7/2018 11/7/2018 11/9/2018 6/11/2018 6/11/2018
10 M.HAFIZ Q A 53 1 KOMARIYAH KRAJAN 7 1 24-11-2017 6/1/2018 6/1/2018 8/2/2018 7/4/2018 7/4/2018 11/7/2018 8/7/2019 8/4/2019
11 M.TAJUDDIN AS SUBKI 55 1 ALEX KRAJAN 1 1 29-10-2017 29-4-2017 29-12-2017 29-1-2018 29-2-2018 29-3-2018 29-4-2018 29-5-2018 29-6-2018
12 M.FAHRI ARDIANSYAH 52 1 NIKMATUL KRAJAN 5 1 PINDAH
13 KEISYA AURELIA ZAIN 51 1 MAHMUDAH KRAJAN 3 1 10/1/2018 17-2-2018 7/4/2018 7/4/2018 10/7/2018 10/7/2018 29-9-2018 29-9-2018 30-10-2018
14 M.RAFLI 51 1 BAHRIYA KRAJAN 5 1 20-1-2018 6/3/2018 6/3/2018 4/7/2018 4/7/2018 7/5/2018 7/5/2018 11/7/2018 11/7/2018
15 ARINA MANASIKANA 50 2 YUNI INDRIASKRAJAN 1 1 8/2/2018 7/5/2018 17-7-2018 17-7-2018 11/9/2018 11/9/2018 6/11/2018 6/11/2018
16 QOTRU ELGHAIS S F 49 1 FAIQ KRAJAN 1 1 PINDAH
17 M RAYHAN 49 2 SULAIHA KRAJAN 1 1 25-3-2018 5/5/2018 5/5/2018 11/7/2018 11/7/2018 12/9/2018 12/9/2018 6/11/2018 6/11/2018
18 M.DAWAM 48 1 NAFISA KRAJAN 5 1 17-4-2018 7/8/2018 7/8/2018 11/9/2018 11/9/2018 8/2/2019 8/10/2018 11/12/2018
19 AZRIEL DIKI PRAYOGA 48 1 YAYUK KRAJAN 5 1 28-4-2018 14-7-2018 14-7-2018 11/9/2018 11/9/2018 4/1/2019 6/11/2018 8/7/2019 14-1-2019
20 ARRAFI FARZAN SAKEEL 47 2 FINATUL KRAJAN 1 1 PINDAH
21 HIZRUL FAHMI AKBAR 46 1 SUBAIDA KRAJAN 5 1 17-6-2018 7/8/2018 7/8/2018 8/9/2018 8/10/2018 8/11/2018 9/3/2019 14-1-2019
22 MUHAMMAD ANWAR FAU44 2 IDA KRAJAN 4 1 25-8-2018 29-9-2018 29-9-2018 27-10-2018 6/11/2018 1/12/2018 11/12/2018 2/2/2019 2/2/2019
23 NAURA MUTHIA 47 2 RIRIT KRAJAN 7 1
24 KHOLIFAH RAQILA MANA 43 1 NURAINI KRAJAN 5 1 9/9/2018 19-1-2019 19-1-2019 9/3/2019 9/3/2019
25 M.IRVAN ABDILLAH 43 1 FITRIYAH KRAJAN 5 1 11/10/2018 15-1-2019 15-1-2019 12/6/2019 8/4/2019 8/12/2019 12/6/2019 8/6/2020 19-8-2019
26 SITI N.MAULIDAH 40 1 WIWIK AQOBKRAJAN 5 1 PINDAH
27 NAHLA KHAIRIN ALIFIYA 39 1 JUMAATI KRAJAN 5 1 24-1-2019 9/3/2019 9/3/2019 12/6/2019 8/4/2019 6/8/2019 12/6/2019 6/1/2020 10/7/2019
28 ASYFATUL UMMIYAH 37 1 IMA SUSANTI KRAJAN 2 1 22-7-2019 22-8-2019 22-9-2019 22-10-2019 22-10-2019 22-11-2019 22-12-2019 20-1-2020 22-2-2020
29 NURUL HAYA ISHI R 35 2 FATIMATUS KRAJAN 2 1 7/5/2019 15-6-20196 12/6/2019 6/8/2019 6/8/2019 10/9/2019 10/9/2019 8/12/2019 8/12/2019
30 M ALDIANSYAH R 35 1 SITI AMINA KRAJAN 4 1 22-5-2019 6/7/2019 6/7/2019 6/8/2019 6/8/2019 10/9/2019 10/9/2019 12/10/2019 12/10/2019
31 M.AZKA B.N 34 1 USWATUN H KRAJAN 5 1
32 FAUZIYATUL MALIKAH 34 2 DURATUN M KRAJAN 2 1 22-7-2019 22-8-2019 22-9-2019 22-10-2019 22-11-2019 22-12-2019 22-1-2020 22-2-2020 22-3-2020
33 M. ALFIN ZAFRAN 34 2 URIFATUL KRAJAN 3 1 26-6-2019 10/8/2019 10/8/2019 10/9/2019 10/9/2019 9/10/2019 9/10/2019 9/11/2019
34 SAYYIDAH MAIMUNAH 33 2 NING UCIK KRAJAN 2 1
35 M AFISENA 33 2 ANGGI KRAJAN 3 1 7/7/2019 6/8/2019 6/8/2019 12/10/2019 10/9/2019 19-11-2019 12/10/2019 28-12-2019 20-12-2019
36 M RAFKA A 33 1 YULIATUL KRAJAN 5 1
37 ALINA BINTAH HUMAIRO 33 1 SITI NUR A KRAJAN 3 1 26-7-2019 3-1-8-2019 3/1/2019 10/10/2019 10/10/2019 11/12/2019 11/12/2019 14-1-2020 14-1-2020
38 M.AZKA N.H 32 2 ELA KRAJAN 7 1
39 M.RAFIF AR ROYAN 32 1 NARNI KRAJAN 2 1 28-9-2019 28-10-2019 28-11-2019 28-12-2019 28-1-2020 28-2-2020 28-3-2020 28-4-2020 28-5-2020
40 M.BRYAN DEVANA 31 2 KIKI KRAJAN 3 1
41 M. ILTIZAM 30 1 SAM'A 2 KRAJAN 2 1 10/11/2019 10/12/2019 10/1/2020 10/2/2020 10/3/2020 10/4/2020 10/5/2020 10/6/2020 10/7/2020
42 NAZWA K.P 28 1 IZE KRAJAN 7 1
43 M.ZIDAN AL AZMI 28 2 NUR ZAINAB KRAJAN 7 1 21-12-2019 4/2/2020 4/2/2020 9/3/2020 9/3/2020 8/6/2020 8/6/2020 8/7/2020 8/7/2020
44 TAZKIA MUFADHO 24 1 JAMILA KRAJAN 5 1
45 ALIZA AZZAHRA R 24 1 ZAHROTUN KRAJAN 5 1 26-4-2020 9/6/2020 9/6/2020 8/7/2020 8/7/2020 7/10/2020 7/9/2020 11/1/2021 7/10/2020
46 CLEANDREW 23 1 MARIA ULFA KRAJAN 1 1 25-5-2020 25-6-2020 25-7-2020 25-8-2020 25-9-2020 25-10-2020 25-11-2020 25-12-2020 25-1-2021
47 M. FAQIH R 24 1 SYARIFAH KRAJAN 2 1 28-5-2020 28-6-2020 28-7-2020 28-8-2020 28-9-2020 28-10-2020 28-11-2020 28-12-2020 28-1-2021
48 MARKO ADITIA 22 2 NUR AWALIA KRAJAN 5 1
49 M HAIKAL M 22 1 HORIYAH KRAJAN 7 1
50 SAKILA NURA TAZKIA 20 2 ZULAIHA KRAJAN 5 1
51 FAIZA AURELYA KINANDI 20 2 LUFTI KRAJAN 4 1 26-8-2020 6-10-2-020 6/10/2020 7/12/2020 18-11-2020 9/3/2021 11/1/2021 9/3/2021
52 NUR DIANA HOLIDA 18 1 YULIA CITRA KRAJAN 4 1 23-10-2020 22-2-2020 22-2-2020 9/3/2021 11/1/2021 8/2/2021 9/3/2021
53 ANINDIRA MYSHA FAUZI 16 1 IDA KRAJAN 3 1 10/12/2020 12/1/2021 12/1/2021 9/3/2021 9/3/2021
54 M. ALI LAZUARDI 15 1 ELSA KRAJAN 3 1 8/1/2021 9/2/2021 9/2/2021 14-9-2021 9/3/2021 12/11/2021 14-9-2021 9/12/2021 9/12/2021
55 RUFAIDAH EL ZAHRA K.F 15 1 FAIQ KRAJAN 1 1 21-1-2021 27-2-2021 28-3-2021 27-4-2021 28-5-2021 28-5-2021 28-6-2021 28-7-2021 28-8-2021
56 RAFAN GHIFARI A 14 2 ST KHOTIJAH KRAJAN 5 1 PINDAH
57 M. INDRA KEVIN 12 2 ENI KRAJAN 1 1
LIGUS FORMAT PELAYANAN IMUNISASI KEJAR TAHUN 2022
SD 59 BULAN UNTUK KEJAR IMUNISASI

IMUNISASI LANJ
IMUNISASI DASAR YANG BELUM DIDAPAT YANG BELUM
DIDAPAT
KET
CAMPAK
IPV CAMPAK DPT LANJUTAN LANJUTAN ORI DIFTERI OPV 1 DPT-HB-IB 1 OPV 2 DPT-HB-HIB 2 OPV 3 DPT-HB-HIB3 OPV 4 IPV campak DPT-HB-HIB 4

19 20 21 22 23 24 25 26 27 28 29 30 31 33
1 1 1 1 1 1 1 1
7/5/2018
11/12/2018
8/4/2018 8/5/2018
5/5/2018 5/5/2018
7/5/2018 11/7/2018 6/11/2018
7/5/2018 10/7/2018
1 1 1 1 1 1 1 1
6/11/2018 8/10/2018
8/7/2019 8/4/2019
29-7-2018 29-8-2018
pindah
8/10/2018
6/11/2018 11/12/2018 6/11/2018
6/11/2018 8/12/2018
pindah
6/11/2018 13-1-2019
18-1-2019
8/4/2019 8/4/2019
1 1 1 1 1 1 1 1 1 pindah
1 1 1
2/2/2019 8/7/2019
1 1 1 1 1 1 1 1
1 1 1 1 1 1
10/9/2019 8/6/2020
pindah
8/12/2019
22-3-2020 22-4-2020
11/2/2020
11/2/2020
lengkap
22-4-2020 22-5-2020
 8/6/2020
1 1 1 1 1 1 1 1
9/5/2020
lengkap
7/7/2020 lengkap
lengkap
28-6-2020 28-7-2020
lengkap
10/8/2020 10/9/2020
lengkap
6/10/2020 lengkap
1 1 1 1 1
5/4/2021 9/3/2021
25-2-2021 25-3-2021
28-2-2021 28-3-2021
lengkap
lengkap
lengkap
1 1 1
1 1 1 1

5/10/2021
28-8-2021 28-8-2021

1 1 1 1 1 1 1 1
1 6 6 10 7 10 8 11 11 0
 FORMAT PELACAKAN / PENDATAAN SEKALIGUS FORMAT PELAYANAN IMUNISASI KEJAR TAHUN 2022
SASARAN ≥ 12 BULAN SD 59 BULAN UNTUK KEJAR IMUNISASI
POSYANDU KOLOR RT/RW :
DESA SUMBERAN PUSKESMAS :
KELURAHAN KAB/KO :
PROVINSI :

ALAMAT
lengkap
NO NAMA SASARAN UMUR JK NAMA IBU (RT/RW/ RT RW TELP
DSN/DES
HBO BCG POL 1 DPT 1 POL 2 DPT 2 POL 3 DPT 3 POL 4
A)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 M.HAIKAL P.A 59 1 DINA KOLOR 13 2 5/28/2017 8/12/2017 8/12/2017 9/7/2017 9/7/2017 11/10/2017 12/12/2017 12/12/2017
2 ACHMAD ROYHAN 58 1 NURUL HALIMAH KOLOR 8 2 8/12/2017 8/12/2017 9/9/2017 10/13/2017 10/13/2017 11/10/2017 11/21/2017 11/21/2017
3 M KHOLILI 57 1 MANISA KOLOR 8 2 7/24/2017 9/9/2017 9/9/2017 10/11/2017 11/10/2017 12/12/2017
4 M AZKA MAULANA FADIL 55 1 QUROTA AINI KOLOR 11 2 8/1/2017 9/9/2017 9/9/2017 11/10/2017 11/10/2017 12/12/2017 12/12/2017 12/17/2018 11/8/2018
5 M.SHOLEH 52 1 MILAWATI KOLOR 12 2 10/17/2017 11/20/2017 11/20/2017 3/7/2018 5/9/2018 7/9/2018 7/9/2018 7/9/2019 7/9/2019
6 NUR DIANA 52 2 FARIDA KOLOR 12 2 1/9/2018 2/17/2018 4/13/2018 7/9/2018 7/9/2018 9/8/2018 9/8/2018 2/12/2019
7 JAZILAH NAYLA PUTRI 51 2 SITI RAHMA KOLOR 10 2
8 SRI WULANDARI 51 2 SURYATI KOLOR 9 2 2/5/2018 3/13/2018 3/13/2018 4/13/2018 5/9/2018 7/9/2018 7/9/2018 10/9/2018 10/9/2018
9 SITI AISYAH NURDIANA 50 2 LULUK KOLOR 12 2 2/8/2018 3/20/2018 3/20/2018 4/9/2018 4/9/2018 11/8/2018 1/9/2019
10 DAVID MAULANA I 49 1 LUSI C KOLOR 12 2 3/21/2018 5/5/2018 5/5/2018 5/12/2018 5/12/2018 9/12/2018 9/12/2018 1/17/2019 1/17/2019
11 M NUR AHLAN 48 1 SITI AMINA KOLOR 12 2 4/4/2018 5/12/2018 5/12/2018 7/9/2018 7/9/2018 11/8/2018 2/13/2019 1/9/2019
12 M.FISKAL DIRGANTARA 47 1 SUNARSIH KOLOR 12 2 5/24/2018 8/11/2018 8/11/2018 9/12/2018 10/14/2018 2/13/2019 11/12/2018
13 AHMAD FITO FIRDAUS 47 1 IFA HANDINI KOLOR 8 2 6/5/2018 7/14/2018 7/14/2018 8/7/2018 9/7/2019 11/8/2018 11/8/2018 2/13/2019 2/13/2019
14 ISHAK PUTRA R 46 1 JUMAATI KOLOR 8 2 6/9/2018 8/11/2018 8/11/2018 2/13/2019 6/13/2019 7/12/2019
15 AINAYA MUMTAZ A 44 2 LINDA SUSANTI KOLOR 11 2 7/25/2018 2/15/2018 11/8/2018 9/12/2019 1/19/2019 3/12/2019 2/18/2019 12/19/2019 3/12/2019
16 M.ADZAN ZAIM 44 1 YUYUN KOLOR 9 2 9/13/2018 11/6/2018 11/6/2018 12/22/2018 12/22/2018 3/12/2019 2/13/2019 6/13/2019 6/13/2019
17 ELYSA OLIVIA SALSABILA 44 2 BARIDATUL .U KOLOR 8 2 9/15/2018 10/27/2018 10/27/2018 1/22/2019 1/22/2019 3/12/2019 3/12/2019 5/2/2019 5/2/2019
18 SALSABILA 43 2 SUNITA KOLOR 12 2 9/24/2018 11/10/2018 11/10/2018 1/9/2019 1/9/2019 2/13/2019 2/13/2019 6/13/2019
19 M.ISMAIL 38 1 SULIYASNINGSIH KOLOR 8 2 10/27/2018 1/5/2019 1/5/2019 2/13/2019 6/13/2019 7/14/2019
20 DZAKY AL FATIH D. 38 1 AFI NORYANI KOLOR 12 2 3/12/2019 6/15/2019 6/15/2019 8/7/2019 8/7/2019 12/9/2019 9/11/2019 3/9/2020 12/9/2019
21 LUBABATUL MAGHFIROH 37 2 LILIS JAMILA KOLOR 11 2 3/12/2019 5/11/2019 5/11/2019 6/13/2019 6/13/2019 7/20/2019 7/20/2019 8/21/2019 8/21/2009
22 M.ABIDZAR AL GHIFARI 36 1 SULASTRI KOLOR 10 2 4/22/2019 4/30/2019 6/15/2019 6/15/2019 9/11/2019 12/9/2019
23 VARISHA AFANIN A.R 35 2 HALIMATUS S KOLOR 10 2 5/18/2019 5/16/2019 5/16/2019 8/7/2019 8/7/2019 9/10/2019 9/10/2019 2/9/2020 12/9/2019
24 M.NAZRIL IBRAM 34 1 KHOIRUN NISA KOLOR 10 2 6/14/2019 8/10/2019 8/10/2019 11/2/2019 9/11/2019 1/9/2020 12/9/2019 2/10/2020 1/9/2020
25 DWI CITRA A 34 2 SUBAIDA KOLOR 9 2 7/15/2019 9/3/2019 9/3/2019 12/9/2019 12/9/2019 2/10/2020 1/9/2020 2/10/2020
26 AINA TALITA Z 34 2 LULUK F KOLOR 10 2 7/22/2019 9/24/2019 9/24/2019 10/24/2019 12/10/2019 1/10/2020
27 CITRA KIRANA 34 2 SUMIATI KOLOR 12 2
28 M WILDAN ALI 33 1 LAILA M KOLOR 11 2 7/28/2019 9/14/2019 9/14/2019 12/9/2019 12/9/2019 2/10/2020 1/9/2020 3/10/2020 2/10/2020
29 M.ALBIN HASAN 32 1 YAYUK ROHANI KOLOR 8 2 8/7/2019 9/4/2019 9/14/2019 12/9/2019 1/9/2020 2/10/2020
30 M.NASRULLAH 32 1 ASTUTIK KOLOR 12 2 9/2/2019 2/10/2029 2/10/2019 2/10/2020 2/10/2020 3/10/2020 3/10/2020 9/8/2020 6/9/2020
31 AHMAD NATHAN R 32 1 IMARUL KOLOR 10 2 9/20/2019 12/10/2019 12/10/2019 2/10/2020 6/10/2020 3/10/2020 6/10/2020
32 M.FAHMI HUSAIN 30 1 TUTIK H KOLOR 13 2 9/24/2019 12/10/2019 12/10/2019 1/11/2020 1/11/2020 6/10/2020 2/10/2020 11/9/2020 6/10/2020
33 M. ZAINI 26 1 ISABELLA KOLOR 10 2
34 RAISYA NUR K 25 2 MEGAWATI KOLOR 8 2 3/19/2020 5/9/2020 5/9/2020 6/10/2020 6/10/2020 9/9/2020
35 NOVITA APRILIA 24 2 BARIDATUL .U KOLOR 8 2 4/13/2020 6/6/2020 6/6/2020 7/8/2020 7/8/2020 11/9/2020 11/2/2021 10/8/2021
36 SITI AISYAH 22 2 USWATUN H KOLOR 8 2 9/12/2020 9/12/2020 11/11/2020 11/11/2021 11/11/2021 1/11/2021 2/11/2021 3/19/2022
37 M SAMSUL ARIFIN 21 2 ERNA YULIA KOLOR 8 2 7/12/2020 9/12/2020 9/12/2020 11/9/2020 12/8/2020 9/16/2021 4/6/2021 10/8/2021 9/6/2021
38 HULLIYA NURUL AINI 21 2 ISTIQOMAH KOLOR 9 2 7/13/2020 8/24/2020 8/24/2020 10/23/2020
39 ATIKA DINDA ALMAHYRA 20 2 NUR AINI KOLOR 10 2 8/3/2020 9/15/2020 9/15/2020 11/9/2020 12/8/2020 12/8/2020 1/12/2021 2/11/2021
40 ALENA ZEA RACHEL D 20 2 RISKA KOLOR 10 2 9/4/2020 9/10/2020 9/10/2020 11/9/2020 12/8/2020 12/8/2020 1/12/2021 11/11/2021 2/11/2021
41 ARSYILA ROMEESA F 20 2 MUSLEHA KOLOR 10 2
42 M.NAUFAL AFKAR 19 1 RISALAH KOLOR 10 2 9/27/2020 11/10/2020 10/5/2020 2/11/2021 11/10/2020 12/9/2020 1/12/2021
43 AIRA RESYAQILLA P 19 1 DESI RATNASARI KOLOR 13 2 10/14/2020 2/8/2020 2/8/2020 1/12/2021 1/12/2021 2/11/2021 2/11/2021 11-11-121 9/7/2021
44 M. ANGGA 17 1 LINDAYANI KOLOR 8 2 10/25/2020 12/12/2020 12/12/2020 10/8/2021 2/11/2021 4/6/2021 10/8/2021
45 ADINDA YULIANSYAH 17 2 YULIATIN KOLOR 8 2 12/7/2020 2/16/2021 2/16/2021 1/12/2021 4/6/2021 10/8/2021
46 ABDUL GHANI 17 1 MUKARROMAH KOLOR 8 2 12/14/2020 2/16/2021 2/16/2021 4/6/2021 4/6/2021 9/16/2021 9/16/2021 10/8/2021 10/8/2021
47 REVITA JIHAN MAZAYA 17 2 ENI KOLOR 11 2 12/23/2020 2/16/2021 2/16/2021 4/6/2021 4/6/2021 9/17/2021 11/11/2021 1/11/2022
48 ARUMI NATASYA RAZETA 18 2 USWATUN H KOLOR 13 2 12/26/2020 2/16/2021 2/16/2021 4/6/2021 4/6/2021 9/17/2021 9/17/2021 12/7/2021 12/7/2021
49 MOCH. HONGKI KYH 18 1 ENDAH SRI KOLOR 8 2 10/15/2020 11/14/2020 11/14/2020 1/13/2021 1/13/2021 3/13/2021 3/13/2021 5/8/2021 5/8/2021
50 M. BASIL H.A 23 1 HALIMATUS S KOLOR 10 2 2/8/2022
51 FATIR AHMAD AZAMI 22 1 SULAIHA KOLOR 10 2 6/19/2021 9/8/2021 9/17/2021 11/11/2021 12/10/2021 11/10/2021 1/11/2022
52 NADIA SOFIATUN F 15 1 FAHIRA KOLOR 10 2 7/8/2020 7/7/2020 11/9/2020 9/8/2020 1/12/2021 2/11/2021
53 AHMAD ZAINAL AKBAR 15 1 SALAMA KOLOR 10 2 PINDAHAN BARU TIDAK IMUNISASI
54 M. ADZRIEL 14 1 JUMAATI KOLOR 11 2 4/17/2021 6/15/2021 6/15/2021 10/8/2021 10/8/2021 2/8/2021 2/8/2021 1/11/2021
55 SHELINDA MEISYA O. 13 2 SOFIATUN KOLOR 11 2 2/6/2021
56 M. ALTHAF A.Z 13 1 MARTI KOLOR 11 2 4/4/2021 6/15/2021 6/15/2021 11/11/2021 9/17/2021 12/16/2022 12/16/2022 1/11/2022
57 M. ROMI I.P.A 12 2 IIN MUTMAINAH KOLOR 10 2 MENOLAK
NISASI KEJAR TAHUN 2022
NISASI

IMUNISAS
I LANJ
IMUNISASI DASAR YANG BELUM DIDAPAT YANG
BELUM
DIDAPAT KET
CAMPAK
IPV CAMPAK DPT LANJUTAN ORI DIFTERI OPV 1DPT-HB-IB 1OPV D
2PT-HB-HIB O
2 PV 3DPT-HB-HIB3OPV 4 IPV DPT-HB-HIB 4
LANJUTAN campak
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
12/12/2017 3/24/2018
11/12/2017 7/9/2018

2/9/2018 11/8/2018
7/9/2019 1/9/2019
9/8/2018 2/13/2019

10/9/2018 2/13/2019
11/8/2018
1/17/2019 1/7/2019
2/13/2019 1/9/2019

2/13/2019 6/13/2019

12/19/2019 6/12/2019
6/13/2019 8/9/2019
6/29/2019 6/29/2019

2/10/2020
8/21/2019 1/7/2019
2/10/2020 1 1 1
3/10/2020
3/14/2020
9/8/2020
 6/10/2020
4/6/2020
6/9/2020
7/9/2020
9/8/2020
1 1 1 1 1 1

3/19/2022
12/11/2021

9/17/2021
1 1 1 1 1 1 1 1 1

9/17/2021 1
1 1

12/11/2021
9/17/2021
9/17/2021
8/25/2021 11/17/2021
1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1
1/11/2021
1 1 1 1 1 1 1 1 1
1 1 1
1 1 1 1 1 1 1 1 1
4 5 5 7 6 7 7 10 7 0
 FORMAT PELACAKAN / PENDATAAN SEKALIGUS FORMAT PELAYANAN IMUNISASI KEJ
SASARAN ≥ 12 BULAN SD 59 BULAN UNTUK KEJAR IMUNISASI
POSYANDU TALAR RT/RW :
DESA SUMBERAN PUSKESMAS :
KELURAHAN KAB/KO :
PROVINSI :

ALAMAT
lengkap
NO NAMA SASARAN UMUR JK NAMA IBU (RT/RW/ RT RWTELP
DSN/DES
A) HBO BCG POL 1 DPT 1 POL 2 DPT 2 POL 3 DPT 3 POL 4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 DWI MIFTAH A 59 L SUDARWATI TALAR 19 3 5/17/2017 7/8/2017 7/8/2017 12/19/2017 9/5/2017 3/7/2018 12/19/2017 4/12/2018
2 M.SYARIF HIDAYATULLAH 58 L SRI WAHYUNI TALAR 15 3 6/16/2017 7/29/2017 7/29/2017 10/12/2017 9/6/2017 8/11/2018 8/7/2018 8/7/2018 11/9/2017
3 LIDIA ROMADHONI 58 P MISTIANI TALAR 19 3 6/20/2017 8/10/2017 8/10/2017 2/12/2017
4 M.ANDRIANSYAH 58 L MISNATI TALAR 14 3 6/30/2017 10/11/2017 11/9/2017 9/18/2018
5 M.LUBI ALFAYAD S 56 L SALAMATUS TALAR 18 3
6 M.FAJAR SIDIQ 55 L HATIJA TALAR 17 3
7 SITI AMINAH 54 P SULAMI TALAR 15 3 10/13/2017 4/17/2018 4/12/2018 5/5/2018 7/10/2018 7/10/2018 8/8/2018 9/18/2018 9/18/2018
8 FAUZIYAH S.DARAINI A. 54 P IKA MUSTIKA TALAR 15 3 11/1/2017 12/2/2017 12/2/2017 1/3/2018 1/3/2018 2/1/2018 4/21/2018 4/12/2018 5/25/2018
9 INNI NIKMATUN NAFISA 52 P HALIMATUS S TALAR 18 3 12/8/2017 1/3/2018 1/3/2018 2/13/2018 4/12/2018 4/12/2018 8/8/2018 9/11/2019 11/7/2018
10 M.HUSAIN 52 L MAIMUNAH TALAR 17 3 12/22/2017 2/17/2018 4/11/2018 4/11/2018 7/10/2018 8/8/2018 8/8/2018 11/7/2018 9/13/2018
11 TASYA ROSMALA 52 P SULAIHA TALAR 16 3 12/23/2017 3/13/2018 3/13/2018 4/12/2018 4/12/2018 5/12/2018 5/12/2018 9/13/2018 9/13/2018
12 M.ALFIE ALFANDI 52 L SUMIATI TALAR 18 3 12/28/2017 2/24/2018 2/24/2018 4/12/2018 4/12/2018 7/10/2018 7/10/2018 8/8/2018
13 ALMEERA AZZAHRA A 51 P UMI MARDIYAH TALAR 14 3 1/28/2018 5/5/2018 5/5/2018 9/9/2018 6/9/2018 7/10/2018 7/10/2018 9/13/2018 9/13/2018
14 M. ABDULLAH AZIZ 49 L UMI KULSUM TALAR 17 3 3/11/2018 5/22/2018 5/22/2018 8/8/2018 8/8/2018 9/13/2018 11/7/2018
15 M.AL FATIH 49 L EVI OKTAVIA TALAR 15 3 3/23/2018 1/26/2018 5/26/2018 7/24/2018 7/24/2018 3/13/2019 3/12/2009 7/11/2019 7/11/2019
16 M FAREL 49 L ROFIDA TALAR 17 3 3/23/2018 5/22/2018 5/22/2018 8/8/2018 8/8/2018 11/7/2018 9/3/2018 12/9/2019 11/7/2018
17 PUTRI NABILA 48 P MISNAHAYATI TALAR 17 3 4/10/2018 7/21/2018 7/21/2018 9/13/2018 11/7/2018 12/10/2018
18 M ROBIT QOLBI R 47 L LATIFA TALAR 16 3 5/18/2018 7/7/2018 7/7/2018 8/8/2018 8/8/2018 1/22/2019 9/13/2019 3/12/2019 11/7/2018
19 M RAHIL R 47 L RISKA AGUSTINA TALAR 15 3 MENOLAK
20 M ZAIDAN MADANI 46 L JUNAIDA TALAR 18 3 6/1/2018 7/14/2018 7/14/2018 9/13/2018 9/13/2018 1/10/2019 11/7/2018 7/11/2019 1/10/2019
21 M FIKRI P 46 L FITRIYAH TALAR 18 3 6/9/2018 7/14/2018 7/14/2018 9/13/2018 9/13/2018 1/10/2019 11/7/2018 11/11/2020 1/10/2019
22 QURRATUL AINI 58 P SAMINA TALAR 17 3 3/6/2017 7/8/2017 7/8/2017 12/12/2017 10/10/2017 2/13/2018 11/10/2017 5/26/2018 12/12/2017
23 ARIFATUL WILDAN 44 P SALAMATUS TALAR 16 3 8/9/2018 9/22/2018 9/22/2018 11/7/2018 11/7/2018 2/11/2019 1/10/2019 6/11/2019 2/11/2019
24 MEILINDA K.M 44 P AISAH TALAR 14 3 8/21/2018 11/7/2018 11/7/2018 1/10/2019 1/10/2019 2/11/2019 2/11/2019 9/11/2019 3/13/2019
25 DIMAS SAPUTRA 43 L MISTIANI TALAR 19 3 MENOLAK
26 ANINDYA KEISYA ZAHRA 42 P KHOIRUN NISA TALAR 18 3 10/7/2018 11/17/2018 11/17/2018 1/9/2019 1/9/2019 3/26/2019 2/10/2019 10/10/2019 3/26/2019
27 KASYIFA AZMYA AIRA 41 P SUSRIHATIN TALAR 15 3 11/10/2018 12/22/2018 12/22/2018 2/11/2019 2/11/2019 3/12/2019 3/12/2019 7/11/2019 6/19/2019
28 FIZKA INAYATUL FATWA 40 P HOLIPAH TALAR 14 3 12/3/2018 1/12/2019 1/12/2019 7/11/2019 7/11/2019 9/24/2019 9/24/2019 1/8/2020 12/9/2019
29 M.RAKA RAHMATULLAH 40 L SRI DEVI TALAR 17 3 12/8/2018 2/11/2019 2/11/2019 3/12/2019 3/12/2019 6/17/2019 6/17/2019 6/9/2020 9/11/2019
30 M.JAZILUL FAWAID 40 L SUHARTINI TALAR 17 3 12/17/2018 3/12/2019 3/12/2019 7/11/2019 6/15/2019 9/11/2019 9/11/2019 2/12/2020
31 M.MUSTOFA 39 L ZIDA TALAR 17 3 5/14/2019 6/22/2019 6/22/2019 8/13/2019 8/5/2019 12/21/2019 9/11/2019 10/7/2020 10/11/2029
32 M.ALLI ZAFLAN 37 L ANIS MARSELA TALAR 17 3 3/11/2019 5/4/2019 5/4/2019 7/11/2019 6/17/2019 6/9/2020 8/5/2019 11/11/2020
33 ATIKA ZAHRO N.Q 37 P UMI KULSUM TALAR 17 3 3/13/2019 5/4/2019 5/4/2019 7/11/2019 7/11/2019 9/11/2019 8/5/2019 9/11/2019
34 MADINATUL MUNAWAROH 37 P SOFIANATUN N TALAR 15 3 3/25/2019 6/22/2019 6/22/2019 9/11/2019 8/5/2019 12/9/2019 12/9/2019 3/11/2020 1/8/2020
35 DHEMA LUBNA FILLAH 36 P NURHIDYATI TALAR 19 3 4/3/2019 5/11/2019 5/11/2019 6/17/2019 6/17/2019 8/5/2019 8/5/2019 9/11/2019 9/11/2019
36 WIRAYUDA RAMADHAN 35 L SUSILOWATI TALAR 16 3 MENOLAK
37 M.MAHER AL MAGLY 35 L SIHA W TALAR 17 3 5/14/2019 6/22/2019 6/22/2019 8/5/2019 8/5/2019 12/21/2019 9/11/2019 10/7/2020 10/11/2019
38 NAJWA RAMADHANI 35 P FITRIYAH TALAR 17 3 5/25/2019 7/13/2019 7/13/2019 10/12/2019 9/11/2019 10/10/2019 10/10/2019 11/19/2019
39 FATIMAH AZ ZAHRO 34 P HALIMAH TALAR 17 3 6/15/2019 8/6/2019 8/6/2019 9/11/2019 9/11/2019 10/10/2019 10/10/2019 12/19/2019 12/19/2019
40 YASMIN AULIA PUTRI 33 P NIPATUN TALAR 17 3 7/22/2019 8/26/2019 8/26/2019 10/10/2019 10/10/2019 2/16/2021 11/10/2019 1/8/2020
41 ZAANA NAURUHUS S 32 P AYU TALAR 14 3 8/22/2019 1/4/2020 1/8/2020 3/11/2020
42 ZILFA SAJIDI H.A 34 P RATNA TALAR 14 3 6/12/2019 6/22/2019 6/22/2019 9/11/2019 10/10/2019 10-1019 11/9/2019 11/9/2019 1/8/2020
43 LU'LU'AH M F 30 P IKA MUSTIKA TALAR 15 3 10/18/2019 12/11/2019 12/11/2019 3/4/2020 3/4/2020 4/8/2020 4/5/2020 5/13/2020 5/13/2020
44 M.AZKA MAULANA 30 L NURAINI TALAR 17 3 10/23/2019 12/21/2019 11/14/2019 1/8/2020 1/8/2020 2/12/2020 2/12/2020 6/9/2020 3/11/2020
45 M.JADID BAHA.U 29 L SUPMAHAYATI TALAR 17 3 MENOLAK
46 DESWITA KARINA P 28 P SITI HOLILA TALAR 16 3 MENOLAK
47 M.ILTIZAM 26 L AFI TALAR 17 3 MENOLAK
48 KADEK MAULANA M 25 L NOVI TALAR 17 3 3/9/2020 10/10/2020 10/10/2020 11/11/2020 11/11/2020 2/16/2021
49 HELMI HAEDAR ALI 23 L UMI MARDIYAH TALAR 14 3 MENOLAK
50 SAFIRA AIDA A 23 P DEWI YULIANA TALAR 15 3
51 SITI ARISA 23 P NURHAYATI TALAR 18 3 5/14/2020 7/11/2020 7/11/2020 9/9/2020 9/9/2020 12/10/2020 1/14/2021
52 M ALVIN 23 L MISNAHAYATI TALAR 17 3 5/21/2020 MENOLAK ASMA
53 M FAREL WAHYU A 21 L LULUK IL TALAR 17 3 7/27/2020 KEJANG
54 AFIZAH KARENA L 20 P NUR HASANAH TALAR 19 3 8/4/2020
55 THALINIA FAIZAH 20 P ROSYIDA TALAR 17 3 8/26/2020 10/6/2020 10/6/2020 11/11/2020 11/11/2020 2/16/2021 2/16/2021 10/30/2021 10/30/2021
56 M. KENZU NAJAH 18 L MUSRIFA TALAR 19 3 10/3/2020 12/12/2020 12/12/2020 1/14/2021 1/14/2021 3/9/2021 3/9/2021 10/7/2021 10/7/2021
57 NARUMI NASHA M R 18 P WIWIN TALAR 16 3 MENOLAK
58 DAFA IBNU HAFIDZ 18 L RISKA AGUSTINA TALAR 15 3 MENOLAK
59 M. ALFARISI KEFINDRA 16 L ARWANIS TALAR 18 3 12/18/2020 2/16/2021 2/16/2021 3/16/2021 3/16/2021 9/8/2021 1/12/2022
60 M. AMRI YAHYA 15 L UMI KULSUM TALAR 16 3
61 M. SULTHAN 12 L RIRIN TALAR 17 3 4/5/2021 9/21/2021 2/9/2022 MENOLAK
62 ANZILNA FARADISA R. 12 P UMI KULSUM TALAR 17 3 4/15/2021 5/21/2021 5/21/2021 9/18/2021 9/18/2021 9/18/2021 12/10/2021 1/29/2022 1/12/2022
63 NADA AULIA R 12 P ULFAIDA TALAR 17 3 PINDAH
AT PELAYANAN IMUNISASI KEJAR TAHUN 2022
UNTUK KEJAR IMUNISASI

IMUNISASI LANJ
IMUNISASI DASAR YANG BELUM DIDAPAT YANG BELUM
DIDAPAT
KET
CAMPAK
IPV CAMPAK DPT LANJUTAN LANJUTAN ORI DIFTERI OPV 1 DPT-HB-IB 1 OPV 2 DPT-HB-HIB 2 OPV 3 DPT-HB-HIB3 OPV 4 IPV campak DPT-HB-HIB 4
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
4/12/2018 1 1
4/12/2018 1
1 1 1 1 1 1 1
9/13/2018 1 1 1 1 1
1 1 1 1
1 1 1 1 1
9/10/2018 8/8/2018
4/28/2018 8/8/2018
11/7/2018 3/12/2018
11/7/2018 3/12/2019
9/13/2018 11/7/2018
11/7/2018 1/10/2019 1
1 1
3/12/2019 1 1 1
7/11/2019 6/16/2019
3/12/2019 1
1 1 1 1 1
3/12/2019 6/16/2019
1 1 1 1 1 1 1 1 1
7/11/2019 3/12/2019
3/12/2019 1
5/26/2018 4/12/2018
6/11/2019 6/17/2019
8/11/2019 6/16/2019
1 1 1 1 1 1 1 1 1
9/11/2019 1
7/11/2019 9/11/2019
12/9/2019 1
12/9/2019 1
 2/12/2020 1 1
9/9/2020 1 pindah
1/8/2020 1 1
1/8/2020 1
2/12/2020 1
9/11/2019 1/8/2020
1 1 1 1 1 1 1 1 1
2/2/2020 1
6/9/2020 1 1
6/9/2020 1
6/9/2020 1 1
1 1 1 1 1 1 1
3/11/2020 1
9/9/2020 1
9/9/2020 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
4/8/2021 1 1 1 1 1 1 1 1
1
1 1 1 1 1 1 1 1
1
11/13/2021 1 pindah
12/13/2021 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
11/13/2021 1 1 1

1 1 1 1 1 1 1 1
1/29/2022 1
1 1 1 1 1 1 1 1 1 pindah
4 18 13 22 16 27 19 47 21 0
 FORMAT PELACAKAN / PENDATAAN SEKALIGUS FORMAT PELAYANAN KAMPANYE MR
SASARAN USIA 9 BULAN SD 59 BULAN untuk KAMPANYE MR
POSYANDU KRAJAN RT/RW :
DESA SUMBERAN PUSKESMAS :
KELURAHAN KAB/KO :
PROVINSI :

ALAMAT Tanggal
NO NAMA SASARAN UMUR JK NAMA IBU lengkap
(RT/RW/D RT RW TELP CAMPAK
Imunisasi MR
saat Kampanye
KET
SN/DESA) CAMPAK LANJUTAN

1 2 3 4 5 6 7 8 9 8 9
1 ALIKA NAYLA PUTRI 59 2 FIFIN KRAJAN 1 1
2 ATIKA ZAHRA R 59 2 JAMILATUN N KRAJAN 5 1
3 M.HUSNI 59 1 KHOLILA KRAJAN 6 1 11/12/2018
4 M.IDAD ROBBANI 58 1 SITI MARYAM KRAJAN 1 1 8/5/2018
5 M.FAIZ 57 2 SUDARTI KRAJAN 2 1 5/5/2018
6 M IQBAL FARIS H 56 1 HOTIM KRAJAN 2 1 11/7/2018
7 AHMAD AL FARISI 55 2 ULFA KRAJAN 4 1 10/7/2018
8 AMMAR ARKHAN N R 64 2 ANIK KRAJAN 3 1
9 KHUSNUL KHOTIMAH 53 1 HOSNAWATI KRAJAN 3 1 8/10/2018
10 M.HAFIZ Q A 53 1 KOMARIYAH KRAJAN 7 1 8/4/2019
11 M.TAJUDDIN AS SUBKI 55 1 ALEX KRAJAN 1 1 29-8-2018
12 M.FAHRI ARDIANSYAH 52 1 NIKMATUL KRAJAN 5 1
13 KEISYA AURELIA ZAIN 51 1 MAHMUDAH KRAJAN 3 1 8/10/2018
14 M.RAFLI 51 1 BAHRIYA KRAJAN 5 1 11/12/2018
15 ARINA MANASIKANA 50 2 YUNI INDRIAS KRAJAN 1 1 8/12/2018
16 QOTRU ELGHAIS S F 49 1 FAIQ KRAJAN 1 1
17 M RAYHAN 49 2 SULAIHA KRAJAN 1 1 13-1-2019
18 M.DAWAM 48 1 NAFISA KRAJAN 5 1 18-1-2019
19 AZRIEL DIKI PRAYOGA 48 1 YAYUK KRAJAN 5 1 8/4/2019
20 ARRAFI FARZAN SAKEEL 47 2 FINATUL KRAJAN 1 1
21 HIZRUL FAHMI AKBAR 46 1 SUBAIDA KRAJAN 5 1
22 MUHAMMAD ANWAR FAU44 2 IDA KRAJAN 4 1 8/7/2019
23 NAURA MUTHIA 47 2 RIRIT KRAJAN 7 1
24 KHOLIFAH RAQILA MANA 43 1 NURAINI KRAJAN 5 1
25 M.IRVAN ABDILLAH 43 1 FITRIYAH KRAJAN 5 1 10/9/2019
26 SITI N.MAULIDAH 40 1 WIWIK AQOBAKRAJAN 5 1
27 NAHLA KHAIRIN ALIFIYA 39 1 JUMAATI KRAJAN 5 1 8/12/2019
28 ASYFATUL UMMIYAH 37 1 IMA SUSANTI KRAJAN 2 1 22-4-2020
29 NURUL HAYA ISHI R 35 2 FATIMATUS KRAJAN 2 1 11/2/2020
30 M ALDIANSYAH R 35 1 SITI AMINA KRAJAN 4 1 11/2/2020
31 M.AZKA B.N 34 1 USWATUN H KRAJAN 5 1
32 FAUZIYATUL MALIKAH 34 2 DURATUN M KRAJAN 2 1 22-5-2020
33 M. ALFIN ZAFRAN 34 2 URIFATUL KRAJAN 3 1 8/6/2020
34 SAYYIDAH MAIMUNAH 33 2 NING UCIK KRAJAN 2 1
35 M AFISENA 33 2 ANGGI KRAJAN 3 1 9/5/2020
36 M RAFKA A 33 1 YULIATUL KRAJAN 5 1
37 ALINA BINTAH HUMAIRO 33 1 SITI NUR A KRAJAN 3 1 7/7/2020
38 M.AZKA N.H 32 2 ELA KRAJAN 7 1
39 M.RAFIF AR ROYAN 32 1 NARNI KRAJAN 2 1 28-7-2020
40 M.BRYAN DEVANA 31 2 KIKI KRAJAN 3 1
41 M. ILTIZAM 30 1 SAM'A 2 KRAJAN 2 1 10/9/2020
42 NAZWA K.P 28 1 IZE KRAJAN 7 1
43 M.ZIDAN AL AZMI 28 2 NUR ZAINAB KRAJAN 7 1 6/10/2020
44 TAZKIA MUFADHO 24 1 JAMILA KRAJAN 5 1
45 ALIZA AZZAHRA R 24 1 ZAHROTUN KRAJAN 5 1 9/3/2021
46 CLEANDREW 23 1 MARIA ULFA KRAJAN 1 1 25-3-2021
47 M. FAQIH R 24 1 SYARIFAH KRAJAN 2 1 28-3-2021
48 MARKO ADITIA 22 2 NUR AWALIA KRAJAN 5 1
49 M HAIKAL M 22 1 HORIYAH KRAJAN 7 1
50 SAKILA NURA TAZKIA 20 2 ZULAIHA KRAJAN 5 1
51 FAIZA AURELYA KINANDI 20 2 LUFTI KRAJAN 4 1
52 NUR DIANA HOLIDA 18 1 YULIA CITRA KRAJAN 4 1
53 ANINDIRA MYSHA FAUZI 16 1 IDA KRAJAN 3 1
54 M. ALI LAZUARDI 15 1 ELSA KRAJAN 3 1 5/10/2021
55 RUFAIDAH EL ZAHRA K.F 15 1 FAIQ KRAJAN 1 1 28-8-2021
56 RAFAN GHIFARI A 14 2 ST KHOTIJAH KRAJAN 5 1
57 M. INDRA KEVIN 12 2 ENI KRAJAN 1 1
58 M. MUZAYYAN A 11 IFIN NINDAYATKRAJAN 3 1 3/15/2022
59 NAZILA DANIA KHANZA 11 AISA KRAJAN 2 1
60 M.SAUQI ALAIKA R 11 SITI AMINA KRAJAN 3 1 3/15/2022
61 M.H RIYAD M SATYA 11 SITI NUR AISA KRAJAN 3 1
62 ATHAYA KHAFI S 10 Q.AINI KRAJAN 1 1
 FORMAT PELACAKAN / PENDATAAN SEKALIGUS FORMAT PELAYANAN KAMPANYE MR
SASARAN USIA 9 BULAN SD 59 BULAN untuk KAMPANYE MR
POSYANDU KOLOR RT/RW :
DESA SUMBERAN PUSKESMAS :
KELURAHAN KAB/KO :
PROVINSI :

ALAMAT
lengkap Tanggal Imunisasi
NO NAMA SASARAN UMUR JK NAMA IBU (RT/RW/ RT RW TELP CAMPAK CAMPAK MR saat KET
LANJUTAN
DSN/DES Kampanye
A)
1 2 3 4 5 6 7 8 9 8 9
1 M.HAIKAL P.A 59 1 DINA KOLOR 13 2 3/24/2018
2 ACHMAD ROYHAN 58 1 NURUL HALIM KOLOR 8 2 7/9/2018
3 M KHOLILI 57 1 MANISA KOLOR 8 2
4 M AZKA MAULANA FADIL 55 1 QUROTA AINI KOLOR 11 2 11/8/2018
5 M.SHOLEH 52 1 MILAWATI KOLOR 12 2 1/9/2019
6 NUR DIANA 52 2 FARIDA KOLOR 12 2 2/13/2019
7 JAZILAH NAYLA PUTRI 51 2 SITI RAHMA KOLOR 10 2
8 SRI WULANDARI 51 2 SURYATI KOLOR 9 2 2/13/2019
9 SITI AISYAH NURDIANA 50 2 LULUK KOLOR 12 2 11/8/2018
10 DAVID MAULANA I 49 1 LUSI C KOLOR 12 2 1/7/2019
11 M NUR AHLAN 48 1 SITI AMINA KOLOR 12 2 1/9/2019
12 M.FISKAL DIRGANTARA 47 1 SUNARSIH KOLOR 12 2
13 AHMAD FITO FIRDAUS 47 1 IFA HANDINI KOLOR 8 2 6/13/2019
14 ISHAK PUTRA R 46 1 JUMAATI KOLOR 8 2
15 AINAYA MUMTAZ A 44 2 LINDA SUSANTIKOLOR 11 2 6/12/2019
16 M.ADZAN ZAIM 44 1 YUYUN KOLOR 9 2 8/9/2019
17 ELYSA OLIVIA SALSABILA 44 2 BARIDATUL .U KOLOR 8 2 6/29/2019
18 SALSABILA 43 2 SUNITA KOLOR 12 2
19 M.ISMAIL 38 1 SULIYASNINGSIKOLOR 8 2
20 DZAKY AL FATIH D. 38 1 AFI NORYANI KOLOR 12 2 2/10/2020
21 LUBABATUL MAGHFIROH 37 2 LILIS JAMILA KOLOR 11 2 1/7/2019
22 M.ABIDZAR AL GHIFARI 36 1 SULASTRI KOLOR 10 2 2/10/2020
23 VARISHA AFANIN A.R 35 2 HALIMATUS S KOLOR 10 2 3/10/2020
24 M.NAZRIL IBRAM 34 1 KHOIRUN NISAKOLOR 10 2 3/14/2020
25 DWI CITRA A 34 2 SUBAIDA KOLOR 9 2 9/8/2020
26 AINA TALITA Z 34 2 LULUK F KOLOR 10 2
27 CITRA KIRANA 34 2 SUMIATI KOLOR 12 2
28 M WILDAN ALI 33 1 LAILA M KOLOR 11 2 6/10/2020
29 M.ALBIN HASAN 32 1 YAYUK ROHANIKOLOR 8 2 4/6/2020
30 M.NASRULLAH 32 1 ASTUTIK KOLOR 12 2 6/9/2020
31 AHMAD NATHAN R 32 1 IMARUL KOLOR 10 2 7/9/2020
32 M.FAHMI HUSAIN 30 1 TUTIK H KOLOR 13 2 9/8/2020
33 M. ZAINI 26 1 ISABELLA KOLOR 10 2
34 RAISYA NUR K 25 2 MEGAWATI KOLOR 8 2
35 NOVITA APRILIA 24 2 BARIDATUL .U KOLOR 8 2
36 SITI AISYAH 22 2 USWATUN H KOLOR 8 2 3/19/2022
37 M SAMSUL ARIFIN 21 2 ERNA YULIA KOLOR 8 2 12/11/2021
38 HULLIYA NURUL AINI 21 2 ISTIQOMAH KOLOR 9 2
39 ATIKA DINDA ALMAHYRA 20 2 NUR AINI KOLOR 10 2
40 ALENA ZEA RACHEL D 20 2 RISKA KOLOR 10 2 9/17/2021
41 ARSYILA ROMEESA F 20 2 MUSLEHA KOLOR 10 2
42 M.NAUFAL AFKAR 19 1 RISALAH KOLOR 10 2
43 AIRA RESYAQILLA P 19 1 DESI RATNASARKOLOR 13 2 9/17/2021
44 M. ANGGA 17 1 LINDAYANI KOLOR 8 2
45 ADINDA YULIANSYAH 17 2 YULIATIN KOLOR 8 2
46 ABDUL GHANI 17 1 MUKARROMAHKOLOR 8 2 12/11/2021
47 REVITA JIHAN MAZAYA 17 2 ENI KOLOR 11 2 9/17/2021
48 ARUMI NATASYA RAZETA 18 2 USWATUN H KOLOR 13 2 9/17/2021
49 MOCH. HONGKI KYH 18 1 ENDAH SRI KOLOR 8 2 11/17/2021
50 M. BASIL H.A 23 1 HALIMATUS S KOLOR 10 2
51 FATIR AHMAD AZAMI 22 1 SULAIHA KOLOR 10 2
52 NADIA SOFIATUN F 15 1 FAHIRA KOLOR 10 2
53 AHMAD ZAINAL AKBAR 15 1 SALAMA KOLOR 10 2
54 M. ADZRIEL 14 1 JUMAATI KOLOR 11 2 1/11/2021
55 SHELINDA MEISYA O. 13 2 SOFIATUN KOLOR 11 2
56 M. ALTHAF A.Z 13 1 MARTI KOLOR 11 2
57 M. ROMI I.P.A 12 2 IIN MUTMAINAKOLOR 10 2
58 FATIR AHMAD AZAMI 11 1 SULAIHA KOLOR 10 2
59 M.REVAN ADITYA 10 1 SUKMAH KOLOR 12 2
 FORMAT PELACAKAN / PENDATAAN SEKALIGUS FORMAT PELAYANAN KAMPANYE MR
SASARAN USIA 9 BULAN SD 59 BULAN untuk KAMPANYE MR
POSYANDU TALAR RT/RW :
DESA SUMBERAN PUSKESMAS :
KELURAHAN KAB/KO :
PROVINSI :

ALAMAT Tanggal
lengkap CAMPAK
NO NAMA SASARAN UMUR JK NAMA IBU (RT/RW/D RT RW TELP CAMPAK LANJUTAN Imunisasi MR KET
saat Kampanye
SN/DESA)

1 2 3 4 5 6 7 8 9 8 9
1 DWI MIFTAH A 59 L SUDARWATI TALAR 19 3 4/12/2018
2 M.SYARIF HIDAYATULLAH 58 L SRI WAHYUNITALAR 15 3 4/12/2018
3 LIDIA ROMADHONI 58 P MISTIANI TALAR 19 3
4 M.ANDRIANSYAH 58 L MISNATI TALAR 14 3 9/13/2018
5 M.LUBI ALFAYAD S 56 L SALAMATUS TALAR 18 3
6 M.FAJAR SIDIQ 55 L HATIJA TALAR 17 3
7 SITI AMINAH 54 P SULAMI TALAR 15 3 8/8/2018
8 FAUZIYAH S.DARAINI A. 54 P IKA MUSTIKATALAR 15 3 8/8/2018
9 INNI NIKMATUN NAFISA 52 P HALIMATUS STALAR 18 3 3/12/2018
10 M.HUSAIN 52 L MAIMUNAH TALAR 17 3 3/12/2019
11 TASYA ROSMALA 52 P SULAIHA TALAR 16 3 11/7/2018
12 M.ALFIE ALFANDI 52 L SUMIATI TALAR 18 3 1/10/2019
13 ALMEERA AZZAHRA A 51 P UMI MARDIYTALAR 14 3
14 M. ABDULLAH AZIZ 49 L UMI KULSUMTALAR 17 3 3/12/2019
15 M.AL FATIH 49 L EVI OKTAVIA TALAR 15 3 6/16/2019
16 M FAREL 49 L ROFIDA TALAR 17 3 3/12/2019
17 PUTRI NABILA 48 P MISNAHAYATTALAR 17 3
18 M ROBIT QOLBI R 47 L LATIFA TALAR 16 3 6/16/2019
19 M RAHIL R 47 L RISKA AGUSTTALAR 15 3
20 M ZAIDAN MADANI 46 L JUNAIDA TALAR 18 3 3/12/2019
21 M FIKRI P 46 L FITRIYAH TALAR 18 3 3/12/2019
22 QURRATUL AINI 58 P SAMINA TALAR 17 3 4/12/2018
23 ARIFATUL WILDAN 44 P SALAMATUS TALAR 16 3 6/17/2019
24 MEILINDA K.M 44 P AISAH TALAR 14 3 6/16/2019
25 DIMAS SAPUTRA 43 L MISTIANI TALAR 19 3
26 ANINDYA KEISYA ZAHRA 42 P KHOIRUN NISTALAR 18 3 9/11/2019
27 KASYIFA AZMYA AIRA 41 P SUSRIHATIN TALAR 15 3 9/11/2019
28 FIZKA INAYATUL FATWA 40 P HOLIPAH TALAR 14 3 12/9/2019
29 M.RAKA RAHMATULLAH 40 L SRI DEVI TALAR 17 3 12/9/2019
30 M.JAZILUL FAWAID 40 L SUHARTINI TALAR 17 3 2/12/2020
31 M.MUSTOFA 39 L ZIDA TALAR 17 3 9/9/2020
32 M.ALLI ZAFLAN 37 L ANIS MARSELTALAR 17 3 1/8/2020
33 ATIKA ZAHRO N.Q 37 P UMI KULSUMTALAR 17 3 1/8/2020
34 MADINATUL MUNAWARO 37 P SOFIANATUNTALAR 15 3 2/12/2020
35 DHEMA LUBNA FILLAH 36 P NURHIDYATI TALAR 19 3 1/8/2020
36 WIRAYUDA RAMADHAN 35 L SUSILOWATI TALAR 16 3
37 M.MAHER AL MAGLY 35 L SIHA W TALAR 17 3 2/2/2020
38 NAJWA RAMADHANI 35 P FITRIYAH TALAR 17 3 6/9/2020
39 FATIMAH AZ ZAHRO 34 P HALIMAH TALAR 17 3 6/9/2020
40 YASMIN AULIA PUTRI 33 P NIPATUN TALAR 17 3 6/9/2020
41 ZAANA NAURUHUS S 32 P AYU TALAR 14 3
42 ZILFA SAJIDI H.A 34 P RATNA TALAR 14 3 3/11/2020
43 LU'LU'AH M F 30 P IKA MUSTIKATALAR 15 3 9/9/2020
44 M.AZKA MAULANA 30 L NURAINI TALAR 17 3 9/9/2020
45 M.JADID BAHA.U 29 L SUPMAHAYATTALAR 17 3
46 DESWITA KARINA P 28 P SITI HOLILA TALAR 16 3
47 M.ILTIZAM 26 L AFI TALAR 17 3
48 KADEK MAULANA M 25 L NOVI TALAR 17 3
49 HELMI HAEDAR ALI 23 L UMI MARDIYTALAR 14 3
50 SAFIRA AIDA A 23 P DEWI YULIANTALAR 15 3
51 SITI ARISA 23 P NURHAYATI TALAR 18 3 4/8/2021
52 M ALVIN 23 L MISNAHAYATTALAR 17 3
53 M FAREL WAHYU A 21 L LULUK IL TALAR 17 3
54 AFIZAH KARENA L 20 P NUR HASANATALAR 19 3
55 THALINIA FAIZAH 20 P ROSYIDA TALAR 17 3 11/13/2021
56 M. KENZU NAJAH 18 L MUSRIFA TALAR 19 3 12/13/2021
57 NARUMI NASHA M R 18 P WIWIN TALAR 16 3
58 DAFA IBNU HAFIDZ 18 L RISKA AGUSTTALAR 15 3
59 M. ALFARISI KEFINDRA 16 L ARWANIS TALAR 18 3 11/13/2021
60 M. AMRI YAHYA 15 L UMI KULSUMTALAR 16 3
61 M. SULTHAN 12 L RIRIN TALAR 17 3
62 ANZILNA FARADISA R. 12 P UMI KULSUMTALAR 17 3
63 NADA AULIA R 12 P ULFAIDA TALAR 17 3
64 M. ZABIR AL RAFISQI 11 L ALFIA TALAR 17 3
65 M. RAIHAN GIBRAN 11 L SRI ASTUTIK TALAR 17 3
66 AHMAD NABIL AFNANI 10 L DINDA EVI TALAR 14 3
67 MUH. GAVIN AL HAQ 9 L ISMAWATI TALAR 17 3
68 KALINGGA P G 9 L YULI HERMA TALAR 14 3
 FORMAT PELACAKAN / PENDATAAN SEKALIGUS FORMAT PELAYANAN KA
SASARAN USIA 9 BULAN SD 59 BULAN untuk KAMPANYE MR
POSYANDU : RT/RW
DESA : PUSKESMAS
KELURAHAN : KAB/KO
PROVINSI

ALAMAT
TANGGAL
lengkap
NO NAMA SASARAN LAHIR/(umur dlm JENIS KELAMIN NAMA IBU
(RT/RW/DSN/
bln)
DESA)
1 2 3 4 5 6
1
2
3
4
5
6
7
8
DST

TOTAL

NB jika belum terimunisasi kolom 8 diisi centang (V) sehingga berfungsi sebagai format pendata
jika sudah mendapat IMUNISASI KAMPANYE MR kolom 8 diganti diisi TANGGAL mendapatka
sehingga berfungsi sebagai form pelaporan pelayanan KAMPANYE MR
Khusus untuk kolom 8 jika sdh mendapatkan MR pada pelaksanaan KAMPANYE MR , serta u
maka dilaporkan 2 kali sebagai laporan imunisasi rutin dan KAMPANYE MR
cont MR 1 saat KAMPANYE didapat usia < 1 tahun dan belum mendapat Imunisasi MR Bayi m
cont MR 2 saat KAMPANYE didapat usia 18 sd 24 bulan dan belum mendapat Imunisasi MR L
S FORMAT PELAYANAN KAMPANYE MR
LAN untuk KAMPANYE MR
:
:
:
:

Tanggal Imunisasi MR saat

TELP KET
Kampanye

7 8 9

berfungsi sebagai format pendataan / pelacakan

ganti diisi TANGGAL mendapatkan imunisasi

aksanaan KAMPANYE MR , serta usia sasaran masuk dalam Sasaran Imunisasi Rutin
KAMPANYE MR
m mendapat Imunisasi MR Bayi maka dilaporkan sebagai cakupan imunisasi dasar bayi dan imunisasi KAMPANYE
belum mendapat Imunisasi MR Lanjutan, maka dilaporkan sebagai cakupan imunisasi lanjutan dan KAMPANYE MR
 KAMPANYE
KAMPANYE MR
KEJAR IMUNISASI
KRAJAN 57
KOLOR 57
TALAR 63
177

MR
KRAJAN 62
KOLOR 59
TALAR 68
189