LAPORAN PEMAKAIAN DAN LEMBA

PUSKES

PUSKESMAS : PETIR
KECAMATAN : PETIR PELAPORAN BULAN / PERIODE :
KABUPATEN : SERANG PERMINTAAN BULAN / PERIODE :
PROVINSI : BANTEN

NO NAMA OBAT SATUAN STOK AWAL PENERIMAAN PERSEDIAAN

1 2 3 4 5 6
1 Acetylceysteine 200mg Kapsul 14,880 - 14,880

2 Alat Suntik 1 ml Set 200 - 200

3 Alat suntik 10 ml SET 200 - 200

4 Alat suntik 20 ml Unit 130 - 130

5 Alat Suntik 3 ml Set 1,000 - 1,000

6 Alat suntik 5 ml set 100 - 100

7 Albendazole Tablet - - -

8 Albendazole suspensi botol - - -

9 Alkohol swab Kotak 14 - 14

10 Allopurinol 100 mg Tablet 2,300 - 2,300

11 Allupurinol 300 mg Tablet 600 - 600

12 Ambroxol sirup 15 mg/ml Botol - - -

13 Ambroxol tablet 30 mg Tablet - - -

14 Aminophilin 200 mg Tablet - - -

15 Aminophilin inj Ampul - - -

16 Amitriptillin tab 25 mg Tablet 300 - 300

17 Amlodipin 10 mg Tablet - - -

18 Amlodipin 5 mg Tablet - - -

19 Amoxicillin Inj Vial - - -

20 Amoxicillin Syrup Forte 250 mg/ml Botol 240 - 240

21 Amoxisilin 125 mg syr Botol - - -

22 Amoxisilin 250 mg Kapsul 8,800 - 8,800

23 Amoxisilin 500 mg Kapsul 14,200 - 14,200

24 Ampicillin 1 gr injeksi Ampul 70 - 70

25 Antalgin 500 mg Tablet - - -

26 Antasida Doen Tablet 4,900 - 4,900

27 Antasida Doen Sirup Botol 200 - 200

28 Anti vertigo (Betahistin maleat) Tablet - - -

29 Antibakteri Doen Salep Tube - - -

30 Antihaemoroid Doen Komb. Supp Supp 50 - 50

31 Antimigrain Doen Komb. Tablet - - -

32 Aqua Pro inj Steril 20 ml Ampul 24 - 24

33 Artesunate inj Ampul - - -

34 Asam Aselilsalisilat 100mg Tablet - - -

35 Asam Askorbat 250 mg Tablet - - -

36 Asam Askorbat 50 mg Tablet 3,000 - 3,000

37 Asam Mefenamat 500 mg Tablet 100 - 100

38 Asam Traneksamat inj 250 mg / ml Ampul - - -

39 Aseptic gel botol - - -

40 Asering 500 cc Botol - - -

41 Asiclovir 400 mg Tablet 1,300 - 1,300

42 Asiclovir cream Tube - - -

43 Atrofin Sulfat inj 0,25 mg / ml Ampul - - -

44 Attapulgit 650 mg Tablet 500 - 500

45 Azythromycin 500 mg Tablet - - -

46 Benzatin Benzilpenisillin 1,2 Juta IU/Vial Vial - - -

47 Betamethason Krim Tube 100 - 100

48 Biodinamika CHKM Botol - - -

49 Bisacodyl Tablet - - -

50 Bisturi kotak 3 - 3

51 Ca glukonas Vial 48 - 48
Cairan pembersih gigi poliren (Technodent
52 botol - - -
poliren)
53 Calsium Hidroksida Pasta (Dorident) Set - - -

54 Captopril 12,5 mg Tablet 1,000 - 1,000

55 Captopril 25 mg Tablet - - -

56 Cat- Gut Plain 3/0 HR-27 Unit 132 - 132

57 Catgut chromic 3-0 kotak/24 - - -

58 Cefadroxil 250 mg syr Botol - - -

59 Cefadroxyl sirup kering 125mg/ml Botol - - -

60 Catgut chromic 2-0 onemed Unit - - -

61 Cuticell Classic Plaster 10x10 cm Kapsul - - -

62 Cefixime syr botol - - -

63 Cendo Lyteers Botol - - -

64 Cetirizine Tablet - - -

65 Cetirizine 5 mg/5 ml Syrup 60 ml Botol 1,000 - 1,000

66 Cimetidine 200 mg Tablet - - -

67 Clobazam 10 mg Tablet 1,100 - 1,100

68 Clozapine Tablet - - -

69 Combivent 2,5 ml Vial 60 - 60

70 Composit (Diafil) Tube - - -

71 Cresophene Botol - - -

72 Decacetin (Kloramfenikol TM) Botol - - -

73 Deksametason 0,5 mg Tablet - - -

74 Deksametason inj 5 mg Ampul 20 - 20

75 Devitalisasi pasta (non arsen) Botol - - -

76 Dextrose 40% inj Ampul - - -

77 Diazepam inj 5 mg / ml Ampul 40 - 40

78 Diazepam rektal 5mg /2.5 ml (Stesolid) Tube 15 - 15

79 Dietylcarbamazin Sitrat 100 mg Tablet - - -

80 Difenhidramin HCL inj 10 mg/ml Ampul 60 - 60

81 Digoksin 0,25 mg Tablet - - -

82 Diltiazem HCl 30 mg Tablet 100 - 100

83 Doksisiklin 100 mg Capsul 270 - 270

84 Domperidon susp 5mg/ml Botol - - -

85 Domperidone tab Tablet 1,400 - 1,400

86 Ekstraks Belladona tab 10 mg Tablet - - -

87 Epinefrin HCL inj 0,1%-1 ml Ampul 29 - 29

88 Erythromycin 500 mg Tablet Salut Tablet 100 - 100

89 Erytromisin syr Botol - - -

90 Etakridin ( Rivanol ) 0.1% Botol 21 - 21

91 Etanol 70% - 1.000 ml Botol 7 - 7

92 Etanol 70% - 100 ml Botol 48 - 48

Etching+bonding (3M-Scotbond+3Madper
93 Syringe+Botol - - -
single bond 2)
94 Etilklorida Semprot - 100 ml Botol - - -

95 Eugenol cairan Botol 2 - 2

96 FDC KAT II Paket - - -

97 FDC Kat. I Paket 51 - 51

98 Fenitoin 100 mg Kapsul - - -

99 Fenobarbital inj Ampul - - -

100 Fenol Glicerol TT Botol 48 - 48

101 Fitomenadion 10 mg Tablet 500 - 500

102 Fitomenadion inj 10 mg / ml Ampul - - -

103 Fluconazole 150 mg Tablet - - -

104 Fluoxetine 10 mg Tablet - - -

105 Fluphenazine Decanoate Ampul 31 - 31

106 Foley Catheter Pcs - - -

107 Foley Catheter no 16 Set 60 - 60

108 Foley Catheter no 18 Set 40 - 40

109 Fescoplast Zinc Oxide Dressing Roll - - -

110 Furosemida 40 mg Tablet - - -

111 Furosemida inj 10 mg/ml Ampul 45 - 45

112 Garam Oralit 200 ml Sachet 600 - 600

113 Gentamisin TT 2% tube - - -

114 Gentamycine inj Ampul - - -

115 Gentamycine salep kulit 0,1 % Tube - - -

116 Gentamycine salep mata tube 72 - 72

117 Gentamysin tetes mata Botol 24 - 24

118 Glass Ionomer Semen ( GC-Fuji IX) Set - - -

119 Glibenklamid 5 mg Tablet 1,700 - 1,700

120 Glimepirid 2mg Tablet - - -

121 Gliseril Guaiacolat 100 mg Tablet - - -

122 Glucosa 5% Botol - - -

123 Glucose Test Strip Kotak/50 - - -

124 Glukosa 10 % Botol - - -

125 Griseovulfin 125 mg Tablet - - -

126 Haloperidol 5 mg Tablet - - -

127 Haloperidol decanoat Ampul - - -

128 Haloperidol decanoat inj 5 mg Ampul - - -

129 Hand schoon non steril Kotak - - -

130 Handscoon steril pasang - - -

131 Hand sanitizer Botol 16 - 16

132 Hanscoon non steril L Kotak 20 - 20

133 Hanscoon non steril M Kotak 40 - 40

134 Hanscoon non steril S Kotak - - -

135 Hidrocortison Cream 2,5% Tube 72 - 72

136 Hidroklortiazid (HCT) Tablet - - -

137 Hyoscine-N-Butilbromide 20 mg/ml inj Ampul - - -

138 Hyoscine-N-Butilbromide 10 mg Tablet 300 - 300

139 I.V catheter no : 18 Pcs 250 - 250

140 I.V catheter no : 20 Pcs 350 - 350

141 I.V catheter no : 24 Set 250 - 250

142 I.V catheter no 26 Set 95 - 95

143 I.V catheter No.22 Set 250 - 250

144 Ibuprofen 200 mg Tablet - - -

145 Ibuprofen 200mg/5ml suspensi botol 144 - 144

146 Ibuprofen 400 mg Tablet - - -

147 Infus Set Anak Set 400 - 400

148 Infus Set Dewasa Set 400 - 400

149 Isosorbit Dinitrat 5 mg Tablet - - -

150 IV. Catheter no. 16 Pcs - - -

151 Kalium Permanganat Serbuk Pot - - -

152 Kalsium Laktas 500 mg Tablet 400 - 400

153 Kanamycin inj Vial - - -

154 Kapas Pembalut Adsorben Rol 7 - 7

155 Kasa 40 m x 80 cm Rol 4 - 4

156 Kasa Elastis 4 Inch Roll 10 - 10

157 Kasa Kompres 40/40 Steril Bungkus 20 - 20

158 Kasa Pemb.Hidropil 4mx10cm Rol - - -

159 Kasa Pemb.Hidropil 4mx15cm Rol 150 - 150

160 Kassa 16 x 16 cm Steril Kotak 100 - 100

161 Ketokonazol cream 2 % Tube 50 - 50

162 Ketokonazol Tab Tablet 200 - 200

163 Ketorolac Ampul - - -

164 Klindamisin kap 150 mg Kapsul - - -

165 Klindamisin kap 300 mg Kapsul - - -

166 Kloramfenikol 250 mg Kapsul - - -

167 Kloramfenikol salep kulit Tube 96 - 96

168 Kloramfenikol SM 1% Tube 48 - 48

169 Kloramfenikol suspensi Botol - - -

170 Kloramfenikol TT Botol 35 - 35

171 Klorfeniramin Maleat ( CTM ) 4 mg Tablet 7,500 - 7,500

172 Klorpromazin tab 100 mg Tablet 2,200 - 2,200

173 Kotrimoksazol 480 mg Tablet 900 - 900

174 Kotrimoksazol susp. Botol 200 - 200

175 Laxadin Emulsi 60 ml Botol - - -

176 Leukomed IV Film Kotak/50 10 - 10

177 Levofloxacin tab 500 mg Tablet - - -

178 Lidocain Jelly 2 % Tube - - -

Lidocain kombinasi inj : lidokain HCl 2% +
179 Ampul - - -
Epinefrin 1:80.000
180 Lidokain inj Ampul - - -

181 Lodomer Tablet Salut Selaput 2mg Tablet - - -

182 Loratadine 10 mg Tablet 1,200 - 1,200

183 Lysol 1 Ltr Botol 9 - 9

184 Lytacur botol - - -

185 Magnesium Sulfat 20 % Ampul 54 - 54

186 Magnesium Sulfat 40 % Vial - - -

187 Masker pcs - - -

188 MDT MB Anak Blister - - -

189 MDT MB Dewasa Blister - - -

190 MDT PB Anak blister - - -

191 MDT PB Dewasa Blister - - -

192 Megatic salep tube - - -

193 Meloxicam 15 Tablet - - -

194 Metformin 500 mg Tablet - - -

195 Metildopa tab 250 mg Tablet - - -

196 Metilergometrin Maleat 0,125 mg Tablet 300 - 300

197 Metilergometrin Maleat inj Ampul - - -

198 Metilprednisolon 4 mg Tablet 500 - 500

199 Metilprednisolon 8 mg Tablet - - -

200 Metoclopramide 5 mg Tablet - - -

201 Metoclorpropamid injeksi Ampul - - -

202 Metoclorpropamid 10 mg Tablet 300 - 300

203 Metronidazol 250mg Tablet - - -

204 Metronidazol 500 mg/ml infus Botol - - -

205 Metronidazol 500mg Tablet 700 - 700

206 Miconazole cream Tube 72 - 72

207 Mineral mix Sachet - - -

208 Miniaspi 80 mg Tablet - - -

209 minyak kayu putih botol - - -

Mumifying Pasta (Technodent Iodotin
210 Ampul - - -
Pasta)
211 Nalokson Hcl inj Vial - - -

212 Nasal Cannula Anak Set 41 - 41

213 Nasal Cannula Dewasa Set 36 - 36

214 Natrium Bicarbonat 500 mg Tablet - - -

215 Natrium Bicarbonat lar 8,4 % Botol - - -

216 Natrium dikloffenak tab 25 mg Tablet - - -

217 Natrium dikloffenak tab 50 mg Tablet 2,300 - 2,300

218 Natrium Klorida 0,9% Botol 80 - 80

219 Neo K (fitomenadion 2mg/ml) Ampul - - -

220 Neokolina syr Botol - - -

221 Nifedipin tab Tablet - - -

222 Nistatin Vaginal tab 100.000 IU Tablet 300 - 300

223 Nistatin Vaginal tab 500.000 IU Tablet 100 - 100

224 O.B.H.Sirup Botol - - -

225 OAT Kat Anak Paket 1 - 1

226 Ofloxacin Tablet - - -

227 Oksitetrasiklin HCL inj Vial - - -

228 Oksitetrasiklin HCL SK 3% Tube - - -

229 Oksitetrasiklin HCL SM 1% Tube 125 - 125

230 Oksitosin Inj Vial 65 - 65

231 Omeprazol INJ Vial 30 - 30

232 Omeprazol kap 20 mg Kapsul - - -

233 Papaverin 40 mg Tablet - - -

234 Parasetamol 100 mg Tablet - - -

235 Parasetamol 160 mg supp supp - - -

236 Parasetamol 240 mg supp supp - - -

237 Parasetamol 500 mg Tablet 10,000 - 10,000

238 Parasetamol 80 mg supp supp - - -

239 Parasetamol drop botol 180 - 180

240 Parasetamol Sirup Botol 480 - 480

241 peahavral tab Tablet - - -

242 Perak Sulfadiazin 1 % Tube 5 - 5

243 Pine oil 7,0%+benzyl clorophenol 0,6% Botol - - -

244 Pirantel Pamoat 125 mg Tablet - - -

245 Piridoksin HCL 10 mg Ampul 3,200 - 3,200

246 Piridoksin HCL 25 mg Tablet - - -

247 Piroksikam 10 mg Tablet - - -

248 Piroksikam 20 mg Tablet - - -

249 Plester 10 yard x 1 inch Roll - - -

250 Plester 5 yards x 1 inc Roll - - -

251 Povidon 60 mL Botol - - -

252 Povidon iodin 60 ml botol 40 - 40

253 Povidon Yodida 30 ml Botol - - -

254 Povidon Yodida 300 ml Botol 7 - 7

255 Prednison 5 mg Tablet - - -

256 Primaquine Tablet - - -

257 Propanolol HCL 40 mg Tablet - - -

258 Protexinal sy botol - - -

259 Quantidex sy botol - - -

260 Ranitidine Tablet - - -

261 Ranitidine inj Ampul - - -

262 Retinol 100.000 IU Kapsul 150 - 150

263 Retinol 200.000 iu Kapsul 2,050 - 2,050

264 Ringer Laktat Botol 700 - 700

265 Risperidon tab 20 mg Tablet 2,300 - 2,300

266 Salbutamol 2 mg Tablet 2,300 - 2,300

267 Salbutamol 4 mg Tablet - - -

268 Salep 2-4 Kombinasi Pot 48 - 48

269 Salisil Bedak 2% - 50 gr Kotak 60 - 60

270 Sanadril syr Botol - - -

271 Sanadril syr botol - - -

272 sanvita B syr Botol - - -

273 Scabimet Tube - - -

274 Semen Seng Fosfat Set - - -

275 Serum ABU I Vial - - -

276 Serum ADS Ampul - - -

277 Serum ATS 1.500 IU Vial - - -

278 Sianokobalamin inj. Ampul 188 - 188

279 Sianokobalamin tab Tablet - - -

280 Sianokobalamin tab (Vit B12) Tablet 1,600 - 1,600

281 Silk Benang Bedah Sutra Kotak 132 - 132

282 Simvastatin 10 mg Kapsul - - -

283 Simvastatin 20 mg Tablet 1,000 - 1,000

284 Siprofloksasin 250 mg Tablet - - -

285 Siprofloxacin 500 mg Tablet 2,100 - 2,100

286 Spironolactone Tablet - - -

287 Sterizyme 5L Botol 2 - 2

288 Tablet tambah darah Tablet 6,600 - 6,600

289 Technodent cresotin liquid botol - - -

290 Technodent cresotin pasta Tube - - -

291 Temporary Stopping Fletcher Set - - -

292 Tetrakain 0,5 % T.M (PANTOCAIN) Botol - - -

293 Tetrasiklin 250 mg Tablet - - -

294 Tetrasiklin 500 mg Tablet 300 - 300

295 Thiamin HCL 50 mg Tablet 4,100 - 4,100

296 Thiamin HCL inj Ampul - - -

297 Tiamfenikol kap 500 mg Kapsul - - -

298 Total colesterol test strip Kotak/10 - - -

299 Tramadol inj Ampul - - -

300 Transfusi set Set - - -

301 Triamcinolone asetonide cream Tube - - -

302 Trifluoperazine Tablet - - -

303 Trihexyphenidyl 2 mg Tablet - - -

304 Tumpatan sementara (GC-Caviton) Pot - - -

305 Ulric test strip Kotak/25 - - -

306 Under pad pcs 50 - 50

307 Urine Bag Set 40 - 40

308 USG Gel 250 (onemed) Botol - - -

309 Vaksin rabies verro Vial - - -

310 Ventolin Nebules 2,5 mg Ampul - - -

311 Vitamin B.Komplek Tablet 5,800 - 5,800

312 Zinc Dispersible tab Tablet 800 - 800

313 Zink pro/drop botol - - -

314 Zink Syrup (Zirkumkid Sirup) Botol 180 - 180

Pasta Desinfeksi Saluran Akar Yang Tidak

315 Pot - - -
Mengandung Arsen (Denpro-Pulp X)

316 Resin Komposite (3M-Z35OXT Tube - - -

317 Handscoon Obgyn pasang 90 - 90

318 Masker Kotak/50 38 - 38

319 Klem umbilikal Box/50 - - -

 320 Asam Folat 0 300 - 300

321 Silk Benang Bedah Sutra (3/0 HR-27) 0 - - -

322 Meditape 3 inchi Kotak/4 - - -
323 Handscoon Steril no. 7.5 pcs 100 - 100
324 Handscoon Steril no. 7 pcs 10 - 10

UMUM BPJS
JUMLAH KUNJUNGAN RESEP
375 593

Mengetahui/Menyetujui :
Kepala Dinas Kesehatan Kab/ Kota Yang Menyerahkan :
An. Kepala Bidang SDK Kab/Kota

……………………………………………. ………………………………………………
NIP. NIP.
MAKAIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO )
PUSKESMAS

DESEMBER 2020 DOKUMEN NOMOR

JANUARI 2021 GUDANG FARMASI
PUSKESMAS

PEMBERIAAN
PERSEDIAAN PEMAKAIAN STOK AKHIR STOK OPT PERMINTAAN
APBD II APBD I ASKES LAIN - LAIN

6 7 8 9 10 11 12 13 14
14,880 9,080 5,800 13,306 10,980

200 100 100 147 200

200 - 200 - -

130 30 100 44 -

1,000 700 300 1,026 700

100 - 100 - 100

- - - - -

- - - - -

14 9 5 13 7

2,300 300 2,000 440 400

600 200 400 293 -

- - - - -

- - - - 0

- - - - -

- - - - -

300 100 200 147 -

- - - - 3,000

- - - - -

- - - - -

240 120 120 176 120

- - - - -

8,800 5,800 3,000 8,499 6,000

14,200 10,200 4,000 14,947 13,000

 70 10 60 15 -

- - - - -

4,900 3,900 1,000 5,715 5,000

200 100 100 147 100

- - - - -

- - - - -

50 - 50 - -

- - - - -

24 4 20 6 -

- - - - -

- - - - -

- - - - -

3,000 2,500 500 3,663 3,000

100 100 - 147 3,000

- - - - -

- - - - -

- - - - -

1,300 900 400 1,319 1,000

- - - - -

- - - - -

500 400 100 586 600

- - - - -

- - - - -

100 25 75 37 25

- - - - -

- - - - -

3 1 2 1 1

48 - 48 - -

- - - - -

- - - - -

1,000 700 300 1,026 1,500

- - - - -

132 48 84 70 24
 - - - - -

- - - - -

- - - - -

- - - - 48

- - - - -

- - - - -

- - - - -

- - - - -

1,000 150 850 220 -

- - - - -

1,100 100 1,000 147 -

- - - - -

60 40 20 59 40

- - - - -

- - - - -

- - - - -

- - - - 3,000

20 20 - 29 30

- - - - -

- - - - -

40 - 40 - -

15 - 15 - -

- - - - -

60 - 60 - -

- - - - -

100 - 100 - -

270 70 200 103 -

- - - - 200

1,400 900 500 1,319 1,000

- - - - -

29 9 20 13 -

100 100 - 147 -

- - - - -
 21 11 10 16 -

7 4 3 6 5

48 18 30 26 12

- - - - -

- - - - -

2 - 2 - -

- - - - -

51 11 40 16 -

- - - - -

- - - - -

48 - 48 - -

500 200 300 293 500

- - - - 90

- - - - -

- - - - -

31 16 15 23 -

- - - - -

60 30 30 44 30

40 20 20 29 20

- - - - 30

- - - - 100

45 - 45 - -

600 400 200 586 400

- - - - -

- - - - -

- - - - -

72 - 72 - -

24 24 - 35 48

- - - - -

1,700 1,100 600 1,612 1,500

- - - - -

- - - - -

- - - - -
 - - - - -

- - - - 20

- - - - -

- - - - -

- - - - -

- - - - -

- - - - -

- - - - -

16 6 10 9 5

20 20 - 29 40

40 40 - 59 40

- - - - 60

72 48 24 70 48

- - - - -

- - - - -

300 300 - 440 500

250 200 50 293 200

350 200 150 293 100

250 200 50 293 200

95 45 50 66 -

250 100 150 147 100

- - - - -

144 72 72 106 72

- - - - 3,000

400 200 200 293 200

400 250 150 366 200

- - - - 300

- - - - -

- - - - -

400 400 - 586 4,000

- - - - -

7 2 5 3 2

4 3 1 4 3
 10 - 10 - -

20 10 10 15 -

- - - - -

150 100 50 147 100

100 50 50 73 100

50 25 25 37 50

200 200 - 293 1,000

- - - - -

- - - - 2,000

- - - - 2,000

- - - - 2,000

96 48 48 70 48

48 24 24 35 24

- - - - -

35 15 20 22 10

7,500 4,500 3,000 6,594 4,000

2,200 1,000 1,200 1,465 -

900 500 400 733 500

200 100 100 147 100

- - - - -

10 5 5 7 5

- - - - -

- - - - -

- - - - 90

- - - - 200

- - - - -

1,200 400 800 586 300

9 6 3 9 7

- - - - -

54 14 40 21 -

- - - - 18

- - - - -

- - - - -
 - - - - -

- - - - -

- - - - -

- - - - -

- - - - -

- - - - 4,000

- - - - -

300 - 300 - -

- - - - -

500 500 - 733 3,000

- - - - -

- - - - -

- - - - -

300 100 200 147 -

- - - - -

- - - - -

700 300 400 440 300

72 48 24 70 48

- - - - -

- - - - -

- - - - -

- - - - -

- - - -

41 21 20 31 20

36 26 10 38 30

- - - - -

- - - - -

- - - - -

2,300 1,800 500 2,638 3,000

80 40 40 59 40

- - - - 90

- - - - -

- - - - 500
 300 - 300 - -

100 - 100 - -

- - - - -

1 - 1 - -

- - - - -

- - - - -

- - - - -

125 - 125 - -

65 65 - 95 100

30 10 20 15 -

- - - - 2,000

- - - - -

- - - - -

- - - - -

- - - - -

10,000 8,000 2,000 11,723 12,000

- - - - -

180 60 120 88 60

480 130 350 191 100

- - - - -

5 2 3 3 2

- - - - -

- - - - -

3,200 2,200 1,000 3,224 2,000

- - - - -

- - - - -

- - - - -

- - - - -

- - - - -

- - - - -

40 4 36 6 -

- - - - -

7 4 3 6 5
 - - - - 500

- - - - -

- - - - -

- - - - -

- - - - -

- - - - 2,000

- - - - -

150 - 150 - -

2,050 - 2,050 - -

700 400 300 586 500

2,300 1,300 1,000 1,905 -

2,300 800 1,500 1,172 500

- - - - -

48 24 24 35 24

60 12 48 18 12

- - - - -

- - - - -

- - - - -

- - - - 60

- - - - -

- - - - 6

- - - - -

- - - - 20

188 88 100 129 100

- - - - -

1,600 1,100 500 1,612 1,500

132 48 84 70 24

- - - - -

1,000 500 500 733 500

- - - - -

2,100 1,600 500 2,345 1,500

- - - - -

2 - 2 - -
6,600 2,600 4,000 3,810 -

- - - - -

- - - - -

- - - - -

- - - - -

- - - - -

300 - 300 - -

4,100 2,100 2,000 2,000

- - - - -

- - - - -

- - - - -

- - - - -

- - - -

- - - - -

- - - - -

- - - - -

- - - - -

- - - -

50 50 - 73 100

40 - 40 - -

- - - - 5

- - - - -

- - - -

5,800 3,800 2,000 5,568 4,000

800 800 - 1,172 2,000

- - - - -

180 72 108 106 36

- - - - -

- - - - -

90 40 50 59 50

38 30 8 44 30

- - - - -
 300 - 300 - -

- - - - -
- - 6 - 1
100 - 100 - 100
10 - 10 - 100

ASTEK JPS/ GAKIN IMUNISASI GRATIS / KTP JUMLAH

820 1788

Yang Menyerahkan : Yang Meminta : Yang Menerima

Kepala UPT Puskesmas Petir Petugas Puskesmas

……………………………………. Agus Kusumah, SKM Mega Anggita Hermawati, S.Farm Apt

NIP :19720817 199203 1 007 NRTTK : 814.1.18.3.011
 FORM : LPLPO

TANGGAL

N
KET
JUMLAH

15 16
 JUMLAH

1788

ang Menerima
tugas Puskesmas

ta Hermawati, S.Farm Apt

TK : 814.1.18.3.011