PKM GUNUNG

SUGIH

PESERTA KB

NO. TANGGAL ISTRI

NAMA SUAMI
NIK (NOMOR INDUK KEPENDUDUKAN) NAM

1 2 3 4 5

1 1/3/2022 AKO ANDI PUTRA 1 8 0 2 0 4 5 7 0 4 8 5 0 0 0 3 MIFTASARI

2 1/3/2022 ERWANSYAH 1 8 0 2 0 4 6 2 0 3 9 3 0 0 0 5 AYU SUMIATI
3 1/3/2022 JAINURI 1 8 0 3 0 8 5 5 0 9 9 6 0 0 0 4 SITI KUSNAENI
4 1/3/2022 MUHAMMAD SAIFUL 1 8 0 2 0 4 7 0 0 5 9 0 0 0 0 3 SETIOWAI
5 1/4/2022 WIDODO 1 8 0 2 0 4 5 9 0 2 8 4 0 0 0 2 ENI PUTRI WATI
6 1/4/2022 KAISAR SOPYANSYAH 1 8 0 2 0 4 7 0 1 2 9 1 0 0 0 3 NURUL HIDAYATI
7 1/4/2022 FIKO FERDIANSYAH 1 6 0 1 0 9 5 5 1 0 9 0 0 0 0 3 EMIL SILVIA
8 1/4/2022 ROHMADI 1 8 0 2 0 4 4 9 0 9 8 7 0 0 0 3 YUNITA MELDASA
9 1/4/2022 NOVI WAHYUDI 1 8 0 2 0 7 4 5 0 9 8 0 0 0 0 5 RIZKI PINDARI
10 1/5/2022 HERIYANI 1 8 0 2 0 4 4 8 0 4 7 4 0 0 0 1 MEGAWATI
11 1/5/2022 PANJI PRASETYA 1 8 0 2 0 4 4 6 1 0 9 2 0 0 0 2 SITI NURBAYA
12 1/5/2022 HUSNAINI 1 8 0 2 0 4 7 1 0 8 8 3 0 0 0 1 SULASMI
13 1/5/2022 KOMANG ARNITE 1 8 0 2 0 4 4 5 0 7 8 0 0 0 0 6 PUJI WAHYUNI
14 1/6/2022 LATIF 1 8 0 2 0 4 5 3 0 3 8 1 0 0 0 3 SULASTRI
15 1/6/2022 M. SUKRI 1 8 0 2 0 4 0 3 0 3 8 2 0 0 0 5 SITI SARAH
16 1/6/2022 YUSRI 1 8 0 2 0 4 4 4 0 4 8 0 0 0 0 7 SURTI
17 1/6/2022 KUSWARA 1 8 0 2 0 4 6 6 1 0 9 6 0 0 0 4 ERLIN FIA SEPTIAN
18 1/7/2022 SUTRISNO 1 8 0 2 0 4 6 9 0 4 8 3 0 0 0 1 NELI SUSANTI
19 1/7/2022 DEVI NIRWANI 1 8 0 2 0 4 4 6 1 2 8 7 0 0 0 1 DEVI NIRWANI
20 1/7/2022 1 8 0 2 0 4 6 8 0 6 8 0 0 0 0 3 ENI ERLINA
21 1/7/2022 1 8 0 2 0 4 0 0 0
22 1/7/2022 1 8 0 2 0 4 0 0 0
23 1/10/2022 1 8 0 2 0 4 0 0 0
24 1/10/2022 1 8 0 2 0 4 0 0 0
25 1/10/2022 1 8 0 2 0 4 0 0 0
26 1/10/2022 1 8 0 2 0 4 0 0 0
27 1/10/2022 1 8 0 2 0 4 0 0 0
28 1/10/2022 1 8 0 3 0 4 0 0 0
29 1/10/2022 1 8 0 2 0 4 0 0 0
30 1/10/2022 1 8 0 2 0 4 0 0 0
31 1/10/2022 1 8 0 2 0 4 0 0 0
32 1/10/2022 1 8 0 2 0 4 0 0 0
33 1/10/2022 1 8 0 2 0 4 0 0 0
34 1/11/2022 1 8 0 2 0 4 0 0 0
35 1/11/2022 1 8 0 2 0 4 0 0 0
36 1/11/2022 1 8 0 2 0 4 0 0 0
37 1/11/2022 1 8 0 2 0 4 0 0 0
38 1/11/2022 1 8 0 2 0 4 0 0 0
39 1/11/2022 1 8 0 2 0 4 0 0 0
40 1/11/2022 1 8 0 2 0 4 0 0 0
41 1/12/2022 1 8 0 2 0 4 0 0 0
42 1/12/2022 1 8 0 2 0 4 0 0 0
43 1/12/2022 1 8 0 2 0 4 0 0 0
44 1/12/2022 1 8 0 2 0 4 0 0 0
45 1/12/2022 1 8 0 2 0 0 0
46 1/13/2022 1 8 0 2 0 0 0
47 1/13/2022 1 8 0 2 0 0 0
48 1/13/2022 1 8 0 2 0 0 0
49 1/13/2022 1 8 0 2 0 0 0
50 1/13/2022 1 8 0 2 0 0 0
51 1/13/2022 1 8 0 2 0 0 0
52 1/13/2022 1 6 0 2 0 0 0
53 1/14/2022 1 8 0 2 0 0 0
54 1/14/2022 1 8 0 2 0 0 0
55 1/14/2022 1 8 0 2 0 0 0
56 1/14/2022 1 8 0 2 0 0 0
57 1/14/2022 1 8 0 2 0 0 0
58 1/15/2022 1 8 0 2 0 0 0
59 1/17/2022 1 8 0 2 0 0 0
60 1/17/2022 1 8 0 2 0 0 0
61 1/17/2022 1 8 0 2 0 0 0
62 1/17/2022 1 8 0 2 0 0 0
63 1/17/2022 1 8 0 2 0 0 0
64 1/17/2022 1 8 0 2 0 0 0
65 1/17/2022 1 8 1 2 0 0 0
66 1/17/2022 1 8 0 6 0 0 0
67 1/17/2022 1 8 0 8 0 0 0
68 1/17/2022 1 8 0 8 0 0 0
69 1/17/2022 1 8 0 2 0 0 0
70 1/17/2022 1 8 1 2 0 0 0
71 1/17/2022 1 8 0 5 0 0 0
72 1/18/2022 1 8 0 8 0 0 0
73 1/18/2022 1 8 0 7 0 0 0
74 1/18/2022 1 8 0 8 0 0 0
75 1/18/2022 1 8 1 1 0 0 0
76 1/19/2022 1 8 0 2 0 0 0
77 1/19/2022 1 8 0 2 0 0 0
78 1/19/2022 1 8 0 2 0 0 0
79 1/19/2022 1 8 0 2 0 0 0
80 1/19/2022 1 8 0 2 0 0 0
81 1/19/2022 1 8 0 2 0 0 0
82 1/20/2022 1 8 0 2 0 0 0
83 1/20/2022 1 8 0 2 0 0 0
84 1/20/2022 1 8 0 2 0 0 0
85 1/20/2022 1 8 0 2 0 0 0
86 1/21/2022 1 8 0 2 0 0 0
87 1/21/2022 1 8 0 2 0 0 0
88 1/21/2022 1 8 0 2 0 0 0
89 1/21/2022 1 8 0 2 0 0 0
 90 1/21/2022 1 8 0 2 0 0 0
91 1/21/2022 1 8 0 2 0 0 0
92 1/21/2022 1 8 0 2 0 0 0
93 1/21/2022 1 8 0 2 0 0 0
94 1/22/2022 1 8 0 2 0 0 0
95 1/22/2022 1 8 0 2 0 0 0
96 1/24/2022 1 8 0 2 0 0 0
97 1/24/2022 1 8 0 2 0 0 0
98 1/24/2022 1 8 0 2 0 0 0
99 1/24/2022 1 8 0 2 0 0 0
100 1/24/2022 1 8 0 2 0 0 0
101 1/25/2022 1 8 0 2 0 0 0
102 1/25/2022 1 8 0 2 0 0 0
103 1/25/2022 1 8 0 2 0 0 0
104 1/25/2022 1 8 0 2 0 0 0
105 1/26/2022 1 8 0 2 0 0 0
106 1/26/2022 1 8 0 2 0 0 0
107 1/26/2022 1 8 0 2 0 0 0
108 1/26/2022 1 8 0 2 0 0 0
109 1/26/2022 1 8 0 2 0 0 0
110 1/27/2022 1 8 0 7
111 1/27/2022 1 8 0 2
112 1/27/2022 1 8 0 7
113 1/28/2022 1 8 0 2
114 1/28/2022 1 8 0 2
115 1/28/2022 1 8 0 7
116 1/28/2022 1 8 0 2
117 1/28/2022 1 8 0 2
118 1/29/2022 1 8 0 2
119 1/29/2022 1 8 0 9
120 1/29/2022 1 8 0 2
 8 0 2 1 5

ISTRI ALAMAT

TANGGAL
NAMA LAHIR

5 6 7

MIFTASARI 4/17/1985 PANGGUNGAN RT/RW 001/004

AYU SUMIATI 3/22/1983 LK. IV PANGGUNGAN UTARA RT/RW 003/004
SITI KUSNAENI 9/15/1996 LK V PANGGUNG ASRI RT/RW 2/5
SETIOWAI 5/30/1985 PANGGUNGAN SELATAN RT/RW 002/004
ENI PUTRI WATI 2/19/1984 GSR, RT/RW 002/004
NURUL HIDAYATI 12/30/1991 JL PATIMURA NO 96 LK II RT/RW 009/003
EMIL SILVIA 10/15/1990 GSR RT/RW 003/004
YUNITA MELDASARI 09/09//87 LK IV PANGGUNGAN RT/RW 002/004
RIZKI PINDARI 9/5/1980 LK IV PANGGUNGAN UTARA RT/RW 002/004
MEGAWATI 4/8/1974 LK IV PANGGUNGAN RT/RW 003/002
SITI NURBAYA 10/6/1992 LK IV PANGGUNGAN RT/RW 003/002
SULASMI 8/31/1983 LK IV PANGGUNGAN RT/TW 002/002
PUJI WAHYUNI 7/5/1980 LK IV PANGUNGAN UTARA RT/RW 001/004
SULASTRI 8/13/1983 LK IV PANGGUNGAN RT/RW 003/002
SITI SARAH 03/03/82 LK IV PANGGUNGAN UTARA RT/RW 001/004
SURTI 4/4/1980 LK IV PANGGUNGAN UTARA RT/RW 001/004
ERLIN FIA SEPTIANA 9/21/1996 LK IV PANGGUNGAN UTARA RT/RW 001/004
NELI SUSANTI 4/29/1983 LK IV PANGGUNGAN RT/RW 003/004
DEVI NIRWANI 12/6/1987 LK IV PANGGUNGAN RT/RW 002/004
ENI ERLINA 6/28/1980 LK VI GAYUH REJO, RT/RW 001/006
 1 2 3 4 5 6
2022
7 8 9 10 11 12

JENIS TINDAKAN KASUS PENGGUNAAN SUMBER

STATUS PESERTA KB (Kode)
(Kode) (Kode) ASURANSI ALOKON

PELAYANAN BERGERAK
INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN

KOMPLIKASI BERAT
OPERATIF/PEMBERIAN/

BPJS KESEHATAN
PENCABUTAN DAN

PENCABUTAN

KEGAGALAN
NO. HANDPHONE

PEMASANGAN

PEMASANGAN

MANDIRI
LAINNYA
TIDAK
APBN
APBD
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

3 √ 3
3 √ 3
2 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 4
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
1 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
1 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
1 √ 3
1 √ 3
PKM GUNUNG
SUGIH

PESERTA KB

NO. TANGGAL ISTRI

NAMA SUAMI
NIK (NOMOR INDUK KEPENDUDUKAN) NAM

1 2 3 4 5

1 1/3/2022 HERI SANTOSO 1 8 0 2 0 4 6 6 0 3 8 7 0 0 0 1 SITI MARDIANA

2 1/3/2022 ARDIYANTO 1 8 0 7 1 3 6 5 0 8 9 7 0 0 0 1 IKA NURJANAH
3 1/3/2022 1 8 0 2
4 1/3/2022 1 8 0 2
5 1/4/2022 1 8 0 2
6 1/4/2022 1 8 0 2
7 1/4/2022 1 8 0 2
8 1/4/2022 1 8 0 7
9 1/4/2022 1 8 0 2
10 1/5/2022 1 8 0 2
11 1/5/2022 1 8 0 2
12 1/5/2022 1 8 0 2
13 1/5/2022 1 8 0 2
14 1/6/2022 1 8 0 2
15 1/6/2022 1 8 0 2
16 1/6/2022 1 8 0 2
17 1/6/2022 3 3 1 8
18 1/7/2022 1 8 0 2
19 1/7/2022 1 8 0 2
20 1/7/2022 1 8 0 2
21 1/7/2022 1 8 0 2
22 1/7/2022 1 8 0 2
23 1/10/2022 1 8 0 2
24 1/10/2022 1 8 0 2
25 1/10/2022 1 8 0 2
26 1/10/2022 1 8 0 2
27 1/10/2022 1 8 0 2
28 1/10/2022 1 8 0 3
29 1/10/2022 1 8 0 2
30 1/10/2022 1 8 0 2
31 1/10/2022 1 8 0 2
32 1/10/2022 1 8 0 2
33 1/10/2022 1 8 0 2
34 1/11/2022 1 8 0 2
35 1/11/2022 1 8 0 2
36 1/11/2022 1 8 0 2
37 1/11/2022 1 8 0 2
38 1/11/2022 1 8 0 2
39 1/11/2022 1 8 0 2
40 1/11/2022 1 8 0 2
41 1/12/2022 1 8 0 2
42 1/12/2022 1 8 0 2
43 1/12/2022 1 8 0 2
44 1/12/2022 1 8 0 2
45 1/12/2022 1 8 0 2
46 1/13/2022 1 8 0 2
47 1/13/2022 1 8 0 2
48 1/13/2022 1 8 0 2
49 1/13/2022 1 8 0 2
50 1/13/2022 1 8 0 2
51 1/13/2022 1 8 0 2
52 1/13/2022 1 6 0 2
53 1/14/2022 1 8 0 2
54 1/14/2022 1 8 0 2
55 1/14/2022 1 8 0 2
56 1/14/2022 1 8 0 2
57 1/14/2022 1 8 0 2
58 1/15/2022 1 8 0 2
59 1/17/2022 1 8 0 2
60 1/17/2022 1 8 0 2
61 1/17/2022 1 8 0 2
62 1/17/2022 1 8 0 2
63 1/17/2022 1 8 0 2
64 1/17/2022 1 8 0 2
65 1/17/2022 1 8 1 2
66 1/17/2022 1 8 0 6
67 1/17/2022 1 8 0 8
68 1/17/2022 1 8 0 8
69 1/17/2022 1 8 0 2
70 1/17/2022 1 8 1 2
71 1/17/2022 1 8 0 5
72 1/18/2022 1 8 0 8
73 1/18/2022 1 8 0 7
74 1/18/2022 1 8 0 8
75 1/18/2022 1 8 1 1
76 1/19/2022 1 8 0 2
77 1/19/2022 1 8 0 2
78 1/19/2022 1 8 0 2
79 1/19/2022 1 8 0 2
80 1/19/2022 1 8 0 2
81 1/19/2022 1 8 0 2
82 1/20/2022 1 8 0 2
83 1/20/2022 1 8 0 2
84 1/20/2022 1 8 0 2
85 1/20/2022 1 8 0 2
86 1/21/2022 1 8 0 2
87 1/21/2022 1 8 0 2
88 1/21/2022 1 8 0 2
89 1/21/2022 1 8 0 2
 90 1/21/2022 1 8 0 2
91 1/21/2022 1 8 0 2
92 1/21/2022 1 8 0 2
93 1/21/2022 1 8 0 2
94 1/22/2022 1 8 0 2
95 1/22/2022 1 8 0 2
96 1/24/2022 1 8 0 2
97 1/24/2022 1 8 0 2
98 1/24/2022 1 8 0 2
99 1/24/2022 1 8 0 2
100 1/24/2022 1 8 0 2
101 1/25/2022 1 8 0 2
102 1/25/2022 1 8 0 2
103 1/25/2022 1 8 0 2
104 1/25/2022 1 8 0 2
105 1/26/2022 1 8 0 2
106 1/26/2022 1 8 0 2
107 1/26/2022 1 8 0 2
108 1/26/2022 1 8 0 2
109 1/26/2022 1 8 0 2
110 1/27/2022 1 8 0 7
111 1/27/2022 1 8 0 2
112 1/27/2022 1 8 0 7
113 1/28/2022 1 8 0 2
114 1/28/2022 1 8 0 2
115 1/28/2022 1 8 0 7
116 1/28/2022 1 8 0 2
117 1/28/2022 1 8 0 2
118 1/29/2022 1 8 0 2
119 1/29/2022 1 8 0 9
120 1/29/2022 1 8 0 2
 8 0 2 1 5

ISTRI ALAMAT

TANGGAL
NAMA LAHIR

5 6 7

SITI MARDIANA 3/26/1987 SRIWALUYO I RT/RW 015/006 BUYUT ILIR

IKA NURJANAH 8/25/1997 DS.2 PUTRA BUYUT RT/RW 004/002
 1 2 3 4 5 6
2022
7 8 9 10 11 12

JENIS TINDAKAN KASUS PENGGUNAAN SUMBER

STATUS PESERTA KB (Kode)
(Kode) (Kode) ASURANSI ALOKON

PELAYANAN BERGERAK
INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN

KOMPLIKASI BERAT
OPERATIF/PEMBERIAN/

BPJS KESEHATAN
PENCABUTAN DAN

PENCABUTAN

KEGAGALAN
NO. HANDPHONE

PEMASANGAN

PEMASANGAN

MANDIRI
LAINNYA
TIDAK
APBN
APBD
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 4
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
3 √ 4
3 √ 3
3 √ 3
1 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
1 √ 4
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
3 √ 3
1 √ 3
1 √ 3