Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Bener Kelipah

Kabupaten/Kota : Bener Meriah

Provinsi : Aceh
Tanggal ;26-6-2021

No No. Registrasi NIK Nama Penerima Vaksin

1 1 1117051708480000
MUSLIMAR
2 2 1117054606510001
HASANAH

3 3 1117031003900001
JUHRANUDDIN

4 4 1117055804830001
SAMSINAR

5 5 1117051803540001
SYEH MAHMUD

6 6 111705501870001
KAIDAH

7 7 1117056512850002
RUSDA

8 8 1117057007530001
HALIMATUS SAKDIYAH

9 9 1117054610730004
ANISAH

10 10 1117050107630094
HADIRWAN

11 11 1117080506750001
AZZIRAN

12 12 1117055010870006
HASIMAH

13 13 1117050603700001
SUHADA

14 14 1117084710890001
RAHMANI

15 15 1117051507610002
ANSAR SALEH

16 16 117054706810005
MAWADDAH

17 17 1117055502890005
RAHYANI

18 18 117055905940001
LISDAWANI
19 19 1117050805680002
M.ISA

20 20 1117054107730108
JERIAH

21 21 1117052909840003
SABARUDDIN GAYO

22 22 1117054107630077
FATIMAH

23 23 1117050107710083
TAMRIN

24 24 1117084207840001
ISRAH WANI

25 25 1117051606600002
M. ABDUH

26 26 1117055002740005
IRMINA

27 27 1117085109790001
HAYATI

28 28 1117084504890001
SYARIAH

29 29 1117076408950003
MAHARANI

30 30 2117115605839002
TRISNAWATI

31 31 1117074903780001
KAWSARITA

32 32 1117084106800001
SETIAWATI

33 33 1117056103800005
JUMIATI

34 34 1117054804710002
ASMAWATI

35 35 1117054409820005
SUSILAWATI
36 36 1117054107750185
MULYANA

37 37 1110403550863000
ISMI FARIDA

38 38 1117084105910001
ANASTIANA

39 39 1117054404710002
NURJANNAH

40 40 1117050107600109
SAMUDDIN

41 41 1117085212690001
IDAINI

42 42 1117051809760001
FAUZI HANDIKA

43 43 1117054405810004
JARMINAWATI

44 44 1117054306740002
ISNAINI

45 45 111703581890003
FATIMAH

46 46 1117050404800004
SUBAHANDI

47 47 1117050107780096
M. YUNUS

48 48 1117056810850002
SAPURA

49 49 1117050204780007
KAMADDIN

50 50 1117050101570004
M. HASAN

51 51 1117054108010001
ZAIDA AMALA

52 52 1117051612820001
SALMAN FARSI
53 53 1407055703780006
SALFIANI SIREGAR

54 54 1205133012690002
SYAHRIN

55 55 1117056407810004
ISLAMIYAH

56 56 1117050305760004
SURAHMAN

57 57 1117055009700002
SAIMAH

58 58 1117082609940001
JAROT

59 59 1117056412850000
SUSILAWATI

60 60 1117054107650190
NAIMAN

61 61 1117054708730002
RATNA JUWITA

62 62 1117050107720155
SUHADI

63 63 1117055707950003
YUPIDA

64 64 1117057112580003
NURAINI

65 65 1117054910760001
APDAWATI

66 66 1117052208480001
HASANUDIN

67 67 1117051412720003
IRSAD YOGA

68 68 1117050403680003
NURUL HUDA

69 69 1117055308740003
ZULAIHA
70 70 1117054412680003
SAPURA WATI

71 71 1117054107560050
NURBIAH

72 72 1117053112570002
M AMIN

73 73 1117050712810002
HALIDIN

74 74 1117065304830001
NURIDAYANTI

75 75 1117052504880002
DAMAN HURI

76 76 1117055006760003
MILAWARNI

77 77 1117084612810001
MAWADDAH

78 78 1117056308890001
SERIWAHYUNI

79 79 1117054607540001
BASARIAH

80 80 1117080808680001
ABDUS SALAM

81 81 1117054301700001
RAHMAWATI

82 82 1117080211690001
MUHAMAD NAZIR

83 83 1117054107840106
ASNAINI

84 84 1117086608720001
SITI JERIAH

85 85 1117024107730050
RINA

86 86 1117055403750003
KARTINI
87 87 1117056812880001
RASDIANA

88 88 1117054611760001
SAFRIDA

89 89 1117051102780001
MUSPIRA

90 90 1117055610800001
HASNAH

91 91 1117054107740165
RUWAIDA

92 92 1117056411820001
MASTURA

93 93 1104086010940001
KASMAWATI.SM

94 94 1117051004920002
ALI SURAHMAN

95 95 1117055312790001
SUMINI

96 96 111705715970003
LIARIZQIANI

97 97 111705211880001
ALIMSYAH

98 98 1117054712980003
UNGKI RATNA SARI

99 99 1117074107930095
HANISAH PITRI

100 100 1117094701780001

SARIYATI

101 101 1117050101740005

SALWANI

102 102 1117084106800001

SATIAWATI

103 103 1117051510690001

IRSYAD
104 104 1117054912650001
MURNI

105 105 1117060108700001

JAM'AN

106 106 1117054107800125

DIANA

107 107 1117050107730101

SARFIAN

108 108 1117051205900001

SYAIFUL HAIRI

109 109 1117054801830001

MASYANI

110 110 1117050107630061

ALISYAHBANA

111 111 1117057004000002

MAHARANI

112 112 1117052701680001

SAFWAN NAIM

113 113 1117054107650140

SUNARTI

114 114 1117055607690001

KARTINI

115 115 1117052508860002

SUHAIRI

116 116 1117050101760001

KAHARUDDIN

117 117 1117050112770005

ISMAIL

118 118 1117054107660039

RADIATUN

119 119 1117054107790122

SUKMA WATI

120 120 111054107750164

RAMLANI
121 121 1117085212720001
RISNA YANTI

122 122 1117084512820001

JASMANIAR

123 123 1117054107650141

ASMAINI

124 124 1117074702950001

HIDAYATI

125 125 1117054205860004

EVI FITRINA

126 126 1117050806700002

MUSPIDA

127 127 1117054107660049

JURNIALA

128 128 1117044408920002

ZULAIHA

129 129 1117075111930003

HIDAYATI

130 130 1407050905750004

UJANG SAPUTRA

131 131 1117052111680002

ZULKIPLI

132 132 1117054107690071

HALIAH

133 133 1117085203670001

MARYAM

134 134 1117054404720002

SUMARNI

135 135 1117054107640058

MURSIDAH

136 136 1117050107720107

ISRAK

137 137 1117050506830003

MUZAKIR
138 138 1117052709900001
WAJNI

139 139 1106185902860001

ZUBAIDAH

140 140 1117080905910001

SUBHAN

141 141 1117050107650110

SAMSUDDIN

142 142 1117054107570043

HASNAH

143 143 1117081402950001

RIZKI RAMADAN

144 144 1117054107670003

NURAINI

145 145 1117054107620082

NURHAYATI

146 146 1117055404800006

KURNIA RAHMAH

147 147 1117054605690000

HABSAH

148 148 1117050107560065

ZULKIFLI

149 149 1117074403670001

HADIJAH

150 150 1117074204020001

NEIMAMA LINI TEXISEN

151 151 1117056406930001

CITRA ROSNIA DEWI

152 152 1104126412970002

YUNI GEMASIH TEBE

153 153

154 154
155 155

156 156

157 157

158 158

159 159

160 160

161 161

162 162

163 163

164 164

165 165

166 166

167 167

168 168

169 169

170 170

171 171
172 172

173 173

174 174

175 175

176 176

177 177

178 178

179 179

180 180

181 181

182 182

183 183

184 184

185 185

186 186

187 187

188 188
189 189

190 190

191 191

192 192

193 193

194 194

195 195

196 196

197 197

198 198

199 199

200 200

201 201

202 202

203 203

204 204

205 205
206 206

207 207

208 208

209 209

210 210

211 211

212 212

213 213

214 214

215 215

216 216

217 217

218 218

219 219

220 220

221 221

222 222
 223 223

224 224

225 225

226 226

227 227

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Fa
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
 Kelompok Umur:
18-30 0
31-45 0
46-59 0
Total 0
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Jenis Umur
Pekerjaan* Kelompok Umur Alamat
Kelamin (18-59 tahun)

L B 73 0 BENER KELIPAH SELATAN

P B 72 0 BINTANG MUSARA

L A 30 18-30 LOT BENER KELIPAH

L B 38 31-45 DUSUN PORAS

L B 63 0 DUSUN LOT BENER KELIPAH

P B 34 31-45 DUSUN TELEGE MUMATA

L B 36 31-45 DUSUN PORAS

P B 68 0 DUSUN PORAS

P A 45 31-45 BENER KELIPAH SELATAN

L B 58 46-59 DUSUN GENTING

L B 46 46-59 BENER KELIPAH SELATAN

P A 34 31-45 KALA TENANG

L B 51 46-59 BANDAR JAYA

P B 32 31-45 DUSUN LOT BENER KELIPAH

L B 60 0 DUSUN MUSARA

P A 40 31-45 BENER KELIPAH SELATAN

P A 32 31-45 BENER KELIPAH SELATAN

P B 27 18-30 GUNUNG MUSARA

L A 53 46-59 GUNUNG MUSARA

P B 48 46-59 NOSAR BAWAH

L B 37 31-45 DUSUN JONGOK RAYA

P B 58 46-59 NOSAR BAWAH

L B 50 46-59 NOSAR BAWAH

P A 37 31-45 DUSUN ANGKASA

L B 61 0 BENER KELIPAH SELATAN

P B 47 46-59 KALA TENANG

P A 42 31-45 BATIN ATAS

P B 32 31-45 BENER KELIPAH SELATAN

P B 26 18-30 CEDING AYU

P B 43 31-45 BENER KELIPAH SELATAN

P B 43 31-45 BLANG JORONG

P B 41 31-45 GUNUNG MUSARA

P A 41 31-45 NOSAR BAWAH

P B 50 46-59 DUSUN AYU

P A 39 31-45 NOSAR TENGAH

P B 46 46-59 BENER

P B 58 46-59 LOT BENER KELIPAH

P A 30 18-30 NOSAR BAWAH

P B 50 46-59 BENER KELIPAH SELATAN

L B 61 0 NOSAR BAWAH

P B 52 46-59 LOT BENER KELIPAH

L B 45 31-45 NOSAR BAWAH

P A 40 31-45 SIMPANG TERITIT

P B 47 46-59 DUSUN GENTING

P A 32 31-45 BENER KELIPAH SELATAN

L B 41 31-45 DUSUN GENTING

L A 43 31-45 NOSAR BARU

L B 36 31-45 JONGOK ASLI

L B 42 31-45 DUSUN AYU

L B 64 0 NOSAR BAWAH

P B 20 18-30 LOT BENER KELIPAH

L B 39 31-45 DUSUN REJE MULYO

P B 43 31-45 DUSUN BENER

L B 52 46-59 BINTANG MUSARA

P B 40 31-45 DUSUN GENTING

L B 45 31-45 DUSUN GENTING

P B 51 46-59 NOSAR TAWAR JAYA

L A 27 18-30 KALA TENANG

P B 36 31-45 DUSUN SETIE

L B 56 46-59 BINTANG MUSARA

P B 48 46-59 DUSUN SETIE

L B 49 46-59 DUSUN PASAR

P B 26 18-30 DUSUN SETIE

P B 44 31-45 LOT BENER KELIPAH

P B 45 31-45 SUKU BENER

L B 73 0 LOT BENER KELIPAH

L B 49 46-59 BENER KELIPAH SELATAN

P B 53 46-59 BENER KELIPAH UTARA

P B 47 46-59 BENER KELIPAH SELATAN

P B 53 46-59 BENER KELIPAH UTARA

P B 65 0 DUSUN BINA UMAT

L B 64 0 DUSUN PORAS

L B 40 31-45 DUSUN PORAS

P B 32 31-45 DUSUN AMPUN

L B 33 31-45 SUKU BENER

P B 45 31-45 LOT BENER KELIPAH

P B 40 31-45 BENER KELIPAH SELATAN

P B 33 31-45 BENER KELIPAH SELATAN

P B 67 0 DUSUN SAGI

L B 53 46-59 BENER KELIPAH SELATAN

P B 51 46-59 BENER KELIPAH UTARA

L B 52 46-59 BANDAR JAYA

P B 38 31-45 BINTANG MUSARA

P B 49 46-59 BENER KELIPAH UTARA

P B 48 46-59 SUKU BENER

P B 46 46-59 DUSUN SIMAHBENGI

P B 33 31-45 DUSUN NOSAR BAWAH

P B 45 31-45 DUSUN SETIE

L B 38 31-45 DUSUN PORAS

P B 41 31-45 BINTANG MUSARA

P B 47 46-59 BENER KELIPAH UTARA

L B 39 31-45 DUSUN PORAS

P B 28 18-30 DUSUN UJUNG

L B 89 0 DUSUN BUGE MUSARA

P B 42 31-45 DUSUN BUKIT

L B 24 18-30 BAHGIE BERTONA

L B 40 31-45 NOSAR TAWAR JAYA

P B 23 18-30 DUSUN BENARA

P B 28 18-30 DUSUN BUKIT

P A 43 31-45 BENER KELIPAH UTARA

L B 47 46-59 BENER KELIPAH

P B 41 31-45 GUNUNG MUSARA

L B 53 46-59 JONGOK ASLI

P B 56 46-59 JONGOK MELUEM

L B 51 46-59 JONGOK MELUEM

P A 41 31-45 JONGOK MELUEM

L B 48 46-59 JONGOK MELUEM

L A 31 31-45 JONGOK MELUEM

P B 38 31-45 BINTANG MUSARA

L A 58 46-59 JONGOK MELUEM

P B 21 18-30 AYU LOT BENER KELIPAH

L B 53 46-59 JONGOK RAYA

P B 56 46-59 NOSAR BAWAH

P A 52 46-59 JONGOK ASLI

P A 35 31-45 JONGOK ASLI

L B 46 46-59 BINTANG MUSARA

L B 44 31-45 BINTANG MUSARA

L B 55 46-59 JONGOK ASLI

P B 42 31-45 JONGOK ASLI

P B 46 46-59 NOSAR BAWAH

P B 49 46-59 SIMAH BENGI

L A 39 31-45 NOSAR TENGAH

P B 56 46-59 NOSAR BAWAH

P A 26 18-30 NOSAR TENGAH

P B 35 31-45 NOSAR TENGAH

L B 51 46-59 JONGOK ASLI

P B 55 46-59 NOSAR BAWAH

P A 29 18-30 NOSAR TENGAH

P A 27 18-30 BENER PEPANYI

L B 46 46-59 BENER

L B 53 46-59 BENER KELIPAH SELATAN

P B 52 46-59 JONGOK MELUEM

P B 54 46-59 NOSAR BAWAH

P B 49 46-59 JONGOK ASLI

P B 57 46-59 JONGOK ASLI

L B 49 46-59 JONGOK MELUEM

L B 39 31-45 DUSUN MUTUAH

P A 31 31-45 JONGOK ASLI

P B 35 31-45 DUSUN MAHARA

L B 30 18-30 NOSAR TENGAH

L B 56 46-59 NOSAR BAWAH

P B 64 0 JONGOK ASLI

L B 26 18-30 DUSUN MUSARA

P B 54 46-59 NOSAR BAWAH

P B 59 46-59 JONGOK MELUEM

P A 41 31-45 DUSUN MUSARA

L B 52 46-59 DUSUN MUSARA

L B 65 0 NOSAR BAWAH

P B 54 46-59 TAWAR SEDENGE

P B 19 18-30 TAWAR SEDENGE

P B 28 18-30 TAWAR SEDENGE

P A 23 18-30 ACEH TENGAH

0
0

0
0

0
0

0
0

0
 0

n yang diterima Puskesmas/Faskes)

Kepesertaan BPJS Pekerjaan
BPJS PBI 0 A
BPJS Non PBI 0 B
Non Anggota 0 C
Total 0 D
Pemberian Dosis E
Dosis 1 0 Total
Dosis 2 0
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp Merek Vaksin***

BPJS PBI BPJS Non PBI Non Anggota

085276357554 √ Corona , VaC

085261316871 √ Corona , VaC

085275362564 √ Corona , VaC

082362575462 √ Corona , VaC

082299085750 √ Corona , VaC

085277911269 √ Corona , VaC

082262748800 √ Corona , VaC

082237874646 √ Corona , VaC

082381689608 √ Corona , VaC

085250241938 √ Corona , VaC

082262463718 √ Corona , VaC

082261816802 √ Corona , VaC

082272136568 √ Corona , VaC

082360059538 √ Corona , VaC

081319743870 √ Corona , VaC

085245656909 √ Corona , VaC

081265631199 √ Corona , VaC

082161030058 √ Corona , VaC

08528999452 √ Corona , VaC

082384428873 √ Corona , VaC

085277388299 √ Corona , VaC

082384428873 √ Corona , VaC

082384428872 √ Corona , VaC

085379348430 √ Corona , VaC

085262261714 √ Corona , VaC

082361161512 √ Corona , VaC

082279958983 √ Corona , VaC

082283960119 √ Corona , VaC

082277030202 √ Corona , VaC

085270577844 √ Corona , VaC

085296736035 √ Corona , VaC

082360495525 √ Corona , VaC

082366975190 √ Corona , VaC

082231768201 √ Corona , VaC

081260015189 √ Corona , VaC

082294630984 √ Corona , VaC

085262645520 √ Corona , VaC

082361645071 √ Corona , VaC

08221778414 √ Corona , VaC

082260285882 √ Corona , VaC

08227784194 √ Corona , VaC

085359229535 √ Corona , VaC

081212903471 √ Corona , VaC

085270385934 √ Corona , VaC

082262750159 √ Corona , VaC

085270385934 √ Corona , VaC

081212903471 √ Corona , VaC

085297339522 √ Corona , VaC

082231768201 √ Corona , VaC

085296735526 √ Corona , VaC

082217990855 √ Corona , VaC

085398898199 √ Corona , VaC

082215212709 √ Corona , VaC

085262251658 √ Corona , VaC

082217605759 √ Corona , VaC

082217605759 √ Corona , VaC

082248402534 √ Corona , VaC

082271461933 √ Corona , VaC

085296027514 √ Corona , VaC

085260360410 √ Corona , VaC

085358180179 √ Corona , VaC

085360992013 √ Corona , VaC

085211643289 √ Corona , VaC

08229985750 Corona , VaC

082272612716 Corona , VaC

085261272530 √ Corona , VaC

082286854621 Corona , VaC

082214971229 √ Corona , VaC

082286854621 √ Corona , VaC

082214971229 √ √ Corona , VaC

082370506190 √ Corona , VaC

082237874646 √ Corona , VaC

082262748800 √ Corona , VaC

085296805708 √ Corona , VaC

085207679555 √ Corona , VaC

085296263716 √ Corona , VaC

082362463718 √ Corona , VaC

082276735045 √ Corona , VaC

082283960119 √ Corona , VaC

085277045524 √ Corona , VaC

082165569162 √ Corona , VaC

082292445430 √ Corona , VaC

082251499893 √ Corona , VaC

085277045524 √ Corona , VaC

082272612716 √ Corona , VaC

08221189857 √ Corona , VaC

082384425572 √ Corona , VaC

081265626060 √ Corona , VaC

085345996111 √ Corona , VaC

085262251658 √ Corona , VaC

081263378974 √ Corona , VaC

082211750238 √ Corona , VaC

082246318188 √ Corona , VaC

082246318188 √ Corona , VaC

081217992973 √ Corona , VaC

081264408366 √ Corona , VaC

082214971190 √ Corona , VaC

082260539592 √ Corona , VaC

081317992973 √ Corona , VaC

081317992973 √ Corona , VaC

082277200733 √ Corona , VaC

082360495525 √ Corona , VaC

085297281707 √ Corona , VaC

085260856018 √ Corona , VaC

082283382686 √ Corona , VaC

082259488953 √ Corona , VaC

082259488954 √ Corona , VaC

085260856018 √ Corona , VaC

081375784929 √ Corona , VaC

085270923097 √ Corona , VaC

082274734232 √ Corona , VaC

085262467426 √ Corona , VaC

082262713290 √ Corona , VaC

082363189353 √ Corona , VaC

085261808062 √ Corona , VaC

081375784929 √ Corona , VaC

085276861817 √ Corona , VaC

082277626172 √ Corona , VaC

081249369140 √ Corona , VaC

081361705045 √ Corona , VaC

085206280933 √ Corona , VaC

085360158849 √ Corona , VaC

085270242651 √ Corona , VaC

082213041641 √ Corona , VaC

085370027891 √ Corona , VaC

085277311171 √ Corona , VaC

082249358286 √ Corona , VaC

085270987963 √ Corona , VaC

082289979362 √ Corona , VaC

082215212709 √ Corona , VaC

081274532458 √ Corona , VaC

085218316255 √ Corona , VaC

085294621032 √ Corona , VaC

082360729475 √ Corona , VaC

082214606654 √ Corona , VaC

085218316255 √ Corona , VaC

085277615316 √ Corona , VaC

085261925750 √ Corona , VaC

082239009299 √ Corona , VaC

085270987963 √ Corona , VaC

082369214854 √ Corona , VaC

082360729475 √ Corona , VaC

082363786194 √ Corona , VaC

082293159311 √ Corona , VaC

082289979362 √ Corona , VaC

08529764100 √ Corona , VaC

085207365278 √ Corona , VaC

085239091482 √ Corona , VaC

085262170464 √ Corona , VaC

085270006519 √ Corona , VaC

085362290647 √ Corona , VaC

082370137091 √ Corona , VaC

Corona , VaC

Corona , VaC
Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC
Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC
aan
0
0
0
0
0
0
 Dosis I Dosis 2

Tanggal Screening
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi

26-06-2021 26-06-2021 24003921

26-06-2021 26-06-2021 24003921

26-06-2021 26-06-2021 24003921

26-06-2021 26-06-2021 24003921

26-06-2021 26-06-2021 24003921

26-06-2021 26-06-2021 24003921

26-06-2021 26-06-2021 24003921

26-06-2021 26-06-2021 24003921

26-06-2021 26-06-2021 24003921

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26-06-2021 26-06-2021 24003921

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26-06-2021 26-06-2021 24003921

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26-06-2021 26-06-2021 24003921

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24003921

24003921
24003921

24003921

24003921

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24003921

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24003921

24003921

24003921

24003921

24003921

24003921

24003921

24003921

24003921

24003921

24003921
 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Bener Kelipah
Kabupaten/Kota : Bener Meriah
Provinsi : Aceh
Tanggal ;28-6-2021

No No. Registrasi NIK Nama Penerima Vaksin

1 1 1117056903930001
SUCIHATI
2 2 3671054505780023
YUMNA

3 3 1117050207690004
USMAN ALI

4 4 1117024309930001
RAYDA MUNAWARI

5 5 1117052707850003
RAMDONA

6 6 1117055506650002
HALIMAH

7 7 3671050612740009
SUBANDI

8 8 1117055911850002
SUNARTI

9 9 111705205830005
SITI FATIMAH

10 10 1117051811780001
HASRI

11 11 1171061711850002
KAMARUZZAMAN

12 12 1117054404740002
KAHWATINA

13 13 1117054107740138
SUMIATI

14 14 1117054107600133
SUMINAR

15 15 1175026803930001
MARETTA ANAK AMPUN

16 16 1117056308740001
SANAWIYAH

17 17 1117055203930001
LINA HAYATI

18 18 1116064108840003
LEGIYEM
19 19 1116061608810003
AGUS IRAWAN

20 20 1117051706670001
ALFITRA

21 21 1117054107720108
KAMILAH

22 22 1117057012730001
SITI AISYAH

23 23 1117080107940001
SAPUTRA YOGA

24 24 1117074112980001
SALMIYATI

25 25 1117054107670094
HABIBAH

26 26 1117051702800001
SOFA SUSANDI

27 27 1117035408650002
NURHAYATI

28 28 1117010608680002
MUSDIR

29 29 1117032105720001
T. MARDIUS

30 30 1117054107770155
KURNIATI

30 30

31 31

32 32

33 33

34 34
35 35

36 36

37 37

38 38

39 39

40 40

41 41

194 194

195 195

196 196

197 197

198 198

199 199

200 200

201 201

202 202

203 203
204 204

205 205

206 206

207 207

208 208

209 209

210 210

211 211

212 212

213 213

214 214

215 215

216 216

217 217

218 218

219 219

220 220
221 221

222 222

223 223

224 224

225 225

226 226

227 227

228 228

229 229

230 230

231 231

232 232

233 233

234 234

235 235

236 236
 237 237

238 238

239 239

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Fa
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja

Kelompok Umur:
18-30 0
31-45 0
46-59 0
Total 0
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Jenis Umur
Pekerjaan* Kelompok Umur Alamat
Kelamin (18-59 tahun)

P A 28 18-30 DUSUN PASAR

P B 43 31-45 DUSUN PASAR

L B 52 46-59 LOT BENER KELIPAH

P B 28 18-30 DUSUN PASAR

L A 36 31-45 DUSUN PASAR

P B 56 46-59 DUSUN AYU

L B 47 46-59 DUSUN PASAR

P A 36 31-45 BAHGIE BERTONA

P B 38 31-45 KUTE TANYUNG

L B 43 31-45 DUSUN GENTING

L B 36 31-45 DESA JUNGKE

P B 47 46-59 JONGOK MELUEM

P B 47 46-59 JONGOK ASLI

P B 61 0 BINTANG BARU

P B 28 18-30 NOSAR BAWAH

P B 47 46-59 LOT BENER KELIPAH

P A 28 18-30 DUSUN SETIE

P B 37 31-45 LOT BENER KELIPAH

L B 40 31-45 LOT BENER KELIPAH

L B 54 46-59

P B 48 46-59 NOSAR BAWAH

P B 53 46-59 DUSUN AMPUN

L A 28 18-30 NOSAR TAWAR JAYA

P B 22 18-30 DUSUN SETIE

P B 54 46-59 JONGOK MELUEM

P B 39 31-45 NOSAR BAWAH

P B 56 46-59 BLANG SENTANG

L A 53 46-59 GAJAH PUTIH

L A 49 46-59 UNING BERSAH

P A 44 31-45 LOT BENER KELIPAH

0
0

0
0

0
0

0
 0

n yang diterima Puskesmas/Faskes)

Kepesertaan BPJS Pekerjaan

BPJS PBI 0 A
BPJS Non PBI 0 B
Non Anggota 0 C
Total 0 D
Pemberian Dosis E
Dosis 1 0 Total
Dosis 2 0
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp Merek Vaksin***

BPJS PBI BPJS Non PBI Non Anggota

√ Corona , VaC
082364011803
 √ Corona , VaC
082113249188

√ Corona , VaC
082163567092

√ Corona , VaC
082279367530

√ Corona , VaC
082279367530

√ Corona , VaC
082213452196

√ Corona , VaC
082113249188

√ Corona , VaC
081262927286

√ Corona , VaC
085276919321

√ Corona , VaC
085276357203

√ Corona , VaC
082365884012

√ Corona , VaC
085270923097

√ Corona , VaC
085206225412

√ Corona , VaC
082284848058

√ Corona , VaC
082367229320

√ Corona , VaC
082246198080

√ Corona , VaC
085361150113

√ Corona , VaC
081362973582
 √ Corona , VaC
081362973582

√ Corona , VaC

√ Corona , VaC
082360707422

√ Corona , VaC
082299703331

√ Corona , VaC
082274498398

√ Corona , VaC
082321425440

√ Corona , VaC
085362467248

√ Corona , VaC
082275328007

√ Corona , VaC
082210793298

√ Corona , VaC
085277261238

085218556766 √ Corona , VaC

082276188950 √ Corona , VaC

√ Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC
Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC
aan
0
0
0
0
0
0
 Dosis I Dosis 2

Tanggal Screening
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021 28-06-2021 24003921

28-06-2021

28-06-2021

28-06-2021
 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Bener Kelipah
Kabupaten/Kota : Bener Meriah
Provinsi : Aceh
Tanggal : 29-6-2021

No No. Registrasi NIK Nama Penerima Vaksin

1 1 1117054604820003
MAWARNI
2 2 1117055606680002
MURSIYAH

3 3 1117054202860004
ASMIRA

4 4 1117024407900001
SAFRINA

5 5 1117055003860004
MAULIDAINI

6 6 1117054107830122
DIYANA YUSRA

7 7 1117051606650002
HUSNI ANGKASA

8 8 1117055706880002
SURYANI

9 9 1103202412870001
USMAN DANI

10 10 1117056306000001
SIMAHBENGI

11 11 1104124206980001
SIRYANA

12 12 1103244811910002
ZULAEKHA

13 13 1117050610900002
BASILI

14 14 1117086504920001
SANTRI

15 15 1104117012930001
NURMAHYUNI

16 16 1104115906880001
SUSYANTI

17 17 111702290430002
MAKMUR JAYA

18 18 1117054809800003
EMIDAWATI
19 19 1117032912910002
BUHARI MUSLIM

20 20 1117050212900001
RUDI PRAMATA PUTRA

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

30 30

31 31

32 32

33 33

34 34
35 35

36 36

37 37

38 38

39 39

40 40

41 41

194 194

195 195

196 196

197 197

198 198

199 199

200 200

201 201

202 202

203 203
204 204

205 205

206 206

207 207

208 208

209 209

210 210

211 211

212 212

213 213

214 214

215 215

216 216

217 217

218 218

219 219

220 220
221 221

222 222

223 223

224 224

225 225

226 226

227 227

228 228

229 229

230 230

231 231

232 232

233 233

234 234

235 235

236 236
 237 237

238 238

239 239

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Fa
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja

Kelompok Umur:
18-30 0
31-45 0
46-59 0
Total 0
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Jenis Umur
Pekerjaan* Kelompok Umur Alamat
Kelamin (18-59 tahun)

P B 39 31-45 LOT BENER KELIPAH

P B 53 46-59 LOT BENER KELIPAH

P B 35 31-45 LOT BENER KELIPAH

P A 31 31-45 LOT BENER KELIPAH

P B 35 31-45 LOT BENER KELIPAH

P B 38 31-45 DUSUN BENER

L B 56 46-59 LOT BENER KELIPAH

P B 33 31-45 DUSUN BENER

P B 34 31-45 DUSUN JATI

P B 21 18-30 LOT BENER KELIPAH

P B 23 18-30 DUSUN BENER

P B 30 18-30 DUSUN JATI BBJ

L B 30 18-30 LOT BENER KELIPAH

P B 29 18-30 DUSUN BENER

P B 28 18-30 DUSUN BENER

P B 33 31-45 LOT BENER KELIPAH

L B 38 31-45 LOT BENER KELIPAH

P B 41 31-45 JONGOK MELUEM

L A 30 18-30 LOT BENER KELIPAH

L A 31 31-45 DUSUN SEPAKAT

0
0

0
0

0
0

0
 0

n yang diterima Puskesmas/Faskes)

Kepesertaan BPJS Pekerjaan

BPJS PBI 0 A
BPJS Non PBI 0 B
Non Anggota 0 C
Total 0 D
Pemberian Dosis E
Dosis 1 0 Total
Dosis 2 0
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp Merek Vaksin***

BPJS PBI BPJS Non PBI Non Anggota

√ Corona , VaC
085358268640
 √ Corona , VaC
081362135237

√ Corona , VaC
081362135237

√ Corona , VaC
082363143094

√ Corona , VaC
085262122365

√ Corona , VaC
081350552205

√ Corona , VaC
081362135237

√ Corona , VaC
082304200737

√ Corona , VaC
085262133624

√ Corona , VaC
082264747641

√ Corona , VaC
082236629433

√ Corona , VaC
082268272763

√ Corona , VaC
085373114505

√ Corona , VaC
085210259997

√ Corona , VaC
085373114505

√ Corona , VaC
085296520552

√ Corona , VaC
082363143094

√ Corona , VaC
085249490391
 √ Corona , VaC
081342712867

√ Corona , VaC
085277373383

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC
Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC

Corona , VaC
aan
0
0
0
0
0
0
 Dosis I Dosis 2

Tanggal Screening
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

29-06-2021 29-06-2021 24003921

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 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Bener Kelipah
Kabupaten/Kota : Bener Meriah
Provinsi : Aceh
Tanggal : 29-6-2021

No No. Registrasi NIK Nama Penerima Vaksin

1 1 1117054102760004
YURDANI
2 2 1117051708710001
USMAN

3 3 1117055009600001
HARIJAH

4 4 1117055806960002
ASMAUL HUSNA

5 5 1117054612810002
HAJRAWANI

6 6 1117035706790003
RUBIAH

7 7 1113025605760001
HIKMAH

8 8 1117051206910002
MUSTAQIM AZMI

9 9 1117050909880011
JOHANDIKO

10 10 3301052308820003
FADLAN

11 11 1117014105920001
ASMAWATI

12 12 1117054107750140
ALAMSARI

13 13 1103086005900001
FITRIA

14 14 1104120111920001
SUBHAN

15 15 1117034203850001
SUSI YANTI

16 16 1117052611820001
IRSADI. HL

17 17 1117054501920001
MAHYANA

18 18 1117050208920001
ABD. GAFUR
19 19 1117084405830001
AJANAH

20 20 1117055108890001
HAIRAH

21 21 1103200203800001
BAHKRI

22 22 1103205405860001
ANI

23 23 1101086507870003
ERA WATI

24 24 1117054107620096
JUBAIDAH

25 25 1117050107560057
SAMSUDIN.BS

26 26 1112040309880001
ARIF SAPUTRA

27 27 1117054107690087
NASRAH

28 28 1117044701970001
MERI HERAWATI

29 29 1117052711960001
ARAMIKO

30 30 1117055203860007
INDAH PERMATA SARI

30 30 111705010107730133
SAIDUL

31 31 1117034708860005
FITRIANA

32 32 1117051808740001
ISNADI

33 33 1117050307780003
ASRA MUDA

34 34 1117051306800001
MISRAN ALDIAN PUTRA
35 35 1117054403840001
MARLINA

36 36 1104115210720003
SUMARNI

37 37 1117050511740002
MUCHSIN

38 38 1117050708650002
ALIYUS

39 39 1117050708800001
ZULKARNAIN

40 40 1117050504770003
TARLIAN

41 41 1117050809760001
WIN JUSRI

194 194 1117051002840002

SYAMSUL HUDA

195 195 117052603840001

IHWAN

196 196 1117051703930001

RIZKA RAHMADI

197 197 1117050311730001

ADEMI

198 198 1117054203690003

SURIANI

199 199 1117056308700001

MASDIANA

200 200

201 201

202 202

203 203
204 204

205 205

206 206

207 207

208 208

209 209

210 210

211 211

212 212

213 213

214 214

215 215

216 216

217 217

218 218

219 219

220 220
221 221

222 222

223 223

224 224

225 225

226 226

227 227

228 228

229 229

230 230

231 231

232 232

233 233

234 234

235 235

236 236
 237 237

238 238

239 239

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Fa
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja

Kelompok Umur:
18-30 0
31-45 0
46-59 0
Total 0
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Jenis Umur
Pekerjaan* Kelompok Umur Alamat
Kelamin (18-59 tahun)

P B 45 31-45 NOSAR BAWAH

L B 50 46-59 NOSAR BAWAH

P B 61 0 PUJA MULIA

P B 25 18-30 PURWOSARI

P A 40 31-45 BENER KELIPAH SELATAN

P A 42 31-45 KARANG REJO

P A 45 31-45 BINTANG BENER

L B 30 18-30 LOT BENER KELIPAH

L B 33 31-45 LOT BENER KELIPAH

L A 39 31-45 LOT BENER KELIPAH

P B 27 18-30 JONGOK ASLI

P B 46 46-59 JONGOK MELUEM

P B 31 31-45 JONGOK ASLI

L B 29 18-30 KUTE PANANG

P B 36 31-45 LOT BENER KELIPAH

L B 39 31-45 LOT BENER KELIPAH

P B 29 18-30 JONGOK ASLI

L B 29 18-30 LOT BENER KELIPAH

P B 38 31-45 JONGOK MELUEM

P B 32 31-45 LOT BENER KELIPAH

L B 41 31-45 DUSUN MANGGIS

P B 35 31-45 DUSUN MANGGIS

P B 34 31-45 BINTANG MUSARA

P B 59 46-59 NOSAR BAWAH

L B 65 0 JONGOK MELUEM

L B 33 31-45 BINTANG MUSARA

P B 52 46-59 NOSAR TAWAR JAYA

P B 24 18-30 JONGOK MELUEM

L B 25 18-30 JONGOK MELUEM

P B 35 31-45

L B 48 46-59 NOSAR TAWAR JAYA

P B 35 31-45 BATIN BARU

L B 47 46-59 BATIN BARU

L B 43 31-45

L B 41 31-45 LOT BENER KELIPAH

P A 36 31-45 LOT BENER KELIPAH

P B 49 46-59

L B 47 46-59

L B 56 46-59 DUSUN PORAS

L B 41 31-45 DUSUN PORAS

L B 44 31-45 DUSUN PORAS

L B 45 31-45 DUSUN SETIE

L B 37 31-45 LAM BELANG TRIENG

L A 37 31-45 DUSUN PORAS

L A 28 18-30 DUSUN SETIE

L B 48 46-59 LOT BENER KELIPAH

P B 52 46-59 DUSUN TELEGE MUTAMA

P B 51 46-59 DUSUN BERKAT

n yang diterima Puskesmas/Faskes)

Kepesertaan BPJS Pekerjaan

BPJS PBI 0 A
BPJS Non PBI 0 B
Non Anggota 0 C
Total 0 D
Pemberian Dosis E
Dosis 1 0 Total
Dosis 2 0
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp Merek Vaksin***

BPJS PBI BPJS Non PBI Non Anggota

√ Corona , VaC
085297570933
 √ Corona , VaC
085297570933

√ Corona , VaC
085288257522

√ Corona , VaC
082216908170

√ Corona , VaC
085277240206

√ Corona , VaC
081361650734

√ Corona , VaC
085262471212

√ Corona , VaC
085210259997

√ Corona , VaC
082387373529

√ Corona , VaC
082274110997

√ Corona , VaC
082260820044

√ Corona , VaC
082260820044

√ Corona , VaC
082297421352

√ Corona , VaC
082280115630

√ Corona , VaC
085358440079

√ Corona , VaC
085358440079

√ Corona , VaC
082249506094

√ Corona , VaC
082211708618
 √ Corona , VaC
082272534671

√ Corona , VaC
085279225089

√ Corona , VaC
082286748343

√ Corona , VaC
082286748343

√ Corona , VaC
085338818856

√ Corona , VaC
085297570933

√ Corona , VaC
082280115630

√ Corona , VaC
085338818856

√ Corona , VaC
085297570933

√ Corona , VaC
082241946912

0812633658 √ Corona , VaC

√ Corona , VaC

085297570933 √ Corona , VaC

085260982287 √ Corona , VaC

085260982287 √ Corona , VaC

√ Corona , VaC

082215073109 √ Corona , VaC

085277475584 √ Corona , VaC

√ Corona , VaC

√ Corona , VaC

085260399338 √ Corona , VaC

082362077454 √ Corona , VaC

082370672405 √ Corona , VaC

082229210022 √ Corona , VaC

085269857484 √ Corona , VaC

085270008596 √ Corona , VaC

082271374878 √ Corona , VaC

082365295955 √ Corona , VaC

081289824847 √ Corona , VaC

082365977489 √ Corona , VaC

aan
0
0
0
0
0
0
 Dosis I Dosis 2

Tanggal Screening
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi

30-06-2021 30-06-2021 24003921

30-06-2021 30-06-2021 24003921

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 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Bener Kelipah
Kabupaten/Kota : Bener Meriah
Provinsi : Aceh
Tanggal : 06-07-2021

No No. Registrasi NIK Nama Penerima Vaksin

1 1 1117041502580003
JARYANSYAH
2 2 1117075407750003
SAHRANI

3 3 1117085404760001
RATNA DEWI

4 4 1117050508750002
TRI SUYATNO

5 5 1117040607870007
JUMIADI KORPA

6 6 1117055208650003
NURASIAH

7 7 1117054107600151
RUHBANIAH

8 8 11170531240002
M SALEH AB

9 9 1117082405990001
SAHRI

10 10 1117051712980001
INDRA BUDIMAN

11 11 1117054108730003
MASNAH

12 12 1117055405850001
SAMURI

13 13 1117055707740002
RASYIDAH

14 14 1117055207630001
HASANAH

15 15 1117050107650114
BUCHARI

16 16 1104025408890004
PATIMAH

17 17 1117050204580002
BASYAR WIRA S.PD.I

18 18 1117050107760120
ASWANDI
19 19 1117051510680002
RAPANDI

20 20 1117052504760001
KARTAWI

21 21 1117050709920001
SUKRI

22 22 11170347703840004
SUKMIATI

23 23 1117050107770105
RASULAN

24 24 1117054912700003
FARIDA YUSRA

25 25 1117074112890001
SELAMAH

26 26 1117055303740003
SURYANI

27 27 1117055007690004
HUDDENAH

28 28 1117030306940001
MULQIA SAFRAN NAZMI

29 29 1117051507870001
SULAIMAN

30 30 1117074506780001
SAMSIDAR

30 30 1117053012580004
M YUNUS

31 31 1117055708720005
WAHYU

32 32 1117054203400005
HJ JAMILAH

33 33 1117056804990002
ADINDA AFRILIA

34 34 1117054203400005
SRIWINDU
35 35 1117051401920001
SUARDI RIZKI

36 36 1117085512930001
RAHMAYANI

37 37 11170771120870001
ISNAWARNI

38 38 1117015112750001
MASPIDA

39 39 1117050807660001
SAFARUDIN

40 40 1117054712730002
NURLAILA

41 41 1117053008690001
IRPAN SAP

42 42 1117050604880001
HASBI

43 43 1117050609620002
PIRDAUS

44 44 1117051404770002
RISWANDI

45 45 1117056910690001
HASNAWATI

46 46 1117055110580003
SYANI

47 47 1117055706680001
WARDIANA

48 48 1117055706680001
SAWIDAH

49 49 1104030909900001
SAFRIJAL

50 50 1117051005890002
SUHADA

51 51 1117055902640001
MAWARTI
52 52 1117054105910002
HAYATI

53 53 1117055006620002
SURYATI

54 54 1117056008930003
GUSVITA RIANTI

55 55 1117050107880145
MAHMUDIN

56 56 1117051007760001
JOHANSYAH

57 57 1117051111770001
DARMANSYAH

58 58 1117036008810002
ASNIWATI

59 59 1117085306960001
LISA LUSIANA

60 60 1117050701670002
ILIYAS

61 61 1117015404840002
RAHAYUNI

62 62 1117051301730002
DARLIAN HASDI PUTRA

63 63 1117051708890005
AGUSNI

64 64 1117050107840102
EFENDI

65 65 1117052809700003
SUBHAN

66 66 1117050786300002
BAKHTIAR

67 67 1117056304950001
SAIDA AFRIDAYANI

68 68 1117054107770185
RADIAH
69 69 1117054101850004
JANIAR

70 70 1117070711720001
MUCHLIS

71 71 111705490578005
SITI HADIJAH

72 72 1117054404660001
SITI SARAH

73 73 1117060506770002
SAIDI

74 74 1117050411820003
JAUHARI

75 75 1117052906890002
KHAIRUNNAS. Y

76 76 1117081804000001
RUHIJA WANRANTO

77 77 1117055907740002
SAWIDAH

78 78 11117054304710004
ZURAIDAH

79 79 1117081102850001
SOFIANDI

80 80 1117055105860001
ISTIARA

81 81 1117052812730001
RIDWAN MS

82 82 1117056606010002
DIANA PITA SARI

83 83 1117050605750002
SARIPUDIN

84 84 111704026712730002
HIJRAH
 85 85 1117076404830003
HAYATI

86 86 1117056905760001
MAISYARAH

87 87 11170576202660001
RUSDIANA
88 88 1117051712870002
NURHIJRAH NANDA

89 89 1117050197730116
SUKIMAN

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Fa
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
 Kelompok Umur:
18-30 0
31-45 3
46-59 2
Total 5
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Jenis Umur
Pekerjaan* Kelompok Umur Alamat
Kelamin (18-59 tahun)

L B 63 0 BKU
P B 48 46-59 BKU

P B 45 31-45 LOT BENER KELIPAH

L B 46 46-59 BENER LUKUP II

L B 34 31-45 BENER LUKUP II

P B 56 46-59 LOT BENER KELIPAH

L B 61 0 BENER LUKUP II

L B 80 0 BKU

L B 21 18-30 BINTANG MUSARA

L B 21 18-30 BINTANG MUSARA

P B 48 46-59 BKU

P B 36 31-45 BENER LUKUP II

P B 48 46-59 BENER LUKUP II

P B 58 46-59 BENER LUKUP II

L B 56 46-59 BKS

P B 32 31-45 BKU

L B 63 0 LOT BENER KELIPAH

L B 45 31-45 JONGOK MELUEM

L B 53 46-59 BENER LUKUP II

L B 45 31-45 BKS

L B 29 18-30 BENER LUKUP II

P B 35 31-45 PILAR JAYA

L B 44 31-45 NOSAR BARU

L B 51 46-59 LOT BENER KELIPAH

P B 32 31-45 NOSAR BARU

P B 48 46-59 BANDAR JAYA

P B 52 46-59 LOT BENER KELIPAH

L B 27 18-30 JONGOK MELUEM

L B 34 31-45 NOSAR BARU

P B 43 31-45 LOT BENER KELIPAH

L B 63 0 BKU

P B 50 46-59 BKS

P B 87 0 LOT BENER KELIPAH

P B 22 18-30 BENER LUKUP II

P B 53 46-59 LOT BENER KELIPAH

L B 29 18-30 BENER LUKUP II

P B 28 18-30 BENER LUKUP II

P B 34 31-45 GENTING BULEN

P B 46 46-59 BENER LUKUP II

L B 55 46-59 LOT BENER KELIPAH

P B 48 46-59 LOT BENER KELIPAH

L B 52 46-59 BANDAR JAYA

L B 33 31-45 BENER LUKUP II

L B 59 46-59 BKU

L B 44 31-45 BENER LUKUP II

P B 52 46-59 BATIN BANDAR JAYA

P B 63 0 LOT BENER KELIPAH

L B 53 46-59 LOT BENER KELIPAH

P B 52 46-59 LOT BENER KELIPAH

L B 30 18-30 BENER LUKUP II

L B 32 31-45 BUNTUL GAYO

P B 57 46-59 LOT BENER KELIPAH

P B 30 18-30 BUNTUL GAYO

P B 59 46-59 LOT BENER KELIPAH

P B 28 18-30 LOT BENER KELIPAH

L B 33 31-45 BINTANG MUSARA

L B 45 31-45 BENER LUKUP II

L B 44 31-45 BENER LUKUP II

P B 41 31-45 BENER LUKUP II

P B 25 18-30 BKS

L B 54 46-59

P B 37 31-45 LOT BENER KELIPAH

L B 49 46-59 LOT BENER KELIPAH

L B 32 31-45 JONGOK MELUEM

L B 37 31-45 JONGOK MELUEM

L B 51 46-59 BKS

L B 58 46-59 BATIN BARU

P B 26 18-30 JANARATA

P B 44 31-45 BENER LUKUP II

P B 35 31-45 BENER LUKUP II

L B 49 46-59 LOT BENER KELIPAH

P B 43 31-45 BENER LUKUP II

P B 55 46-59 BENER LUKUP II

L B 44 31-45 BKS

L B 39 31-45 BKS

L B 29 18-30

L B 21 18-30 NOSAR BARU

P B 47 46-59 BENER LUKUP II

P B 51 46-59 LOT BENER KELIPAH

L B 37 31-45 GUNUNG MUSARA

P B 36 31-45 BENER LUKUP II

L B 44 31-45 BENER LUKUP II

P B 20 18-30

L B 47 46-59 BENER LUKUP II

P B 48 46-59 LOT BENER KELIPAH

 P A 38 31-45 BENER PEPANYI

P B 45 31-45 BENER LUKUP II

P B 55 46-59 BANDAR JAYA

P B 34 31-45 LOT BENER KELIPAH

L B 48 46-59 BKU

n yang diterima Puskesmas/Faskes)

Kepesertaan BPJS Pekerjaan
BPJS PBI 0 A
BPJS Non PBI 0 B
Non Anggota 0 C
Total 0 D
Pemberian Dosis E
Dosis 1 0 Total
Dosis 2 3
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp Merek Vaksin***

BPJS PBI BPJS Non PBI Non Anggota

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
aan
0
0
0
0
0
0
 Dosis I Dosis 2

Tanggal Screening
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

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6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

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6/7/2021 6/7/2021 24003921

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6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

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6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

6/7/2021 6/7/2021 24003921

 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Bener Kelipah
Kabupaten/Kota : Bener Meriah
Provinsi : Aceh
Tanggal : 07-07-2021

No No. Registrasi NIK Nama Penerima Vaksin

1 1 1117054107870105
ZAHRIKA
2 2 1117054107630080
SITI PATIMAH

3 3 1117050107800165
ATMAJA

4 4 1117050202800002
MARBAWI

5 5 1117052001670002
MUHAMMAD DAUD

6 6 1117054406700010
SUSPARIDAINI

7 7 1117051201710001
ZUHRI HUSAINI

8 8 1117055208650002
RUSMANI

9 9 1117054107800153
MUSLINA

10 10 1117051505780003
SAURI

11 11 1117054107600121
DARMIKA

12 12 1117055806720001
KAMARIAH

13 13 1117051405700003
HASYIMI

14 14 1117055610770001
SALMIAH SK

15 15 1117054503790003
JULAIHAH

16 16 1117071710850003
SUUDDI

17 17 1117051003750001
RUHDI

18 18 1117070807740003
YUSA
19 19 1117054107620100
BASTIAH

20 20 1117081403790001
ALWIN

21 21 1117055127300002
SUHAIBAH

22 22 1117085204820001
SAFRINA WATI

23 23 1117054907590002
KHATIJAH

24 24 1117076101830004
RUKAJAH

25 25 1117054107800157
HAYATI

26 26 1117050102700001
ALI SARWANI

27 27 1117081010840001
MUHAMMAD ILHAM

28 28 1117054107660050
RAMLAH

29 29 1117084103800001
BULKISAH

30 30 1117051202940002
MUSDI

30 30 1117050107680161
RUSDI

31 31 1117036505910002
MAULIDA

32 32 1117054902760002
SITI JORAH

33 33 1117054112850005
KASIMAH

34 34 1117050112650002
MUDA HUSIN
35 35 1117087011500001
NURHAYATI

36 36 1117085601840001
RITA ARMAEDA

37 37 1117057012780004
DARMANIAH

38 38 1117071207920002
ZAINI FAJRI

39 39 1117050501710002
SANIP ARIPIN

40 40 11041500490001
SUSYANTI

41 41 1117050902760002
RAMDAN

42 42 1117050910680002
ALI SARCOANI

43 43 1117053008860001
LIAN SIBARA

44 44 1117084303870001
MUSDALIPAH

45 45 1117054110530001
SAMSIAH

46 46 1117052705600002
ABDURRAHMAN

47 47 1117054803770001
SAHRI DAYANI

48 48 1117050708560002
RAMLAH

49 49 1117054909990005
SASTRI DALILA

50 50 1117056706610001
PAIRAH

51 51 1117050908860002
ALDI M YANI
52 52 1117085107920001
DEVI SARI

53 53 1117056312790001
SUPRIATI

54 54 1117056809950001
RAIHANI TANJUNG

55 55 1117050605950002
EDQITONORA

56 56 1117051105720001
ANSARUDIN

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64 64

65 65

66 66

67 67

68 68
69 69

70 70

71 71

72 72

73 73

74 74

75 75

76 76

77 77

78 78

79 79

80 80

81 81

82 82

83 83

84 84
 85 85

86 86

87 87

88 88

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Fa
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
 Kelompok Umur:
18-30 0
31-45 0
46-59 0
Total 0
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Jenis Umur
Pekerjaan* Kelompok Umur Alamat
Kelamin (18-59 tahun)

P B 34 31-45 BINTANG MUSARA

P B 58 46-59 BINTANG MUSARA

L B 45 31-45 BINTANG MUSARA

L B 41 31-45 BENER LUKUP II

L B 43 31-45 BENER LUKUP II

P B 51 46-59

L B 50 46-59 BKU

P B 56 46-59 BINTANG MUSARA

P B 41 31-45 BINTANG MUSARA

L B 42 31-45 KALA TENANG

P B 61 0 BENER LUKUP II

P B 49 46-59 LOT BENER KELIPAH

P B 51 46-59 LOT BENER KELIPAH

P B 44 31-45 BENER LUKUP II

P B 42 31-45 BENER LUKUP II

L B 36 31-45 BKU

L B 48 46-59 BKU

P B 47 46-59 MUTIARA
P B 59 46-59 BINTANG BARU

L B 42 31-45 NOSAR BARU

P B 41 31-45 PERMATA

P B 36 31-45 LOT BENER KELIPAH

P B 62 0 LOT BENER KELIPAH

P B 38 31-45 MUTIARA

P B 40 31-45 BINTANG MUSARA

L B 51 46-59 BENER LUKUP II

L B 35 31-45 BINTANG MUSARA

P B 55 46-59 BKS

L B 30 18-30 BENER LUKUP II

L B 27 18-30 BENER LUKUP II

L B 53 46-59

P B 30 18-30 BENER LUKUP II

P B 46 46-59 BENER LUKUP II

P B 47 46-59 KALA TENANG

L B 56 46-59 KALA TENANG

P B 71 0 BKU

P B 37 31-45 BENER LUKUP II

P B 45 31-45 BKU

L B 28 18-30 BENER LUKUP II

L B 49 46-59 KALA TENANG

P B 28 18-30 NOSAR BARU

L B 46 46-59 BENER LUKUP II

L B 55 46-59 BKU

L B 35 31-45 LOT BENER KELIPAH

P B 34 31-45 GUNUNG MUSARA

P B 68 0 BKU

L B 61 0

P B 44 31-45 BINTANG MUSARA

L B 65 0 BINTANG BARU

P B 23 18-30 BINTANG MUSARA

P B 60 0 BKS

L B 35 31-45
P B 29 18-30 BKU

P B 42 31-45 BKS

P B 26 18-30 BENER LUKUP II

L B 26 18-30

L B 49 46-59 SUKU BENER

n yang diterima Puskesmas/Faskes)
Kepesertaan BPJS Pekerjaan
BPJS PBI 0 A
BPJS Non PBI 0 B
Non Anggota 0 C
Total 0 D
Pemberian Dosis E
Dosis 1 0 Total
Dosis 2 4
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp Merek Vaksin***

BPJS PBI BPJS Non PBI Non Anggota

√ Corona , VaC
085214078405
 √ Corona , VaC
085214078405

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

Corona , VaC

√ Corona , VaC
aan
0
0
0
0
0
0
 Dosis I Dosis 2

Tanggal Screening
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

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7/7/2021 7/7/2021 24003921

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7/7/2021 7/7/2021 24003921

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7/7/2021 7/7/2021 24003921

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7/7/2021 7/7/2021 24003921

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7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

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7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

7/7/2021 7/7/2021 24003921

 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Bener Kelipah
Kabupaten/Kota : Bener Meriah
Provinsi : Aceh
Tanggal : 09-07-2021

No No. Registrasi NIK Nama Penerima Vaksin

1 1 1117051008750001
HUDDNI
2 2 1111705630700001
SARDIANI

3 3 111705010760083
MUCHLIS

4 4 1117056107720003
JURMANILA

5 5 1117050811790002
SULAIMAN

6 6 1117086901020001
ENDANG FITRI WAHDANI

7 7 1117052307650001
JUNAIDI

8 8 1117051406940001
INDRA JAYADI

9 9 1117055909730001
JARKIAH

10 10 1117050410720003
HASANUDDIN

11 11 1117055005720002
IRMAWATI

12 12 1117056307000003
WARDIANA

13 13 1117050103710006
SUPARDI

14 14 1104046512920001
DESI PITRI ARA

15 15 1117055108830002
GUSNIARTI

16 16 1117056207730002
JULIANA

17 17 1117054107750135
NURHASANAH

18 18 1117081208780001
WAHDANI
19 19 1117031212870002
JAYA MIKO

20 20 1117082508890001
MIFTAHUL FAUZI

21 21 1117055412820001
SUARNI

22 22 1117085204780001
FATMAWATI

23 23 1117081212750001
JOHANSYAH

24 24 1117054812750005
MASMIRI

25 25 1117055609020001
SAFIRA HIDAYAH

26 26 1117051606770003
M. MABRURA

27 27 1117074504780001
BULKISAH

28 28 1117070102770002
SARIFUDDIN

29 29 1117051009730002
ALFIAN FAUZI

30 30 1117056509930001
SARMILA

30 30 1117057001700001
MARYANI

31 31 1117055309980003
MAHYANA PENAWAR NATE

32 32 1117054107760140
HASANAH

33 33 1117051408010002
MUARA BAHGIE

34 34 1117055211650002
JUNIAR
35 35 1104171009870002
ARHAM

36 36 1117054107770169
SUKMAWATI

37 37 1117054705820003
FITRI DEWI

38 38 1117050909800002
RESTU NIKA PUTRA

39 39 1117054309940001
LISNAWATI

40 40 1104172707970002
ARIP JULIAN SUTRISNO

41 41 1104102006970001
MUHAMMAD NAJARUDDIN

42 42 1117052401880002
LUKMAN HAKIM

43 43 1117076209950002
YAUMA KAMILA

44 44 1117054708670002
JEMIAH

45 45 1117056103770003
SAKDIAH

46 46 1117054205720001
MISDAWATI

47 47

48 48

49 49

50 50

51 51
52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64 64

65 65

66 66

67 67

68 68
69 69

70 70

71 71

72 72

73 73

74 74

75 75

76 76

77 77

78 78

79 79

80 80

81 81

82 82

83 83

84 84
 85 85

86 86

87 87

88 88

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Fa
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
 Kelompok Umur:
18-30 0
31-45 0
46-59 0
Total 0
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Jenis Umur
Pekerjaan* Kelompok Umur Alamat
Kelamin (18-59 tahun)

L B 45 31-45 BKS
P B 21 18-30 LOT BENER KELIPAH

L B 59 46-59 JONGOK MELUEM

P B 49 46-59 JONGOK MELUEM

L B 45 31-45 BANDAR JAYA

P B 20 18-30 LOT BENER KELIPAH

L B 56 46-59 MULYA JAYA

L B 27 18-30 DUSUN GENTING

P B 46 46-59 BANDAR JAYA

L B 49 46-59 BENER LUKUB II

P B 49 46-59 BENER LUKUB II

P B 21 18-30 LOT BENER KELIPAH

L B 49 46-59 LOT BENER KELIPAH

P B 28 18-30 JONGOK MELUEM

P B 38 31-45 JONGOK ASLI

P B 48 46-59 MULYA JAYA

P B 45 31-45 JONGOK MELUEM

P B 43 31-45 BANDAR JAYA

L B 34 31-45 JONGOK MELUEM

P B 32 31-45 BANDAR JAYA

P B 35 31-45 LOT BENER KELIPAH

P B 36 31-45 BANDAR JAYA

L B 45 31-45 BANDAR JAYA

L B 45 31-45 LOT BENER KELIPAH

P B 21 18-30 LOT BENER KELIPAH

L A 41 31-45 LOT BENER KELIPAH

P B 43 31-45 BENER LUKUB II

L B 43 31-45 BENER LUKUB II

L B 48 46-59 LOT BENER KELIPAH

P B 28 18-30 JONGOK ASLI

P B 51 46-59 TAWAR NATE

P B 23 18-30 JONGOK ASLI

P B 45 31-45 BKU

P B 22 18-30 BKU

P B 56 46-59 BKU
L B 34 31-45 BENER LUKUB II

P B 44 31-45 LOT BENER KELIPAH

P B 39 31-45

L B 42 31-45 BENER LUKUB II

P B 27 18-30 LOT BENER KELIPAH

L B 24 18-30 LOT BENER KELIPAH

L B 24 18-30 KETOL

L B 33 31-45 LOT BENER KELIPAH

P B 26 18-30 UNING SEJUK

P B 54 46-59 DUSUN PORAS

P B 44 31-45 DUSUN PORAS

P B 48 46-59 DUSUN PORAS

n yang diterima Puskesmas/Faskes)
Kepesertaan BPJS Pekerjaan
BPJS PBI 0 A
BPJS Non PBI 0 B
Non Anggota 0 C
Total 0 D
Pemberian Dosis E
Dosis 1 0 Total
Dosis 2 0
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp Merek Vaksin***

BPJS PBI BPJS Non PBI Non Anggota

√ Corona , VaC
 √ Corona , VaC
082260321792

√ Corona , VaC
085261756638

√ Corona , VaC
082235027905

√ Corona , VaC
085275174204

√ Corona , VaC
082286655770

√ Corona , VaC
085275728463

√ Corona , VaC
08126969001

√ Corona , VaC
085213965190

√ Corona , VaC
082362066977

√ Corona , VaC
082362066977

√ Corona , VaC
082231469502

√ Corona , VaC
085276672022

√ Corona , VaC
085296009615

√ Corona , VaC
085261756638

√ Corona , VaC
085275728463

√ Corona , VaC
082261694651

√ Corona , VaC
082277584206
 √ Corona , VaC
081334295405

√ Corona , VaC
082161448193

√ Corona , VaC
081343295405

√ Corona , VaC
082269188317

√ Corona , VaC
082269188317

√ Corona , VaC
085283413526

√ Corona , VaC
082298759202

√ Corona , VaC
082370974485

√ Corona , VaC
085294546209

√ Corona , VaC
085294546209

085210433573 √ Corona , VaC

081343295405 √ Corona , VaC

082282013659 √ Corona , VaC

082277825138 √ Corona , VaC

081253378210 √ Corona , VaC

082165867438 √ Corona , VaC

082165867438 √ Corona , VaC

 √ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

085373742564 √ Corona , VaC

085373742564 √ Corona , VaC

082296973817 √ Corona , VaC

085213018727 √ Corona , VaC

085296742382 √ Corona , VaC

081370243227 √ Corona , VaC

08223773076 √ Corona , VaC

081269160023 √ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

Corona , VaC

√ Corona , VaC
aan
0
0
0
0
0
0
 Dosis I Dosis 2

Tanggal Screening
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi

9/7/2021 24003921
9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/72021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/72021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

9/7/2021 9/7/2021 24003921

 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Bener Kelipah
Kabupaten/Kota : Bener Meriah
Provinsi : Aceh
Tanggal : 12-07-2021

No No. Registrasi NIK Nama Penerima Vaksin

1 1 1117051008750001
HUDDNI
2 2 1111705630700001
SARDIANI

3 3 111705010760083
MUCHLIS

4 4 1117056107720003
JURMANILA

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

14 14

15 15

16 16

17 17

18 18
19 19

20 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

30 30

31 31

32 32

33 33

34 34
35 35

36 36

37 37

38 38

39 39

40 40

41 41

42 42

43 43

44 44

45 45

46 46

47 47

48 48

49 49

50 50

51 51
52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64 64

65 65

66 66

67 67

68 68
69 69

70 70

71 71

72 72

73 73

74 74

75 75

76 76

77 77

78 78

79 79

80 80

81 81

82 82

83 83

84 84
 85 85

86 86

87 87

88 88

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Fa
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
 Kelompok Umur:
18-30 0
31-45 0
46-59 0
Total 0
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Jenis Umur
Pekerjaan* Kelompok Umur Alamat
Kelamin (18-59 tahun)

L B 45 31-45 BKS
P B 21 18-30 LOT BENER KELIPAH

L B 59 46-59 JONGOK MELUEM

P B 49 46-59 JONGOK MELUEM

n yang diterima Puskesmas/Faskes)
Kepesertaan BPJS Pekerjaan
BPJS PBI 0 A
BPJS Non PBI 0 B
Non Anggota 0 C
Total 0 D
Pemberian Dosis E
Dosis 1 0 Total
Dosis 2 0
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp Merek Vaksin***

BPJS PBI BPJS Non PBI Non Anggota

√ Corona , VaC
 √ Corona , VaC
082260321792

√ Corona , VaC
085261756638

√ Corona , VaC
082235027905

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC

√ Corona , VaC
√ Corona , VaC

√ Corona , VaC

Corona , VaC

√ Corona , VaC
aan
0
0
0
0
0
0
 Dosis I Dosis 2

Tanggal Screening
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

12/7/2021 12/7/2021 24003921

 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)