FORMAT PENCAT

TINGKAT PU

Nama Puskesmas/Fasyankes/Pos : Bantuas

Kabupaten/Kota : Samarinda
Provinsi : Kalimantan Timur
Hari, Tanggal : Senin, 29 November 2021

No. Tiket NIK Nama Penerima Vaksin

No

1 P-B28D0VTR OKTAVIA RAMADHINI

6472014910050003
2 6472011110940002
P-BVDZY6UW MUHAMMAD NORHASANDI
3 6472017105940002
P-BMTGJU3T IIN FATMINAWATI
4
P-7WNHZ4KO 6472040203010002 WAHYU SETIAWAN
5 6402156710900001
P-BI5EVI8K LINDA NOVIANTI
6 6472015205990003
P-B5DT300B SULIS TYAMELANI
7
P-6BKC8FIJ 6472011206070001 YUNANDA IQBAL ERMARDIANSYAH
8 6472010609060004
Q-0018XN38 AHMAD
9 6472015910650001
P-AUA2ZARI RUKINAH
10 6472016410980001
Q-00133VRE DITA RAHAYU
11
P-91YF9PMY 6472014302970004 PITRI PURNAMASARI
12 7604075102800004
Q-0018Y7PR HJ RUSNI
13 6472015401840001
P-6MGZJB57 HERLINA
14 6472011904610001
P-66T86XO0 NORHAYADI
15 6472011910730002
P-5QPK3QMH SLAMET MIFTAKHUDIN
16 5316031606850001
Q-00132SHK MUHAMAD BENJAMIN
17 6472015508680004
P-DJLJBDS SALMIAH
18 6472015705580002
S-53080437 RUSMANIAH
19
Q-000RM4GC 6472011606970002 ALDIANUR
20 6472015606620003
P-2S0CL5EI MUSRIPAH
21 6472010606720007
P-HAGLXLD7 SYAHRANI
22 6472011003840001
P-2HUGCCWV ALEXSANDAR BETTENG
23 6472012708060002
Q-0013RIW8 RIDHO SYAHPUTRA
24 6472010507520002
S-B4D90DFD H ASRA
25
P-32GBRFQG 6402072002850001 M RODY KADRAFI
26 6472014905950002
P-2WOLPS2L RAHMAH
27 6471034810760004
P-2UBOK8VF HARIANI
28 3507261105890002
P-2NZAYE4D VIKI AGUNG PRATAMA
29 3509021307870001
P-29OOOYRA TOTOK YULIANTO
30 6472015105770002
P-2DSF8ETU MUSDALIPAH
31 6472010606820002
P-2FA8VO8D SETIAWAN ADI SAPUTRO
32 3527095004840001
Q-0015ON3C SITI ROFI'AH
33 6472015012540001
S-6754D2B7 MASNAH
34 6472015408880001
P-25IVRCLT JELITA JUNAIDI
35 3507071107550006
S-3AE7FF46 SUWONO
36 3527096105040003
Q-0015O5B5 SUSI DARMAWATI
37
Q-001J93QP 3522131011700006 SUPARI
38
P-1WVKWJ2W 64720160099870002 FARAH DYAH FAHRUDIN RAMLI
39
P-1ZAX6PM 6471025703850004 RISMAWATI
40 6472010306790006
Q-0018WWQT BARIANI
41 6472011905080008
P-0UMA2PVY MUHAMMAD RASYA
42 3527090107750457
Q-0015RGSB HADIRI
43 6472012302700001
P-21J8YNIB SYAHRIL
44
Q-000SWVTE 6472016502820002 MARIANI
45 3506086907890004
P-2Q97K90L WAHYUNINGTIAS
46 5203111107850001
P-2ZLFBD1H SUKRIADI
47 6472010905760004
P-34VYMRCX THAMRIN
48 6472016212790002
P-372HPU90 NUR LINA
49 7308122406940001
P-3MY44SOQ MISRANG
50
Q-001GYJEP 6472011608920001 AGUS PIANNUR
51 6472012505990003
P-3OMICWSL ARIANSYAH
52
P-3QHCCV90 5203113112760178 SUPAR
53 5203040303710002
P-3TRLUHSI SAPARUDIN BADNAN
54 5203110107930311
P-46C3VOJT M SARUJI
55 6472017107920005
P-4A6ADRXM LIA PUJI LESTARI
56 6472012403020001
P-4CDM3VP5 MUHAMAD SALMAN
57
P-4EE5DZKA 6472012208710001 DARMADI
58 5316035206720002
Q-00132S30 JAMILA HAMID
59 6472014602780008
- NURAINI
60 5203092405070003
P-5NSCY6R7 M ZAMHARI FALAGUNA
61 6472015504680003
P-5YUC6R5Q KARTINI
62 7604072710850006
P-6EO1D37U NASRUDDIN
63 3518064605960004
P-6TXX2CU1 BINTI UMUL FARIDA
64 6472015412080001
P-8SO9E6PW DEVINIA SYAH PUTRI
65 6472014412660003
P-ACI0JLKB UMIDAH
66 6472016007740001
P-53DJTBO6 TIATUL MARDIAH
67 6472011711740003
P-A23WG0V5 ALFIAN
68 5202063112790087
S-69363163 H FAHMI KAMAR
Keterangan ***Merek Vaksin
* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayan B = Lainnya (Mohon disebutkan jenis vaksin yang diterim
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
≥ 60 tahun 6
Total 0
Pekerjaan:
A 0
B 0
C 0
D 0
E 0
Total 0
ORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Umur
Kelomp
Jenis Pekerjaa Tempat tanggal (18 sd ≥
ok
Kelamin n* Lahir 60
Umur
tahun)

P E 16 0
10/9/2005
L D 26 18-30
10/11/1995
P E 28 18-30
5/31/1994
L D 21 18-30
3/2/2001
P D 31 31-45
10/27/1990
P D 23 18-30
5/12/1999
L E 15 0
6/12/2007
L E 15 0
9/6/2006
P E 36 31-45
10/19/1985
P E 23 18-30
10/24/1998
P E 25 18-30
2/3/1997
P E 42 31-45
2/11/1980
P E 38 31-45
1/14/1984
L D 61 ≥60
4/19/1961
L D 48 46-59
10/19/1973
L D 37 31-45
8/16/1985
L D 54 46-59
8/15/1968
P E 64 ≥60
5/17/1958
L D 25 18-30
6/16/1997
P E 60 ≥60
6/16/1962
L D 50 46-59
6/6/1972
L D 38 31-45
3/10/1984
L E 16 0
8/27/2006
L D 70 ≥60
7/5/1952
L D 37 31-45
2/2/1985
P E 27 18-30
5/9/1995
P E 43 31-45
10/8/1978
L D 33 31-45
5/11/1989
L D 35 31-45
7/13/1987
P E 45 31-45
6/11/1977
L D 40 31-45
6/6/1982
P E 38 31-45
4/10/1984
P E 67 ≥60
12/10/1954
P E 34 31-45
8/14/1988
L D 67 ≥60
7/11/1955
P E 18 18-30
5/21/2004
L D 51 46-59
11/10/1970
P E 34 31-45
9/20/1987
P E 37 31-45
3/17/1985
L D 43 31-45
6/3/1979
L E 14 0
5/19/2008
L D 47 46-59
7/1/1975
L D 52 46-59
2/23/1970
P D 40 31-45
2/25/1982

P E 33 31-45
7/29/1989

L D 37 31-45
7/11/1985
L D 46 46-59
5/9/1976

P E 42 31-45
12/22/1979
P D 28 18-30
6/24/1994

L D 30 18-30
8/16/1992
L D 23 18-30
5/25/1999

L D 45 31-45
12/31/1976

L D 51 46-59
3/3/1971

L D 31 31-45
7/13/1991

P E 30 18-30
7/31/1992

L E 20 18-30
3/24/2002

L D 51 46-59
8/22/1971

P E 50 46-59
6/13/1972

P E 44 31-45
2/5/1978

L E 15 0
5/24/2007

P E 54 46-59
4/15/1968

L D 36 31-45
10/27/1985

P D 26 18-30
5/6/1996

P E 13 0
12/14/2008

P E 55 46-59
12/4/1966

P E 48 46-59
7/20/1974

L D 47 46-59
11/17/1974

L D 42 31-45
12/31/1979
utkan jenis vaksin yang diterima Puskesmas/Faskes)

Kepesertaan BPJS
BPJS PBI 0
BPJS Non PBI 0
Non Anggota 0

Total 0
Pemberian Dosis
Dosis 1 #REF!
Dosis 2 1
Total
ANAAN VAKSINASI COVID-19
ANKES/POS VAKSINASI

181

Kepesertaan BPJS (tulis 'Ya' pada

ALAMAT No. Hp
kolom yang sesuai)

BPJS Non
BPJS PBI
PBI

JL KAMPUNG TENGAH RT 04 081545465815

JL KAMPUNG TNGAH RT 02 082243265802

JL NANAS RT 11 082346565611

JL MASAJI 082252816859

JL KAMPUNG TENGAH RT 03 085244226807

JL AL HASNIE RT 05 082398036234

JL KAMPUNG TENGAH RT02 081347249373

JL AL HASNIE RT 06 085249368041

JL SRIKANDI RT 10 085350465301

JL AL HASNIE RT 05 082219227151

JL AL HASNIE RT 05 081347580401

JL SULAWESI 082357509755

JL BUNGA RT 01 085245800028

JL KAMPUNG TENGAH RT 03 082158119767

JL AL HASNIE RT 05 081254558117

JL AL HASNIE RT 05 085386832560
JL KAMPUNG TENGAH RT 02 082149771790

JL KAMPUNG TENGAH RT 02 082246514667

JL KAMPUNG TENGAH RT 02 082256465930

JL BUNGA RT 01 085245800028

JL SULAWESI 081522527295

JL SULAWESI 081235773090

JL AL HASNIE RT 06 081352232986

JL AL HASNIE RT 06 081346444211

JL AL HASNIE RT 06 082155668312

JL SULAWESI RT 13 085250205072

JL AL HASNIE RT 05 085787585563

JL AL HASNIE RT 05 082251731902

JL SULAWESI RT 12 081234620208

JL SULAWESI RT 13 082250578112

JL SULAWESI 085349497015

JL KAMPUNG TENGAH RT 02 082352092366

JL AL HASNIE RT 05 085347876966

JL MESJID RT 14 085250102961

JL AL HASNIE RT 06 081253485585

JL KAMPUNG TENGAH RT 02 082352092366

BANTUAS 081256510460

JL AL HASNIE RT 06 085155254334

JL SULAWESI 082251146126

JL AL HASNIE RT 05 082148035566

JL SULAWESI RT 13 085651935629

JL KAMPUNG TENGAH RT 02 085246698447

JL AL HASNIE RT 05 082211376202
JL AL HASNIE RT 05 082250850314

JL AL HASNIE RT 05 082326785657

PENGEMBUE RT 00 085389805503

JL AL HASNIE RT 06 081254240366

JL AL HAS IE RT 06 085248160708

JL SULAWESI RT 13 081225949806

JL AL HASNIE RT 06 082154452323

JL KAMPUNG TENGAH RT 04 082250343173

PRINGGAJURANG 081258146267

MANGKING 085249302722

SERIJATA 081251689703

JL KAMPUNG TENGAH RT 02 085246297446

JL BUNGA RT 01 081258013556

JL KAMPUNG TENGAH RT 03 085248966429

JL AL HASNIE RT 05 081237079619

JL AL HASNIE RT 05 081347580401

JL SRIKANDI RT 10 082151711162

JL KAMPUNG TENGAH RT 03 082158119767

JL SULAWESI RT 13 082358421911

JL MILONO RT 14 081355498024

JL KAMPUNG TENGAH RT 04 082251501656

JL KAMPUNG TENGAH RT 02 082149763512

JL KAMPUNG TENGAH RT 02 081347249373

JL KAMPUNG TENGAH RT 04 082157216865

JL AL HASNIE RT 05 082252785572
Pekerjaan
A 0
B 0
C 0

D 0
E 0
Total 0
BPJS (tulis 'Ya' pada Tanggal Nama/Jenis/Merek
Dosis I
yang sesuai) Screening Vaksin***

Non Tanggal Pemberian

Anggota Vaksinasi

29/11/2021 SINOVAC 29/11/2021

29/11/2021 SINOVAC 29/11/2021

29/11/2021 SINOVAC 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC 29/11/2021

29/11/2021 SINOVAC

29/11/2021 SINOVAC 29/11/2021

29/11/2021 SINOVAC

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC

29/11/2021 SINOVAC 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC
29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 21/11/2021

29/11/2021 SINOVAC

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC

29/11/2021 SINOVAC

29/11/2021 SINOVAC 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC

29/11/2021 SINOVAC 29/11/2021

29/11/2021 SINOVAC

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC 29/11/2021

29/11/2021 SINOVAC 29/11/2021

29/11/2021 SINOVAC 29/11/2021

29/11/2021 ASTRAZENECA 29/11/2021

29/11/2021 SINOVAC 29/11/2021

 Dosis I Dosis 2

Tanggal Pemberian
No. Batch No. Serial No. Batch
Vaksinasi

202108173I

202108173I

202108173I

ABZ7661

ABZ7661 30140BA

ABZ7661 30140BA

202108173I
29/11/2028
202108173I

202108173I
29/11/2028
202108173I

ABZ7661
29/11/2028
202108173I

202108173I

ABZ7661

ABZ7661
29/11/2021
202108173I
ABZ7661

ABZ7661
29/11/2021
202108173I

ABZ7661

ABZ7661

ABZ7661
29/11/2021
202108173I

ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661
21/11/2021
202108173I

ABZ7661

ABZ7661

ABZ7661
29/11/2021
202108173I
29/11/2021
202108173I

202108173I

ABZ7661
29/11/2021
202108173I

202108173I
29/11/2021
20210873I

ABZ7661
 29/11/2021 ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661
29/11/2021 2202108173I

ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661

ABZ7661
29/11/2021 202108173I

ABZ7661

202108173I

ABZ7661

ABZ7661

ABZ7661

202108173I

202108173I

202108173I

ABZ7661

ABZ7661
 Keterangan
s2 (Ditunda/Tidak
Diberikan/Lanjut)

No. Serial

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

SELESAI

LANJUT

SELESAI

LANJUT

SELESAI

LANJUT

LANJUT

LANJUT

SELESAI
LANJUT

LANJUT

SELESAI

LANJUT

LANJUT

LANJUT

SELESAI

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

SELESAI

LANJUT

LANJUT

LANJUT

SELESAI

SELESAI

LANJUT

LANJUT

SELESAI

LANJUT

SELESAI

LANJUT
SELESAI

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

SELESAI

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

SELESAI

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT