Format Pencatatan Manual Hasil Pelayanan Vaksinasi Manual PATARUMAN 3

Nama Puskesmas/Fasyankes/Pos
Kabupaten/Kota
Provinsi
No No. Tiket
1 N-1A3D5C51
2 N-4F01F71D
3 N-6A5DD82C
4 N-7B385153
5 N-8F9AB89C
6 N-A53E7314
7 N-AD524C2D
8 N-BC4B8679
9 BLM TERDAFTAR
1 N-B8E3E47
2 N-015CD120
3 N-C9F5623F
4 N-2566DAE9
5 N-0DF567BD
6 N-FC07E4F4
7 N-723BB29C
8 P-01I1TGW7
9 N-AA1B9EFE
10 N-071280D7
11 N-28E6D5B2
1 P-19S95XJH
2 P-19VUY0XH
3 P-1A0TDEPE
4 P-1A1TVZ19
5 P-1AC4VLIC
6 P-1AFXSZCL
7 P-1AST3TYD
8 P-1AVI2D0J
9 P-1AAVQKL1
10 P-1A6WZ97O
11 P-1A9A4SM2
12 P-1APRCGRP
13 P-1AIU4WJR
14 P-1AIU4WJR
15 P-16C7FWI7
16 P-16BN9A78
17 P-1A5LSYC7
18 P-1DYZY7LY
19 P-1DIEQPCL
20 P-1DHBDNCB
21 P-1DXGFP5Z
22 P-1DECFQUK
23 P-1DN4OS27
24 P-1E8E9X8D
25 P-1E6AIJKV
26 P-1DBWKPGS
27 P-1E44UCRZ
28 P-1E1LJBT1
29 P-1E0CMYID
30 P-1DBWKPGS
51 P-1K758QY1
52 P-1K52I3TH
1 W-6303DDFA
2 W-AF8069F8
3 W-9C5791F3
4 W-26047934
5 W-37A506DD
6 W-B5748D11
7 W-14E02661
8
9 P-00UG3QVM
10 W-88ACA9D8
11 W-C916741A
12 W-60D801BA
13 W-CAF178DB
14 W-932CE9C8
15 W-4A3ED16E
16 P-DFF54422
17 W-6218FD9C
18 W-AC0715B5
19 W-8A2E99B4
1 P-0D115A77
2 P-20CDA795
3 P-E685CEA6
4 P-3BFA1B2A
5 P-F87EAA0A
6 P-6A304756
7 P-3124A60C
8 P-18F6B4B2
9 P-D7FAC28B
10 P-EE435BEC
11 P-E357790C
12 W-64B61D00
13 N-9252F430
14 P-3OO1SS79
15 P-3OSUZG1S
16 P-3PEYXRVV
17 P-3PR5CXFN
18 P-3R0OTBIW
19 P-1CY1D20B
20 N-56C96E00
21 S-A44D7934
22 N-4A892BC0
23 P-3RVXKRUR
24 S-6C6F4593
25 N-546EDC30
26 P-3S5FPUAU
27 N-45C87880
28 P-DF2ED9F6
29 P-494BCE5F
30 P-0AFFC4DC
31 P-399408C3
32 P-4470837C
33 P-FF23AA8A
34 P-9C11CDB4
35 P-0460B5FD
36 P-D7E19DA5
37 P-C116D427
38 P-71585F41
39 P-AF478C6C
40 P-404DC7DA
41 P-9329D4F4
42 P-6DAED8AE
Keterangan
* Pekerjaan dikelompokkan menjad
A = Petugas Medis dan Non Medis
B = Petugas pelayanan publik yang
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
NIK
3279024310860001
3279021510650005
3279026209770001
3279025212960004
3279024302660002
3279016501710001
3279026606750001
3279020502730001
3279022402930002
9171034707680005
3279025611810003
3279013107780001
3279034803850003
3279014607860003
3279014604710002
3279024303740001
3279027003000002
3279024506750002
3207014212850001
3279027112790001
3279022011570001
3279045701980000
3279012004740002
3279021508810001
3674055904870001
3279047010990001
3279025509910000
3279026102990002
3279020909000001
3279020307930001
3279016503900002
3279036111870001
3279026509010001
3279024506920001
3279016407910001
3279011711840001
3279024103590004
3206086707880001
3207175509840003
3207175707910001
1804056209890001
3213012708940001
3279021907980002
3279020211980001
3279010506640004
3207041605750002
3279045904910001
3279026509950002
3279014801970001
3279015902010003
3279026604520001
3279022707480001
3279024310860001
3279021510650005
3279026209770001
3279025212960004
3279024302660002
3279016501710001
3279026606750001
3279020502730001
3279022402930002
3279025611810003
3279013107780001
3279034803850003
3279014607860003
3279014604710002
3279024303740001
3279027003000002
3279024506750002
3207014212850001
3279027112790001
3279045701980000
3279012004740002
3279021508810001
3674055904870001
3279025509910000
3279026102990002
3279020909000001
3279020307930001
3279016503900002
3279036111870001
3279016407910001
3273255410880002\
3207036908970000
3279026807950000
3279025707930000
3207214807890000
3279026211970000
3207185201920000
3302215908870000
3279025808760000
3207126012920000
3207105604880000
3205016809950000
3277025112940010
3279024504910000
3279016503850000
9171034707680005
3279011711840001
3206086707880001
3207175509840003
3207175707910001
1804056209890001
3213012708940001
3279021907980002
3279020211980001
3279010506640004
3207041605750002
3279045904910001
3279026509950002
3279014801970001
3279015902010003
3279047010990001
kkan menjadi:
Non Medis di Fasilitas Pelaya
publik yang berhadapan langsung den
erintahan
Kelom
18-30
31-45
46-59
Total
Pek
A
B
C
D
E
Total
: BLUD UPTD PUSKESMAS PATARUMAN 3
: KOTA BANJAR
: JAWA BARAT
Nama Penerima Vaksin
DEVI OKTAVIANY
DASMAN
ANENG YUNENGSIH
Devi Siti Rohmah, A.Md. Kep
NIA KANIA
ANCE EKA WIDIANTI
DADAH UKIDAH RATNADARYATI
H. ATENG
WIGI TRI PEBRIANA
SOLIKAH
INTAN NARULITA
JULI ARIKO SANDHI
YUYUM JUM'ATI SETYA I
YULIA RISMAYANTI
SETIAWATI
TETI NURHAETI
NADYA SOPYANI
NARTIAH
RIDA NENGSIH
DESI EKARINI WIYANTI
H. ABDURRAUF KANDANG MANO
FITRI HIDAYAH
AHMAD HIDAYAT
TOTO SAEPUDIN
ANE APRIANI
NIDA OKTAVIANI
LENI MULYAWATI
REZCA JANESTRIE
IMRON NURYANA
YOGI NUR ROHMAN
ARESTA LISTIOWATI
NIKMA NOVALINA
MIRDA SEPTIANI
DINA PAMELAWATI
SALMA ADAWIYAH
ARI TANRI NOFANA
ENI ROSTINI
Desri Nurajizah, A.Md.Keb
Siti Sopiatun, A.Md.Keb
SITI HARDIYANTI
Nida Ulfatusholihah, A.Md.Keb
Irpan Maulana
Corry Firmansyah
Ridwan
Herman
Deni
Nevi Riani, S.Farm.,Apt
Novi Setiani
Iis Tati Marlina
Shania Setyawati
ENTIN SUNARTI
H. ADE SUKANDA RAFE'I
DEVI OKTAVIANY
DASMAN
ANENG YUNENGSIH
Devi Siti Rohmah, A.Md. Kep
NIA KANIA
ANCE EKA WIDIANTI
DADAH UKIDAH RATNADARYATI
H. ATENG
WIGI TRI PEBRIANA
INTAN NARULITA
JULI ARIKO SANDHI
YUYUM JUM'ATI SETYA I
YULIA RISMAYANTI
SETIAWATI
TETI NURHAETI
NADYA SOPYANI
NARTIAH
RIDA NENGSIH
DESI EKARINI WIYANTI
FITRI HIDAYAH
AHMAD HIDAYAT
TOTO SAEPUDIN
ANE APRIANI
LENI MULYAWATI
REZCA JANESTRIE
IMRON NURYANA
YOGI NUR ROHMAN
ARESTA LISTIOWATI
NIKMA NOVALINA
SALMA ADAWIYAH
NIKITA IRZANA UTAMI
TINA SITI ROHMAH
ERNAWATI
NITA JULISTIANI
ERI NURYANI
YUNITA HIDAYATI
RATNA
AGUSTINA IIN KURNIATI
NINA KHRISNAHAYATI BARJAH
DINI ARYANTI
IKA SRIHAYATI
MUTHIYA NUR AZIZAH
SHARFINA NISA HANIFAH
EGIS SUGIARTI
UCI SUSILAWATI SAPUTRA
SOLIKAH
ARI TANRI NOFANA
Desri Nurajizah, A.Md.Keb
Siti Sopiatun, A.Md.Keb
SITI HARDIYANTI
Nida Ulfatusholihah, A.Md.Keb
Irpan Maulana
Corry Firmansyah
Ridwan
Herman
Deni
Nevi Riani, S.Farm.,Apt
Novi Setiani
Iis Tati Marlina
Shania Setyawati
NIDA OKTAVIANI
A = Sinovac
B = Lainnya (Mohon disebutkan jen
ngsung dengan masyarakat
Kelompok Umur:
3
9
8
20
Pekerjaan:
0
0
0
0
0
0
Jenis
Kelamin
P
L
P
P
P
P
P
L
L
P
P
L
P
P
P
P
P
P
P
P
L
P
L
L
P
P
P
P
L
L
P
P
P
P
P
L
P
P
P
P
P
L
L
L
L
L
P
P
P
P
P
L
P
L
P
P
P
P
P
L
L
P
L
P
P
P
P
P
P
P
P
P
L
L
P
P
P
L
L
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
L
P
P
P
P
L
L
L
L
L
P
P
P
P
P
yang diterima Puskesmas/Faskes)

FORMAT PENCATATAN PEL
TINGKAT PUSKESMAS
Pekerjaan*
PERAWAT GIGI
PENJ. MALAM
BIDAN
PERAWAT
PET. KEBERSIHAN
DOKTER
BIDAN
PERAWAT
TENAGA ADMIN/SUKWAN
BENDAHARA
BIDAN
ANALIS
BIDAN
PERAWAT
PERAWAT
BIDAN
TENAGA ADMIN/SUKWAN
BIDAN
DOKTER
PERAWAT
DOKTER
NAKES LAINNYA
NAKES LAINNYA
NAKES LAINNYA
BIDAN
BIDAN
BIDAN
BIDAN
NAKES LAINNYA
PERAWAT
APOTEKER
APOTEKER
NAKES LAINNYA
NAKES LAINNYA
ASISTEN APOTEKER
NAKES LAINNYA
BIDAN
BIDAN
BIDAN
BIDAN
BIDAN
KEUANGAN
PEKARYA
NAKES LAINNYA
NAKES LAINNYA
KEAMANAN
APOTEKER
FARMASI
FARMASI
NAKES LAINNYA
TENAGA KESEHATAN
DOKTER
PERAWAT GIGI
PENJ. MALAM
BIDAN
PERAWAT
PET. KEBERSIHAN
DOKTER
BIDAN
PERAWAT
TENAGA ADMIN/SUKWAN
BIDAN
ANALIS
BIDAN
PERAWAT
PERAWAT
BIDAN
TENAGA ADMIN/SUKWAN
BIDAN
DOKTER
PERAWAT
NAKES LAINNYA
NAKES LAINNYA
NAKES LAINNYA
BIDAN
BIDAN
BIDAN
NAKES LAINNYA
PERAWAT
APOTEKER
APOTEKER
ASISTEN APOTEKER
DOKTER GIGI
BIDAN
NAKES LAINNYA
NAKES LAINNYA
BIDAN
NAKES LAINNYA
BIDAN
BIDAN
BIDAN
ANALIS KESEHATAN
PROMKES
AHLI GIZI
KESLING
PERAWAT
BIDAN
BENDAHARA
NAKES LAINNYA
BIDAN
BIDAN
BIDAN
BIDAN
KEUANGAN
PEKARYA
NAKES LAINNYA
NAKES LAINNYA
KEAMANAN
APOTEKER
FARMASI
FARMASI
NAKES LAINNYA
BIDAN
a Puskesmas/Faskes)
Kepesertaan BPJS
BPJS PBI
BPJS Non PBI
Non Anggota
Total
Pemberian Dosis
Dosis 1
Dosis 2
Total
ATAN PELAKSANAAN VAKSINASI COVID-19
KESMAS/FASYANKES/POS VAKSINASI
Umur Kelom
(18-59 pok
tahun) Umur
34 31-45
55 46-59
43 31-45
24 18-30
54 46-59
49 46-59
45 31-45
48 46-59
27 18-30
52 46-59
40 31-45
43 31-45
36 31-45
35 31-45
50 46-59
47 46-59
21 18-30
46 46-59
36 31-45
42 31-45
65 >60
24 18-30
48 46-59
41 31-45
45 31-45
22 18-30
30 18-30
22 18-30
21 18-30
28 18-30
30 18-30
34 31-45
20 18-30
21 18-30
29 18-30
37 31-45
62 >60
33 31-45
37 31-45
29 18-30
32 31-45
25 18-30
23 18-30
23 18-30
57 46-59
46 46-59
29 18-30
26 18-30
24 18-30
20 18-30
69 >60
73 >60
34 31-45
55 46-59
43 31-45
24 18-30
54 46-59
49 46-59
45 31-45
48 46-59
27 18-30
40 31-45
43 31-45
36 31-45
35 31-45
50 46-59
47 46-59
21 18-30
46 46-59
36 31-45
42 31-45
24 18-30
48 46-59
41 31-45
45 31-45
30 18-30
22 18-30
21 18-30
28 18-30
30 18-30
34 31-45
29 18-30
33 31-45
24 18-30
26 18-30
28 18-30
32 31-45
24 18-30
29 18-30
34 31-45
45 31-45
29 18-30
33 31-45
26 18-30
27 18-30
30 18-30
36 31-45
52 46-59
37 31-45
33 31-45
37 31-45
29 18-30
32 31-45
25 18-30
23 18-30
23 18-30
57 46-59
46 46-59
29 18-30
26 18-30
24 18-30
20 18-30
22 18-30
0
19
1
20
20
0
SINASI COVID-19
VAKSINASI
Alamat
LINGK. JELAT 1/3 KEL.PATARUMA

LEMBURBALONG 3/8. PATARUMA
DUSUN PANANJUNG 23/5, SINAR
LINGK. PANATASAN 1/20, KEL. PA
PANANJUNG TIMUR 30/07, SINAR
LINGK. BANJAR 4/2 KEL.BANJAR
LINGK. PATARUMAN 1/12, KEL. P
LANGKAP LANCAR, KEL. BOJONG
RANCAKOLE 2/2, DESA MULYASA
DUSUN PARUNG 41/4, BALOKAN
LINGKUNGAN PATARUMAN 02/13
JL. DIPATI UKUR 01/13, LINGK BA
CIMENYAN I 03/05, MEKARSARI
LINGK. BANJARKOLOT 3/11, BAN
LINGK. CIMENYAN I 04/05, MEKAR
JELAT 3/1 KEL. PATARUMAN
SUKAMAJU 7/5, MULYASARI
JL.H. HASAN NO 41 LINGK. DESA
DUSUN SUKAMAJU 02/04, MULYA
LINGKUNGAN BABAKANSARI 05/
DUSUN CIJUREY 03/04 DESA KUJ
LINGKUNGAN BANJARKOLOT 03
LINGKUNGAN CIKABUYUTAN TIM
LINGKUNGAN PINTUSINGA 01/19
DUSUN SIDAMULYA 01/08 KELUR
KALANGSARI II 04/02 DESA SUKA
CIPEDES TASIKMALAYA
LINGKUNGAN JELAT 03/03 KEL P
JL. PURNOMOSIDI NO 36 PATARU
BABAKANSARI 02/09 PATARUMA
LINGK. HAURMUKTI RT 41 RW 02
DUSUN KIDUL RT 08 RW 03 DESA
DUSUN NAMBO RT 29 RW 06, JAW
LINGK. CIKADU RT 19 RW 08 DES
KP. KRAJAN RT 10 RW 08 DESA S
LINGK. JADIMULYA, RT 02 RW 05
LINGK. BABAKANSARI RT 04 RW
DUSUN CIAREN RT 40 RW 13 DS
DUSUN DESA RT 06 RW 02 DESA
LINGKUNGAN BOJONGSARI RT 0
LINGKUNGAN SILUMAN RT 27 RW
dusun cibodas RT 22 RW 05 DESA
LINGK. PARUNGLESANG RT 05 R
JL. PEGADAIAN NO 32, RT 002 RW
JL. PEGADAIAN NO 32, RT 02 RW
LINGK. JELAT 1/3 KEL.PATARUMA
LEMBURBALONG 3/8. PATARUMA
LINGK. PANATASAN 1/20, KEL. PA
PANANJUNG TIMUR 30/07, SINAR
LINGK. BANJAR 4/2 KEL.BANJAR
LINGK. PATARUMAN 1/12, KEL. P
LANGKAP LANCAR, KEL. BOJONG
RANCAKOLE 2/2, DESA MULYASA
JL. DIPATI UKUR 01/13, LINGK BA
CIMENYAN I 03/05, MEKARSARI
LINGK. BANJARKOLOT 3/11, BAN
LINGK. CIMENYAN I 04/05, MEKAR
JL.H. HASAN NO 41 LINGK. DESA
DUSUN SUKAMAJU 02/04, MULYA
DUSUN CIJUREY 03/04 DESA KUJ

LINGKUNGAN CIKABUYUTAN TIM
KALANGSARI II 04/02 DESA SUKA
CIPEDES TASIKMALAYA
LINGKUNGAN JELAT 03/03 KEL P
Komp. Eastren Hill Regency Jl. Ruselia I
Cipadung Kecamatan Cibiru
DUSUN PAMOTAN RT 01 RW 01,
DUSUN PANANJUNG BARAT RT 0
DUSUN PANANJUNG BARAT RT 0
LINGK. PATARUMAN RT 02 RW 1
LINGK. SUKARAME RT 01 RW 14,
LINGK. AWILUAR RT 14 RW 04, S
KEDUNGMALANG RT 02 RW 02, K
Lingk. Babakansari RT 003 RW 011 Kelu
Dusun Sukamenak RT 003 RW 009 Des
Dusun Pangasinan RT 008 RW 009 Desa
Mekarsari RT 001 RW 015 Desa Muara
Kota
Jl. RH Abdul Halim No. 80 RT 001 RW 0
Dusun Pananjung RT 019 RW 004 Desa
Dusun Karangtengah, RT 025 RW 009, D
DUSUN PARUNG 41/4, BALOKAN
LINGK. HAURMUKTI RT 41 RW 02
DUSUN KIDUL RT 08 RW 03 DESA
DUSUN NAMBO RT 29 RW 06, JAW
LINGK. CIKADU RT 19 RW 08 DES
KP. KRAJAN RT 10 RW 08 DESA S
LINGK. JADIMULYA, RT 02 RW 05
LINGK. BABAKANSARI RT 04 RW
DUSUN CIAREN RT 40 RW 13 DS
DUSUN DESA RT 06 RW 02 DESA
LINGKUNGAN BOJONGSARI RT 0
LINGKUNGAN SILUMAN RT 27 RW
dusun cibodas RT 22 RW 05 DESA
LINGK. PARUNGLESANG RT 05 R
DUSUN SIDAMULYA 01/08 KELUR
A
B
C
D
E
Total
Kepesertaan B
(tulis 'Ya' pa
No. Hp kolom
BPJS yang se
PBI
085220572030
089515689183
081321793844
081324470712
089643294725
082126683550
081323083657
081320037865
082140031215
081344277543
08122490936
085222512601
081324151885
081313981211
081320694082
085295259474
089657888792
082214330683
087826759789
085223018158
081321354401
08989557693
083875295469
081224538583
081313649500
085703278388
085294922241
081615710797
081990549258
082120042355
081214104347
0895619903204
081933324271
082115665115
085224461504
081384926970
081323242772
81321065558
85223396699
82240602338
82183654820
82218109598
85294440541
82121133142
81224099640
85323239411
85223141118
85314747277
85314597144
85722792688
081222888610
081222888610
085220572030
089515689183
081321793844
081324470712
089643294725
082126683550
081323083657
081320037865
082140031215
08122490936
085222512601
081324151885
081313981211
081320694082
085295259474
089657888792
082214330683
087826759789
085223018158
08989557693
083875295469
081224538583
081313649500
085294922241
081615710797
081990549258
082120042355
081214104347
0895619903204
085224461504
081320008607
087737583338
082240380192
087834554246
081214181374
08977857292
082127480600
O81224230668
081323100780
082240576480
082240576480
082240314750
082115565439
085215515466
081344277543
081384926970
81321065558
85223396699
82240602338
82183654820
82218109598
85294440541
82121133142
81224099640
85323239411
85223141118
85314747277
85314597144
85722792688
085703278388
0
0
0
0
0
0
pesertaan BPJS
tulis 'Ya' pada Tanggal
BPJS Non
om yang sesuai)
Non Anggo Screening
PBI ta
YA 2/2/2021
YA 2/2/2021
YA 2/2/2021
YA 2/2/2021
YA 2/2/2021
YA 2/2/2021
YA 2/2/2021
YA 2/2/2021
YA 2/2/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 04/02/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/10/2021
YA 2/11/2021
YA 2/11/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/18/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
YA 2/25/2021
Nama/Jenis/Merek
Vaksin***
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
SINOVAC
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
COVID-19 VACCINE
Dosis I
Tanggal
Pemberian No. Batch
Vaksinasi
2/2/2021 202011043
2/2/2021 202011043
2/2/2021 202011043
2/2/2021 202011043
2/2/2021 202011043
2/2/2021 202011043
2/2/2021 202011043
2/2/2021 202011043
2/2/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
04/02/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/10/2021 202011043
2/11/2021 202011043
2/11/2021 202011043
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
2/25/2021 24000421
Dosis 2
Tanggal
No.
Pemberian
Serial
Vaksinasi
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/18/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
2/25/2021
Dosis 2
No.
No. Batch
Serial
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
202011043
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
24000421
Keterangan
(Ditunda/Tidak
Diberikan/Lanju
t)
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
TUNDA
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
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
LANJUT
TUNDA
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
Nama Puskesmas/Fasyankes/Pos : BLUD UPTD PUSKESMAS PATARUMAN 3
Kabupaten/Kota : KOTA BANJAR
Provinsi : JAWA BARAT
Jenis
No No. Tiket NIK Nama Penerima Vaksin
Kelamin
1 P-46LX3HKN 3175075707840013 RISA ROSNELITA P

2 N-7A7FCC89 1401114307960000 DINI RIZKI ANDINI P
3 P-F52C377C 3279024506920000 DINA PAMELAWATI P
4 P-3955E0CA 3279026509010001 MIRDA SEPTIANI P
5 P-49P4VBSE 3279016103630000 IMAS MASRIAH P
6 P-49VMFS5E 3207305911990000 SITI NURAENI P
7 P-4A49NAFV 3279015706950000 RIKA YUNIARTI BASTAMAN P
8 P-4AB9J5CS 3207306801980000 ELIS KURNENGSIH P
9 P-4AM5VNSC 3279024511960000 TITA FITRIANI P
10 P-4APF27TY 3279015805970000 IKA SUCIANTI P
11 P-4B3R726V 3279014306020000 SAFIRA JUNITA QAFSOH P
12 P-4B6R41SA 3279015803920000 FITRIYANI P
13 P-4BCZG1D5 3279025111000000 ANISA NOPIATIN P
14 P-4BIAB0S1 3279036605920000 YOSI ARSIANTI P
15 P-90B1X8Q8 3207190206890000 FADZILLAH NURSALAM L
16 P-CFWTCRAM 3279010707960005 ADE ZAYADI L
17 P-EQIOBR7S 3207155904950001 AZIZAH NURAENI P
18 P-HRESZGBG 3279025103900001 ASTRI SETIAWATI P
19 P-IVQP8GY0 3279032302920001 YUDI NURDIANSYAH L
INTAN PRANINGTIYAS WINDIAWATI
20 P-JI0DJ6FW 3279046410950003 P
AGUS SAPUTRI
21 P-K0FA7MRF 3279035411950001 TITA PURNAMASARI P
22 P-KGVG1XS8 3301154811910002 TUTI NOVIANTI P
23 P-L9EQH9SA 3279035911950001 RESFIA RACHMAN NOVIANA P
24 P-L5AP7VT2 3279045812990002 ITA PUSPITASARI P
25 P-LM099OZM 3279016606010001 AYU YUNIAR P
26 P-M38TDEGW 3279025806000004 DEVI PRANSISKA P
27 P-LUPMQEEB 3207175704990002 UMI KULSUM P
28 P-MTROT1AJ 3279015306010003 RESTI DWI CAHYUNI P
29 P-OD77S8US 3206274305920001 ROSMIATI P
30 P-Q6WCWW4Q 3279047009960002 SITI HERDIYANTI P
31 W-5B438807 3279020502730001 H. ATENG L
FORMAT PENCATA
TINGKAT PUS
Umur
Pekerjaan* (18-59 Kelompok Umur
tahun)
PERAWAT 35 31-45
DOKTER 25 18-30
TENAGA KESEHATAN 27 18-30
NAKES LAINNYA 20 18-30
TENAGA KESEHATAN LAINNYA 57 46-59
APOTEKER 25 18-30
PERAWAT 32 31-45
PERAWAT 26 18-30
ADMINISTRASI 29 18-30

PERAWAT 26 18-30
PERAWAT 29 18-30
PERAWAT 25 18-30
PERAWAT 48 46-59
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI
Alamat
DUSUN PANGASINAN RT 002 RW 007, DESA BINANGUN, KEC. PATARUMAN

LINGK. JELAT RT 01 RW 04 KEL. PATARUMAN
LINGKUNGAN PATARUMAN 02/15, PATARUMAN
JL. PURNOMOSIDI NO 36 PATARUMAN 02/15
LINGK. CIMENYAN I NO.75
DUSUN MULYAJAYA,RT 02 RW 11 DESA CISAGA KAB CIAMIS
DUSUN GARDU RT 018 RW 006 DESA BALOKANG KEC BANJAR
DSN SUKAHARJA RT 012 RW 03 DESA BANGUNHARJA KAB CIAMIS
LINGK. GUDANG RT 03 RW 01, HEGARSARI, PATARUMAN
DUSUN CIPANTARAN RT 16 RW 04
LINGK. BANJARKOLOT RT 05 RW 16
DUSUN CIAREN RT 46 RW 14
LINGK. LEMBURBALONG RT 02 RW 5, PATARUMAN
LINGK. CIPADUNG RT 11 RW 05, PURWAHARJA
PAMARICAN RT 01 RW 01, PAMARICAN
LINGK SUMANDING WETAN RT 003 RW 015
LINGK. BANJARKOLOT RT 02 RW 14, BANJAR
ASRAMA YONIF 323 RAIDER RT 30 RW 14, PURWAHARJA
DUSUN CIBENTANG RT 21 RW 09, MEKARHARJA
LINGK. LANGEN RT 05 RW 01, MUKTISARI, LANGENSARI
LINGK. CIMENYAN II RT 03 RW 10
DUSUN KUBANG RT 27 RW 11, SIDAMULYA, CISAGA
DUSUN BANTARDAWA, RT 05 RW 02, REJASARI, LANGENSARI
LINGK. PINTUSINGA RT 05 RW 17, BANJAR
LINGK. BABAKANSARI RT 01 RW 01, PATARUMAN
DUSUN CIKAWUNG RT 40 RW 11, CINTARATU, LAKBOK
LINGK CIMENYAN 2 RT 005 RW 008, MEKARSARI
SUKARAME, MEKARSARI, BANJAR
DUSUN KEDUNGWARINGIN, WARINGINSARI, LANGENSARI
LANGKAP LANCAR, KEL. BOJONGKANTONG
VAKSINASI COVID-19
/POS VAKSINASI
Kepesertaan BPJS (tulis 'Ya' pada

Dosis I
kolom yang sesuai)
Tanggal Nama/Jenis/Merek
No. Hp
Screening Vaksin*** Tanggal
BPJS Non Non
BPJS PBI Pemberian
PBI Anggota
Vaksinasi
081223024111 YA 2/26/2021 COVID-19 VACCINE 2/26/2021

085216988839 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082115665115 YA 2/26/2021 COVID-19 VACCINE
081933324271 YA 2/26/2021 COVID-19 VACCINE
081323313370 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
089524845194 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082240234117 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
085320115264 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
089628765634 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082218864393 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
087722470716 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
081220866673 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
089662418788 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082320346718 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082317312017 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
08562174984 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082217442051 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082214569309 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
081287899040 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082123717190 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082218810113 YA 2/26/2021 COVID-19 VACCINE 2/26/2021

085218331847 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
085723478776 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
081929746362 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
089506047154 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
089621581007 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
081214193892 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
089626655145 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
085318900801
YA 2/26/2021 COVID-19 VACCINE 2/26/2021
082117863582 YA 2/26/2021 COVID-19 VACCINE 2/26/2021
081320037865 YA 2/26/2021 COVID-19 VACCINE
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Tanggal Pemberian Diberikan/Lanjut)
No. Batch No. Serial No. Batch No. Serial
Vaksinasi
24000421 LANJUT
24000421 SELESAI
2/26/2021 24000421 SELESAI
2/26/2021 24000421 LANJUT
24000421 TUNDA
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
24000421 LANJUT
2/26/2021 24000421 SELESAI
Jenis
Kelamin
1 P-EUZZ39TT 3207176002710002 NURUL ZULFANI'MAH P

2 P-6IQXUWHB 3207301308700002 BABAN SEHABUDIN L
3 P-ABNLAFUQ 3207181604930002 DINDA APRILIAN SUHENDI L
4 P-C15LU8JM 3279012202960001 FERI SAPUTRA L
5 P-CPSRXFWV 3279014801940001 NADIA ANISA PUTRI P
6 P-D2D80TF0 3207305906770001 ASIH SETIAWATI P
7 P-DJN7FEBC 3207302203020001 REGY ANGGARETA ISKANDAR L
8 N-0CDB8131 3279026502890001 HENI MULYANI P
9 P-BX2NVBG9 3207241605880001 TOTO FITRIAL L
10 P-PDJY8PB7 3207190603930001 ARIF MIFTAHUL BARKAH L
11 P-Q4PE0OKB 3279011404980001 RIO APRIYANTO L
FORMAT PENCATA
TINGKAT PUSK
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
PERAWAT 29 18-30
PERAWAT 28 18-30
PERAWAT 27 18-30
PERAWAT 32 31-45
PERAWAT 33 31-45
PERAWAT 28 18-30
Alamat No. Hp
DUSUN AJIBARANG WETAN RT 02 RW 02, AJIBARANG, KEC. AJIBARANG, JAWA TENGAH 085292366543
DUSUN KERTAHARJA RT 06 RW 01, BANGUNHARJA 085722731835
DUSUN LUMBUNGSARI RT 14 RW 05, PAMARICAN, CIAMIS 082216766575
LINGK SUMANDING WETAN RT 003 RW 015, MEKARSARI, BANJAR
KARACAK LINGK.KERTAHAYU RT 05 RW 11, SINDANGRASA CIAMIS 085314004063
DUSUN KERTAHARJA RT 06 RW 01, BANGUNHARJA 085256379023
DUSUN SUKAHARJA RT 09 RW 03, BANGUNHARJA, CISAGA 085871029288
LINGK. CIKABUYUTAN BARAT RT 04 RW 10, HEGARSARI, PATARUMAN 081322320969
DUSUN KARANGMUKTI RT 02 RW 07, SELASARI, PARIGI 082218916738
CIBENDA RT 03 RW 01, PAMARICAN 085723144149
LINGK. CIMENYAN II RT 02 RW 10, MEKARSARI, BANJAR 0895370420303
KSINASI COVID-19
OS VAKSINASI

Dosis I
kolom yang sesuai)
Nama/Jenis/Merek
Tanggal Screening
Vaksin***
BPJS Non Non Tanggal Pemberian
BPJS PBI No. Batch
PBI Anggota Vaksinasi
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421

YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421
sis I Dosis 2
Keterangan
(Ditunda/Tidak
Tanggal Diberikan/Lanjut)
No. Serial Pemberian No. Batch No. Serial
Vaksinasi
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
Jenis
Kelamin
1 S-ECC2540F 3279012712850001 Erik Kiswanto L

2 P-T3D1U8II 3279021806670001 Maman Suratman L
3 P-NK6KSQ4S 3279015803880001 Imas Nurhayati P
4 P-YVZSI30I 3279024706820004 Yesi Shrivianty P
5 P-AEDQ62WT 3279024205820002 Sulistiawati P
6 P-CZBMNPJV 3279022408980001 Anjaswara L
7 S-969817B8 3279021202810001 Agus Supriatna L
8 S-F79411CA 3207116009700001 Nunung Nurjanah P
9 S-A477FCE4 3279022004840003 Mahsus L
10 S-DD6AB785 3207304203670002 Ikah Surtikah P
11 S-6C6E0BF8 3207195808740002 Euis Suryamah P
12 S-8810FD35 3207110105920002 Ade Wawan L
13 3279021008650001 Maman Suryaman L
14 3279022804700001 Agus Warjoman L
15 P-HWJCFNPC 3279020505860003 Ucu Herdiana L
16 P-EXUXV49N 3279021603790001 Dedi L
17 32790227012650001 Neneng Utih Haeni P
18 P-UJBIRY4F 3279026601850001 Resi Hartini P
19 P-JZ9NDCOZ 3279015510930002 Nuraeni P
20 P-HAUINPTZ 3279021906910001 Aryo Haryanto L
21 P-ICTYK4YD 3301161809940004 Dani Permana L
22 P-NJBLUUMJ 3207031506750001 IWAN KURNIAWAN L
23 P-T3D5E47Q 3279020406680003 WAWAN GUNAWAN L
24 P-T3DBDHLN 3279021008850003 ARI, A.Md L
25 P-T3DMPW3C 3279021402720001 KANDAR L
26 P-T3DQY5XF 3279020805870003 IWAN KARWAN L
27 P-T3DVRMF2 3279022511910003 ADI WINDA MAULANA N, S.Pd L
28 P-URN18GH4 3279021910890001 DIMAN RUDIAMAN, S.Pd L
29 P-URN4WTB2 3279024509870002 KARTIKA SAFARI D, S.IP P
30 P-URNB5AUD 3279024806840002 YUNI ROHANI LESTARI P
31 P-7MEM6B1Q 3275082806750017 ARIP MUHAEMIN L
32 P-URNK5LDA 3279025401880002 ADE SITI ROHAYANI P
33 P-URNNBQYL 3279026211680002 KARTIWI P
34 P-URNPGJHO 3279021004830001 KAHFI HAMDANI L
35 P-URNSEIBB 3279020412870002 DINDIN NURDIN L
36 P-URNTOGCU 3279022806780003 YUDI YUNIAR L
37 P-VH2JXXAO 3279021101920001 ASEP DENI CAHYADI, S.IP L
38 P-VH2QX6UA 3279021908740002 AGUSYANI L
39 P-VH2SUFRD 3279024710860003 EEM NEMAH, S.Pd P
40 P-VH2WNL51 3279021308820004 MOH.DICKY DZULFADLI L
41 P-VH30R4NG 3279020306910001 DADANG LESMANA L
42 P-VH3317OW 3279026811870003 LINA YULIANI P
43 P-VH35YQRY 3279025508930002 HERA SUMIATI P
44 P-VH37Z3BT 3279021910840002 AHMAD FAUZI L
45 P-SFO35PKC 3279021012840001 ASEP HENDRA SUGIHARTO, A. Md. L
46 P-SFOAJYEL 3279021306740002 DEDE SAIDIN L
47 P-STDF1J4B 3279020503710001 DAYAT HIDAYAT L
48 P-STDGBNE3 3279022502740001 ADE RUKMAN L
49 P-STDL336C 3279022701900001 ERY BACHTIAR L
50 P-STDOVY2R 3279026505940002 DITA SITI JATNIKA P
51 P-STDR8REM 3279025110880002 DEVI SEPTIANI P
52 P-STDUR73J 3279025802900002 ERLI SUFIANA P
53 P-STDXYKQF 3207184703820001 ERNA HANI HANDAYANI P
54 P-STE1Y4GJ 3279023107860002 BAMBANG KURNIADI L
55 P-STE4SIO1 3279020607620002 KUSMANA L
56 P-TLQL12XH 3279026905900002 DEVI TRI LINDUWATI P
57 3279022106910004 ERIS SAEPUL ADHA L
58 3279020708710004 IWAN SETIAWAN L
59 3279021007830002 ASEP PURKON L
60 S-ACA16B57 3207312909890001 DAHLAN L
FORMAT PE
TINGKA
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
Lurah Kelurahan Pataruman 36 31-45

Perangkat Desa 54 46-59
Perangkat Desa 0
Perangkat Desa 0
Perangkat Desa 0
Kepala Desa Mulyasari 53 46-59

Kepala Desa Sinartanjung 37 31-45

DOSIS KE 1
Alamat
DUSUN RANCAKOLE RT 013/ RW 03 DESA MULYASARI KEC. PATARUMAN

LINGK. SUKAMANAH RT 001/ RW 018 KEL. PATARUMAN, KEC. PATARUMAN
LINGK. JADIMULYA RT 001/ RW 006 KEL. HEGARSARI, KEC. PATARUMAN
LINGK. PANATASAN RT 002/ RW 019 KEL. PATARUMAN, KEC. PATARUMAN
LINGK SUKAMANAH RT 004/ RW 017
DUSUN PANANJUNG BARAT 03/02 SINARTANJUNG
DUSUN KIDUL 01/06, BUNISEURI, CIPAKU
DUSUN CISAGA KOTA 01/05, CISAGA
LINGK. BABAKANSARI RT 003/ RW 009 KEL. PATARUMAN, KEC. PATARUMAN

LINGK. LEMBURBALONG RT 003/ RW 007 KEL. PATARUMAN KEC. PATARUMAN
LINGK. LEMBURBALONG RT 003/ RW 006 KEL. PATARUMAN, KEC. PATARUMAN

LINGK. LEMBURBALONG, RT 001/ RW 008, KEL. PATARUMAN
DUSUN PASIR LEUTIK 26/10, MEKARHARJA
Dsn.Sukamaju RT 02 RW 03
Dsn.Rancakole RT 01 RW 01
Dsn.Margaluyu RT 04 RW 08
Dusun Pananjung Timur RT. 031 RW. 007 Desa Sinartanjung Kecamatan Pataruman Kota Banjar
Dususn Pananjuung RT. 021 RW. 005 Desa Sinartanjung Kecamatan Pataruman Kota Banjar
Dusun Sinargalih RT. 033 RW. 008 Desa Sinartanjung Kecamatan Pataruman Kota Banjar
Dusun Pananjung Barat RT. 004 RW. 001 Desa Sinartanjung Kecamatan Pataruman Kota Banjar
Dusun Pananjung RT. 020 RW. 005 Desa Sinartanjung Kecamatan Pataruman Kota Banjar
Dusun Cibeureum RT. 005 RW. 002 Desa Balokang Kecamatan Banjar Kota Banjar
DSN, KELEWIH RT.003 RW.003 KEL.SAGULING KEC.BAREGBEG KAB.CIAMISW
AAN VAKSINASI COVID-19
NKES/POS VAKSINASI

Dosis I
kolom yang sesuai)
Nama/
No. Hp Tanggal Screening Jenis/Merek
BPJS Non Non Vaksin*** Tanggal Pemberian
BPJS PBI
08112110242 YA 3/1/2021 3/1/2021

085223409646 YA 3/1/2021 3/1/2021
082116923292 YA 3/1/2021 3/1/2021
089662495418 YA 3/1/2021 3/1/2021
081222842846 YA 3/1/2021 3/1/2021
081398994752 YA 3/1/2021 3/1/2021
08112340282 YA 3/1/2021 3/1/2021
081321343985 YA 3/1/2021 3/1/2021
082124027800 YA 3/1/2021 3/1/2021
081222833999 YA 3/1/2021 3/1/2021
085223559616 YA 3/1/2021 3/1/2021
08231869950 YA 3/1/2021 3/1/2021
085223402701
081930532070
082130508168 YA 3/1/2021 3/1/2021
085223524639 YA 3/1/2021 3/1/2021
081214848492
085320532666 YA 3/1/2021 3/1/2021
0895600309366 YA 3/1/2021 3/1/2021
082127529959 YA 3/1/2021 3/1/2021
082240185271 YA 3/1/2021 3/1/2021
081321160009 YA 3/1/2021
085221928488 YA 3/1/2021 3/1/2021
081320903618 YA 3/1/2021 3/1/2021
081320903602 YA 3/1/2021 3/1/2021
082261250400 YA 3/1/2021 3/1/2021
089654076504 YA 3/1/2021 3/1/2021
085223393212 YA 3/1/2021 3/1/2021
085322763300 YA 3/1/2021 3/1/2021
081323298411 YA 3/1/2021 3/1/2021
082317340847 YA 3/1/2021 3/1/2021
085223345462 YA 3/1/2021 3/1/2021
085323460910 YA 3/1/2021 3/1/2021
081322444489 YA 3/1/2021 3/1/2021
085323411467 YA 3/1/2021 3/1/2021
081341274734 YA 3/1/2021
085351145888 YA 3/1/2021 3/1/2021
081321183389 YA 3/1/2021 3/1/2021
085223120656 YA 3/1/2021 3/1/2021
085222574716 YA 3/1/2021 3/1/2021
082118113777 YA 3/1/2021 3/1/2021
085294153888 YA 3/1/2021 3/1/2021
085315895750 YA 3/1/2021 3/1/2021
081323466810 YA 3/1/2021
081320637778 YA 3/1/2021 3/1/2021
082315531945 YA 3/1/2021 3/1/2021
085314252860 YA 3/1/2021 3/1/2021
081220519002 YA 3/1/2021 3/1/2021
085294607233 YA 3/1/2021 3/1/2021
082321177939 YA 3/1/2021 3/1/2021
082216783838 YA 3/1/2021 3/1/2021
087777132759 YA 3/1/2021 3/1/2021
081809875806 YA 3/1/2021 3/1/2021
081220582231 YA 3/1/2021 3/1/2021
085294747791 YA 3/1/2021 3/1/2021
085323540005 YA 3/1/2021 3/1/2021
089524442876 YA
081806355268 YA
081323490480 YA
085323404329 YA 3/1/2021 3/1/2021
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
No. Batch No. Serial Pemberian No. Batch No. Serial
Vaksinasi
24000421 LANJUT DOSIS 2

SAKIT (TIDAK HADIR)
SAKIT (TIDAK HADIR)
SAKIT (TIDAK HADIR)
PERNAH KONFIRM
TUNDA (HIPERTENSI)
TUNDA (HIPERTENSI)
24000421 TUNDA (HIPERTENSI)
TDK HADIR TK
TDK HADIR TK
TDK HADIR TK
NAMA INSTANSI
KELURAHAN PATARUMAN
DESA MULYASARI
DESA SINARTANJUNG
LAPAS BANJAR
1 S-F7A11951 3276060906690009 MOHAMAD MAOLANA, A.Md.I.P., S.H., M.Si.

2 3204101711650004 SAEFULLOH
3 S-7D951385 3279011609690001 JEJE SUDRAJAT
4 S-E4018B5B 3207010609700003 A SUPRIADI
5 S-AAB2A5A3 3301150405700002 MAMAN RUSMANTO
6 P-MJL2POJK 3206072103680005 ANIM
7 S-D06D64E7 3209181909870009 DEDY PRAMUDIAN, S.E.
8 3205191804770001 RIDWAN
9 3207271012880001 ASEP SUHAN SUHANA, S.H.
10 S-DBF87CD1 3603031209820008 DADAN HERDIANA, S.H.
11 S-8503F058 3210070101810181 DENI SUDIANA
12 S-0B3A0E4C 3207013007840002 WILI
13 3027014807810002 LULU NURYANI
14 S-CAC21EEC 3207290201850001 RIDWAN PERMANA
15 P-MJL8769Y 3207122901900001 INDRA BUDIANTO
16 P-MJLACWSX 3210062007890001 JEJEN JAENUL MILLAH
17 P-MJLAKQCL 3279012912890002 ASEP DENI WAHYUDI
18 S-1C4B7C38 3279040906900001 WAWAN IRAWAN
19 P-MJLCSHAF 3207312108920001 HENDI GUSTIAWAN
20 S-F9251DF2 3207016208930002 EKA MAULINA DEWI
21 S-6DFBA357 3207060602920001 SHENDY CAHYAMAN
22 P-MJLFHRCG 3207142101940001 DIKI SUNDARA
23 S-83250119 3207101006930001 CEPPI BUDI CAHYANA
24 P-MJLHWW8S 3279041306860001 ALI IMRON
25 S-3BC44DE6 3207352003870002 ARA PERMANA
26 S-26B0D832 3211136910900002 TINA ARDHYANIE

27 S-A0568D83 3273142003910004 GILAR PURNAMA
28 S-D6C124B5 3217071507920007 DIMAS
29 S-514E0988 3211071311920002 ASEP CHOERUL HIDAYAT
30 S-BF03DAAF 3205012908930005 IQBAL MAULUDIN ACHMAD
31 S-71553321 3205052910940001 HADI MAULANA NUGRAHA
32 S-D3CC6D1A 3276051807950004 RIFKI LUTFAN SAMUDRA
33 S-F6AE92B2 3204140704950002 GANJAR SETIA PUTRA
34 S-6D7BB3C4 3207034905960002 SINTIA ULFAH BAHTIAR
35 S-623E2FF2 3518132911960004 MUHAMAD ALI MURSODO
36 S-79DC20ED 3273242001970002 FARIZ RAMADHANSYAH
37 S-17CB3A2F 3205170103970003 FERGAN BAKTI ADIRES
38 S-FB21B0CE 3207312702980001 REGIA HELMINA NUROHMAN
39 S-5B990276 3206131002980001 ALDI PEBRINALDI
40 S-6B153CA3 3207096807980002 FAUZIAH FAZRI MUSTARI
41 S-CBBFACBE 3214010707760008 R ARIF HERMAWAN, A.Md.I.P.,S.H.
42 S-67DE2CF9 3207014403740001 TUTI MULYATI
43 S-2F2010F7 3212290306860001 ADIYANTO
44 S-370511B3 3279016808880001 HESTI
45 S-5E1BC278 3273161102950007 TEGUH TRI RAMDANI
FORMAT P
TINGK
Umur
Jenis Kelompok
Pekerjaan* (18-59
Kelamin Umur
tahun)
L KEPALA LAPAS 51 46-59

L LAPAS BANJAR 55 46-59



P LAPAS BANJAR 39 31-45






DOSIS KE 1
Alamat
JL.BUNI RT/RW. 004/014 KEL.BEJI KEC.BEJI KOTA DEPOK

JL.MEKARSARI KP.BURUJUL RT.001 RW.017 KEL MEKARRAHAYU MARGAASIH KAB. BANDUNG
LINGK.PINTUSINGA RT/RW. 004/018 KEL.BANJAR KEC.BANJAR KOTA BANJAR
LINGKUNGAN KEDUNG PANJANG RT.002 RW.002 KEL.MALEBER KEC.CIAMIS KAB. CIAMIS
SOGATI RT.004 RW.009 KEL.WANAREJA KEC.WANAREJA KAB.CILACAP
KP. PAKUNAGARA RT 007/002 DS. GIRIKANCANA KEC. PARUNGPONTENG
BLOK RAHAYU I RT.003 RW.001 KEL.WANASABA KIDUL KEC.TALUN KAB.CIREBON
KP GALUMPIT RT 005/025 DESA KOTA KULON KEC. GARUT KOTA
PERUM VILLA CICANTEL ASRI NO.20 RT.007 RW.008 KEL. MULYASARI KEC. TAMAN SARI TASIKMALAYA
LINGKUNGQAN BANJAR RT.001 RW.002 KEL.BANJAR KEC.BANJAR KOTA BANJAR
LING.HAURMUKTI RT/RW.041/002 KEL. PURWAHARJA KEC.PURWAHARJA KOTA BANJAR
BLOK CIBODAS RT 001/001 DS. CIBODAS KEC. MAJALENGKA
JL. BENTENG NO. 4 RT. 003/024 CIAMIS
REGENCY 7 BLOK B NO 13 RT/RW.001/009 KEL.MEKARMUKTI KEC.CISAGA KAB.CIAMIS
DSN CIKAPAKALERAN RT 004/002 DS. CINTANAGARA KEC. JATINAGARA
BLOK CIMARA RT.006 RW.003 KEL.MALONGPONG KEC.MAJA KAB. MAJALENGKA
LINGKUNGAN SUKAMANAH RT.001 RW.016 KEL.PATARUMAN KEC.PATARUMAN KOTA BANJAR
DSN.CIJUREY RT/RW. 004/003 KEL. KUJANGSARI KEC.LANGENSARI K0TA BANJAR
DSN. CIWAHANGAN RT 003/009 DS. BAREGBEG KEC. BAREGBEG CIAMIS
LINGK. BANJAR KOLOT RT 002/012 DS. BANJAR KEC. BANJAR
DSN.BANTAR RT.024 RW.007 KEL.SUKARAJA KEC.SINDANGKASIH KAB.CIAMIS
DSN.DESA RT/RW.003/001 KEL.MARGAHARJA KEC.SUKADANA KAB.CIAMIS
DUSUN SAMPIH RT 001/007 DS. REJASARI KEC. LANGENSARI
DUSUN GARDU RT/RW. 017/006 KEL.BALOKANG KEC.BANJAR KOTA BANJAR
PERUM PPI NO 49 BLOK A RT 002/016 DS. CINANJUNG KEC. TANJUNGSARI
KP. RAWASARI RT/RW 003/007 KEL. MANDALASARI KEC. CIPATAT KAB. BANDUNG BARAT
DSN.KEBONKALAPA RT/RW. 003/002 KEL.CIPAMEKAR KEL.CONGGEANG KAB.SUMEDANG
JL. CIWALEN NO.381 RT/RW 004/005 KEL. CIWALEN KEC. GARUT KOTA KAB. GARUT
JL. BUNGUR NUSA INDAH II RT 003/016 DS. JAYARAGA KEC. TORONGGONG KIDUL
BOJONG IJO RT/RW. 004/028 KEL. SUKAMAJU KEC.CILODONG KOTA DEPOK
KP. CIHAMERANG RT. 001/010 DS. BANJAR WETAN KEC. BANJARAN
DUSUN CIMENGGER RT 006/013 BOJONGMENGGER KEC. CIJEUNGJING
DUSUN KEDUNGWARINGIN RT/RW. 002/005 KEL.WARINGINSARI KEC.LANGENSARI KOTA BANJAR
PS. SINDANGLAYA RT/RW 001/001 KEL.CISARANTEN BINA HARAPAN KEC. ARCAMANIK KOTA BANDUNG
KP. KIARA PAYUNG RT/RW 003/002 DS. HEGARMANAH KEC. BAYONGBONG KAB. GARUT
DUSUN KALER RT/RW. 001/003 KEL. KARANGAMPEL KEC.BAREGBEG KAB.CIAMIS
KP. LEGOK KAWUNG RT/RW 021/001 KEL. BANYUASIH KEC. TARAJU KAB. TASIKMALAYA
KILAYUGUNG RT/RW. 006/003 KEL.KAWALIMUKTI KEC.KAWALI KAB.CIAMIS
PONDOK JAYA INDAH BLOK G.4 RT 040 RW 003 DESA MUNJULIAYA KEC. PATARUMAN
LINGK. KEDUNG PANJANG RT 02 RW 02 KEL. MALEBER KEC. CIAMIS KAB. CIAMIS
JL. PATIMURA BLOK II RT 11 RW 004 KEL. KARANGANYAR KEC. PASEKAN, KAB. INDRAMAYU
DSN. KARANGPUCUNG KULON RT 14 RW 04 KEL. JAJAWAR KEC. BANJAR, KOTA BANJAR
JL. DESA NO 16 RT 04 RW 03 KEL. BABAKANSARI KEC. KIARA CONDONG, KOTA BANDUNG
NASI COVID-19
AKSINASI

Dosis I
kolom yang sesuai)
Nama/Jenis/Merek
No. Hp Tanggal Screening
Vaksin***
BPJS PBI
081311009669 YA 02/03/2021 COVID-19 VACCINE 02/03/2021

82119842945 YA
085318555824 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081322166040 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085227271848 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085316905899 YA 02/03/2021 COVID-19 VACCINE
082317777712 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
087723752765 YA
085320442442 YA
082113566186 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085220314534 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081222472560 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081323232910 YA
082315124544 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081323094967 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082346728296 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085224326083 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085223353300 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085223431115 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081224990713 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085221322321 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082317691111 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082130511306 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085220637113 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082218038777 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081214754222 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082118783513 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
087820093345 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082318237963 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
08987748814 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081220052543 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085901724882 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
089656876023 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085353950390 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082319145351 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082116327272 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082321161043 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082123374767 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085351555950 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081221657838 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085318860560 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
085316840219 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
08176903187 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
081323688306 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
082127213676 YA 02/03/2021 COVID-19 VACCINE 02/03/2021
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Vaksinasi
LANJUT DOSIS 2
TDK HADIR TNPA KET
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2
TDK HADIR TNPA KET
TDK HADIR TNPA KET
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR TNPA KET
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
NAMA INSTANSI
LAPAS KELAS IIB BANJAR

1 P-0599292B 3279022011570001 H. ABDURRAUF KANDANG MANON

2 P-5F018BC4 3279024103590004 ENI ROSTINI
3 3279026604520001 ENTIN SUNARTI
4 3279022707480001 H. ADE SUKANDA RAFE'I
5 S-F219DB0B 3207012503630001 Ir. H. TOMY SUBAGJA, MM
6 P-71LZA5PI 3279010303750002 ACEP DARYANTO
7 P-71SWJBKQ 3301152007710001 HARUN AL RASYID,ST
8 P-712TFE2J 3279031111730001 AGUS SARIPUDIN, ST., MT., MM
9 S-ED381C2D 3207012803750001 ASEP BUNYAMIN, ST
10 S-912A16FD
3279025011840002 ANI HERAWATI, ST., MM
11 P-73FLEH43 3279041011800007 RAMDAN MULYANA, SE., MM
12 S-A5E223B3 3207011710830001 MICKY ADAM, SE
13 P-72DRTBEX 3279010503790002 UUN MARYONAH ,ST., M.AP
14 S-99EA2E97 3279035806820001 AAN HASANAH, ST.,M.AP
15 S-050ED391 3279041008800002 MUSTOLIH, ST., MM
16 P-72OHB0PO 3279012811700001 NANAR SUNARYA, ST.,M.Si
17 S-770067EF
3279030503630002 SUPARMAN
18 S-473B33B6 3279045902750002 SULISTIANINGSIH, S.T., M.AP
19 S-D7320F40 3279025310810001 SUKMAWATI, ST., M.AP
20 S-BC2C0239 3207306901800001 NENDEN MULYANI KUSNIAWATI, ST
21 S-9BB08B02 3279012202680003 HERU IRAWAN, S.IP
22 S-15EB3A31 3279010704800003 YOHAN IRMAWAN, SH
23 S-19DF160E 3279010601780001 ASEP DADDY ISKANDAR, ST.,M.S.i
24 P-733NQNEB 3279031808740002 IRMAN NURACHMAN, ST.,M.AP
25 P-8AI8R7BJ 3279010412890001 Sendi Aris Munandar
26 S-113A8269 3207301904750001 JEJE SUJANA
27 S-688C3156 3279031807650002 ADANG SUPRIATNA, S.IP
28 S-49E1C519 3279030111930002 RIAN NURROHMAN, ST
29 S-46F5174A 3279011009610002 AIP SARIPUDIN, S.PdI
30 S-446584AD 3279040302620002 SUPRIYANA, S.Pd
31 S-BB13C51D 3279026603640001 MARYATI, S.Pd
32 S-CC6AA483 3279014310660001 SUMARNI, S.Pd
33 S-47F2E464 3279026310860001 EKA NOVIANTI, S.Pd
34 S-D6040010 3279015504630002 OTIH NURHENDRAWATI S.Pd
35 S-FF2BB356 3279016505640002 AI SYAJAAH, S.Pd
36 S-60ED66ED 3279024901700002 ETIN SUPIATIN,S.Pd
37 S-A4DDFA9E 3279027004620001 ENTIN KARTINI,S.Pd
38 S-09508297 3279043008820002 Asifudin
39 S-EFF39579 3279031006860003 Sofyan Andri Widiantoro
40 S-AEDC3004 3301165206870001 Darinah
41 S-B13587FD 3279045107880002 Sri Sulastri
42 S-D34B4FE9 3279021807900002 Redian Arista
43 S-2ED283A1 3207180805880005 Danil Roik
44 S-19B47E81 3207183009890001 Dede Saripudin
45 P-7MCD7ICX 3301181707970006 Fatul Umam
46 S-5EF5CDE4 3301150503880005 Abdurrohman
47 S-3AAEF865 3207172406940001 Riman
48 S-981CBA85 3279022303680001 TATANG SAPEI HIDAYAT
49 S-F467FD95 3279022102820001 OMAN HADIMAN
50 S-E5D5366B 3279025509620002 EUIS SUMEGAWATI
51 S-500DB97A 3279027101660001 DINDA ROSWATI
52 S-F4A47855 3279022002840001 ASEP MARHUDIN
53 S-BAC7D51F 3207071902870001 BAMBANG NURDIANSYAH
54 S-DF67B49F
3279014301800003 NIA SUMIATI
55 S-C15FA86A 3279015408870004 DEDE HASYAROH
56 S-3F9AFC99
3279025611700002 LILIS MURNIATIN
57 S-0FE1E98F 3279040810660001 NURHAKIM
FO
Umur
Jenis Kelompok
Pekerjaan* (18-59
Kelamin Umur
tahun)
L DOKTER 65 >60
P BIDAN 62 >60
P TENAGA KESEHATAN 69 >60
L DOKTER 73 >60
L KADIS PU 58 46-59
L PEGAWAI PEMERINTAH 46 46-59
P PEGAWAI PEMERINTAH 37 31-45
L GURU 59 46-59
L GURU 59 46-59
P GURU 57 46-59
P GURU 55 46-59
P GURU 35 31-45
P GURU 58 46-59
P GURU 57 46-59
P GURU 51 46-59
P GURU 59 46-59
L GURU 38 31-45
L GURU 34 31-45
P GURU 33 31-45
P GURU 32 31-45
L GURU 30 18-30
L GURU 32 31-45
L GURU 31 31-45
L GURU 23 18-30
L GURU 32 31-45
L GURU 26 18-30
L GURU 53 46-59
L PET. KEBERSIHAN 39 31-45
P GURU 58 46-59
P GURU 55 46-59
L GURU 37 31-45
L GURU 33 31-45
P GURU 41 31-45
P GURU 33 31-45
P GURU 50 46-59
L GURU 55 46-59
DOSIS KE 1
Alamat
LINGKUNGAN BABAKANSARI 05/11, PATARUMAN

BABAKANSARI 02/09 PATARUMAN
JL. PEGADAIAN NO 32, RT 002 RW 002, HEGARSARI
JL. PEGADAIAN NO 32, RT 02 RW 02, HEGARSARI
Jl.Lembursitu No.07 RT/RW 003/027 Kel/Desa.Ciamis Kec.Ciamis
Lingk. Sukarame no.58 rt.3 rw.11 Kel. Mekarsari Kec. Banjar Kota Banjar
Dsn Wanareja Timut rt.4 rw.6 Ds. Wanareja Kec. Wanareja Kab Cilacap
Perum Dobo Regency Kel. Pataruman Kec. Pataruman Kota Banjar
Dsn. Cibodas rt3 rw.24 Desa Cisadap Kecamatan Ciamis Kabupaten Ciamis
Lingk. Babakansari rt.3 rw.11 Kel. Pataruman Kecamatan Pataruman Kota Banjar
Lingk. Pintu singa rt.5 rw.18 Kel. Banjar Kec. Banjar Kota Banjar
Jl.Ir.H.Juanda RT/RW 002/018 Ciamis
Dsn. Cibentang rt.14 rw.7 Ds. Mekarharja Kec. Purwaharja Kota Banjar
Dsn. Citangkolo rt.5 rw.1 Ds. Kujangsari Kec. Langensari Kota Banjar
Cikabuyutan Barat RT 02/10 Kel.Hegarsari
Dsn. Pasirleutik rt.27 rw.11 Ds. Mekarharja Kec. Purwaharja Kota Banjar
Babakansari RT 003/011 Kec.Pataruman Kota Banjar
Lingk. Cikabuyutan Timur rt.4 rw.11 Kel. Hegarsari Kec. Pataruman Kota Banjar
Dsn. Babakan Ciminyak rt.1 rw.1 Ds. Karyamulya Kec. Cisaga Kab. Ciamis
Lingk. Cimenyan I rt.4 rw.3 Kel. Mekarsari Kec. Banjar Kota Banjar
Perum Griya Banjar Raharja Blok A 4/5 Lingk.Haurmukti
Lingk. Cimenyan II rt.1 rw.6 Kel. Mekarsari Kec. Banjar Kota Banjar
Randegan I RT 007/003
Lingk.Haurmukti RT 041/002
Dsn Mekar Mulya rt.11 rw.5 Ds. Kepel Kec. Cisaga Kab. Ciamis
Lingk.Siluman RT 025/012 Kec.Purwaharja Kel.Purwaharja
Dusun Randegan I 11/04 Purwaharja Banjar
Dusun Cibereum Rt. 6 Rw. 2
Jl. Pasar Langen Rt. 2 Rw.1
Babakansari Rt. 2 Rw. 8
Cimenyan II Rt. 01 Rw.08
Banjar Kolot Rt. 3 Rw. 14
Perum Balokang Blok B No. 60
Karang Pucung
LINGK. BABAKANSARI
LINGK. LEMBUR BALONG
Kedungwaringin RT/RW. 9/6 Desa Waringinsari Kec. Langensari Kota Banjar
Ling. Parungsari RT14 RW 06 RT/RW. 14/6 Desa Karangpanimbal Kec. Purwaharja Kota Banjar
Dsn. Cilulu RT/RW. 3/11 Desa Dayeuhluhur Kec. Dayeuhluhur Kab. Cilacap
Ling. Sidamukti RT/RW. 6/6 Desa Muktisari Kec. Langensari Kota Banjar
Link. Langkap Lancar RT/RW. 5/1 Desa Bojongkantong Kec. Langensari Kota Banjar
Jln Desa Kujangsari RT/RW. 1/2 Desa Kujangsari Kec. Langensari Kota Banjar
JL. Pesantren No.02 RT/RW. 1/2 Desa Kujangsari Kec. Langensari Kota Banjar
JL. Malang Dirana NO.35 RT/RW. 1/2 Desa Segaralangu Kec. Cipari Kab. Cilacap
cijurey RT/RW. 1/3 Desa Kujangsari Kec. Langensari Kota banjar
Sukabakti RT/RW. 9/3 Desa Puloerang Kec. Lakbok, Kab. Ciamis
DUSUN PANANJUNG TIMUR RT.31/RW.07 DESA SINARTANJUNG KEC.PATARUMAN KOTA BANJAR
JL.RE.KURDIJAN NO.66 LING. CIKABUYUTAN TIMUR KEL. HEGARSARI KEC.PATARUMAN KOTA BANJAR
DUSUN MARGALUYU RT.009 RW.009 DESA MULYASARI KEC.PATARUMAN KOTA BANJAR
DUSUN CIDOYANG RT.004/RW.021 DESA JALATRANG KEC CIPAKU KAB CIAMIS
DUSUN KARANG PUCUNG WETAN RT.11/RW.03 DESA JAJAWAR KEC.BANJAR KOTA BANJAR
DUSUN CILENGKONG RT.14/RW.07 DESA NEGLASARI KECAMATAN BANJAR KOTA BANJAR
DUSUN PANANJUNG BARAT RT.008 RW.002 DESA SINARTANJUNG KEC.PATARUMAN KOTA BANJAR
DUSUN MARGASARI RT.04/RW.06 DESA BOJONGKANTONG KEC.LANGENSARI KOTA BANJAR
SINASI COVID-19
VAKSINASI

kolom yang sesuai)
Nama/Jenis/Merek
Vaksin***
BPJS Non Non
BPJS PBI
PBI Anggota
081321354401 YA 10/03/2021 COVID-19 VACCINE

081323242772 YA 10/03/2021 COVID-19 VACCINE
081222888610 YA 10/03/2021 COVID-19 VACCINE
081222888610 YA 10/03/2021 COVID-19 VACCINE
081312677770 YA 10/03/2021 COVID-19 VACCINE
085353238389 YA 10/03/2021 COVID-19 VACCINE
082221180750 YA 10/03/2021 COVID-19 VACCINE
082117998096 YA 10/03/2021 COVID-19 VACCINE
085314000888 YA 10/03/2021 COVID-19 VACCINE
085223860690 YA 10/03/2021
081320731601 YA 10/03/2021 COVID-19 VACCINE
085724118674 YA 10/03/2021 COVID-19 VACCINE
085322185274 YA 10/03/2021 COVID-19 VACCINE
085228158718 YA 10/03/2021 COVID-19 VACCINE
082126499174 YA 10/03/2021 COVID-19 VACCINE
085353354334 YA 10/03/2021 COVID-19 VACCINE
082119812626 YA 10/03/2021 COVID-19 VACCINE
081323197969 YA 10/03/2021 COVID-19 VACCINE
082120372022 YA 10/03/2021 COVID-19 VACCINE
085223022780 YA 10/03/2021 COVID-19 VACCINE
082218109380 YA 10/03/2021 COVID-19 VACCINE
082118779598 YA 10/03/2021 COVID-19 VACCINE
082321200250 YA 10/03/2021 COVID-19 VACCINE
083826753777 YA 10/03/2021 COVID-19 VACCINE
089662031886 YA 10/03/2021 COVID-19 VACCINE
082118247458 YA 10/03/2021 COVID-19 VACCINE
085314434264 YA 10/03/2021 COVID-19 VACCINE
085223964144 YA 10/03/2021 COVID-19 VACCINE
089629643061 YA 10/03/2021 COVID-19 VACCINE
081221984211 YA 10/03/2021 COVID-19 VACCINE
089529999332 YA 10/03/2021 COVID-19 VACCINE
087798384402 YA 10/03/2021 COVID-19 VACCINE
082130173985 YA 10/03/2021 COVID-19 VACCINE
081394116709 YA 10/03/2021 COVID-19 VACCINE
081321046006 YA 10/03/2021 COVID-19 VACCINE
081324254065 YA 10/03/2021 COVID-19 VACCINE
0895362423090 YA 10/03/2021 COVID-19 VACCINE
081320288585 YA 10/03/2021 COVID-19 VACCINE
085223100914 YA 10/03/2021 COVID-19 VACCINE
082258281474 YA 10/03/2021 COVID-19 VACCINE
083827724948 YA 10/03/2021 COVID-19 VACCINE
085323984969 YA 10/03/2021 COVID-19 VACCINE
085282053572 YA 10/03/2021 COVID-19 VACCINE
081312632856 YA 10/03/2021 COVID-19 VACCINE
082216555385 YA 10/03/2021 COVID-19 VACCINE
087728254206 YA 10/03/2021 COVID-19 VACCINE
082318337505 YA 10/03/2021 COVID-19 VACCINE
085221501535 YA 10/03/2021 COVID-19 VACCINE
082315146421 YA 10/03/2021 COVID-19 VACCINE

081312966677 YA 10/03/2021 COVID-19 VACCINE
085223883334 YA 10/03/2021 COVID-19 VACCINE
085223141423 YA 10/03/2021 COVID-19 VACCINE
085294749922 YA 10/03/2021 COVID-19 VACCINE
085294894786 YA 10/03/2021 SINOVAC
082320595195 YA 10/03/2021 SINOVAC
085324471395 YA 10/03/2021 SINOVAC
082118739745 YA 10/03/2021 SINOVAC
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Tanggal Tanggal Diberikan/Lanjut)
Pemberian No. Batch No. Serial Pemberian No. Batch No. Serial
Vaksinasi Vaksinasi
10/03/2021 24000421 SELESAI

10/03/2021 24000421 SELESAI
10/03/2021 24000421 SELESAI
10/03/2021 24000421 SELESAI
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2

10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
10/03/2021 24000421 LANJUT DOSIS 2
NAMA INSTANSI
NAKES LANSIA
DINAS PU
TUNDA, SEDANG SAKIT (HADIR)
SDN I PATARUMAN
SDN I PATARUMAN
SDN 4 PATARUMAN
SMK AL-AZHAR
SDN SINARTANJUNG
Kabupaten/Kota
Provinsi
No No. Tiket NIK
1 P-2F20B430 3279016103630000
2 Q-6ED5168A 3175075707840013
3 W-3535C1EB 1401114307960000
4 Q-7026DD7C 3207305911990000
5 Q-70349300 3279015706950000
6 Q-70006D3C 3207306801980000
7 Q-70C4F410 3279024511960000
8 Q-70BB81E4 3279015805970000
9 Q-ED8302F2 3279014306020000
10 Q-70B3C86D 3279015803920000
11 Q-BA923C51 3279025111000000
12 Q-C5759D90 3279036605920000
13 Q-583CA6BC 3207190206890000
14 Q-5B670D3A 3279010707960005
15 Q-6F89275F 3207155904950001
16 3279025103900001
17 Q-71F173BC 3279046410950003
18 Q-71573F6B 3279035411950001
19 Q-DCEF5397 3301154811910002
20 Q-71EAC451 3279045812990002
21 Q-82D0CF42 3279016606010001
22 3279025806000004
23 Q-7019233B 3207175704990002
24 Q-1BAF5F66 3206274305920001
25 Q-D1C964D9 3279047009960002
26 3279032302920001
27 3279035911950001
28 3279015306010003
29 W-67E5EB32 3207036908970000
30 Q-C339A6F8 3279026807950000
31 Q-4CA29E65 3279025707930000
32 Q-D6567FD1 3207214807890000
33 Q-A1BEA76B 3279026211970000
34 Q-EA1E284E 3207185201920000
35 Q-94FAC850 3302215908870000
36 W-E6E73DAA 3273255410880002
37 3279025808760001
38 W-1E6002A2 3207126012920000
39 W-409E3C7D 3207105604880000
40 Q-71DEFEE3 3205016809950000
41 W-11486B80 3277025112940010
42 W-0B0EC084 3279024504910000
43 Q-AB92D88C 3279016503850000
44 S-E164B88F 3279020505520001
45 S-D87DE0D7 3279022807600001
46 P-9IMREHWZ 3279021001610001
47 S-4F6C2DC2 3279020406570004
48 S-3A5201EE 3279020401690001
49 P-9KAZVOWP 3279020709610001
50 S-6EE44A43 3279021712600001
51 S-CA4D94BA 3279021504600004
52 S-747C9BE7 3279020408560001
53 S-64DA4ED5 3279020607590003
54 P-9H6LL2QN 3279020508650004
55 S-F9EF915D 32790207095880004
56 P-9FNVKPTA 3279022704620001
57 P-9GT56AWU 3279020805650002
58 S-89C18260 3279021605410001
59 P-9TREMD3S 3279021806630001
60 S-2C333998 3279020111530001
61 S-9A28AC3B 3279020727400003
62 P-9KOAMXUI 3279021302650001
63 P-9TREMD3S 3279021104480001
64 3279021506600003
65 3279012404570002
66 3279012404570002
67 3279020604420003
68 3279020105640001
69 3279020611590003
70 3279021302640002
71 3279023008670001
72 3279020603050139
73 3279022505630001
: KOTA BANJAR
: JAWA BARAT
Jenis
Nama Penerima Vaksin Pekerjaan*
Kelamin
IMAS MASRIAH P TENAGA KESEHATAN LAINNYA

RISA ROSNELITA P PERAWAT
DINI RIZKI ANDINI P DOKTER
SITI NURAENI P TENAGA KESEHATAN LAINNYA
RIKA YUNIARTI BASTAMAN P TENAGA KESEHATAN LAINNYA
ELIS KURNENGSIH P TENAGA KESEHATAN LAINNYA
TITA FITRIANI P APOTEKER
IKA SUCIANTI P TENAGA KESEHATAN LAINNYA
SAFIRA JUNITA QAFSOH P TENAGA KESEHATAN LAINNYA
FITRIYANI P TENAGA KESEHATAN LAINNYA
ANISA NOPIATIN P TENAGA KESEHATAN LAINNYA
YOSI ARSIANTI P TENAGA KESEHATAN LAINNYA
FADZILLAH NURSALAM L PERAWAT
ADE ZAYADI L TENAGA KESEHATAN LAINNYA
AZIZAH NURAENI P PERAWAT
ASTRI SETIAWATI P TENAGA KESEHATAN LAINNYA
INTAN PRANINGTIYAS WINDIAWATI AGUS SAPUTRI P TENAGA KESEHATAN LAINNYA
TITA PURNAMASARI P TENAGA KESEHATAN LAINNYA
TUTI NOVIANTI P TENAGA KESEHATAN LAINNYA
ITA PUSPITASARI P TENAGA KESEHATAN LAINNYA
AYU YUNIAR P TENAGA KESEHATAN LAINNYA
DEVI PRANSISKA P TENAGA KESEHATAN LAINNYA
UMI KULSUM P TENAGA KESEHATAN LAINNYA
ROSMIATI P PERAWAT
SITI HERDIYANTI P PERAWAT
YUDI NURDIANSYAH L ADMINISTRASI
RESFIA RACHMAN NOVIANA P PERAWAT
RESTI DWI CAHYUNI P ADMINISTRASI
TINA SITI ROHMAH P BIDAN
ERNAWATI P NAKES LAINNYA
NITA JULISTIANI P NAKES LAINNYA
ERI NURYANI P BIDAN
YUNITA HIDAYATI P NAKES LAINNYA
RATNA P BIDAN
AGUSTINA IIN KURNIATI P BIDAN
NIKITA IRZANA UTAMI P DOKTER GIGI
NINA KHRISNAHAYATI BARJAH P BIDAN
DINI ARYANTI P ANALIS KESEHATAN
IKA SRIHAYATI P PROMKES
MUTHIYA NUR AZIZAH P AHLI GIZI
SHARFINA NISA HANIFAH P KESLING
EGIS SUGIARTI P PERAWAT
UCI SUSILAWATI SAPUTRA P BIDAN
Darsono L PURNAWIRAWAN TNI
Jajat Sudrajat L PURNAWIRAWAN TNI
Odih Hadian L PURNAWIRAWAN TNI
Sujana L PURNAWIRAWAN TNI
Sukardi L PURNAWIRAWAN TNI
H.Sukatman L PURNAWIRAWAN TNI
H.Munadi L PURNAWIRAWAN TNI
Endang Syawa L PURNAWIRAWAN TNI
Tahirun L PURNAWIRAWAN TNI
Ading L PURNAWIRAWAN TNI
Miswan L PURNAWIRAWAN TNI
Daswan L PURNAWIRAWAN TNI
Dedi Suhendi L PURNAWIRAWAN TNI
Misno L PURNAWIRAWAN TNI
Ruhana L PURNAWIRAWAN TNI
Ujang Jaelani L PURNAWIRAWAN TNI
Kardi L PURNAWIRAWAN TNI
Umar L PURNAWIRAWAN TNI
Tulus L PURNAWIRAWAN TNI
Sarko L PURNAWIRAWAN TNI
Yaya L PURNAWIRAWAN TNI
Yunus L PURNAWIRAWAN TNI
Pardi L PURNAWIRAWAN TNI
Karmadi L PURNAWIRAWAN TNI
Didin Muhidin L PURNAWIRAWAN TNI
Sirun L PURNAWIRAWAN TNI
Wawan Hermawan L PURNAWIRAWAN TNI
Gunadi L PURNAWIRAWAN TNI
Nanang L PURNAWIRAWAN TNI
Darmanto Darja L PURNAWIRAWAN TNI
FORMAT PENCATATAN PELAKSANAAN VAKSINA
TINGKAT PUSKESMAS/FASYANKES/POS VAK
Umur
Kelompok
(18-59
Umur
tahun)
57 46-59
35 31-45
25 18-30
22 18-30
26 18-30
23 18-30
25 18-30
24 18-30
19 18-30
29 18-30
21 18-30
29 18-30
32 31-45
25 18-30
26 18-30
30 18-30
26 18-30
26 18-30
30 18-30
22 18-30
20 18-30
21 18-30
22 18-30
29 18-30
25 18-30
29 18-30
26 18-30
20 18-30
24 18-30
26 18-30
28 18-30
32 31-45
24 18-30
29 18-30
34 31-45
33 31-45
45 31-45
29 18-30
33 31-45
26 18-30
27 18-30
30 18-30
36 31-45
69 >60
61 >60
60 >60
64 >60
52 46-59
59 46-59
61 >60
61 >60
65 >60
62 >60
56 46-59
64 60
59 46-59
56 46-59
80 >60
58 46-59
68 >68
81 >60
56 46-59
73 >60
DOSIS 1 DAN DOSIS 2
Alamat

DUSUN PANGASINAN RT 002 RW 007, DESA BINANGUN, KEC. PATARUMAN
LINGK. JELAT RT 01 RW 04 KEL. PATARUMAN
DUSUN MULYAJAYA,RT 02 RW 11 DESA CISAGA KAB CIAMIS
DUSUN GARDU RT 018 RW 006 DESA BALOKANG KEC BANJAR
DSN SUKAHARJA RT 012 RW 03 DESA BANGUNHARJA KAB CIAMIS
LINGK. GUDANG RT 03 RW 01, HEGARSARI, PATARUMAN
DUSUN CIPANTARAN RT 16 RW 04
LINGK. BANJARKOLOT RT 05 RW 16
DUSUN CIAREN RT 46 RW 14
LINGK. LEMBURBALONG RT 02 RW 5, PATARUMAN
PAMARICAN RT 01 RW 01, PAMARICAN
LINGK SUMANDING WETAN RT 003 RW 015
LINGK. BANJARKOLOT RT 02 RW 14, BANJAR
LINGK. LANGEN RT 05 RW 01, MUKTISARI, LANGENSARI
LINGK. CIMENYAN II RT 03 RW 10
DUSUN KUBANG RT 27 RW 11, SIDAMULYA, CISAGA
DUSUN BANTARDAWA, RT 05 RW 02, REJASARI, LANGENSARI
LINGK. PINTUSINGA RT 05 RW 17, BANJAR
LINGK. BABAKANSARI RT 01 RW 01, PATARUMAN
DUSUN CIKAWUNG RT 40 RW 11, CINTARATU, LAKBOK
SUKARAME, MEKARSARI, BANJAR
DUSUN KEDUNGWARINGIN, WARINGINSARI, LANGENSARI
DUSUN PAMOTAN RT 01 RW 01, DESA PAMOTAN, KEC. KALIPUCANG
DUSUN PANANJUNG BARAT RT 09 RW 02, DESA SINARTANJUNG, KEC. PATARUMAN
DUSUN PANANJUNG BARAT RT 09 RW 02, DESA SINARTANJUNG, KEC. PATARUMAN
LINGK. PATARUMAN RT 02 RW 12, PATARUMAN
LINGK. SUKARAME RT 01 RW 14, MEKARSARI, BANJAR
LINGK. AWILUAR RT 14 RW 04, SITUBATU
KEDUNGMALANG RT 02 RW 02, KEDUNGMALANG, SUMBANG
Komp. Eastren Hill Regency Jl. Ruselia IIIB RT 07 RW 013 Desa Cipadung Kecamatan Cibiru
Lingk. Babakansari RT 003 RW 011 Kelurahan Pataruman
Dusun Sukamenak RT 003 RW 009 Desa Mekarmukti
Dusun Pangasinan RT 008 RW 009 Desa Binangun
Mekarsari RT 001 RW 015 Desa Muarasanding Kecamatan Garut Kota
Jl. RH Abdul Halim No. 80 RT 001 RW 019 Desa Cigugur Tengah
Dusun Pananjung RT 019 RW 004 Desa Sinartanjung
Dusun Karangtengah, RT 025 RW 009, Desa Balokang
Rancakole RT 10/2 Mulyasari-Kec Pataruman
Margaluyu RT 8/9 Mulyasari-Kec Pataruman
Sinartanjung RT 3/02 Kec Pataruman
Pataruman RT 3/12 Kec Pataruman
Babakansari RT 01/11 Kel / Kec Pataruman
Babakansari RT 6/11 Kec Pataruman
Babakansari RT 8/11 Kel/Kec Pataruman
Jelat RT 3/3 Kel / Kec Pataruman
Babakansari RT 7/11 - Kel/Kec Pataruman
Ciktim 1/12 Hegarsari Kec.Pataruman
Sukamaju RT 2/04 Mulyasari -Kec.Pataruman
DSN SUKAMAJU RT 08 RW 05, MULYASARI, PATARUMAN
AKSINASI COVID-19
POS VAKSINASI
IS 2

Dosis I
kolom yang sesuai)
Nama/Jenis/Merek
Vaksin*** Tanggal
BPJS Non Non
BPJS PBI Pemberian
PBI Anggota
Vaksinasi
081323313370 YA 3/12/2021 COVID-19 VACCINE 3/12/2021

081223024111 YA 3/12/2021 COVID-19 VACCINE
085216988839 YA 3/12/2021 COVID-19 VACCINE
089524845194 YA 3/12/2021 COVID-19 VACCINE
082240234117 YA 3/12/2021 COVID-19 VACCINE
085320115264 YA 3/12/2021 COVID-19 VACCINE
089628765634 YA 3/12/2021 COVID-19 VACCINE
082218864393 YA 3/12/2021 COVID-19 VACCINE
087722470716 YA 3/12/2021 COVID-19 VACCINE
081220866673 YA 3/12/2021 COVID-19 VACCINE
089662418788 YA 3/12/2021 COVID-19 VACCINE
082320346718 YA 3/12/2021 COVID-19 VACCINE
082317312017 YA 3/12/2021 COVID-19 VACCINE
08562174984 YA 3/12/2021 COVID-19 VACCINE
082217442051 YA 3/12/2021 COVID-19 VACCINE
082214569309 YA
082123717190 YA 3/12/2021 COVID-19 VACCINE
082218810113 YA 3/12/2021 COVID-19 VACCINE
085218331847 YA 3/12/2021 COVID-19 VACCINE
081929746362 YA 3/12/2021 COVID-19 VACCINE
089506047154 YA 3/12/2021 COVID-19 VACCINE
089621581007 YA
081214193892 YA 3/12/2021 COVID-19 VACCINE
085318900801 3/12/2021
YA COVID-19 VACCINE
082117863582 YA 3/12/2021 COVID-19 VACCINE
081287899040 YA
085723478776 YA
089626655145 YA
087737583338 YA 3/12/2021 COVID-19 VACCINE
082240380192 YA 3/12/2021 COVID-19 VACCINE
087834554246 YA 3/12/2021 COVID-19 VACCINE
081214181374 YA 3/12/2021 COVID-19 VACCINE
08977857292 YA 3/12/2021 COVID-19 VACCINE
082127480600 YA 3/12/2021 COVID-19 VACCINE
O81224230668 YA 3/12/2021 COVID-19 VACCINE
081320008607 YA 3/12/2021 COVID-19 VACCINE
081323100780 YA
082240576480 YA 3/12/2021 COVID-19 VACCINE
082240576480 YA 3/12/2021 COVID-19 VACCINE
082240314750 YA 3/12/2021 COVID-19 VACCINE
YA 3/12/2021 COVID-19 VACCINE
082115565439 YA 3/12/2021 COVID-19 VACCINE
085215515466 YA 3/12/2021 COVID-19 VACCINE
81321702482 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
0852236969999 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
81214557810 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
YA 3/12/2021 COVID-19 VACCINE 3/12/2021
082317600250 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
089635539261 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
08122188361 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
82121415178 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
81313812718 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
81224200666 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
82121892020 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
YA 3/12/2021
89660591938 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
81323530447 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
YA 3/12/2021 COVID-19 VACCINE 3/12/2021
085223161330 YA 3/12/2021
0812610082170 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
0895803178745 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
082119129777 YA 3/12/2021
081385335060 YA 3/12/2021 COVID-19 VACCINE 3/12/2021
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Vaksinasi

3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
SAKIT TIDAK HADIR
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
SAKIT TIDAK HADIR
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
TIDAK HADIR
TIDAK HADIR
TIDAK HADIR
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
SAKIT TIDAK HADIR
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
3/12/2021 24000421 SELESAI
DITUNDA
DITUNDA
DITUNDA
TIDAK HADIR
NAMA INSTANSI
KLINIK PEGADAIAN DAN KLINIK

SARAF MEDIKA
ASS BIDAN ERMILA

APOTEK MEDIKA HUTAMA
KLINIK KASIH IBU

KLINIK KASIH IBU
PKM PATARUMAN 3
PURNAWIRAWAN TNI
Jenis
Kelamin
1 Q-48250A2E 3279015306010003 RESTI DWI CAHYUNI P

2 Q-71DB343D 3279035911950001 RESFIA RACHMAN NOVIANA P
3 Q-971F02C6 3279032302920001 YUDI NURDIANSYAH L
4 Q-B3A2657C 3207305906770001 ASIH SETIAWATI P
5 Q-8153D6DB 3207181604930002 DINDA APRILIAN SUHENDI L
6 Q-057427C9 3207301308700002 BABAN SEHABUDIN L
7 Q-62C37892 3207302203020001 REGY ANGGARETA ISKANDAR L
8 Q-7FAC16B6 3279011404980001 RIO APRIYANTO L
9 Q-801736CE 3279014801940001 NADIA ANISA PUTRI P
10 P-A7F42FVT 3207176002710002 NURUL ZULFANI'MAH P
11 N-26DFEB60 3279026502890001 HENI MULYANI P
12 3279012202960001 FERI SAPUTRA L
13 3207241605880001 TOTO FITRIAL L
14 3207190603930001 ARIF MIFTAHUL BARKAH L
15 S-6CF234B3 3279025805630001 AAS AISAH P
16 S-92F0F3D8 3207015410910002 TSINTA NUR FAJRIAH P
17 S-6B529243 3279021207640002 TATA L
18 S-1368DB66 3279025409790005 JUJU JUARIAH P
19 S-E271CABA 3279026901970002 SRI HAYATI P
20 S-F60B5798 3279026112610002 OOM ROMLAH P
21 S-EDE642E4 3279026703620002 YANI ROHAYANINGSIH P
22 S-59E4EAE6 3301192806860001 MUHAMAD DALHAR L
23 S-D46B63B5 3279024704660003 SIYAMTI P
24 S-773794A0 3279025603960003 NURRAHMI PUJIANI P
25 S-E748DA31 3279021301820002 Hendri Gunawan L
26 S-0BF3075F 3279042907800001 AGUS SUPRIATNA L
27 S-DD3DE6F4 3279032809820001 SUTARDIAWAN L
28 S-F1A4FC40 3207317101950003 ARIE MEGAWATIE SA`BANI P
29 S-92EA76E0 3279014602960002 NURHAYATI P
30 S-83465450 3279024705770004 Dede Nuryatin, S.Pd.I P
31 S-AE58DC5D 3279025312710001 TITA NURBAETI R P
32 S-60C61067 3279026303860001 IKA ARISTYA PUTRI P
33 S-0236E6AB 3279016709910002 AYU YULIA FRIDAY P
34 S-B8C68232 3207131101920002 ILHAM ZAMZAM NURJAMAN L
35 S-37D87635 3279044909710001 TINI P
36 S-5E3F0573 3279024505740004 DAHLIA, S.Pd P
37 S-4C478DD9 3279045212850001 Dede Irma Nurmala P
38 S-01EEBAA8 3207174107840011 SUGIATUN P
39 S-E0CB25ED 3279046311920001 DINY FOERNAMASARI P
40 S-0B11B768 3279034608730003 EUTIK P
41 Ahmad Lutfi Nazwarudin L
42 Yusuf Kamil L
43 S-96C16954 3279021811650001 SARIPUDIN L
44 Iwan Irawan L
45 S-7B390071 3279020106830003 Jajang Sunarto L
46 S-2F250AC3 3279024308850003 INA HERLINA AGUSTINA P
47 S-A0E49C7E 3207176212860001 TRIYANI P
48 S-9D10E5D7 3279025011680008 CARINAH P
49 S-A8D01138 3207046612860002 Santi Kartiwi P
50 S-F3484FA6 3279036308750002 Kokom P
51 S-03AA4BE2 3207233107820001 DEDI NURWANDI L
52 P-AAE20ZGG 3278051402900001 FEBRY SYARIF HIDAYAT L
53 S-E2B94A1D 1806011305930005 Dima Surya Buana L
54 S-8425CEE9 3279010205920002 Adi Hardiansyah L
55 S-ED0C9983 3279016807850001 Rani Kristamas Irawati P
56 S-72DF1602 3279042811930004 SAHRIR ALI MUSTOPA L
57 S-446AA166 3279022401820002 Ganjar Shirih L
58 S-D76BC1DC 3279015703860003 Ratih Koesdiani Dewi P
59 S-B081E1E2 3279010910790001 Asep Suharto L
60 P-AAZ0UMTS 3279021406970001 RIKI RIMANSAH L
61 S-909B7006 3203010102920022 Feby Rizaldi Putra L
62 S-55AF655A 3279046205830002 Tuti Kurniati P
63 P-ABCD0AHJ 3279022108770002 DODY GUNAWAN L
64 S-D2B61871 3207036805860001 Ikah Atikah P
FORMAT PEN
TINGKAT
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
PERAWAT 26 18-30
PERAWAT 28 18-30
PERAWAT 27 18-30
PERAWAT 29 18-30
PERAWAT 32 31-45
PERAWAT 33 31-45
PERAWAT 28 18-30
GURU 58 46-59
GURU 30 18-30
GURU 57 46-59
GURU 42 31-45
GURU 24 18-30
GURU 59 46-59
GURU 59 46-59
GURU 35 31-45
GURU 55 46-59
GURU 25 18-30
GURU 39 31-45
GURU 41 31-45
GURU 39 31-45
GURU 26 18-30
GURU 25 18-30
GURU 44 31-45
GURU 50 46-59
GURU 35 31-45
GURU 30 18-30
GURU 29 18-30
GURU 50 46-59
GURU 47 46-59
GURU 36 31-45
GURU 37 31-45
GURU 29 18-30
GURU 48 46-59
GURU
GURU
GURU 56 46-59
GURU
GURU 38 31-45
GURU 36 31-45
GURU 35 31-45
GURU 53 46-59
GURU 35 31-45
GURU 46 46-59
GURU 39 31-45
GURU 31 31-45
GURU 28 18-30
GURU 29 18-30
GURU 36 31-45
GURU 28 18-30
GURU 39 31-45
GURU 35 31-45
GURU 42 31-45
GURU 24 18-30
GURU 29 18-30
GURU 38 31-45
GURU 44 31-45
GURU 35 31-45
DOSIS 1 DAN DOSIS 2
Alamat

DUSUN KERTAHARJA RT 06 RW 01, BANGUNHARJA
DUSUN LUMBUNGSARI RT 14 RW 05, PAMARICAN, CIAMIS
DUSUN KERTAHARJA RT 06 RW 01, BANGUNHARJA
DUSUN SUKAHARJA RT 09 RW 03, BANGUNHARJA, CISAGA
LINGK. CIMENYAN II RT 02 RW 10, MEKARSARI, BANJAR
KARACAK LINGK.KERTAHAYU RT 05 RW 11, SINDANGRASA CIAMIS
DUSUN AJIBARANG WETAN RT 02 RW 02, AJIBARANG, KEC. AJIBARANG, JAWA TENGAH
LINGK. CIKABUYUTAN BARAT RT 04 RW 10, HEGARSARI, PATARUMAN
DUSUN KARANGMUKTI RT 02 RW 07, SELASARI, PARIGI
CIBENDA RT 03 RW 01, PAMARICAN
LINGK. BABAKANSARI RT02 RW09 KEL. PATARUAMAN, KEC. PATARUMAN
JL. RANCAPETIR NO. 6 RT02 RW24 CIAMIS
LIGK. SUKAMANAH RT02 RW17 KEL. PATARUMAN, KEC. PATARUMAN
LINGK. SUKAMANAH RT01 RW16 KEL. PATARUMAN
LINGK. PATARUMAN RT01 RW12 KEL. PATARUMAN
Pananjung Barat RT 4 RW 1, Desa Sinartanjung, Kec. Pataruman
Cikabuyutan Timur RT 6 RW 12, Desa Hegarsari, Kec. Pataruman
Dusun Magersari RT 04 RW 02, Desa Cinyawang, Kec. Patimuan
Cikabuyutan Barat RT 5 RW 10, Desa Hegarsari, Kec. Pataruman
Lingk. Tanjungsukur Rt/Rw: 4/15 Desa/Kel. Hegarsari Kec. Pataruman Kota Banjar
Dusun Priagung Rt/Rw: 10/4 Desa Binangun Kec. Pataruman Kota Banjar
Langkap Lancar Rt/Rw: 1/2 Desa/Kel. Bojong kantong Kec. Langensari Kota Banjar
Dusun Siluman Rt/Rw: 26/12 Desa/Kel. Purwaharja Kec. Purwaharja Kota Banjar
Dusun Kalapanunggal II Rt/Rw: 45/14 Desa/Kec. Sindangkasih Kab. Ciamis
Parung Lesang Rt/Rw: 1/9 Desa/Kel: Banjar Kec. Banjar Kota Banjar
Ling. Pananjung RT 009 RW 002 Sinar Tanjung
Ling. Sukamaju RT 010 RW 006 Mulyasari
Ling. Cimeyan II RT 003 RW 09 Mekasari
Dusun Parung RT 013/005 Balokang
Dsn. Karanganyar Rt 01 Rw 11
Jln. Langkaplancar Rt 02 Rw 02
Jln Purwanegara Rt 02 Rw 05
Dsn Bojongsari Rt 03 Rw 03
Dsn. Baregbeg Rt 13/ Rw 04 Baregbeg, Lakbok, Ciamis
Dsn. Cigadung Rt 01/ Rw 03 Karyamukti, Patarumna, Banjar
Lingk. Cikadu Rt 20/ Rw 09 Karangpanimbal, Purwaharja, Banjar
Lingk. Sumanding Wetan Rt 02/ Rw 16 Mekarsari, Banjar, Banjar
Dsn. Pananjung Timur Rt 30/ Rw 07, Sinartanjung, Pataruman, Banjar
Mulyasari RT. 01/04
Bojongkantong RT. 02/03
Mulyasari RT.03/04
Sinartanjung RT. 16/04
Hegarsari RT. 06/13
Rejasari RT. 01/07
Dsn Desa rt 01/rw08 Des. Sukajadi Kec. Sadananya. Ciamis
Lingk. Cikadu rt 28/rw 13 Karangpanimbal purwaharja Banjar
Dsn. Cikalong rt 01/ rw 02 Des.Cikalong. Kec. Sidamulih Pangandaran
Dsn. Pamarican rt 08/rw02 Des. Pamarican. Kec Pamarican Ciamis
Lingk. Babakan sari rt 01/rw09 Pataruman kec Pataruman kota Banjar
Dsn. Karangpucung rt 30/rw 10 Des. Balokang Kec. Banjar kota Banjar
Sukamaju
CIJUREY
Pananjung
Parunglesang
Parunglesang
Margaluyu
Cikabuyutan Timur
Langkap Lancar
Sukamulya
MARGALUYU
ELAKSANAAN VAKSINASI COVID-19
S/FASYANKES/POS VAKSINASI
OSIS 2

kolom yang sesuai)
No. Hp Tanggal Screening Nama/Jenis/Merek Vaksin***

BPJS Non Non
BPJS PBI
PBI Anggota
089626655145 YA 3/13/2021 CORONA-VAC

085723478776 YA 3/13/2021 CORONA-VAC
81287899040 YA 3/13/2021 COVID-19 VACCINE

085256379023 YA 3/13/2021 COVID-19 VACCINE
082216766575 YA 3/13/2021 COVID-19 VACCINE
085722731835 YA 3/13/2021 COVID-19 VACCINE
085871029288 YA 3/13/2021 COVID-19 VACCINE
0895370420303 YA 3/13/2021 COVID-19 VACCINE
085314004063 YA 3/13/2021 COVID-19 VACCINE
085292366543 YA 3/13/2021 COVID-19 VACCINE
YA 3/13/2021 COVID-19 VACCINE
081223147713 YA
082218916738 YA
085723144149 YA
081323179876 YA 3/13/2021 COVID-19 VACCINE
085223058007 YA 3/13/2021 COVID-19 VACCINE
085323489011 YA 3/13/2021 COVID-19 VACCINE
082127786804 YA 3/13/2021 COVID-19 VACCINE
085217362282 YA 3/13/2021 COVID-19 VACCINE
081994666844 YA 3/13/2021 COVID-19 VACCINE
088224438665 YA 3/13/2021 COVID-19 VACCINE
085741729204 YA 3/13/2021 COVID-19 VACCINE
085323940266 YA 3/13/2021 COVID-19 VACCINE
081321452096 YA 3/13/2021 COVID-19 VACCINE
082123386810 YA 3/13/2021 COVID-19 VACCINE
081323170288 YA 3/13/2021 COVID-19 VACCINE
085294364228 YA 3/13/2021 COVID-19 VACCINE
82315756362 YA 3/13/2021 COVID-19 VACCINE
82214458150 YA 3/13/2021 COVID-19 VACCINE
81910203973 YA 3/13/2021 COVID-19 VACCINE
85352326314 YA 3/13/2021 COVID-19 VACCINE
85860240053 YA 3/13/2021 COVID-19 VACCINE
85320528191 YA 3/13/2021 COVID-19 VACCINE

85223372995 YA 3/13/2021 COVID-19 VACCINE
82119615048 YA 3/13/2021
81322591150 YA 3/13/2021 COVID-19 VACCINE
85223450061 YA 3/13/2021 COVID-19 VACCINE
82219513830 YA 3/13/2021 COVID-19 VACCINE
82214612093 YA 3/13/2021 COVID-19 VACCINE
85294313068 YA 3/13/2021 COVID-19 VACCINE

YA
YA
- YA 3/13/2021 COVID-19 VACCINE

YA
85294313366 YA 3/13/2021 COVID-19 VACCINE
82321677240 YA 3/13/2021 COVID-19 VACCINE
81322203402 YA 3/13/2021 COVID-19 VACCINE
82128414703 YA 3/13/2021 COVID-19 VACCINE

85320349123 YA 3/13/2021 COVID-19 VACCINE
89697236881 YA 3/13/2021 COVID-19 VACCINE
85221754488 YA 3/13/2021 COVID-19 VACCINE
85724517956 YA 3/13/2021 COVID-19 VACCINE
82280045630 YA 3/13/2021 COVID-19 VACCINE
81222707397 YA 3/13/2021 COVID-19 VACCINE
82319063292 YA 3/13/2021 COVID-19 VACCINE
89662636272 YA 3/13/2021 COVID-19 VACCINE

089670348735 YA 3/13/2021 COVID-19 VACCINE
85353610613 YA 3/13/2021
8122073425 YA 3/13/2021 COVID-19 VACCINE
89643223152 YA 3/13/2021 COVID-19 VACCINE
81221192440 YA 3/13/2021 COVID-19 VACCINE
82240606076 YA 3/13/2021 COVID-19 VACCINE
88222510373 YA 3/13/2021 COVID-19 VACCINE
85223486339 YA 3/13/2021 CORONA-VAC

Dosis I Dosis 2
Tanggal
Tanggal Pemberian
Pemberian No. Batch No. Serial No. Batch No. Serial
Vaksinasi
Vaksinasi
3/13/2021 202011043
3/13/2021 202011043
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 24000421
3/13/2021 202011043
Keterangan
(Ditunda/Tidak NAMA INSTANSI
Diberikan/Lanjut)
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
NAKES KLINIK PEGADAIAN
SELESAI
SELESAI
SELESAI
LANJUT DOSIS 2
TIDAK HADIR
TIDAK HADIR
TIDAK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 SDN 2 PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
SDN 5 PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
SDN 3 PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
MI RANCAKOLE
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
SDN 3 MULYASARI
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 MTs-AS Salam
TIDAK HADIR
TIDAK HADIR
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
SDN 1 MULYASARI
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
SLB NEGERI BANJAR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2
SMK MUHAMMADIYAH
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
Jenis
Kelamin
1 P-B1PIHD4D 3279025405910001 EUIS LINLIN MARLIANI P

2 S-FCED7BB4 3207301603700001 Hanasa L
3 S-96181312 3279024812690003 Lilis Setiawati P
4 S-A9AC4D66 3279024308750010 Lilis Lisnawati P
5 S-B1B43F79 3279036101860001 Nisa Yuliany P
6 S-7A324C0A 3279024503800000 AI WIDANINGSIH, S.Pd P
7 S-B4161509 3279020407960001 Liyana Kuswaya L
8 S-39C909B6 3279040110900005 BUANG SUTARJO L
9 S-2B669B33 3279021303820007 Yusup Kamil, A.Ma L
10 P-AVVCSWW9 3279024812950006 Dessy Khairunnisa P
11 Q-7FA1404D 3207241605880001 TOTO FITRIAL L
12 Q-D6FD7BDA 3207190603930001 ARIF MIFTAHUL BARKAH L
13 Q-4F2B1C24 3279012202960001 FERI SAPUTRA L
14 W-18CFE4DB 3279012712850001 Erik Kiswanto L
15 Q-D1CE41A0 3279021806670001 Maman Suratman L
16 Q-180A3CA0 3279015803880001 Imas Nurhayati P
17 Q-5D8433C5 3279024706820004 Yesi Shrivianty P
18 Q-DEFEFC56 3279024205820002 Sulistiawati P
19 Q-46DA3066 3279022408980001 Anjaswara L
20 W-0548C098 3279021202810001 Agus Supriatna L
21 W-4F454625 3207116009700001 Nunung Nurjanah P
22 W-A64787C9 3279022004840003 Mahsus L
23 W-CF74F6E9 3207195808740002 Euis Suryamah P
24 Q-830187D1 3207110105920002 Ade Wawan L
25 Q-D0427618 3279021603790001 Dedi L
26 Q-B939A249 3279026601850001 Resi Hartini P
27 Q-FC4107B3 3279015510930002 Nuraeni P
28 Q-761F60E6 3279021906910001 Aryo Haryanto L
29 Q-6DB55AA8 3301161809940004 Dani Permana L
30 3207304203670002 Ikah Surtikah P
31 3279020505860003 Ucu Herdiana L
32 Q-86F80F98 3279020406680003 WAWAN GUNAWAN L
33 Q-3EEA9423 3279021008850003 ARI, A.Md L
34 Q-8356E7BD 3279021402720001 KANDAR L
35 Q-3A4D5E1D 3279020805870003 IWAN KARWAN L
36 Q-9F7D3D61 3279022511910003 ADI WINDA MAULANA N, S.Pd L
37 Q-00C2A64E 3279021910890001 DIMAN RUDIAMAN, S.Pd L
38 Q-149B097A 3279024509870002 KARTIKA SAFARI D, S.IP P
39 Q-6D682AC8 3279024806840002 YUNI ROHANI LESTARI P
40 Q-3458D763 3275082806750017 ARIP MUHAEMIN L
41 Q-D8BF457F 3279025401880002 ADE SITI ROHAYANI P
42 Q-A512F3D1 3279026211680002 KARTIWI P
43 Q-A9CE8EAA 3279021004830001 KAHFI HAMDANI L
44 Q-5C72D756 3279020412870002 DINDIN NURDIN L
45 Q-DDCD3A38 3279021101920001 ASEP DENI CAHYADI, S.IP L
46 Q-07CBBE62 3279021908740002 AGUSYANI L
47 Q-00485F7C 3279024710860003 EEM NEMAH, S.Pd P
48 Q-1012C7CD 3279021308820004 MOH.DICKY DZULFADLI L
49 Q-80C16E21 3279020306910001 DADANG LESMANA L
50 Q-98809C8E 3279026811870003 LINA YULIANI P
51 Q-45BE92BE 3279025508930002 HERA SUMIATI P
52 P-DD360910 3279021910840002 AHMAD FAUZI L
53 Q-7CF7FA72 3279021012840001 ASEP HENDRA SUGIHARTO, A. Md. L
54 Q-EE5290EC 3279020503710001 DAYAT HIDAYAT L
55 Q-CA887AD9 3279022502740001 ADE RUKMAN L
56 Q-9E9BAF20 3279022701900001 ERY BACHTIAR L
57 Q-86E8A5C1 3279025110880002 DEVI SEPTIANI P
58 Q-C59FA9C9 3207184703820001 ERNA HANI HANDAYANI P
59 Q-84D9F7EE 3279023107860002 BAMBANG KURNIADI L
60 Q-47D03E7D 3279020607620002 KUSMANA L
61 Q-84A0F7D7 3279026905900002 DEVI TRI LINDUWATI P
62 Q-313A0732 3207312909890001 DAHLAN L
63 3279026505940002 DITA SITI JATNIKA P
64 3279025802900002 ERLI SUFIANA P
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
PERAWAT 30 18-30
Kepsek 51 46-59
GURU 52 46-59
GURU 36 31-45
GURU 35 31-45
GURU 41 31-45
GURU 25 18-30
GURU 30 18-30
GURU 39 31-45
GURU 25 18-30
PERAWAT 33 31-45
PERAWAT 28 18-30
Lurah Kelurahan Pataruman 36 31-45
Kepala Desa Mulyasari 53 46-59
Kepala Desa Sinartanjung 37 31-45
FORMAT PENCATATAN PELAKSANAAN VAK
TINGKAT PUSKESMAS/FASYANKES/PO
DOSIS 1 DAN DOSIS 2
Alamat
PANANJUNG TIMUR RT 31 RW 07, SINARTANJUNG

Cisaga Kota RT 01 RW 01, Cisaga
BABAKANSARI RT 05 RW 10, PATARUMAN
Wargamulya RT 20 RW 09, Purwaharja

Lemburbalong rt 03 rw 0, pataruman
SASAGARAN RT 01 RW 07, BOJONGKANTONG
Dsn. Rancakole Rt 11/ Rw 03 Mulyasari, Pataruman, Banjar
DUSUN KARANGMUKTI RT 02 RW 07, SELASARI, PARIGI
CIBENDA RT 03 RW 01, PAMARICAN
DUSUN RANCAKOLE RT 013/ RW 03 DESA MULYASARI KEC. PATARUMAN

LINGK. JADIMULYA RT 001/ RW 006 KEL. HEGARSARI, KEC. PATARUMAN
LINGK. PANATASAN RT 002/ RW 019 KEL. PATARUMAN, KEC. PATARUMAN
LINGK SUKAMANAH RT 004/ RW 017
DUSUN PANANJUNG BARAT 03/02 SINARTANJUNG
DUSUN KIDUL 01/06, BUNISEURI, CIPAKU
LINGK. LEMBURBALONG RT 003/ RW 007 KEL. PATARUMAN KEC. PATARUMAN

LINGK. LEMBURBALONG RT 003/ RW 006 KEL. PATARUMAN, KEC. PATARUMAN
LINGK. LEMBURBALONG, RT 001/ RW 008, KEL. PATARUMAN
DUSUN PASIR LEUTIK 26/10, MEKARHARJA
Dususn Pananjuung RT. 021 RW. 005 Desa Sinartanjung Kecamatan Pataruman Kota Banjar
Dusun Sinargalih RT. 033 RW. 008 Desa Sinartanjung Kecamatan Pataruman Kota Banjar
Dusun Pananjung RT. 020 RW. 005 Desa Sinartanjung Kecamatan Pataruman Kota Banjar
Dusun Cibeureum RT. 005 RW. 002 Desa Balokang Kecamatan Banjar Kota Banjar
DSN, KELEWIH RT.003 RW.003 KEL.SAGULING KEC.BAREGBEG KAB.CIAMISW
TAN PELAKSANAAN VAKSINASI COVID-19
ESMAS/FASYANKES/POS VAKSINASI
S2

kolom yang sesuai)
Tanggal
No. Hp Screening
Nama/Jenis/Merek Vaksin***
BPJS Non Non
BPJS PBI
PBI Anggota
82130737263 YA 3/15/2021 COVID 19 VACCINE
85320438917 YA 3/15/2021 COVID 19 VACCINE

82318356772 YA 3/15/2021 COVID 19 VACCINE
85320140093 YA 3/15/2021 COVID 19 VACCINE
87728023772 YA 3/15/2021 COVID 19 VACCINE
81323207151 YA 3/15/2021 COVID 19 VACCINE
81318096463 YA 3/15/2021 COVID 19 VACCINE
85353352873 YA 3/15/2021 COVID 19 VACCINE
087736640632 YA 3/15/2021 COVID 19 VACCINE
0895635821731 YA 3/15/2021 COVID 19 VACCINE

082218916738 YA 3/15/2021 COVID 19 VACCINE
085723144149 YA 3/15/2021 COVID 19 VACCINE
YA 3/15/2021 COVID 19 VACCINE
08112110242 YA 3/15/2021 COVID 19 VACCINE
085223409646 YA 3/15/2021 COVID 19 VACCINE
082116923292 YA 3/15/2021 COVID 19 VACCINE
089662495418 YA 3/15/2021 COVID 19 VACCINE
081222842846 YA 3/15/2021 COVID 19 VACCINE
081398994752 YA 3/15/2021 COVID 19 VACCINE
08112340282 YA 3/15/2021 COVID 19 VACCINE
081321343985 YA 3/15/2021 COVID 19 VACCINE
082124027800 YA 3/15/2021 COVID 19 VACCINE
085223559616 YA 3/15/2021 COVID 19 VACCINE
08231869950 YA 3/15/2021 COVID 19 VACCINE
085223524639 YA 3/15/2021 COVID 19 VACCINE
085320532666 YA 3/15/2021 COVID 19 VACCINE
0895600309366 YA 3/15/2021 COVID 19 VACCINE
082127529959 YA 3/15/2021 COVID 19 VACCINE
082240185271 YA 3/15/2021 COVID 19 VACCINE
081222833999 YA
082130508168 YA
085221928488 YA 3/15/2021 COVID 19 VACCINE
081320903618 YA 3/15/2021 COVID 19 VACCINE
081320903602 YA 3/15/2021 COVID 19 VACCINE
082261250400 YA 3/15/2021 COVID 19 VACCINE
089654076504 YA 3/15/2021 COVID 19 VACCINE
085223393212 YA 3/15/2021 COVID 19 VACCINE
085322763300 YA 3/15/2021 COVID 19 VACCINE
081323298411 YA 3/15/2021 COVID 19 VACCINE
082317340847 YA 3/15/2021 COVID 19 VACCINE
085223345462 YA 3/15/2021 COVID 19 VACCINE
085323460910 YA 3/15/2021 COVID 19 VACCINE
081322444489 YA 3/15/2021 COVID 19 VACCINE
085323411467 YA 3/15/2021 COVID 19 VACCINE
085351145888 YA 3/15/2021 COVID 19 VACCINE
081321183389 YA 3/15/2021 COVID 19 VACCINE
085223120656 YA 3/15/2021 COVID 19 VACCINE
085222574716 YA 3/15/2021 COVID 19 VACCINE
082118113777 YA 3/15/2021 COVID 19 VACCINE
085294153888 YA 3/15/2021 COVID 19 VACCINE
085315895750 YA 3/15/2021 COVID 19 VACCINE
081323466810 YA 3/15/2021 COVID 19 VACCINE
081320637778 YA 3/15/2021 COVID 19 VACCINE
085314252860 YA 3/15/2021 COVID 19 VACCINE
081220519002 YA 3/15/2021 COVID 19 VACCINE
085294607233 YA 3/15/2021 COVID 19 VACCINE
082216783838 YA 3/15/2021 COVID 19 VACCINE
081809875806 YA 3/15/2021 COVID 19 VACCINE
081220582231 YA 3/15/2021 COVID 19 VACCINE
085294747791 YA 3/15/2021 COVID 19 VACCINE
085323540005 YA 3/15/2021 COVID 19 VACCINE
085323404329 YA 3/15/2021 COVID 19 VACCINE
082321177939 YA
087777132759 YA
Dosis I Dosis 2
Tanggal Pemberian Tanggal Pemberian

No. Batch No. Serial No. Batch
Vaksinasi Vaksinasi
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
3/15/2021 24000421
Keterangan
Diberikan/Lanjut)
No. Serial
LANJUT DOSIS 2 PKM PATARUMAN 3

LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 SMP PATROMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
MTs AS-SALAM
LANJUT DOSIS 2
SELESAI
SELESAI NAKES KLINIK PEGADAIAN
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
KELURAHAN PATARUMAN
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
TIDAK HADIR
TIDAK HADIR
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI DESA MULYASARI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
LANJUT DOSIS 2
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
DESA SINARTANJUNG
SELESAI
SELESAI
SELESAI
SELESAI
TIDAK HADIR
TIDAK HADIR
1 Z-EE6E3DBD 3276060906690009 MOHAMAD MAOLANA, A.Md.I.P., S.H., M.Si.

2 Z-346503A8 3279011609690001 JEJE SUDRAJAT
3 W-28CB905F 3207010609700003 A SUPRIADI
4 W-9CB12714 3301150405700002 MAMAN RUSMANTO
5 3209181909870009 DEDY PRAMUDIAN, S.E.
6 W-49D38DF5 3603031209820008 DADAN HERDIANA, S.H.
7 W-073BF5D0 3210070101810181 DENI SUDIANA
8 W-5BF21EF7 3207013007840002 WILI
9 W-BA35DE31 3207290201850001 RIDWAN PERMANA
10 Q-E99718E7 3207122901900001 INDRA BUDIANTO
11 Q-175436B1 3210062007890001 JEJEN JAENUL MILLAH
12 Q-97B67448 3279012912890002 ASEP DENI WAHYUDI
13 W-BCDC8646 3279040906900001 WAWAN IRAWAN
14 3207312108920001 HENDI GUSTIAWAN
15 W-DC317EC2 3207016208930002 EKA MAULINA DEWI
16 W-F512127A 3207060602920001 SHENDY CAHYAMAN
17 Q-4BF95B7C 3207142101940001 DIKI SUNDARA
18 W-5572A25B 3207101006930001 CEPPI BUDI CAHYANA
19 Q-C8F425C4 3279041306860001 ALI IMRON
20 Z-1DAC5694 3207352003870002 ARA PERMANA
21 W-90261E74 3211136910900002 TINA ARDHYANIE

22 Z-47A67E2C 3273142003910004 GILAR PURNAMA
23 Q-9CD73065 3217071507920007 DIMAS
24 W-3082A02F 3211071311920002 ASEP CHOERUL HIDAYAT
25 Z-9D38F128 3205012908930005 IQBAL MAULUDIN ACHMAD
26 Z-0233DB3D 3205052910940001 HADI MAULANA NUGRAHA
27 Q-4D610B6B 3276051807950004 RIFKI LUTFAN SAMUDRA
28 Z-4189E25E 3204140704950002 GANJAR SETIA PUTRA
29 Q-749CE522 3207034905960002 SINTIA ULFAH BAHTIAR
Z-D20EE347 3518132911960004 MUHAMAD ALI MURSODO
30
Q-28357BD7 3273242001970002 FARIZ RAMADHANSYAH

31
32 Q-6BABAC28 3205170103970003 FERGAN BAKTI ADIRES
33 Q-E5E457F6 3207312702980001 REGIA HELMINA NUROHMAN
34 Q-5DD3D4F2 3206131002980001 ALDI PEBRINALDI
35 Q-F719BEB0 3207096807980002 FAUZIAH FAZRI MUSTARI
36 W-3EF83201 3214010707760008 R ARIF HERMAWAN, A.Md.I.P.,S.H.
37 W-F01CB8D1 3207014403740001 TUTI MULYATI
38 W-4F0E1950 3212290306860001 ADIYANTO
39 W-1A91B065 3279016808880001 HESTI
40 Q-F0D5E5E1 3273161102950007 TEGUH TRI RAMDANI
41 S-8851E085 3207271012880001 ASEP SUHAN SUHANA
42 S-6DC04A1B 3277020505950029 GESIT IHSAN AMIN
F
Umur
Jenis Kelompok
Pekerjaan* (18-59
Kelamin Umur
tahun)
L KEPALA LAPAS 51 46-59





24 18-30
L LAPAS BANJAR
24 18-30
L LAPAS BANJAR


FORMAT PENCATATAN PELAKSANAAN VAKSINASI COV
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINAS
DOSIS 1 DAN DOSIS 2
Alamat
JL.BUNI RT/RW. 004/014 KEL.BEJI KEC.BEJI KOTA DEPOK

LINGK.PINTUSINGA RT/RW. 004/018 KEL.BANJAR KEC.BANJAR KOTA BANJAR
LINGKUNGAN KEDUNG PANJANG RT.002 RW.002 KEL.MALEBER KEC.CIAMIS KAB. CIAMIS
SOGATI RT.004 RW.009 KEL.WANAREJA KEC.WANAREJA KAB.CILACAP
LINGKUNGQAN BANJAR RT.001 RW.002 KEL.BANJAR KEC.BANJAR KOTA BANJAR
LING.HAURMUKTI RT/RW.041/002 KEL. PURWAHARJA KEC.PURWAHARJA KOTA BANJAR
BLOK CIBODAS RT 001/001 DS. CIBODAS KEC. MAJALENGKA
DSN CIKAPAKALERAN RT 004/002 DS. CINTANAGARA KEC. JATINAGARA
BLOK CIMARA RT.006 RW.003 KEL.MALONGPONG KEC.MAJA KAB. MAJALENGKA
LINGKUNGAN SUKAMANAH RT.001 RW.016 KEL.PATARUMAN KEC.PATARUMAN KOTA BANJAR
DSN.CIJUREY RT/RW. 004/003 KEL. KUJANGSARI KEC.LANGENSARI K0TA BANJAR
LINGK. BANJAR KOLOT RT 002/012 DS. BANJAR KEC. BANJAR
DSN.BANTAR RT.024 RW.007 KEL.SUKARAJA KEC.SINDANGKASIH KAB.CIAMIS
DSN.DESA RT/RW.003/001 KEL.MARGAHARJA KEC.SUKADANA KAB.CIAMIS
DUSUN SAMPIH RT 001/007 DS. REJASARI KEC. LANGENSARI
PERUM PPI NO 49 BLOK A RT 002/016 DS. CINANJUNG KEC. TANJUNGSARI
KP. RAWASARI RT/RW 003/007 KEL. MANDALASARI KEC. CIPATAT KAB. BANDUNG BARAT
DSN.KEBONKALAPA RT/RW. 003/002 KEL.CIPAMEKAR KEL.CONGGEANG KAB.SUMEDANG
JL. CIWALEN NO.381 RT/RW 004/005 KEL. CIWALEN KEC. GARUT KOTA KAB. GARUT
JL. BUNGUR NUSA INDAH II RT 003/016 DS. JAYARAGA KEC. TORONGGONG KIDUL
BOJONG IJO RT/RW. 004/028 KEL. SUKAMAJU KEC.CILODONG KOTA DEPOK
KP. CIHAMERANG RT. 001/010 DS. BANJAR WETAN KEC. BANJARAN
DUSUN CIMENGGER RT 006/013 BOJONGMENGGER KEC. CIJEUNGJING
DUSUN KEDUNGWARINGIN RT/RW. 002/005 KEL.WARINGINSARI KEC.LANGENSARI KOTA BANJAR
PS. SINDANGLAYA RT/RW 001/001 KEL.CISARANTEN BINA HARAPAN KEC. ARCAMANIK KOTA BANDUNG
KP. KIARA PAYUNG RT/RW 003/002 DS. HEGARMANAH KEC. BAYONGBONG KAB. GARUT
DUSUN KALER RT/RW. 001/003 KEL. KARANGAMPEL KEC.BAREGBEG KAB.CIAMIS
KP. LEGOK KAWUNG RT/RW 021/001 KEL. BANYUASIH KEC. TARAJU KAB. TASIKMALAYA
KILAYUGUNG RT/RW. 006/003 KEL.KAWALIMUKTI KEC.KAWALI KAB.CIAMIS
PONDOK JAYA INDAH BLOK G.4 RT 040 RW 003 DESA MUNJULIAYA KEC. PATARUMAN
LINGK. KEDUNG PANJANG RT 02 RW 02 KEL. MALEBER KEC. CIAMIS KAB. CIAMIS
JL. PATIMURA BLOK II RT 11 RW 004 KEL. KARANGANYAR KEC. PASEKAN, KAB. INDRAMAYU
DSN. KARANGPUCUNG KULON RT 14 RW 04 KEL. JAJAWAR KEC. BANJAR, KOTA BANJAR
JL. DESA NO 16 RT 04 RW 03 KEL. BABAKANSARI KEC. KIARA CONDONG, KOTA BANDUNG
N VAKSINASI COVID-19
S/POS VAKSINASI
IS 2
Kepesertaan BPJS (tulis 'Ya' pada kolom

yang sesuai)
Nama/Jenis/Merek
Vaksin***
BPJS Non
BPJS PBI Non Anggota
PBI
081311009669 YA COVID-19 VACCINE

082319145351
YA COVID-19 VACCINE
082116327272
YA COVID-19 VACCINE
85320442442 YA
82121949242 YA
Dosis I Dosis 2
Tanggal
Tanggal Pemberian
Vaksinasi
Vaksinasi
3/16/2021 24001021
3/16/2021 24001021
3/16/2021 24001021
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24001021
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24001021
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24001021
3/16/2021 24001021
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
24000421
3/16/2021
3/16/2021 24001021
3/16/2021 24000421
3/16/2021 24001021
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24001021
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
3/16/2021 24000421
Keterangan
Diberikan/Lanjut)
SELESAI LAPAS KELAS IIB BANJAR

SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
LANJUT DOSIS 2
LANJUT DOSIS 2
Jenis
Kelamin
Pekerjaan*
1 S-2C5A9D8D 3279021608460001 ENDIN NASIR L PEDAGANG PASAR

2 S-6A3A7E4A 3279023107520001 NANA RUSMANA L PEDAGANG PASAR
3 S-9EB6E73C 3279025408560001 EDEH P PEDAGANG PASAR
4 P-DNXBAO9C 3279020512850002 DADANG ALAMSYAH L PEDAGANG PASAR
5 S-0903C18B 3279021001270001 SURJA L PEDAGANG PASAR
6 P-DO6129H5 3279015810830002 NITA SITI NURDIAH P PEDAGANG PASAR
7 P-DODAYDM5 3279024709630005 JUNAH P PEDAGANG PASAR
8 S-8152B2B3 3279024304580001 ICIH SUTARSIH P PEDAGANG PASAR
9 S-A38A01F2 3279021002590001 PENDI L PEDAGANG PASAR
10 P-DOLJSNK4 3279025203630004 EMPAT PATIMAH P PEDAGANG PASAR
11 P-DON3UBTP 3279024510990001 ROSI ROSITA P PEDAGANG PASAR
12 S-BE16FB6E 3279020103580001 SARDI L PEDAGANG PASAR
DOSIS 1

kolom yang sesuai)
Umur
Kelompok
(18-59
Umur
Alamat No. Hp
tahun) BPJS Non Non
BPJS PBI
PBI Anggota
75 >60 JELAT, PATARUMAN 85703143780

36 31-45 JELAT, PATARUMAN 8122194612
38 31-45 JELAT, PATARUMAN 81320053336
58 46-59 JELAT, PATARUMAN 81320053336
58 46-59 JELAT, PATARUMAN 81320053336
21 18-30 JELAT, PATARUMAN 81320053336
NAAN VAKSINASI COVID-19
ANKES/POS VAKSINASI
IS 1
Dosis I Dosis 2
Nama/Jenis/Merek
Tanggal Screening
Vaksin*** Tanggal
Tanggal Pemberian
Pemberian No. Batch No. Serial
Vaksinasi
Vaksinasi
3/19/2021 SINOVAC 202011047

3/19/2021 SINOVAC 202011047
3/19/2021 SINOVAC 202011047
3/19/2021 SINOVAC 202011047
3/19/2021
3/19/2021 SINOVAC 202011047
3/19/2021 SINOVAC 202011047
3/19/2021 SINOVAC 202011047
3/19/2021 SINOVAC 202011047
3/19/2021 SINOVAC 202011047
3/19/2021 SINOVAC 202011047
3/19/2021 SINOVAC 202011047
Dosis 2
Keterangan
Diberikan/Lanjut)
No. Batch No. Serial
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2
PEDAGANG PASAR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
1 S-9EAA4910 3279025011840002 ANI HERAWATI, ST., MM

3279012503790001 R. HADI SUPRIATNA, A.Md
2 S-483BFBE7
3 P-EZCN6928 3207012105850001 IMAN BUDI LAKSANA, ST
4 S-01B4D4D6 3279031503690001 ACENG NURSOBAH, ST
5 3207305006690004 SRI KURNIASARI, S.IP
S-999A9603
6 S-9BA9A385
3207300706790004 YADI SUDRAJAT, S.IP
7 S-2B9C1081
3207031707820006 DASEP JAMALUDIN, ST
8 3279013105850001 MULYANA, ST
9 S-E47A2856 3279012102900001 AGUNG NUGRAHA, S.Kom
10 S-F6CAFA5C 3273196010920002 RIZKY DYAH AYU WULANDARY, S.ST
11 S-2E27AB4F 3207205906930003 DINI HANIFAH, S.T
12 S-1487F84C 3275040803900023 DIAN NUR HIDAYAT, ST
13 S-1AE0869D 3204063006920002 ENJANG SAMSUDIN, ST
14 S-B2E8B31C 3279024810860001 SEPTY NOVIKA ARIFIN, S.T
S-02BB104C 32070111812910001 AGUNG RISTIANA, S.T
15
16 S-1300E430 3207150807900002 ADJIA GANJAR RIADI, S.T
17 S-AFACFD7A 3207032002950001 FIRMAN PRAYOGA, SST
18 S-5BC2FB9B 3279014411840002 NOVIE DIANA KARTIKASARI, S.T
S-FE18E9CC 3301091002840002 FEBRY SULISTIANA PUTRA, S.T
19
20 S-3C6A167D 3301134808860004 ERI AGUSRINI, S.T
21 S-52D6F1C0 3279014706940002 NADYA ITSNAINI, S.T
3279010209840004 RINO HADI SUSANTO, S.T
22 S-A6BE05C1
S-719FEF4B 3279021803780001 ADAM EKA HARTANTO
23
24 S-B87234F0 3207300305820002 AGUS WANDA
25 3207030801650001 ASEP ROHANDI
26 S-6F755670 3207300105770001 KASIM
27 3279011503810001 WALUYO, A.Md
28 S-4BB1E4F7 3279010107670001 TARNO
29 S-34D558AC 3279030211720001 UJANG SUPRIADI
30 S-9F1EABB2 3207031303750001 HENDI HERDIMAN
31 S-40D26467 3207300305820002 WAWAN KURNIAWAN
32 DEDE NURMANSYAH
33 P-FDNCL204 3279012303780001 NUR ALI YASIN
34 3279020308830001 TURIMAN
35 S-303673A3 3207012911800004 YADI MULYADI
36 P-EZPDHJWK 3279040512640001 HOLIS HASAN KURNIAWAN
37 S-01D5F3C6 3207011903730002 SUPRIADI
38 S-0553D5A2 3207300706790004 ACENG KARMAT
39 S-1B247E3E 3279010507820004 RICKY RAMDHANI RISWANTO
40 3279041204790002 ACEP IRPAN KOSTAMAN
41 S-30559140 3279031801860001 SANDI GUMILAR
42 S-B2341205 3301141805950002 FAJAR AGUNG WICAKSONO, A.Md.T
43 S-6E0C5692 3279020202640001 SARNO
44 S-E9320859 3279040210660001 NGADNAN
45 3207291107690001 TARSO
46 S-0F267FA1 3301022811870001 AGUS LASTIYONO, ST
47 3207174809890002 DEWI WIDYANINGSIH NUR HIDAYAH, ST
48 3273224109940001 YUMNA NABILA, ST
49 S-FD9B0B20 3207014304980002 CIKA FERNANDA MAHDA RAHMAT, ST
50 3207016312890002 DESY SUMANTI, ST
51 S-C18C1502 3207012903860002 ADANG KISWA, ST
52 S-F3AA0AEA 3207100601940001 DEDE SUHENDAR, ST
53 S-B706A4FE 3279011801940001 GIFAR NUANSA MUNAZIL, ST
54 3207316408860002 RIYAN RISTIAN, SE
55 S-D7844927 3279014703970001 AINNUR SYIFA MARDHIYYAH, S.T
56 S-5A2FF72F 3301090307900002 ANGGORO YOSEPH PRIHANANTYO, S.T
57 S-1DAD8A6C 3207176502860001 PRATIWI HUTAMI. S.T
58 S-B9F811EB 3206200107910003 EDE SUARSA, SE
59 S-9CFD78CB 3279015411960004 NOVIAMILIAH, ST
60 S-F3A567AC 3207060906890001 FAZAR AWALUDIN, ST
61 P-FAAJBVEH 3279010605760002 Surya Suprihat
62 P-F9WJJ8FS 3301161708740001 Agus Waluyo Susanto, SE
63 P-FBF1KTA8 3279034911760002 Ai Maemunah, SE
64 3279022005690001 Abdurahman Saleh
65 P-FAIOT4ZS 3207010802830002 Hendra Munawwar
66 P-FAN2NBAB 3301155709780002 Sri Mulyanti Retno Wulan, ST
67 P-F6R4GA0R 3207301008800003 Kusmana
68 P-F84I1P6X 3279040907780002 Agus Hendrawanto Natadiraksa
69 3207043110850002 Kiki Hamdani
70 P-FDB3OKOF 3279032603820001 Lalan
71 P-F9QOFZS4 330115270479001 Fredy Inta Herian, ST
72 327901020285001 Asep Tata Herdiana
73 P-F7MRXZCL 3279041802840001 Lukipan
74 P-FA0BLARQ 3279021101860003 Yudi Haryanto, S.IP
75 3279020608850004 Bayu Putra Agriyandi
76 P-FDJZMW34 3279041607830001 Mumu Muflihin
77 3207172707820000 Sakirun Priadi
78 3279021211830001 Iwan Sudarmawan
79 3279030803710003 Suyanto
80 3207171609730002 Sopino Priyatno
81 P-FDDGVVVF 327902250482002 Andri Nugroho, ST
82 P-FEFZ9I2T 3279040702800002 Wahid Priantoro, ST
83 P-FEDBHGKN 3279011308800006 Enceng Hendri, ST
84 P-FCE4KHGL 3279021801780005 Rubi Paryandi, ST
85 P-FAU4XV5F 3279022310780003 Syarif Mubaroq
86 P-FE2TCOFE 3207010406750002 R. Moch Sulaeman
87 P-FCWEVFTT 3301155009850002 Indriyawati
88 P-F4DTBBNI 3301160302710001 Opi Sopian, A.Md
89 P-FCI03GFR 3279041308850001 Herdiyana, S.IP
90 3207301401870001 Handris Januar, S.IP
91 3207302311860001 Karis Sumandri
92 P-FD38HHCV 3207306201880001 Yuyu Sri Rahayu
93 P-FE9KWJCU 3279021605870002 Andri Awan
94 P-FDRU9J14 3279035602840001 Hepiani, ST
95 3206292408800001 Jajang Yuhana, ST
96 3207302211820002 Agus Ruhimat
97 P-FD6H98J0 3279041911850001 Nopikal Adif, ST
98 3279045905840001 Titin Nurlina, SE
99 P-FFSMIQW1 3279022601810001 Evi Budianto, SE
100 P-FB9VT04N 3207306305850001 Rini Sukmawati, SE
101 P-FAZVVP1S 3279032606930001 Suryana, S. IP
102 P-FB2MYBXI 3279031303020001 SANDI DWI WISNUKAWIRIAN
103 P-FBRLJQCW 3279025605670001 NANI SUMARNI
104 P-FET67Q5E 3279026211990003 NINA SUMIATI
105 P-FBWQV4KG 3279022004910002 ALFIAN ARIESTA
106 P-FC1HYI8K 3279025411930001 NURHAYATI
107 P-FC9MJGU6 3279020208630002 SUPENDI
108 P-FC50IDHT 3279021307940004 YUDI DWI JULIAN
FORMA
TIN
Umur
Kelompok
Jenis Kelamin Pekerjaan* (18-59
Umur
tahun)

L PEGAWAI PEMERINTAH 0



P PEGAWAI PEMERINTAH 0
P TRAVEL 54 46-59
P TRAVEL 22 18-30
L TRAVEL 30 18-30
P TRAVEL 28 18-30
L TRAVEL 58 46-59
L TRAVEL 27 18-30
DOSIS 1
Alamat
Lingk. Pintusinga rt.2 rw.18 Kel. Banjar Kec. Banjar Kota Banjar
Dsn Randegan I rt.7 rw.3 Desa Raharja Kecamatan Purwaharja Kota Banjar
Dsn.Siluman RT 27/13 Purwaharja Banjar
Dsn Sengkong rt.1 rw.5 Ds. Wangunjaya Kec. Cisaga Kab. Ciamis
Lingk. Haurmukti rt.41 rw.2 Kel. Purwaharja Kec. Purwaharja Kota Banjar
Dsn Timbang Windu rt.25 rw.8 Ds. Pamalayan Kec. Cijeungjing Kab. Ciamis
Lingk. Banjarkolot rt.2 rw.15 Kel. Banjar Kec. Banjar Kota Banjar
rt.004 rw.006 Kel.Babakan Ciamis Kec. Sumur Bandung
Nagrak RT/RW 006/003 Kel.Karangsari Kec.Padaherang
Sukarukun Rt 005 Rw 001 Sukatani Kab.Bekasi Jabar
KP.Cicayur RT/RW 005/012 Kel.Cimenyan Kec.Cimenyan
Jl.Rumah sakit No.23 RT 01 Rw 18 Ciamis
Jl.Ciptomangunkusomo No.545 Kel.Ciamis Kec.Ciamis
Dusun Sukajadi RT/RW 008/003 Kel.Jangalaharja Kec.Rancah
Vila Selaras Kampus No.2 Jl.Arya Janggala RT/RW 003/004
Lingk.Banjarkolot RT/RW 004/012 Kel.banjar Kec.Banjar
KP.Karangiuh RT?RW 002/005 Ke.Rajamandala Kec.Rajapolah
Cileumeuh RT/RW 003/001 Kel.Rejodadi Kec.Cimanggu
Lingk.Parunglesang RT/RW 003/009 Kel.Banjar Kec.Banjar
Lingk Banjarkolot RT/RW 004/012 Kel.Banjar Kec.Banjar
Dsn Cisaga rt.2 rw.17 Ds. Cisaga Kec. Cisaga Kab. Ciamis
Dsn. Cihideung rt.21 rw.8 Desa Utama Kecamatan Cijeungjing kabupaten Ciamis
Dsn Cisagakolot rt.4 rw.5 Ds. Cisaga Kec. Cisaga Kab. Ciamis
Dsn Randegan rt.5 rw.3 Ds. Mekarharja Kec. Purwaharja Kota Banjar
Dsn Cikabuyutan Timur rt.4 rw.11 Ds. Hegarsari Kec. Pataruman Kota Banjar
Dsn Cibeka rt.37 rw.8 Ds. Karangkamulyan Kecamatan Cijeungjing Kab. Ciamis
Sumanding kulon RT 01/20 Kel.Mekarsari
Dsn Cimanggu rt.1 rw.1 Ds. Batulawang Kec. Pataruman Kota Banjar
Dsn.Sukaraja RT/RW 04/09 DS.Linggasari
Lingk. Babakan rt.3 rw.3 Kel. Muktisari Kec. Langensari Kota Banjar
Lingk. Kalapajajar rt.4 rw17 Ds.Ciamis Kec. Ciamis Kab. Ciamis
Dsn Cibeureum rt.6 rw.2 Ds. Balokang Kec. Banjar Kota Banjar
Dsn Cibentang rt.20 rw.8 Ds. Mekarharja Kec. Purwaharja Kota Banjar
Gg.Arjuna No.12 RT/RW 002/004 Kel. Cilopadang Kec.Majenang
Lingk. Pataruman rt.3 rw.12 Kel. Pataruman Kec. Pataruman Kota Banjar
Lingk. Bojongsari rt.1 rw.3 Kel. Bojongkantong Kec. Langensari Kota Banjar
Dsn Tunggal Rahayu rt.21 rw.4 Ds. Cimaragas Kec. Cimaragas Kab. Ciamis
Jl.Merpati No.07 02/02 Slarang Kesugihan Cilacap
Lingk Babakansari 03/11 Pataruman
Margahayu Raya Q-II No.134 02/10 Buahbatu Bandung
Jl.Jend Sudirman 180 03/11 Sindangrasa Ciamis
Jl. Mulyasari No. 14 A 03/19 Baleendah Bandung
Dusun Panyingkiran 04/01 Ciamis
Perum Baiturrohman Blok I 15 Dusun Ciwalung Baregbeg Ciamis
Lingk Cikabuyutan Timur 05/12 Hegarsari Pataruman
Perum Pratama Regency 58/09 Sindangkasih
Dusun Cibeureum 04/02 Balokang Banjar
Dusun Kawunganten 02/02 Cilacap
Dusun Citamiang 12/03 Cintaratu Lakbok
Kp.Sindangsentra 19/04 Cisarua Cineam
Lingk Pintusinga 04/17 Banjar
Dusun Desa Cijulang 01/01 Cihaurbeuti Ciamis
Lingk. Pintusinga RT 01/19
Dsn.Cinagarajaya RT 003/006
Dsn siluman RT 25/12
Lingk.Pataruman RT 001/012
Cisaar RT 09/03
Pakembaran RT 02/04
Sukamenak RT 10/11
Dsn.Purwodadi RT 13/04
RT 01 RW 03
Haurmukti Rt 02/01
Pakembaran Rt 02/04
Cipariuk
Waringinsari Rt 08/06
Babakansari Rt 03/11
Lingk.Pataruman Rt 001/002
Sukanagara RT 01/01
Sidodadi Rt 02/01
Link. Gudang Rt 03/03
Pataruman Rt 01/012
Jatibarang Rt 026/07
Dsn. Babakansari
Dsn. Sindanggalih
dsn. Pananjung Barat Rt 003/001
Lingk.Babakansari RT 008/011
Karanggedang No.49 RT 04/7
Babakan 004/014
Lingk.Bojongsari
Randegan 1 Rt 11/04
Warung buah Rt 023/011
Dsn.Sukajaya
Lingk.Cimenyan II RT 003/006
Cangkudu Rt 02/10
Bantarsari Rt 05/06
Linhk.Bojongsari RT 04/03
Dsn.Sidamukti 03/06
Rancakole RT 003/001
Dsn.Randegan I RT 05/02
LINGK. SILUMAN RT 27 RW 13, PURWAHARJA
: lingk. sukamanah 1/18, PATARUMAN
DSN PANANJUNG RT 023 RW 005 DUSUN PANANJUNG RW 005
DUSUN PANANJUNG RT 23 RW 05, SINARTANJUNG
LINGK PANATASAN RT 002 RW 019, PATARUMAN

lingk. sukamanah 1/18, PATARUMAN
SANAAN VAKSINASI COVID-19
SYANKES/POS VAKSINASI
DOSIS 1

kolom yang sesuai)

BPJS Non Non
BPJS PBI
PBI Anggota
085223860690 3/22/2021 VACCINE COVID-19

81214467325 3/22/2021 VACCINE COVID-19
85223169006 3/22/2021 VACCINE COVID-19
82126629091 3/22/2021 VACCINE COVID-19
85314200791 3/22/2021 VACCINE COVID-19
85624391514 3/22/2021 VACCINE COVID-19
82316583505 3/22/2021 VACCINE COVID-19
85323011121 3/22/2021 VACCINE COVID-19

8112092192 3/22/2021 VACCINE COVID-19
82126941281 3/22/2021 VACCINE COVID-19
8561550282 3/22/2021 VACCINE COVID-19
82120037882 3/22/2021 VACCINE COVID-19
82118425769 3/22/2021 VACCINE COVID-19
81214605022 3/22/2021 VACCINE COVID-19
81214190223 3/22/2021 VACCINE COVID-19
82214020999 3/22/2021 VACCINE COVID-19
81323030264 3/22/2021 VACCINE COVID-19
81333878567 3/22/2021 VACCINE COVID-19
85712677288 3/22/2021 VACCINE COVID-19
81313598878 3/22/2021 VACCINE COVID-19
85353018900 3/22/2021 VACCINE COVID-19
85323779077 3/22/2021 VACCINE COVID-19
82240224689 3/22/2021 VACCINE COVID-19
82116942119 3/22/2021 VACCINE COVID-19
81214476920 3/22/2021 VACCINE COVID-19

85281111890 3/22/2021 VACCINE COVID-19
895333863361 3/22/2021 VACCINE COVID-19
85223564833 3/22/2021 VACCINE COVID-19
81321565052 3/22/2021 VACCINE COVID-19
82116416455 3/22/2021 VACCINE COVID-19

81394801110 3/22/2021 VACCINE COVID-19
85223202616 3/22/2021 VACCINE COVID-19
85222907081 3/22/2021 VACCINE COVID-19
81222370560 3/22/2021 VACCINE COVID-19
81112701986 3/22/2021 VACCINE COVID-19

85726376763 3/22/2021 VACCINE COVID-19
85814622483 3/22/2021 VACCINE COVID-19
82318580832 3/22/2021 VACCINE COVID-19
85726547394 3/22/2021 VACCINE COVID-19
85723568593 3/22/2021 VACCINE COVID-19
82119149009 3/22/2021 VACCINE COVID-19

85318902094 3/22/2021 VACCINE COVID-19
85315720170 3/22/2021 VACCINE COVID-19
81313066517 3/22/2021 VACCINE COVID-19

85293539889 3/22/2021 VACCINE COVID-19
81223024025 3/22/2021 VACCINE COVID-19
85223935526 3/22/2021 VACCINE COVID-19
85353877455 3/22/2021 VACCINE COVID-19
82218848128 3/22/2021 VACCINE COVID-19
85317572442 3/22/2021 VACCINE COVID-19
87826225577 3/22/2021 VACCINE COVID-19
85352279475 3/22/2021 VACCINE COVID-19
85220482898 3/22/2021 VACCINE COVID-19

85227006317 3/22/2021 VACCINE COVID-19
85223476311 3/22/2021 VACCINE COVID-19
85756574637 3/22/2021 VACCINE COVID-19
85223202606 3/22/2021 VACCINE COVID-19

85223249090 3/22/2021 VACCINE COVID-19
81323759220 3/22/2021 VACCINE COVID-19

85322652200 3/22/2021 VACCINE COVID-19
85353953981 3/22/2021 VACCINE COVID-19

83130638777 3/22/2021 VACCINE COVID-19
81310180622 3/22/2021 VACCINE COVID-19
82321191191 3/22/2021 VACCINE COVID-19
81395242772 3/22/2021 VACCINE COVID-19
83827263427 3/22/2021 VACCINE COVID-19
81215067216 3/22/2021 VACCINE COVID-19
85228770013 3/22/2021 VACCINE COVID-19
82120846200 3/22/2021 VACCINE COVID-19
85223366868 3/22/2021 VACCINE COVID-19
85294253750 3/22/2021 VACCINE COVID-19

85320052600 3/22/2021 VACCINE COVID-19
85322448800 3/22/2021 VACCINE COVID-19
82320787000 3/22/2021 VACCINE COVID-19
85223691212 3/22/2021 VACCINE COVID-19

81323916585 3/22/2021 VACCINE COVID-19
85223531967 3/22/2021 VACCINE COVID-19
82126629191 3/22/2021 VACCINE COVID-19
82118737383 3/22/2021 VACCINE COVID-19
83116907763 3/22/2021 VACCINE COVID-19
82219042858 3/22/2021 VACCINE COVID-19
81312317977 3/22/2021 VACCINE COVID-19
89601167203 3/22/2021 VACCINE COVID-19
82116947664 3/22/2021 VACCINE COVID-19
Dosis I Dosis 2
Tanggal
Tanggal Pemberian
Vaksinasi
Vaksinasi
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
3/22/2021 24000421
Keterangan
Diberikan/Lanjut)
LANJUT DOSIS 2 DINAS PU

SUSPEK
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
KOMORBID JANTUNG
SAKIT TIDAK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
TIDAK HADIR
TUNDA KOMORBID
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
TUNDA KOMORBID DM
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
SAKIT TIDAK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
MENOLAK
LANJUT DOSIS 2
HAMIL
HAMIL
LANJUT DOSIS 2
IJIN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
HAMIL
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
TIDAK HADIR
TIDAK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TIDAK HADIR
LANJUT DOSIS 2
IJIN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 TRAVEL CITRA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
AUTO IMUN
TUNDA KOMORBID
1 3279021402890001 Andi Cahyadi, S.IP

2 P-FXBCG55X 3279021806840002 Roni Suryana, ST
3 P-FSJY5WOF 3207020506860002 Edis Sugianto
4 P-FUKFXZZU 3279022910840003 Devi Lastiana
5 P-FUDQ0X20 3279041911880001 Adi Herwanto
6 3207254509890001 Indriyani Siti Hidayat, S.IP
7 327901441072003 Geni Maula, ST
8 P-FWXZ15XN 3207016010880002 Restu Mulyanisari, SE
9 P-G0O3UZ7W 3279032203890002 Ade Irawan
10 P-FU1CBGCJ 3277031211880003 Ari Saeful
11 P-FRWNSGVN 3279026103900003 Ai Rika Rohimah
12 3207304303820001 Dian Marliani A, ST
13 P-FWU51DN3 3279011604880002 Mumung
14 3279025411850002 Dini Noviana
15 3279014301880001 Lela Mandalasari
16 P-FVYP7VQK 3279012509840002 Sevi Saphadi
17 P-FPPT7TGA 3279021806860001 Uud Juarsa, SE
18 P-FSAP6QQS 3279014407820001 Rini Andriyani, ST
19 3279023008820003 Agus Purwanto
20 3279011502830001 Yana Mulyana, S.IP
21 P-FV7EVID0 3207161005810001 Alan Wahyudi
22 P-FT4LUK6P 3207282512850001 Deden Heryanto, SE
23 P-FRQWEHSN 3207302504880001 Bubun Rusmana
24 P-FVDC5IMB 3207302109760001 Ujang Endi Supendi
25 P-FQ3MPY1N 3207142909910001 Hendar Kurniawan
26 P-G07100ZA 3279030706910001 Nursoleh, ST
27 P-FWQ4EQ85 3207036604890001 Nina Herlina A.Md
28 P-FWJTWZED 3279011105910001 Wahyu Firmansyah
29 P-FVQDJ0KX 3207151503780003 Iwan Ruswandi, ST
30 P-FWFOKBVT 3279020909910004 Riki Rianto
31 P-FZRTHNHP 3279031401890001 Tedi
32 P-FWMFTHMN 3279035904920001 Ani Apriani
33 P-FTBV1MPZ 3279026405920002 Alvi Meilani, S.IP
34 P-FUQT0IR9 3279014410910001 Novita Nur Octaviani, S.IP
35 P-FSQDU6ZC 3279040205860002 Elan Ramlan
36 P-FS3DAQZU 3279045905840001 Titin Nurlina, SE
37 3207304812930002 Dyah Ratnasari, S.IP
38 3279015506900002 Dinda Eka Sukandar
39 3207293005940001 Ari Kusnendar
40 3207296901880001 Nenden Sri Nadanti, S.I.Kom
41 P-FZVMBA1F 3279012808930002 Alfi Ilham Maulidin
42 P-FU7IKXMU 3275032701860009 Yayan Sofyan
43 P-FYRZPO7F 3207190405870001 Dian Ramdhani Nugraha, SE
44 P-FSUTQ11S 3279014404960002 Nia Herlina
45 3471011505870001 Agasatya Masnurandita, SE
46 P-G0GWQVC7 3279021503960003 Irfana Jamaludin, S.Kom
47 P-G00ZKFGU 3206220107810029 Dede Juandi
48 3207180207970003 Muhamad Teguh Muhlisin
49 P-FTL186LV 3279034711970001 Sofiatun Janah, SM
50 P-FQAUMOFR 3207301309900001 Rizal Fahrizal Ma'mur
51 P-FYGCLKRH 3301141804890004 Yatin Nursodiq
52 P-FX27UPIV 3279032605980001 Akbar Fajar Pratama
53 3279041508840001 Nur Rahmat
54 P-FUNME9ZK 3279020809860001 Adi Indra
55 P-FW6XV25N 3301192012980002 Dendy Syiantoro Subekti
56 3279015110970001 Rismayanti
57 3279015211910002 Gina Noviandra, S. IP
58 3207300505700000 Yoris Sahara
59 3207171305970000 Pajar Maulana Putra
60 P-G0T7QCSN 3279042312860001 Dian Herdiana
61 S-59343F1A 3207016312890002 DESY SUMANTI, ST
62 P-FVLREVX0 3207011503930002 Wildan Wiraputra, ST
63 P-G2V42J5N 3207312909770001 Heli Heliansah
64 P-7IHZSOGD 3279042005780001 Suwarno
65 P-G1QW29A8 3207302110870001 Cucu Okta Triana
66 P-G80SENBY 3171070707770022 Tusiran
67 P-FZ6Q0IIF 3279010812860001 Entis Sutisna, S.IP
68 P-FVVX8KXZ 3207030606850003 Dani Iskandar
69 P-G2QSPJJB 3279020909780007 Akbar Maulana
70 P-FXVPHYYQ 3279032804710001 Rohartono
71 3279032810960003 Rudi Heryanto
72 P-G6EY05UL 3207150211970002 Tedi Noviansah
73 3279030101960001 Ari Putra Utama
74 S-52F4B11F 3279010705850003 Ifan Ruchyana, S.IP
75 P-FXPCMV3R 3279044109010001 Ajeng Septi Dinanti
76 P-G12NE2DZ 3279046808970002 Ragil Tria Agustin,S.IP
77 P-FUV77URL 3279025408960001 Ina Karlina, SM
78 S-EB93F52E 3207030801650001 ASEP ROHANDI
79 P-FZGWOZLV 3207043110850002 Kiki Hamdani
80 P-FYL6XRB7 3279022010970003 TRI MULYANA
81 P-FXJIB7ZD 327901020285001 Asep Tata Herdiana
82 P-FVIEKBF1 3207302311860001 Karis Sumandri
83 P-FUBXVN2M 3279020608850004 Bayu Putra Agriyandi
84 S-2E9B61B5 3279020308830001 TURIMAN
85 S-BFF83297 3279011503810001 WALUYO, A.Md
86 P-FRK5ZQWV 3207301401870001 Handris Januar, S.IP
87 P-FRF0VLG2 3207171609730002 Sopino Priyatno
88 S-04A84F12 3279011807770001 DEDE NURMANSYAH
89 S-3EEAB4DF 3205020802820003 ISAN NURHAKIM, S.I.P.
90 S-06BDFBD8 3205052402760003 SUGIARTO, S.H.
91 S-8B88286B 3207011006660004 ENDIS, S.H.
92 S-13BE4FD6 3209201206850010 JUNIKO SIHOTANG, S.H.
93 P-MJKWJDMO 3204101711650004 SAEFULLOH
94 3206072103680005 ANIM
95 S-002C79AB 3206250407810001 KOKOK SETIO PRAKOSO YUWONO, S.E.
96 S-EB093D82 3206221208810007 AGUS HERIANTO, S.H.
97 3205191804770001 RIDWAN
98 S-E71AC02D 3315041812850004 DIA V RIANA SYAMSUATY, A.Md.I.P.
99 S-3D2164B8 3207010810810002 SUTAN HASIBUAN, S.H.
100 S-0839BF1D 3207320506790002 DONNY IRAWAN
101 S-B29FB7DD 3175102502670010 ARYA PRASETYA UTAMA
102 S-5BB991C2 3027014807810002 LULU NURYANI
103 S-3FC86CC1 3279021210840002 DARWONO
104 3207012211880002 NOVIANA RUBY DARISMAN
105 S-ED8CD99A 3273290602910001 JERY MUNAJAT
106 S-0ED6E62F 3209011510930001 DIDIN WAHYUDIN
107 3207011504930001 DICKY DARMAWAN
108 S-BB5A153D 3279041206980001 ANOM
109 S-6C49FF52 3207161608920001 AGUS CHERAWAN
110 3203011503970001 BOBY DWI LISTIANTO
111 S-9C6BE110 3206200207980001 RIZAL SAEPUL AZIZ
112 3202330304990002 SYAMSUL MA`ARIF
113 S-6DC27C60 3302152501950003 EGI ALFIAN
114 S-18390469 3207040206970002 ANJAR JUNANDI
115 S-ED9E4D0E 3374132509970004 SEFTIAN GALIH ADHI PRATAMA
116 S-DA33A261 3279022606970001 KRISTIO WAHYUDI
117 S-838D1959 3207220308010001 DONY DHARMAWAN
118 P-G7ROUNVD 3279022403800000 MOECHAMAD IRPAN
119 W-14ABFDBF 3209181909870009 DEDY PRAMUDIAN, S.E.
120 Q-FFCFCDAD 3207312108920001 HENDI GUSTIAWAN
TARUMAN 3
Umur
Kelompok
Jenis Kelamin Pekerjaan* (18-59
Umur
tahun)
Laki-Laki PEGAWAI PEMERINTAH 32 31-45

Perempuan PEGAWAI PEMERINTAH 32 31-45
LAKI-LAKI PEGAWAI PEMERINTAH 39 31-45
PEREMPUAN PEGAWAI PEMERINTAH 39 31-45
FORMAT PENCATATAN PELAKSANAAN VAKSINASI CO
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINA
DOSIS 1
Alamat
Lingk.Tanjungsukur Rt 003/14
Cilewer Rt 01/01
Dsn.Margaluyu Rt 002/007
Dsn.Sindanggalih RT 008/005
Lingk.Bojongsari 001/004
Banjar Kolot Rt 02/11
Jln. Ottista Rt 02/01
Cibentang Rt 16/07
Sembungjaya Rt 04/04
Dsn.Karangpucung wetan
Lingk.Cikabuyutan Barat RT 002/010
Lingk.Sumanding wetan RT 02/15
Lingk.Cikabuyutan Timur 002/013
Lingk.Sukarame RT 004/014
Dsn.Cimanggeng II RT 005/002
Dsn.Cikapundung RT 038/018
Dsn Linggaharja RT 005/002
Dsn.Cibeureum RT 05/02
Mekarmulya Rt 09/04
Sukamenak Rt 05/10
Salegok Rt 39/09
Dsn.Citutut
Lingk.Banjarkolot RT 004/015
Dsn.Tarikolot RT 001/008
Lingk.Tanjungsukur RT 003/014
Lingk.Silumanbaru Rt 39/18
Dsn.Balokang RT 44/14
Dsn.Kalapasabrang
Dsn.Sidamukti 03/06
Dsn.Mekarmulya RT 009/004
Lingk.Parunglesang RT 04/10
Sukahayu Rt 02/01
Dsn.Cibitung RT 15/06
Karangpucung Rt 13/03
Cikabuyutan Timur RT04/011
Dsn.Pamarican RT 005/002
Balirejo UH 2/457 RT 019/006
Lingk.Jelat RT 04/01
Kp Golonggong Rt 09/03
Sukahurip Rt 07/01
Dsn.Randegan RT 6/03
Dsn.Ciawi RT 002/002
Lingk. Siluman Rt 27/13
Bantardawa Rt 05/02
Lingk.Lemburbalong RT 001/006
Kalenanyar Rt 03/11
Sumanding Kulon 03/21
Lingk. Parungsari Rt 006/002
Dsn.Kiarapayung RT 024/007
Bantardawa Rt 05/02
Jl.Sindangbarat Tangsi RT 01 RW 012
Cikabuyutan Timur RT 005/012
Lingk.Sindanggalih RT 008/005
Dsn.Sukamenak
Dsn. Ciawitali Rt 006/002
Sukarame 006/012
Lingjk.Sukarame RT 001/014
Cikabuyutan Timur
RT 01 RW 04 Dsn Cipurut Kel Cisaga Kec.Cisaga Ciamis

Dsn.Sindangjaya RT 006 RW 015 Ds.Cisontrol Kec.Rancah Ciamis
Dsn.Randegan I RT 017 RW 007 Desa Raharja Kec.Purwaharja Banjar
Dsn.Randegan II RT/RW 7/3 Desa Raharja Kec.Purwaharja
Sindanggalih RT 08/05 Rejasari
Desa Waringinsari RT/RW 03/05 Kec.Langensari
Dsn.Pananjung RT/RW 021/005 Desa Sinartanjung Kec.Pataruman
RT 01 RW 03
Cipariuk
Randegan 1 Rt 11/04
LINGKUNGAN CIBULAN RT.004 RW.005 KEL.BANJAR KEC.BANJAR KOTA BANJAR
PERUM CITRA JAYA GORDAH A 31 RT.02 RW.14 KEL.JAYAWARAS TAROGONG KIDUL GARUT
JL. JEND. SUDIRMAN NO.202 RT/RW 003/011 KEL. SINDANGRASA KAB. CIAMIS
JL.TERATAI NO.198 TEDENGDAYA RT.003 RW.004 KEL.KEDUNGJAYA KEC.KEDAWUNG KAB CIREBON
KP. PAKUNAGARA RT 007/002 DS. GIRIKANCANA KEC. PARUNGPONTENG
PKP.EOR RT.008 RW.002 KEL.SUKASUKUR KEC.MANGUNREJA KAB.TASIKMALAYA
DSN. CISALAM RT/RW 003/001 KEL. PASIR PANJANG KEC. MANONJAYA KAB. TASIKMALAYA
KP GALUMPIT RT 005/025 DESA KOTA KULON KEC. GARUT KOTA
RSS SIDODADI A 240 RT.049 RW.015 KEL. PASIRKARUMBI KAB.SUBANG
PERUM PIR BLOK E NO.92 RT.002 RW.011 KEL. IMBANAGARARAYA,KEC.CIAMIS KAB.CIAMIS
DSN.DESA RT.003 RW.001 DESA SAGULING KEC.BAREGBEG KAB CIAMIS
CILEUMEUH RT/RW.003.001 KEL/DS.REJODADI KEC.CIMANGGU KAB. CILACAP
LINGK. SUKAMANAH RT 001 RT 001/018 DS. PATARUMAN KEC. BANJAR
SERAMBI INDAH CLUSTER NO.A 8 JL.HANDAPHERANG RT.007 RW.003 KEL. HANDAPHERANG KEC.CIJENJING KAB.CIAMIS
LINGK. CIKABUYUTAN BARAT RT/RW 003/009 KEL.HEGARSARI KEC. PATARUMAN KOTA BANJAR
DSN. KARANGPUCUNG KULON RT 015/004 DS. JAJAWAR KEC. BANJAR KOTA BANJAR
JL. YOS SUDARSO NO.39 RT/RW 003/013 KEL. CIAMIS KEC.CIAMIS. KAB. CIAMIS
LINGK. BOJONGSARI RT 004/004 DS BOJONGKANTONG KEC. LANGENSARI
LINGK. PASIR ANGIN RT/RW 001/009 KEL. KERTASARI KEC. CIAMIS KAB. CIAMIS
RANCABALI KULON RT/RW. 003/001 DESA MUKA KEC. CIANJUR KAB. CIANJUR
KP KERTAHARJA RT 004/003 DS. CIAMPANAN KEC. CINEAM TASIKMALAYA
JL.YUDISTIRA BLOCK C 04 RT.003 RW.015 KEL.LANGENSARI SUKARAJA SUKABUMI
DUSUN KEDUNGREJO RT/RW. 002/003 KEL. WONOHARJO KEL.PANGANDARAN KAB.PANGANDARAN
DUSUN SEDEKAN RT/RW 027/008 KEL.MEKARJADI KEC.SADANANYA KAB. CIAMIS
RIUNG ASIH RT/RW.002/011 KEL.TUGURAJA KEC.CIHIDEUNG KOTA TASIKMALAYA
DSN. SUKAMAJU RT.006 RW.005 KEL.MULYASARI KEC.PATARUMAN KOTA BANJAR
KARANG GEDANG RT/RE. 003/005 KEL.BABAKAN KEL.PANGANDARAN KAB.PANGANDARAN
LINGK.CIPADUNG RT.12 RW05 DESA PURWAHARJA KEC PURWAHARJA KOTA BANJAR
SINASI COVID-19
VAKSINASI

Dosis I
kolom yang sesuai)
Nama/
No. Hp Tanggal Screening Jenis/Merek
Tanggal
BPJS Non Non Vaksin***
BPJS PBI Pemberian
PBI Anggota
Vaksinasi
85314857097 3/23/2021 3/23/2021

81220507240 3/23/2021 3/23/2021
85320957828 3/23/2021 3/23/2021
85318838338 3/23/2021 3/23/2021
82119119220 3/23/2021 3/23/2021

3/23/2021 3/23/2021
82319179414 3/23/2021 3/23/2021
85283912426 3/23/2021 3/23/2021
3/23/2021 3/23/2021
85320998999 3/23/2021 3/23/2021
82130482078 3/23/2021 3/23/2021

89662012892 3/23/2021 3/23/2021
85314813539 3/23/2021 3/23/2021
85861908766 3/23/2021 3/23/2021

85222578808 3/23/2021 3/23/2021
85318570934 3/23/2021 3/23/2021
82393082900 3/23/2021 3/23/2021
85212316460 3/23/2021 3/23/2021
85223305099 3/23/2021 3/23/2021
85323433026 3/23/2021 3/23/2021
82262028886 3/23/2021 3/23/2021
85294476732 3/23/2021 3/23/2021
82216644617 3/23/2021 3/23/2021
81322924462 3/23/2021 3/23/2021
859111423415 3/23/2021 3/23/2021
89698577172 3/23/2021 3/23/2021
85317217111 3/23/2021 3/23/2021
89662413376 3/23/2021 3/23/2021
8122083741 3/23/2021 3/23/2021
81320621139 3/23/2021 3/23/2021

88910696589 3/23/2021 3/23/2021
3/23/2021 3/23/2021
82240052847 3/23/2021 3/23/2021
3/23/2021 3/23/2021
81313246320 3/23/2021 3/23/2021
87848274443 3/23/2021 3/23/2021

85717885551 3/23/2021 3/23/2021
83827428630 3/23/2021 3/23/2021
82315837520 3/23/2021 3/23/2021
85318318103 3/23/2021 3/23/2021

87708307448 3/23/2021 3/23/2021
3/23/2021 3/23/2021
85322422005 3/23/2021 3/23/2021
87898704296 3/23/2021 3/23/2021
3/23/2021 3/23/2021
3/23/2021 3/23/2021
3/23/2021 3/23/2021
3/23/2021
82321045670 3/23/2021 3/23/2021
82118609088 3/23/2021 3/23/2021
3/23/2021 3/23/2021
82310819012 3/23/2021 3/23/2021
3/23/2021 3/23/2021
3/23/2021 3/23/2021
89664745626 3/23/2021 3/23/2021
3/23/2021 3/23/2021
82315850426 3/23/2021 3/23/2021
81323092085 3/23/2021 3/23/2021
812108817 3/23/2021 3/23/2021
81283150171 3/23/2021 3/23/2021
82376453428 3/23/2021 3/23/2021
85222870876 3/23/2021 3/23/2021
87828166747 3/23/2021 3/23/2021
82320472783 3/23/2021 3/23/2021
81323995858 3/23/2021 3/23/2021
82214782272 3/23/2021 3/23/2021
81323223468 3/23/2021 3/23/2021
82319753599 3/23/2021 3/23/2021
08112000185 3/23/2021 3/23/2021
081222868715 3/23/2021 3/23/2021
082115588311 3/23/2021 3/23/2021
08112414222 3/23/2021 3/23/2021
82119842945 3/23/2021 3/23/2021
085316905899
085317323999 3/23/2021 3/23/2021
082120020304 3/23/2021 3/23/2021
087723752765
087828483000 3/23/2021 3/23/2021
08112123055 3/23/2021 3/23/2021
081313169931 3/23/2021 3/23/2021
087719825700 3/23/2021
081323232910 3/23/2021
085222226739 3/23/2021 3/23/2021
082226669343
088808111772 3/23/2021 3/23/2021
082217683934 3/23/2021 3/23/2021
087733204965
082117383503 3/23/2021 3/23/2021
081221996374 3/23/2021 3/23/2021
082316356361
082320389918 3/23/2021 3/23/2021
082123386880 3/23/2021 3/23/2021
085729747848 3/23/2021 3/23/2021
085351372337 3/23/2021 3/23/2021
081313370904 3/23/2021 3/23/2021
081254141970 3/23/2021 3/23/2021
083827492153 3/23/2021 3/23/2021
082316969336 3/23/2021 3/23/2021
082317777712 3/23/2021
085223431115 3/23/2021
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Tanggal Pemberian Diberikan/Lanjut)
Vaksinasi
TDK HADIR
TDK HADIR
TDK HADIR
24000421 TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TUNDA
TDK HADIR
TDK HADIR
24000421 TUNDA
TDK HADIR
TDK HADIR
TUNDA
TUNDA
TDK HADIR
TDK HADIR
24000421 TUNDA
24000421 TUNDA
TDK HADIR
24000421 TDK HADIR
3/23/2021 24000421 SELESAI
3/23/2021 24000421 SELESAI
NAMA INSTANSI
DINAS PU
LAPAS BANJAR
Jenis
Kelamin
1 W-5B58D9B8 3207012503630001 Ir. H. TOMY SUBAGJA, MM L

2 Q-86EA1159 3279010303750002 ACEP DARYANTO L
3 Q-BA22E1AE 3301152007710001 HARUN AL RASYID,ST L
4 S-8C497277 3279031111730001 AGUS SARIPUDIN, ST., MT., MM L
5 W-ED6B0B39 3207012803750001 ASEP BUNYAMIN, ST L
3279041011800007 RAMDAN MULYANA, SE., MM L
6 S-21D2F03D
3207011710830001 MICKY ADAM, SE L
7 W-80E7D1A2
3279010503790002 UUN MARYONAH ,ST., M.AP P
8 S-D880BCEA
3279035806820001 AAN HASANAH, ST.,M.AP P
9 W-F19077C8
3279041008800002 MUSTOLIH, ST., MM L
10 W-DA9BEC7F
3279012811700001 NANAR SUNARYA, ST.,M.Si L
11 S-02A9445C
3279030503630002 SUPARMAN L
12 W-B0F21DDD
3279045902750002 SULISTIANINGSIH, S.T., M.AP P
13 W-BF62CC21
14 W-10DE2EAE 3279025310810001 SUKMAWATI, ST., M.AP P
15 W-D07FD8A1 3207306901800001 NENDEN MULYANI KUSNIAWATI, ST P
3279012202680003 HERU IRAWAN, S.IP L
16 Z-978EC2FA
3279010704800003 YOHAN IRMAWAN, SH L
17 W-6D43919E
3279010601780001 ASEP DADDY ISKANDAR, ST.,M.S.i L
18
3279031808740002 IRMAN NURACHMAN, ST.,M.AP L
19 Q-A25C19BB
3279010412890001 Sendi Aris Munandar L
20 Q-FF2B8E46
3207301904750001 JEJE SUJANA L
21 W-146DC2A2
3279031807650002 ADANG SUPRIATNA, S.IP L
22 W-A8927835
3279030111930002 RIAN NURROHMAN, ST L
23 Z-37981DCA
24 3279011009610002 AIP SARIPUDIN, S.PdI L
25 W-3FF3433D 3279040302620002 SUPRIYANA, S.Pd L
26 W-658432B1 3279026603640001 MARYATI, S.Pd P
27 W-22C638A2 3279014310660001 SUMARNI, S.Pd P
28 W-9C689275 3279026310860001 EKA NOVIANTI, S.Pd P
29 W-52F8FDED 3279015504630002 OTIH NURHENDRAWATI S.Pd P
30 W-7505A230 3279016505640002 AI SYAJAAH, S.Pd P
31 W-5EABE858 3279024901700002 ETIN SUPIATIN,S.Pd P
32 W-78E59369 3279027004620001 ENTIN KARTINI,S.Pd P
33 3279043008820002 Asifudin L
34 Q-06B88FBA 3279031006860003 Sofyan Andri Widiantoro L
35 Z-F22FB31C 3301165206870001 Darinah P
36 Q-3100A312 3279045107880002 Sri Sulastri P
37 Q-A3356456 3279021807900002 Redian Arista L
38 3207180805880005 Danil Roik L
39 Q-7BDFFEDD 3207183009890001 Dede Saripudin L
40 Q-0752849C 3301181707970006 Fatul Umam L
41 Z-1043E2A3 3301150503880005 Abdurrohman L
42 Q-A9CB71EB 3207172406940001 Riman L
43 W-90A7AD36 3279022303680001 TATANG SAPEI HIDAYAT L
44 W-EABAD305 3279022102820001 OMAN HADIMAN L
45 W-5ACB90DB 3279025509620002 EUIS SUMEGAWATI P
46 W-80E7D1A2 3279027101660001 DINDA ROSWATI P
47 Q-1D6496A2 3279022002840001 ASEP MARHUDIN L
48 W-61094132 3207071902870001 BAMBANG NURDIANSYAH L
49 W-931B18D7 3279014301800003 NIA SUMIATI P
50 W-A33A82D3 3279015408870004 DEDE HASYAROH P
51 W-B34C1985 3279025611700002 LILIS MURNIATIN P
52 W-D544CCEE 3279040810660001 NURHAKIM L

1 S-957B1725 3279024304610001 ENI HAPIDOH P
2 S-D1778787 3279024802640001 UKAMAH P
3 S-522F745A 3279024310700001 NANI NURYANI P
4 S-70ED5984 3279034209830002 WIRDA HASTIKA P
5 S-6D91741F 3211146608890006 TRI SUSILAWATI P
6 S-7A1F6C75 3301185603870005 MIFTAHUL JANAH P
7 S-EE7AD451 3207185209880004 IRMA NOORMAHAENI P
8 S-3CBAF8E6 3301131809890005 ARIF HIDAYAT L
9 P-GQFC8OQ1 3279036807720002 YELIS SUMIATI P
10 S-F0FB2AF2 3279022712830001 DENI KURNIA L
11 NURDIN HERYADIN L
12 S-93DBDB71 3279014405890001 BINA RAINA ANJANI P
13 S-F1ADCA5E 3279014804970002 NURUL IMAN APRILIA P
14 S-B41ECB9E 3279020403770002 HARUN AL RAYSID L
15 S-5D822D18 3279025605840002 WIWI WININGSIH P
16 S-6CAA294C 3279041005880002 MUNTAZIM L
17 S-3B5EA69E 3279026603880002 YANTI SUPRIATIN P
18 S-F565EBDF 3279044701840001 Haniyati, S.Pd.I P
19 3279040505870001 Mujianto, S.Sy L
20 S-45EFCC57 3207192196900001 Abdul Mukhlisin, S.Pd.I L
21 P-GQ4JXIEK 3279014203900002 Ade Ratih P
22 3207304301930003 Kinanti Laras Asih P
23 3207266906880002 Sri Rahayu Ratnasari P
24 S-47E4B686 3279021810760001 Asep Deni, S.Pd.I,M.Pd. L
25 S-C881D290 3279022706950001 Syarif Munawar, S.Pd. L
26 S-99CC328A 3279045204950003 Siti Robingah,S.Pd.I P
27 S-5C907A66 3279020501680001 Jujun Junaedi, S.Pd.I L
28 P-H4UEX3WX 3279024709960001 Dara Mulya Santi, S.Pd. P
29 Herti P
30 S-DA29BBEF 3279024903740001 Ani Anidah P
31 S-C384146B 327901550660001 SUKAESIH, S.Pd P
32 S-8AE3BA76 3279026712650001 NUNUNG SURYANI P
33 S-5FF53F5B 3279011208700001 A. FAOZAN L
34 S-E5D7D3F1 3279036506890001 WINDA TRISWAHYUNI, S.Pd P
35 S-0A152BB1 3279034511890001 ASTRI SULASTRI, S.Pd P
36 3279020406660002 TARYA, S.Pd L
37 P-GTZY1B0X 3279024605760000 NENI SUMARNI, S.Pd. P
38 S-8664DED4 3279660266117902 RIKA RAHMAWATI, S.Pd. P
39 3279016709830000 INTAN NURJAYANTI, S.Pd P
40 S-A8B588A8 3279027105730001 NENI KUSMAWATI, S.Pd P
41 S-947413A1 3279025408650001 WATI HERAWATI, S.Pd P
42 S-CDC9AC93 3207172505800003 AYATULLAH,S.Pd L
43 S-B287F70E 3205060706900006 SUGANDI, S.Pd L
44 S-833ADFE4 3301184803860004 YULIARNI, S.Pd P
45 S-501FB29A 3207285408920001 SITI MARYATI HOBARIAH, S.Pd P
46 3279014109840002 FIRNA SEFTIANA, S.Pd P
47 S-D1778787 3279010808790001 RISMAYADI,S.Pd L
48 S-E896DCCE 3279025909760001 ANA SETIANA,S.Pd P
49 S-63BE9415 3279024603660000 N. NANI SUMARNI A.MPD. P
50 S-9C55A523 198003142003122003 IRMAWATI, S.PD. P
51 S-2620A2A5 3279016606700001 RUMIAH, S.PD. P
52 S-9868E915 3273025511830008 WINA SAPRIANA, S.Pd. P
53 S-84D1B3D6 3207182408880002 RAHMATULLOH, S.Pd L
54 S-AB1B2507 3279020607710005 ANDANG L
55 S-58910678 3279015402880001 NOERIDA MALIANTI, S.Pd.I P
56 S-DDBEE629 3279016503920002 LINDA MEGA APRILDA, S.Pd P
57 S-9F3B3FB7 3279025108780003 DIAN RATNAYUWANGSIH P
58 3279024709630003 DEDEH KURNIASIH P
59 Q-7392E15D 3279025103900001 ASTRI SETIAWATI P
58
12
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
KADIS PU 58 46-59
PEGAWAI PEMERINTAH 46 46-59
GURU 59 46-59
GURU 59 46-59
GURU 57 46-59
GURU 55 46-59
GURU 35 31-45
GURU 58 46-59
GURU 57 46-59
GURU 51 46-59
GURU 59 46-59
GURU 38 31-45
GURU 34 31-45
GURU 33 31-45
GURU 32 31-45
GURU 30 18-30
GURU 32 31-45
GURU 31 31-45
GURU 23 18-30
GURU 32 31-45
GURU 26 18-30
GURU 53 46-59
PET. KEBERSIHAN 39 31-45
GURU 58 46-59
GURU 55 46-59
GURU 37 31-45
GURU 33 31-45
GURU 41 31-45
GURU 33 31-45
GURU 50 46-59
GURU 55 46-59
GURU 59 46-59
GURU 57 46-59
GURU 50 46-59
GURU 37 31-45
GURU 31 31-45
GURU 33 31-45
GURU 32 31-45
GURU 31 31-45
GURU 48 46-59
GURU 38 31-45
GURU 52 46-59
GURU 31 31-45
GURU 24 31-45
GURU 43 31-45
GURU 36 31-45
GURU 32 31-45
GURU 32 31-45
GURU 37 31-45
GURU 34 31-45
GURU 31 18-30
GURU 30 18-30
GURU 28 31-45
GURU 33 31-45
GURU 45 18-30
GURU 26 18-30
GURU 26 18-30
GURU 53 46-59
GURU 25 18-30
GURU 0
GURU 47 46-59
GURU 55 46-59
GURU 56 46-59
GURU 51 46-59
GURU 32 31-45
GURU 32 31-45
GURU 55 46-59
GURU 45 31-45
GURU 42 31-45
GURU 38 31-45
GURU 48 46-59
GURU 56 46-59
GURU 41 31-45
GURU 31 31-45
GURU 35 31-45
GURU 28 18-30
GURU 36 31-45
GURU 42 31-45
GURU 45 31-45
GURU 54 46-59
GURU 40 31-45
GURU 50 46-59
GURU 37 31-45
GURU 32 31-45
GURU 49 46-59
GURU 33 31-45
GURU 28 18-30
GURU 43 31-45
GURU 58 46-59

0
FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKS
Alamat
Jl.Lembursitu No.07 RT/RW 003/027 Kel/Desa.Ciamis Kec.Ciamis

Dsn Wanareja Timut rt.4 rw.6 Ds. Wanareja Kec. Wanareja Kab Cilacap
Perum Dobo Regency Kel. Pataruman Kec. Pataruman Kota Banjar
Dsn. Cibodas rt3 rw.24 Desa Cisadap Kecamatan Ciamis Kabupaten Ciamis
Lingk. Pintu singa rt.5 rw.18 Kel. Banjar Kec. Banjar Kota Banjar
Jl.Ir.H.Juanda RT/RW 002/018 Ciamis
Dsn. Cibentang rt.14 rw.7 Ds. Mekarharja Kec. Purwaharja Kota Banjar
Dsn. Citangkolo rt.5 rw.1 Ds. Kujangsari Kec. Langensari Kota Banjar
Cikabuyutan Barat RT 02/10 Kel.Hegarsari
Dsn. Pasirleutik rt.27 rw.11 Ds. Mekarharja Kec. Purwaharja Kota Banjar
Babakansari RT 003/011 Kec.Pataruman Kota Banjar
Lingk. Cikabuyutan Timur rt.4 rw.11 Kel. Hegarsari Kec. Pataruman Kota Banjar
Dsn. Babakan Ciminyak rt.1 rw.1 Ds. Karyamulya Kec. Cisaga Kab. Ciamis
Lingk. Cimenyan I rt.4 rw.3 Kel. Mekarsari Kec. Banjar Kota Banjar
Perum Griya Banjar Raharja Blok A 4/5 Lingk.Haurmukti
Lingk.Haurmukti RT 041/002
Dsn Mekar Mulya rt.11 rw.5 Ds. Kepel Kec. Cisaga Kab. Ciamis
Lingk.Siluman RT 025/012 Kec.Purwaharja Kel.Purwaharja
Dusun Randegan I 11/04 Purwaharja Banjar
Dusun Cibereum Rt. 6 Rw. 2

Jl. Pasar Langen Rt. 2 Rw.1
Babakansari Rt. 2 Rw. 8
Cimenyan II Rt. 01 Rw.08
Banjar Kolot Rt. 3 Rw. 14
Karang Pucung
LINGK. BABAKANSARI
LINGK. LEMBUR BALONG
Ling. Parungsari RT14 RW 06 RT/RW. 14/6 Desa Karangpanimbal Kec. Purwaharja Kota Banjar
Dsn. Cilulu RT/RW. 3/11 Desa Dayeuhluhur Kec. Dayeuhluhur Kab. Cilacap
Ling. Sidamukti RT/RW. 6/6 Desa Muktisari Kec. Langensari Kota Banjar
JL. Pesantren No.02 RT/RW. 1/2 Desa Kujangsari Kec. Langensari Kota Banjar
JL. Malang Dirana NO.35 RT/RW. 1/2 Desa Segaralangu Kec. Cipari Kab. Cilacap
cijurey RT/RW. 1/3 Desa Kujangsari Kec. Langensari Kota banjar
Sukabakti RT/RW. 9/3 Desa Puloerang Kec. Lakbok, Kab. Ciamis
JL.RE.KURDIJAN NO.66 LING. CIKABUYUTAN TIMUR KEL. HEGARSARI KEC.PATARUMAN KOTA BANJAR
DUSUN MARGALUYU RT.009 RW.009 DESA MULYASARI KEC.PATARUMAN KOTA BANJAR
DUSUN CIDOYANG RT.004/RW.021 DESA JALATRANG KEC CIPAKU KAB CIAMIS

DUSUN KARANG PUCUNG WETAN RT.11/RW.03 DESA JAJAWAR KEC.BANJAR KOTA BANJAR
DUSUN CILENGKONG RT.14/RW.07 DESA NEGLASARI KECAMATAN BANJAR KOTA BANJAR
DUSUN MARGASARI RT.04/RW.06 DESA BOJONGKANTONG KEC.LANGENSARI KOTA BANJAR

DUSUN TANJUNGSUKUR RT.04/RW.17 DESA HEGARSARI KEC.PATARUMAN KOTA BANJAR
JL. DIPATIUKUR RT.03/RW.14 LING. BANJAR KOLOT KEC.BANJAR KOTA BANJAR
DUSUN CIBENTANG RT.017/RW.007 DESA MEKARHARJA KEC. PURWAHARJA KOTA BANJAR
JL.KIHAJAR DEWANTORO NO.17 RT.003 RW.006 DESA KUTASARI KEC.CIPARI KAB. CILACAP
PERUM GRIYA ASRI DUSUN PANANJUNG BARAT DESA SINARTANJUNG KEC.PATARUMAN KOTA BANJAR
DUSUN CIKONDANG RT.003 RW.001 DESA PANIMBANG KEC.CIMANGGU KAB CILACAP
LING.PATARUMAN RT.001 RW.014 DESA PATARUMAN KEC.PATARUMAN KOTA BANJAR
DUSUN RANCAKOLE RT.010 RW.002 DESA MULYASARI KEC.PATARUMAN KOTA BANJAR
PERUM BALOKANG PERMAI BLOK D RT.48 RW.15 DESA BALOKANG KEC. BANJAR KOTA BANJAR
DUSUN GARDU RT.016 RW.006 DESA BALOKANG KEC.BANJAR KOTA BANJAR
LING PANATASAN RT OO3/020 KEL/KEC PATARUMAN
DSN SUKAMAJU RT 009/005 DS MULYASARI-PATARUMAN
LING MARGASARI RT 005/006 DS BOJONGKANTONG-LANGENSARI
LING BAKANSARI RT 001/010 KEL/KEC PATARUMAN
Ling. Margasari RT 0002 RW 005 Bojongkatong
Dusun Citangkolo RT 005/001 Kujangsari
Dsn Kertajaga RT 008 RT 003 Desa Sukajaya
BANJAR
SINDANGASIH
BANJAR
Lingk. Cikabuyutan Timur RT.01 RW.12 Kel.Kec Hegarsari.Pataruman
Lingk. Jelat RT.02 RW.03 Kel.Kec Pataruman
Dusun Kalapasabrang RT.04 RW.08 Kel.Kec Kujangsari Langensari
Cimenyan II Rt. 5 Rw. 8

Perum Dpbo Blok N7
Asrama Yonif 323 Rt. 29 Rw. 14
Randegan Rt 04 Rw 02
Lembur balong Rt 2 RW 06
Cikabuyutan Barat Rt 03 rw 09
Ling. Jadimulya Rt 03 rw 05
Cimenyan Rt 04 rw 07
Lingk. Tanjung sukur rt 04 rw 14
Lemburbalong Rt. 03 Rw. 08
LAKBOK
KP.BABAKANWETAN GARUT
JL. MT.HARYONO CILACAP
LINGK. PATARUMAN
LINGK. CIKABUYUTAN TIMUR
LINGK. CIMENYAN
LINGK. PATARUMAN
LINGK. PATARUMAN RT02 RW15 KEL. PATARUMAN, KEC. PATARUMAN
LINGK. SILUMAN BARU RT35 RW16 PURWAHARJA
LINGK. PARUNGLESANG RT04 RW09 KEL. PATARUMAN
LINGK. CIKABUYUTAN TIMUR RT03 RW13 KEL. HEGARSARI
JLN. HANURA NOMOR 5 RT 04 RW 07 KEL. PANGLAYUNGAN KEC. CIPEDES KOTA TASIKMALAYA
LINGK. SUKAMANAH RT03 RW18 KEL. PATARUMAN, KEC. PATARUMAN
LINGK. CIMENYAN II RT02 RW09 KEL. MEKARSARI KEC. BANJAR
LINGK. CIMENYAN II RT05 RW08 KEL. MEKARSARI KEC. PATARUMAN
DUSUN MARGALUYU RT 10 RW 09, MULYASARI

AKSINASI COVID-19
POS VAKSINASI

kolom yang sesuai)

Nama/Jenis/Merek
Vaksin***
BPJS Non Non
BPJS PBI
PBI Anggota
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085643668173 3/24/2021 VACCINE COVID-19
089502532420 3/24/2021 VACCINE COVID-19
085223157587 3/24/2021 VACCINE COVID-19
085222116130
085220219697 3/24/2021 VACCINE COVID-19
85321534832 3/24/2021 VACCINE COVID-19
085223906108 3/24/2021 VACCINE COVID-19
089644111487 3/24/2021 VACCINE COVID-19
081573453884 3/24/2021 VACCINE COVID-19
08990760891 3/24/2021 VACCINE COVID-19
081323654278 3/24/2021 VACCINE COVID-19
082297091690
088223405038 3/24/2021 VACCINE COVID-19
82219480470 3/24/2021 VACCINE COVID-19
082318126405
085287000250
081323314329 3/24/2021 VACCINE COVID-19
089652887553 3/24/2021 VACCINE COVID-19
085223694359 3/24/2021 VACCINE COVID-19
085223925168 3/24/2021 VACCINE COVID-19
08990758894 3/24/2021 VACCINE COVID-19
3/24/2021
81910722482 3/24/2021 VACCINE COVID-19
085223807415 3/24/2021 VACCINE COVID-19
081323533433 3/24/2021 VACCINE COVID-19
082240060136 3/24/2021 VACCINE COVID-19
08528766268 3/24/2021 VACCINE COVID-19
085316995187 3/24/2021
085223619357
08985781700 3/24/2021 VACCINE COVID-19
085320945658 3/24/2021 VACCINE COVID-19
085221433185
081214344633 3/24/2021 VACCINE COVID-19
085324553430 3/24/2021 VACCINE COVID-19
081395201515 3/24/2021 VACCINE COVID-19
085974597450 3/24/2021 VACCINE COVID-19
082137460175 3/24/2021 VACCINE COVID-19
082130437230 3/24/2021 VACCINE COVID-19
085223469464
085324825450 3/24/2021 VACCINE COVID-19
082315322843 3/24/2021 VACCINE COVID-19
085223704620 3/24/2021
087735358485 3/24/2021 VACCINE COVID-19
089508092008 3/24/2021 VACCINE COVID-19
081318791236 3/24/2021 VACCINE COVID-19
082214519498 3/24/2021 VACCINE COVID-19
081394401153 3/24/2021 VACCINE COVID-19
085322628579 3/24/2021 VACCINE COVID-19
087767891241 3/24/2021 VACCINE COVID-19
8522317728 3/24/2021 VACCINE COVID-19
081214192142
082214569309 3/24/2021 VACCINE COVID-19
Dosis I Dosis 2
Tanggal
Tanggal Pemberian
Vaksinasi
Vaksinasi
3/24/2021 24001021 3/24/2021 24001021

3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021

3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021

3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021

3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021

3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021
3/24/2021 24001021 3/24/2021 24001021

3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
3/24/2021 24001021
NAMA INSTANSI
Keterangan
(Ditunda/Tidak
Diberikan/Lanjut)
SELESAI DINAS PU
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
TDK HADIR
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SDN I PATARUMAN
SELESAI
SELESAI
SELESAI
SDN I PATARUMAN
SELESAI
SELESAI
SELESAI
SDN 4 PATARUMAN
SELESAI
SELESAI
SELESAI
SMK AL-AZHAR
TDK HADIR
SELESAI
SELESAI
SELESAI
SELESAI
TDK HADIR
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI SDN SINARTANJUNG
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
SELESAI
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR
LANJUT DOSIS 2
MI AL-KASYSYAF
LANJUT DOSIS 2
MI PANATASAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
MI RANCAKOLE
LANJUT DOSIS 2
TDK HADIR
LANJUT DOSIS 2
SMP PATROMAN
LANJUT DOSIS 2
TDK HADIR
TDK HADIR
MI JELAT
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2
SDN 1 PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA PROMIL
TDK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
SDN 4 PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
SDN 2 PATARUMAN
TUNDA KOMORBID
LANJUT DOSIS 2
LANJUT DOSIS 2
SDN 2 PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TK TUNAS BAKTI
LANJUT DOSIS 2
TDK HADIR
NAKES PEGADAIAN
SELESAI
Jenis
Kelamin
1 S-E2422301 3279041408880004 Agus Sukmana L

2 S-3253667A 3301123003870003 Angkat Subagyo L
3 S-1889EB0E 3301154206780002 Ati Maria P
4 S-B4DD28E0 3305052102930001 Barkah Al Amin L
5 S-029A6FD8 3207356505000001 Daryati P
6 S-65422272 3279015103860001 Dian Setyoningrum P
7 3279046907680001 Farida P
8 P-HED1X7N1 3279046907680001 Linatu Sofiyah P
9 S-9CCF733D 3279011402610003 Mansur L
10 3279021909640001 Dodi Supardi L
11 S-54D812E5 3279026907630001 Ani Mulyani P
12 S-2F0DDF05 3207122905900002 Asep Kurnia L
13 S-879680A7 3279025908860002 Risnawati Agustien P
14 S-112382B3 3279024704640001 Heni Hernilah P
15 S-66C4ADFF 3279026810830001 Iis Patimah P
16 S-4517E2D6 3279025101690002 Karmanah P
17 S-5947BB87 3279016406610001 Rasih P
18 S-33D597F6 3279025207700001 Siti Khodijah P
19 S-075D1793 3279021207610002 NUR DARISMAN,S.Pd L
20 3279025308530002 N ROHILAH ROFAQOH,S.Ag P
21 3179025501730001 HASANAH,S.Pd P
22 Rano Juanda
23 Henda Laila, SE
24 Diny Foernamasari S.Pd
25 Hj. Wati Hendrawati S.E
26 3279024401640001 ENOK PRIHATININGSIH, S.Pd.
27 3279021308610001 TATA SUMITRA, S.Pd.
28 S-E0F5F8D0 3279020804690001 USUP. S.Pd. L
29 S-F542047A 3207125304870001 MIRA YANI, S.Pd. L
30 3279025012820001 DIAH NURHIDAYANI, S.Pd.
31 S-149865EA 3279024502710001 IKAH ATIKAH, S.Pd. P
32 3279044305700002 Anih P
33 3279022111750002 Ari Sugiat L
34 S-E7C74621 3279024705920001 Arin Aryati P
35 S-08B5DBBB 3279025106640005 Dede Rohanah P
36 3279025112770002 Dedeh Kurniasih P
37 S-08FBBC4F 3279045203760001 Dewi Rismayanti P
38 S-1D640906 3279044905680002 Epi Sopiati P
39 P-HQQ3KF5N 3207192006690001 Ajat Sudrajat L
40 3279024703730001 Neni Nuraeni P
41 S-7D5DDDA7 3279014811670001 Siti Nurhayati Hotijah P
42 S-9405C0ED 3279045312710001 Nurhayati Rahayu P
43 S-CABB834B 3310160701820001 Dadang Susilo L
44 S-9C1F15E3 3207185411940002 Isnarabani P
45 S-E28F7C39 320 7112402940001 Eris Permana L
46 S-4950EC4B 3206300502800001 Adang L
47 S-973FDB95 3207161506750001 Carsan L
48 S-94E54618 3205191109990003 Yusril Hadi Sopyan L
49 Y-00001T8X 3207235412840001 Imas Cunayah P
50 S-59CB3C13 3207195511680002 Dede Hernawati P
51 Neng Partini
52 Kusen
53 Sunita
54 Ratnaningsih
55 S-B6BB8EFA 3279021602550001 Tubagus R L
56 S-47E805AB 3279025005720003 Oyoh. R P
57 Sule Yuliana
58 S-5115826E 3279020611580002 Dudi Kurniadi, S.H L
59 P-I0TCZSCG 3279026003740002 Emay Suryamah P
60 S-0FB62F9D 3279021006580002 Undang Syam L
61 Sumiati
62 W-396C72B9 3207304203670002 Ikah Surtikah P
63 Q-C3ACB680 3279026505940002 DITA SITI JATNIKA P
64 P-SFOAJYEL 3279021306740002 DEDE SAIDIN L
65 W-4D0EC68B 3279010601780001 ASEP DADDY ISKANDAR, ST.,M.S.i L
66 S-D33916A7 3207304301930003 Kinanti Laras Asih P
66
21
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
GURU 32 31-45
GURU 33 31-45
GURU 42 31-45
GURU 27 18-30
GURU 30 18-30
GURU 34 31-45
GURU 52 46-59
GURU 52 0
GURU 59 46-59
GURU 56 46-59
GURU 57 46-59
GURU 30 18-30
GURU 34 31-45
GURU 56 46-59
GURU 37 31-45
GURU 52 46-59
GURU 59 46-59
GURU 50 46-59
GURU 59 46-59
GURU 58 46-59
GURU 48 46-59
GURU 0
GURU 0
GURU 0
GURU 0
GURU 56 46-59
GURU 59 46-59
GURU 51 46-59
GURU 33 31-45
GURU 38 31-45
49 46-59
GURU 51 46-59
GURU 46 46-59
GURU 29 18-30
GURU 57 46-59
GURU 44 31-45
GURU 45 31-45
GURU 53 46-59
GURU 52 46-59
GURU 48 46-59
GURU 54 46-59
GURU 50 46-59
GURU 39 31-45
GURU 27 18-30
GURU 27 18-30
GURU 41 31-45
GURU 46 46-59
GURU 22 18-30
GURU 37 31-45
GURU 53 46-59
JEMA'AH HAJI 0
JEMA'AH HAJI 0
JEMA'AH HAJI 0
JEMA'AH HAJI 0
JEMA'AH HAJI 66 >60
JEMA'AH HAJI 49 46-59
JEMA'AH HAJI 0
JEMA'AH HAJI 63 >60
JEMA'AH HAJI 63 >60
JEMA'AH HAJI 0

GURU 28 46-59
0
Alamat
Jln. Mandalare / Panyingkiran RT/RW. 2/2 Desa Rejasari Kec. Langensari Kota Banjar
Padomasan RT/RW. 22/4 Desa Purwasari Kec. Banjarsari Kab. Ciamis
BANJAR WARU RT/RW. 2/2 Desa MADUSARI Kec. Wanareja Kab. Cilacap
Parto Atmojo RT/RW. 1/2 Desa Langensari Kec. Langensari Kota Banjar
Dusun Panyingkiran RT/RW. 28/13 Desa Ciharalang Kec. Cijeungjing
Citangkolo RT/RW. 4/1 Desa kujangsari Kec. Langensari Kota Banjar
Parunglesang RT 4 RW 10, Desa Banjar, Kec. Banjar
Dusun Jelat, RT 11 RW 4, Desa Pataruman, Kec. Pataruman
Cikabuyutan Timur No. 515, RT 5 RW 11 Desa Hegarari, Kec. Pataruman
Dusun Kutasari, RT 11 RW 4, Desa Dayeuluhur, Kec. Jatinegara
Lingkungan Cikabuyutan Timur RT 1 RW 11, Desa Hegarsari, Kec. Pataruman
Babakansari Rt/Rw: 8/11 Desa/Kel. Pataruman Kec. Pataruman Kota Banjar
Jelat Rt/Rw: 2/2 Desa/Kel. Pataruman Kec. Pataruman Kota Banjar
Cikabuyutan Timur Rt/Rw: 6/12 Desa/Kel. Hegarsari Kec. Pataruman Kota Banjar
Gardu Rt/Rw: 6/16 Desa/Kel. Balokang Kec. Banjar Kota Banjar
Dsn.Sinartanjung Rt 04 Rw 01
Jln Purnomosidi Rt 15 Rw 09
Jln. Langkaplancar Rt 10 Rw 09
Mulyasari RT. 06/02

Mulyasai RT. 07/08
Mulyasari RT. 06/05
Bayasari RT. 01/01
Mulyasari RT. 08/05
Mulyasari RT. 08/05
BOJONGSARI
CIKABUYUTAN TIMUR
SUMANDING WETAN
TANJUNGSUKUR
KP. Cilangla
Lingk. Sidamukti rt 03/ rw 07 Kel. Muktisari Kec. Langen sari Kota Banjar
Lingk. Tanjungsukur rt 05/rw15 kel. Hegarsari Kec Pataruman Kota Banjar
Lingk. Sukarame rt 05/ rw 12 Kel. Mekarsari Kec. Banjar Kota Banjar
Dsn.Sindangmulya rt02/ rw10 Kel. Kujangsari Kec. Langensari Kota Banjar
Dsn. Randegan I rt 07/ rw 03 Kel.Raharja Kec. Purwaharja Kota Banjar
Dsn. Sindangtawang rt 11/rw 03 Des. Sindanghayu Kec. Banjarsari Ciamis
Dsn Munjul rt 05/rw 015 Desa Buniseuri Kec. Cipaku Ciamis
Kp. Nanggewer rt 09/rw04 Des. Sukamulih Kec. Sariwangi Tasikmalaya
Tambaksari rt 03/ rw 01 des Tambaksari Kec Tambaksari Ciamis
Kp. Cimaragas rt 03/ rw 05 Des Ngamplangsari Kec. Ciawi Garut
Dsn. Cibeureum rt 02/ rw 01 Balokang Banjar

SINDANGASIH
AKSANAAN VAKSINASI COVID-19
ASYANKES/POS VAKSINASI

kolom yang sesuai)
Nama/Jenis/Merek
Vaksin***
BPJS Non Non
BPJS PBI
PBI Anggota
085322650999 3/25/2021 VACCINE COVID-19

085747941095 3/25/2021 VACCINE COVID-19
081323272061 3/25/2021 VACCINE COVID-19
085232169160 3/25/2021 VACCINE COVID-19
085318839699 3/25/2021 VACCINE COVID-19
085318189899 3/25/2021 VACCINE COVID-19
081323696931
081323696931 3/25/2021 VACCINE COVID-19
082317193545 3/25/2021
082119612379
082118257515 3/25/2021
085295733309 3/25/2021 VACCINE COVID-19
085318822628 3/25/2021 VACCINE COVID-19
085220056757 3/25/2021 VACCINE COVID-19
082116955383 3/25/2021 VACCINE COVID-19
081323157970 3/25/2021 VACCINE COVID-19
082113653933 3/25/2021 VACCINE COVID-19
085294042120 3/25/2021 VACCINE COVID-19
087886337506 3/25/2021 VACCINE COVID-19
082129838656
085223570611
0852 2119 6629

0852 1584 3336
0823 4966 3938 3/25/2021 VACCINE COVID-19
0852 2261 3636 3/25/2021 VACCINE COVID-19
0853 2013 1531
0853 1465 5541 3/25/2021 VACCINE COVID-19
082217851123
081221558825
085321098286 3/25/2021 VACCINE COVID-19
087737856041 3/25/2021
085794395374
085793292925 3/25/2021 VACCINE COVID-19
81323123688 3/25/2021 VACCINE COVID-19
81220303807 3/25/2021 VACCINE COVID-19
081323012329
085795138330 3/25/2021 VACCINE COVID-19
3/25/2021 VACCINE COVID-19
082120034113 3/25/2021 VACCINE COVID-19
081221391585 3/25/2021 VACCINE COVID-19
083826597680 3/25/2021 VACCINE COVID-19
087826909844 3/25/2021 VACCINE COVID-19
085222705752 3/25/2021 VACCINE COVID-19
085223522779 3/25/2021 VACCINE COVID-19
81323072834 3/25/2021 VACCINE COVID-19

81323072834 3/25/2021 VACCINE COVID-19
81214872400 3/25/2021 VACCINE COVID-19

81312518886 3/25/2021 VACCINE COVID-19
81313613713 3/25/2021 VACCINE COVID-19
081222833999 YA 3/25/2021 VACCINE COVID-19

082321177939 YA 3/25/2021 VACCINE COVID-19
082315531945 YA 3/25/2021 VACCINE COVID-19
082321200250 3/25/2021 VACCINE COVID-19
082318126405 3/25/2021 VACCINE COVID-19
Dosis I Dosis 2

Vaksinasi Vaksinasi
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
3/25/2021 24001021
Keterangan
Diberikan/Lanjut)
LANJUT DOSIS 2 SMK AL-AZHAR

LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR
LANJUT DOSIS 2
TUNDA KOMORBID SDN 5 PATARUMAN
TDK HADIR
TUNDA KOMORBID
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 SDN 3 PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 SDN 3 MULYASARI
SAKIT TDK HADIR
SAKIT TDK HADIR
TDK HADIR MTs AS-SALAM
TDK HADIR
TDK HADIR
TDK HADIR
SUDAH DIVAKSIN SDN 1 MULYASARI
TDK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
KONFIRMASI
LANJUT DOSIS 2
KONFIRMASI SMK MUHAMMADIYAH
TDK HADIR
LANJUT DOSIS 2
SMK MUHAMMADIYAH
TUNDA KOMORBID
TDK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2 SLB NEGERI BANJAR
LANJUT DOSIS 2
TDK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR JEMA'AH HAJI
TDK HADIR
DIVAKSIN DI PASAR
DIVAKSIN DI PASAR
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR
SELESAI KEL.PATARUMAN
DESA SINARTANJUNG
SELESAI
LANJUT DOSIS 2
SELESAI DINAS PU
LANJUT DOSIS 2 SMP PATROMAN
Jenis
Kelamin
1 Q-07814830 3279016103630000 IMAS MASRIAH P

2 W-1181A1B6 3279026502890001 HENI MULYANI P
3 Q-20EDF455 3279020505860003 Ucu Herdiana L
4 W-5B94C02C 3279025805630001 AAS AISAH P
5 Z-FB60F5D6 3207015410910002 TSINTA NUR FAJRIAH P
6 W-99A1FAAC 3279021207640002 TATA L
7 W-8EDCB83C 3279025409790005 JUJU JUARIAH P
8 Q-B9C6284E 3279026901970002 SRI HAYATI P
9 3279026112610002 OOM ROMLAH P
10 W-F514128A 3279026703620002 YANI ROHAYANINGSIH P
11 Q-1C6AF509 3301192806860001 MUHAMAD DALHAR L
12 W-D2921B87 3279024704660003 SIYAMTI P
13 W-32E12920 3279025603960003 NURRAHMI PUJIANI P
14 3279021301820002 Hendri Gunawan L
15 W-AA96FC62 3279042907800001 AGUS SUPRIATNA L
16 W-05104491 3279032809820001 SUTARDIAWAN L
17 W-65F6A855 3207317101950003 ARIE MEGAWATIE SA`BANI P
18 W-6AF43B0C 3279014602960002 NURHAYATI P
19 Z-C8B496E3 3279024705770004 Dede Nuryatin, S.Pd.I P
20 Z-A188791E 3279025312710001 TITA NURBAETI R P
21 Z-B2C09D37 3279026303860001 IKA ARISTYA PUTRI P
22 Z-89365877 3279016709910002 AYU YULIA FRIDAY P
23 3207131101920002 ILHAM ZAMZAM NURJAMAN L
24 Q-88163A06 3279024505740004 DAHLIA, S.Pd P
25 Q-C2B8F852 3279045212850001 Dede Irma Nurmala P
26 Z-2F009FCA 3207174107840011 SUGIATUN P
27 Z-63FD42B5 3279046311920001 DINY FOERNAMASARI P
28 Z-7119FB46 3279034608730003 EUTIK P
29 3279021811650001 SARIPUDIN L
30 Q-01C164AF 3279020106830003 Jajang Sunarto L
31 W-585D6F78 3279024308850003 INA HERLINA AGUSTINA P
32 W-41290A6E 3207176212860001 TRIYANI P
33 3279025011680008 CARINAH P
34 Q-12140BED 3207046612860002 Santi Kartiwi P
35 Q-B94AA7FC 3279036308750002 Kokom P
36 W-E6353047 3207233107820001 DEDI NURWANDI L
37 Q-518D5667 3278051402900001 FEBRY SYARIF HIDAYAT L
38 Z-9C001026 1806011305930005 Dima Surya Buana L
39 Q-7F62771C 3279010205920002 Adi Hardiansyah L
40 W-C6D0C799 3279016807850001 Rani Kristamas Irawati P
41 3279042811930004 SAHRIR ALI MUSTOPA L
42 Z-96A49AC6 3279022401820002 Ganjar Shirih L
43 Q-6D1A6986 3279010910790001 Asep Suharto L
44 Q-7AA8F810 3279021406970001 RIKI RIMANSAH L
45 Q-026798EE 3203010102920022 Feby Rizaldi Putra L
46 W-D298D359 3279046205830002 Tuti Kurniati P
47 Q-B7AD3D4C 3279022108770002 DODY GUNAWAN L
48 3207036805860001 Ikah Atikah P
49 W-FD136FA3 3279020401690001 Sukardi L
50 Q-C276EB93 3279020709610001 H.Sukatman L
51 Q-56419B01 3279020508650004 Miswan L
52 Q-6356B76F 3279022704620001 Dedi Suhendi L
53 Q-3F81EF7B 3279020805650002 Misno L
54 S-DAD3877D 3279025207600001 Sule Yuliana P
55 S-B74A3C5B 3279026308650001 Neng Partini P
56 S-A62928FC 3279020207560002 Kusen L
57 S-3B13C235 3279025402910001 Tria Febrianti P
58 S-96AB4E53 3279025204680002 Turisna P
59 S-F14AC9DE 3279021701620001 Wasidi L
60 S-D18B8216 3279026005770001 Yeti Sumiati P
61 S-E7EA416D 3279020401640001 Herman L
62 S-956321CB 3279036602850001 Inayatul Khoeriyah, S.Si p
63 Y-00002ECF 3279046407680001 Hj. Wati Hendrawati S.E P
64 P-JJ9OFMLP 3279026010850001 Annisa Tating Nurjanah P
65 P-JPZG6USO 3279024305920002 Eem Emyati, S.M P
66 P-JKHOVF2J 3279026711010002 Tasya Rohayanah P
67 S-0AAA237A 327902430883000 1 Mimik Suparmika,S.Pd P
68 P-420GLNMK 330217700884000 5 Puput Suharni, A.Ma P
69 P-41XYCSYZ 3279017011790002 Rohmita Utami P
70 P-41YDQ3MG 3214124601820004 Vina Nurlaela P
71 S-DFB2D7B9 3279015704730002 ELIS ROHANI P
72 S-A222DD6A 3279024312600005 N FARIDAH SPDI P
73 S-60EDFADB 3279024505670004 Nuryeni P
74 P-JI6FBA2L 3279024712850001 irna Riszi P
75 P-JPHEGQDA 3279021310000001 Jajang Purnomo L
76 S-F3EAB3B1 3602196511790001 Novi Irmayanti P
77 S-E703B86C 3279016311880002 Nuna Nurhayati P
78 S-53AA716A 3207202309940001 Ato Hartono L
79 S-CCF27EE0 3279044101950003 Vina Indriani P
80 S-18FDD134 32790462004820001 Santi Widya Hidayat P
81 S-71D228F0 3279015105820001 Intan Rachmawaty P
82 S-783CDF5F 3279020603840001 Wawan Setiawan 2 L
FORMAT PEN
TINGKAT
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)

PERAWAT 32 31-45
GURU 58 46-59
GURU 30 18-30
GURU 57 46-59
GURU 42 31-45
GURU 24 18-30
GURU 59 46-59
GURU 59 46-59
GURU 35 31-45
GURU 55 46-59
GURU 25 18-30
GURU 39 31-45
GURU 41 31-45
GURU 39 31-45
GURU 26 18-30
GURU 25 18-30
GURU 44 31-45
GURU 50 46-59
GURU 35 31-45
GURU 30 18-30
GURU 29 18-30
GURU 47 46-59
GURU 36 31-45
GURU 37 31-45
GURU 29 18-30
GURU 48 46-59
GURU 56 46-59
GURU 38 31-45
GURU 36 31-45
GURU 35 31-45
GURU 53 46-59
GURU 35 31-45
GURU 46 46-59
GURU 39 31-45
GURU 31 31-45
GURU 28 18-30
GURU 29 18-30
GURU 36 31-45
GURU 28 18-30
GURU 39 31-45
GURU 42 31-45
GURU 24 18-30
GURU 29 18-30
GURU 38 31-45
GURU 44 31-45
GURU 35 31-45
PURNAWIRAWAN TNI 52 46-59
JEMA'AH HAJI 61 >60
JEMA'AH HAJI 65 >60
GURU 30 18-30
GURU 52 46-59
GURU 59 46-59
GURU 43 31-45
GURU 57 46-59
GURU 36 31-45
GURU 52 46-59
GURU 35 31-45
GURU 28 18-30
GURU 19 18-30
GURU 37 31-45
GURU 36 31-45
GURU 42 31-45
GURU 39 31-45
GURU 48 46-59
GURU 61 >60
GURU 53 46-59
GURU 35 31-45
GURU 21 18-30
GURU 42 31-45
GURU 33 31-45
GURU 27 18-30
GURU 26 18-30
GURU 39 31-45
GURU 39 31-45
GURU 37 31-45
Alamat

LINGK. CIKABUYUTAN BARAT RT 04 RW 10, HEGARSARI, PATARUMAN
LINGK. BABAKANSARI RT02 RW09 KEL. PATARUAMAN, KEC. PATARUMAN
JL. RANCAPETIR NO. 6 RT02 RW24 CIAMIS
LIGK. SUKAMANAH RT02 RW17 KEL. PATARUMAN, KEC. PATARUMAN
LINGK. SUKAMANAH RT01 RW16 KEL. PATARUMAN
LINGK. PATARUMAN RT01 RW12 KEL. PATARUMAN
Pananjung Barat RT 4 RW 1, Desa Sinartanjung, Kec. Pataruman
Cikabuyutan Timur RT 6 RW 12, Desa Hegarsari, Kec. Pataruman
Dusun Magersari RT 04 RW 02, Desa Cinyawang, Kec. Patimuan
Cikabuyutan Barat RT 5 RW 10, Desa Hegarsari, Kec. Pataruman
Lingk. Tanjungsukur Rt/Rw: 4/15 Desa/Kel. Hegarsari Kec. Pataruman Kota Banjar
Langkap Lancar Rt/Rw: 1/2 Desa/Kel. Bojong kantong Kec. Langensari Kota Banjar
Dusun Siluman Rt/Rw: 26/12 Desa/Kel. Purwaharja Kec. Purwaharja Kota Banjar
Dusun Kalapanunggal II Rt/Rw: 45/14 Desa/Kec. Sindangkasih Kab. Ciamis
Parung Lesang Rt/Rw: 1/9 Desa/Kel: Banjar Kec. Banjar Kota Banjar
Ling. Pananjung RT 009 RW 002 Sinar Tanjung
Ling. Sukamaju RT 010 RW 006 Mulyasari
Ling. Cimeyan II RT 003 RW 09 Mekasari
Dusun Parung RT 013/005 Balokang
Jln Purwanegara Rt 02 Rw 05
Dsn Bojongsari Rt 03 Rw 03
Dsn. Baregbeg Rt 13/ Rw 04 Baregbeg, Lakbok, Ciamis
Lingk. Cikadu Rt 20/ Rw 09 Karangpanimbal, Purwaharja, Banjar
Mulyasari RT. 01/04
Mulyasari RT.03/04
Sinartanjung RT. 16/04
Hegarsari RT. 06/13
Rejasari RT. 01/07
Dsn Desa rt 01/rw08 Des. Sukajadi Kec. Sadananya. Ciamis
Lingk. Cikadu rt 28/rw 13 Karangpanimbal purwaharja Banjar
Dsn. Karangpucung rt 30/rw 10 Des. Balokang Kec. Banjar kota Banjar
Sukamaju
CIJUREY
Pananjung
Parunglesang
Margaluyu
Cikabuyutan Timur
Langkap Lancar
Sukamulya
MARGALUYU
Pataruman RT 3/12 Kec Pataruman
Babakansari RT 01/11 Kel / Kec Pataruman
Pananjung Timur Rt/Rw: 27/6 Desa/Kel. Sinartanjung Kec. Pataruman Kota Banjar
Pananjung Barat Rt/Rw: 2/1 Desa/Kel. Sinartanjung Kec. Pataruman Kota Banjar
Pataruman Rt/Rw: 2/15 Desa/Kel: Pataruman Kec. Pataruman Kota Banjar
Dsn. Sukamaju Rt 02/Rw 04 Mulyasari, Pataruman, Banjar
Dsn. Citangkolo Rt 02/ Rw 01, Kujangsari, Langensari, Banjar
Dsn. Pananjung Rt 14/ Rw 03, Sinartanjung, Pataruman, Banjar
Lingk. Jelat RT 02 RW 04 Kel/Kec Pataruman Kota Banjar
Lingk. Babakansari RT 02 RW 09 Kel/Kec. Pataruman Kota Banjar
lingk. Cimenyan II RT. 03 RW. 08 Mekarsari kota Banjar
lingk. Babakan Sari RT. 01 RW. 11 pataruman
Pananjung timur
Pananjung barat
Rancakole
Parung
CIBEREUM
Lingk. Siluman Baru rt 33/ rw 16 Purwaharja Banjar
Dsn. Sirnagalih rt 01/ rw02 Langensari Kota Banjar
Dsn. Sirnagalih rt 06 rw02 Langensari Kota Banjar
Lingk. Cimenyan I rt 04/ rw 01 Des. Mekarsari Kec. Banjar
Lingk. Jadimulya rt 03/ rw 07 Kel. Hegarsari Kec. Pataruman Kota Banjar
LAKSANAAN VAKSINASI COVID-19
FASYANKES/POS VAKSINASI

Dosis I
kolom yang sesuai)
No. Hp Screening Vaksin*** Tanggal
BPJS Non Non
BPJS PBI Pemberian
PBI Anggota
Vaksinasi
081323313370 3/27/2021 VACCINE COVID-19

81322320969 3/27/2021 VACCINE COVID-19
082130508168 3/27/2021 VACCINE COVID-19
081323179876 3/27/2021 VACCINE COVID-19
085223058007 3/27/2021 VACCINE COVID-19
085323489011 3/27/2021 VACCINE COVID-19
082127786804 3/27/2021 VACCINE COVID-19
085217362282 3/27/2021 VACCINE COVID-19
081994666844 3/27/2021 VACCINE COVID-19
088224438665 3/27/2021 VACCINE COVID-19
085741729204 3/27/2021 VACCINE COVID-19
085323940266 3/27/2021 VACCINE COVID-19
081321452096 3/27/2021 VACCINE COVID-19
082123386810
081323170288 3/27/2021 VACCINE COVID-19
085294364228 3/27/2021 VACCINE COVID-19
82315756362 3/27/2021 VACCINE COVID-19
82214458150 3/27/2021 VACCINE COVID-19
81910203973 3/27/2021 VACCINE COVID-19
85352326314 3/27/2021 VACCINE COVID-19
85860240053 3/27/2021 VACCINE COVID-19
85320528191 3/27/2021 VACCINE COVID-19
85223372995
81322591150 3/27/2021 VACCINE COVID-19
85223450061 3/27/2021 VACCINE COVID-19
82219513830 3/27/2021 VACCINE COVID-19
82214612093 3/27/2021 VACCINE COVID-19
85294313068 3/27/2021 VACCINE COVID-19
-
85294313366 3/27/2021 VACCINE COVID-19
82321677240 3/27/2021 VACCINE COVID-19
81322203402 3/27/2021 VACCINE COVID-19
82128414703
85320349123 3/27/2021 VACCINE COVID-19
89697236881 3/27/2021 VACCINE COVID-19
85221754488 3/27/2021 VACCINE COVID-19
85724517956 3/27/2021 VACCINE COVID-19
82280045630 3/27/2021 VACCINE COVID-19
81222707397 3/27/2021 VACCINE COVID-19
82319063292 3/27/2021 VACCINE COVID-19
89662636272
089670348735 3/27/2021 VACCINE COVID-19
8122073425 3/27/2021 VACCINE COVID-19
89643223152 3/27/2021 VACCINE COVID-19
81221192440 3/27/2021 VACCINE COVID-19
82240606076 3/27/2021 VACCINE COVID-19
88222510373 3/27/2021 VACCINE COVID-19
85223486339
082317600250 3/27/2021 VACCINE COVID-19
089635539261 3/27/2021 VACCINE COVID-19
82121892020 3/27/2021 VACCINE COVID-19
89660591938 3/27/2021 VACCINE COVID-19
81323530447 3/27/2021 VACCINE COVID-19
85324221676 3/27/2021 VACCINE COVID-19 3/27/2021
81312769843 3/27/2021 VACCINE COVID-19 3/27/2021
81312769843 3/27/2021 VACCINE COVID-19 3/27/2021
085294198223 3/27/2021 VACCINE COVID-19 3/27/2021
0895375114744 3/27/2021 VACCINE COVID-19 3/27/2021
082119508295 3/27/2021 VACCINE COVID-19 3/27/2021
085320967877 3/27/2021 VACCINE COVID-19 3/27/2021
082320585193 3/27/2021 VACCINE COVID-19 3/27/2021
082136956919 3/27/2021 VACCINE COVID-19 3/27/2021
085321390362 3/27/2021 VACCINE COVID-19 3/27/2021
082216568341 3/27/2021 VACCINE COVID-19 3/27/2021
082137158184 3/27/2021 VACCINE COVID-19 3/27/2021
082320932515 3/27/2021 VACCINE COVID-19 3/27/2021
0822 4058 2583 3/27/2021 VACCINE COVID-19 3/27/2021
0812 2327 3159 3/27/2021 VACCINE COVID-19 3/27/2021
081211306442 3/27/2021 VACCINE COVID-19 3/27/2021
081394984150 3/27/2021 VACCINE COVID-19 3/27/2021
85223060175 3/27/2021 VACCINE COVID-19 3/27/2021
85323002588 3/27/2021 VACCINE COVID-19 3/27/2021
082316803026 3/27/2021 VACCINE COVID-19 3/27/2021
87772833875 3/27/2021 VACCINE COVID-19 3/27/2021
085320008042 3/27/2021 VACCINE COVID-19 3/27/2021
082240185635 3/27/2021 VACCINE COVID-19 3/27/2021
085283900722 3/27/2021 VACCINE COVID-19 3/27/2021
081224286907 3/27/2021 VACCINE COVID-19 3/27/2021
085799444828 3/27/2021 VACCINE COVID-19 3/27/2021
082316895533 3/27/2021 VACCINE COVID-19 3/27/2021
083825957140 3/27/2021 VACCINE COVID-19 3/27/2021
087836284015 3/27/2021 VACCINE COVID-19 3/27/2021
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
Tanggal Pemberian
Vaksinasi
3/27/2021 24001721 SELESAI

3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
TIDAK HADIR (SAKIT)
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
TIDAK HADIR (SAKIT)
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
TIDAK HADIR (SAKIT)
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
TIDAK HADIR (SAKIT)
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
TIDAK HADIR (SAKIT)
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
TERKONFIRMASI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
3/27/2021 24001721 SELESAI
NAMA INSTANSI
NAKES PEGADAIAN
KEL. PATARUMAN
SDN 2 PATARUMAN
SDN 5 PATARUMAN
SDN 3 PATARUMAN
MI RANCAKOLE
SDN 3 MULYASARI
MTs-AS Salam
SDN 1 MULYASARI
SLB NEGERI BANJAR
SMK MUHAMMADIYAH
TNI PURNAWIRAWAN
CALON JEMA'AH HAJI
SDN 3 MULYASARI
MTs-AS Salam
TK PGRI
RA HIMATUL ALIYAH
TK NANJUNGSARI
SMK MUHAMMADIYAH
SLB NEGERI BANJAR

SLB NEGERI BANJAR
Jenis
Kelamin
1 Q-64F08553 3279025405910001 EUIS LINLIN MARLIANI P

2 Q-A0027458 3207301603700001 Hanasa L
3 Z-158B6625 3279024812690003 Lilis Setiawati P
4 Z-4E56F44A 3279024308750010 Lilis Lisnawati P
5 Z-8A91BE1B 3279036101860001 Nisa Yuliany P
6 Q-8262720B 3279024503800000 AI WIDANINGSIH, S.Pd P
7 Z-061E5721 3279020407960001 Liyana Kuswaya L
8 Z-12C802FF 3279040110900005 BUANG SUTARJO L
9 Z-42E6E077 3279021303820007 Yusup Kamil, A.Ma L
10 Q-64D74BF1 3279024812950006 Dessy Khairunnisa P
11 Q-64B0F29A 3279021910840002 AHMAD FAUZI L
12 W-07E716E8 3207271012880001 ASEP SUHAN SUHANA L
13 Z-9FE9306B 3277020505950029 GESIT IHSAN AMIN L
14 Q-BF6F8972 3279020512850002 DADANG ALAMSYAH L
15 Q-BF5FDE2B 3279015810830002 NITA SITI NURDIAH P
16 Q-BFED9FC2 3279024709630005 JUNAH P
17 Q-C012A931 3279025203630004 EMPAT PATIMAH P
18 Q-BF949C99 3279024510990001 ROSI ROSITA P
19 Z-F9964F1F 3279025011680008 CARINAH P
20 W-B7952844 3207131101920002 ILHAM ZAMZAM NURJAMAN L
21 W-8E61A443 3207180805880005 Danil Roik L
22 S-12963CB6 3279044609890001 Farida P
23 P-NKMD5TMD 3207202612920002 Andri Suryadi L
24 Y-00002E87 3279024808880003 Ristianti Agustini P
25 S-81AA6199 3279045508890002 Tuti Haryanti P
26 S-1FD42F5A 3279035407880001 Yeni Astuti P
27 P-NGJYVLJZ 3279022507850002 Yuli Setiyadi L
28 P-NGB253TW 3279045808940002 Siti Hotimah P
29 P-NGB253TW 3301164507890001 Helga Nureka Navelani P
30 S-6EED91C7 3207205408680001 Wiwin Widaningsih P
31 S-B57D1D03 3279025705930002 Meriani Iswandini P
32 S-1004108F 3205170904820005 Wawan Setiawan 1 L
33 S-7E997EBD 3206352309950002 Sandi Wahyudi L
34 3206074607740003 ELIS,S.Pd.I P
35 S-36EE8B8C 3279024112940002 SITI AMANAH,S.Pd.I P
36 S-9BFEE613 3279024101870000 SITI MARYAM P
37 S-2C74B2A5 3279025103850002 DEVI DWIYANTI P
38 3279026906850001 JUWITA EKA SARI P
39 3279024403940001 ANGGRAENA P
40 S-B54E1CCC 3204056311880003 DEDE RANI, S.Pd.I P
41 3279041401870001 Iim Rohimat L
42 S-411EC64C 3279020307490001 HADI HERJANA ISMAWIDJAJA L
43 S-A1EB54AE 3279026004600003 TITIN ROHANAH L
44 S-B123E0CB 3301167112470017 ROHATI P
45 S-9D51E62F 3301160301480001 HARSO L
46 S-E5CD4396 3279022205590001 YUSUF BUDIARJO L
47 S-01AD9948 3301162908590001 KECO CARSO L
48 S-0679AA2D 3279026412500001 N. KARTIA P
49 P-NFY51OVJ 3279031601610001 MARYANA L
50 ATAM L
51 ESIH P
52 IROH P
53 OOH P
54 S-C78774AF 3279026702520001 EMPONG ATIKAH P
55 S-9AA346D1 3279025010510003 EDAH DARIAH P
56 S-3AD8578D 3279025606480001 IIR IRAH P
57 S-27A4AAE9 3279025010540001 YOYOH ROKAYAH P
58 S-199E87D0 3279025001590001 PARIJAH P
59 S-FE7940A6 3279025205480004 SOPIAH HAYATI P
60 S-CB5E9130 3279021101500001 OLIH RUSPENDI L
61 S-102FDD3D 3279024101540030 ONAH ROHAENAH P
62 S-5E312105 3279021002510002 LILI SUWANTO L
63 S-4D35FAF8 3279024808580002 HODIJAH P
64 S-EF257E03 3279020711580003 ADANG DAUD RHAMLI L
65 S-CD64F4FD 3279020508380001 MADASRI L
66 S-165358E3 3279025208590003 NANI SURYANI P
67 S-D173A012 3279025006600005 UU MASUNAH P
68 S-54E1CFBE 3279024503600001 SITI MARIAM P
69 P-NVVF9YRF 3279024844770002 RAHWATI P
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
PERAWAT 30 18-30
Kepsek 51 46-59
GURU 52 46-59
GURU 36 31-45
GURU 35 31-45
GURU 41 31-45
GURU 25 18-30
GURU 30 18-30
GURU 39 31-45
GURU 25 18-30
LAPAS BANJAR 33 31-45
LAPAS BANJAR 25 18-30
PEDAGANG PASAR 36 31-45
GURU 53 46-59
GURU 29 18-30
GURU 32 31-45
GURU 31 31-45
GURU 28 18-30
GURU 32 31-45
GURU 31 31-45
GURU 32 31-45
GURU 35 31-45
GURU 26 18-30
GURU 31 31-45
GURU 53 46-59
GURU 28 18-30
GURU 39 31-45
GURU 26 18-30
GURU 47 46-59
GURU 26 18-30
GURU 34 31-45
GURU 36 31-45
GURU 35 31-45
GURU 26 18-30
GURU 32 31-45
GURU 34 31-45
LANSIA 72 0
LANSIA 61 0
LANSIA 74 0
LANSIA 73 0
LANSIA 62 0
LANSIA 62 0
LANSIA 70 0
LANSIA 60 0
LANSIA 0
LANSIA 0
LANSIA 0
LANSIA 62 0
LANSIA 69 0
LANSIA 70 0
LANSIA 83 0
LANSIA 77 0
LANSIA 62 0
LANSIA 83 0
LANSIA 70 0
LANSIA 68 0
LANSIA 70 0
LANSIA 64 0
LANSIA 63 0
LANSIA 83 0
LANSIA 62 0
LANSIA 61 0
LANSIA 61 0
PERANGKAT DESA 44 31-45
FORMAT PENCATATAN PELAKSANA
TINGKAT PUSKESMAS/FASYANK
Alamat

Cisaga Kota RT 01 RW 01, Cisaga
Wargamulya RT 20 RW 09, Purwaharja

Lemburbalong rt 03 rw 0, pataruman
SASAGARAN RT 01 RW 07, BOJONGKANTONG
Dsn. Rancakole Rt 11/ Rw 03 Mulyasari, Pataruman, Banjar
JELAT, PATARUMAN
JELAT, PATARUMAN
JELAT, PATARUMAN
JELAT, PATARUMAN
JELAT, PATARUMAN
Rejasari RT. 01/07
Muktisari RT/RW. 5/2 Desa Muktisari Kec. Langensari Kota Banjar
Dusun Cipicung RT.15 RW.08 Desa Karangsari Kec. Padaherang Kab. Pangandaran
Ling Babakansari RT/RW. 3/11 Desa Pataruman Kec. Banjar Kota Banjar
Dsn Citangkolo RT/RW. 5/1 Desa Kujangsari Kec. Banjar Kota Banjar
Ling. Cikadu RT 18 RW 08 RT/RW. 18/8 Desa Karangpanimbal Kec. Purwaharja Kota Banjar
CITANGKOLO RT/RW. 5/1 Desa KUJANGSARI Kec. Langensari Kota Banjar
Kalapa Sabrang RT/RW. 6/7 Desa Kujangsari Kec. Langensari Kota Banjar
Cilulu RT/RW. 1/11 Desa Dayeuhluhur Kec. Dayeuhluhur Kab. Cilacap
Dsn. Padaherang rt 04/ rw01 Des Padaherang kec. Padaherang Pangandaran
Kp. Sindang serang rt 02/ rw 08 Des. Ciburuy Kec. Bayongbong Garut
Kp. Jamanis rt 01/ rw 05 Tanjung mekar kec. Jamanis Tasikmalaya
Sukamaju 03/04 Mulyasari
Rancakole 08/02 Mulyasari
LING SUKAMANAH RT 001/016 KEL/KECPATARUMAN
Pataruman RT. 03/09
Bojongsaari
DUSUN PEUNDEUY RT 01 RW 08, PANULISAN BARAT
DUSUN PEUNDEUY RT 01 RW 08, PANULISAN BARAT
MARGALUYU RT 09 RW 09, MULYASARI
SUKAMAJU RT 12 RW 06, MULYASARI
PANANJUNG RT 23 RW 05, SINARTANJUNG
SINARGALIH RT 41 RW 09, SINARTANJUNG
SINARGALIH RT 36 RW 08, SINARTANJUNG
LEMBURBALONG RT 03 RW 05, PATARUMAN
LEMBURBALONG RT 03 RW 05, PATARUMAN
SUKAMANAH RT 01 RW 17, PATARUMAN
PANANJUNG BARAT RT 01 RW 01, SINARTANJUNG
PANANJUNG BARAT RT 01 RW 01, SINARTANJUNG
ORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

kolom yang sesuai)
Nama/Jenis/Merek
Vaksin***
BPJS Non Non
BPJS PBI
PBI Anggota
82130737263 4/1/2021 VACCINE COVID-19

85320438917 4/1/2021 VACCINE COVID-19
82318356772 4/1/2021 VACCINE COVID-19
85320140093 4/1/2021 VACCINE COVID-19
87728023772 4/1/2021 VACCINE COVID-19
81323207151 4/1/2021 VACCINE COVID-19
81318096463 4/1/2021 VACCINE COVID-19
85353352873 4/1/2021 VACCINE COVID-19
087736640632 4/1/2021 VACCINE COVID-19
0895635821731 4/1/2021
081323466810 4/1/2021 VACCINE COVID-19
85320442442 4/1/2021 VACCINE COVID-19
82121949242 4/1/2021 VACCINE COVID-19
8122194612 4/1/2021 VACCINE COVID-19
81320053336 4/1/2021 VACCINE COVID-19
81320053336 4/1/2021 VACCINE COVID-19
81320053336 4/1/2021 VACCINE COVID-19
81320053336 4/1/2021 VACCINE COVID-19
82128414703 4/1/2021 VACCINE COVID-19
85223372995 4/1/2021 VACCINE COVID-19
085282053572 4/1/2021 VACCINE COVID-19
081322322567 4/1/2021 VACCINE COVID-19
083814591128 4/1/2021 VACCINE COVID-19
085721698279 4/1/2021 VACCINE COVID-19
081214158611 4/1/2021
081394389550 4/1/2021 VACCINE COVID-19
081313978448 4/1/2021 VACCINE COVID-19
085323352788 4/1/2021
087725673307 4/1/2021 VACCINE COVID-19
085352388370 4/1/2021 VACCINE COVID-19
0895803178748 4/1/2021 VACCINE COVID-19
082117154562 4/1/2021 VACCINE COVID-19
08977737720 4/1/2021 VACCINE COVID-19
089608128001
081221826005 4/1/2021 VACCINE COVID-19
082113228605 4/1/2021 VACCINE COVID-19
082130175449 4/1/2021 VACCINE COVID-19
085314003896
085322698494
0895 6088 35239 4/1/2021 VACCINE COVID-19
089510406276
81323135733 4/1/2021 VACCINE COVID-19
85220319145 4/1/2021 VACCINE COVID-19
82122730173 4/1/2021 VACCINE COVID-19
82122730173 4/1/2021 VACCINE COVID-19
89699535464 4/1/2021
87724874777 4/1/2021 VACCINE COVID-19
85223406945 4/1/2021
81323328931 4/1/2021 VACCINE COVID-19
81321793844 4/1/2021
81321793844 4/1/2021 VACCINE COVID-19
81321793844 4/1/2021 VACCINE COVID-19
081331269549 4/1/2021
081320079593 4/1/2021
089510329603 4/1/2021
083123915431 4/1/2021 VACCINE COVID-19
083123915431 4/1/2021 VACCINE COVID-19
85223431375 4/1/2021
08122061538 4/1/2021 VACCINE COVID-19
85323096898 4/1/2021 VACCINE COVID-19
81222814981 4/1/2021 VACCINE COVID-19
81222814981 4/1/2021 VACCINE COVID-19
82117613565 4/1/2021 VACCINE COVID-19
85223431375 4/1/2021 VACCINE COVID-19
85223813333 4/1/2021 VACCINE COVID-19
Dosis I Dosis 2

Vaksinasi Vaksinasi
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
4/1/2021 24001721
Dosis 2
Keterangan
Diberikan/Lanjut)
24001721 SELESAI NAKES PKM PATARUMAN 3

24001721 SELESAI
24001721 SELESAI
24001721 SELESAI
24001721 SELESAI SMP PATROMAN
24001721 SELESAI
24001721 SELESAI
24001721 SELESAI
24001721 SELESAI
MTs AS-SALAM
TUNDA SUSPEK
24001721 SELESAI DESA MULYASARI
24001721 SELESAI
LAPAS BANJAR
24001721 SELESAI
24001721 SELESAI
24001721 SELESAI
24001721 SELESAI PEDAGANG PASAR
24001721 SELESAI
24001721 SELESAI
24001721 SELESAI SDN 1 MULYASARI
24001721 SELESAI SDN 3 MULYASARI
24001721 SELESAI
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA SAKIT SMK AL-AZHAR
LANJUT DOSIS 2
LANJUT DOSIS 2
PROMIL
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
SLBN BANJAR
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR
RA RIYADU SHOLIHIN
LANJUT DOSIS 2
RA RIYADU SHOLIHIN
LANJUT DOSIS 2
LANJUT DOSIS 2
TDK HADIR
MI PANATASAN
TDK HADIR
LANJUT DOSIS 2 SDN 1 MULYASARI
TDK HADIR SMK MUHAMMADIYAH
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2 LANSIA
LANJUT DOSIS 2
TUNDA KOMORBID
TUNDA KOMORBID
TUNDA KOMORBID
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 DESA SINARTANJUNG
Jenis
Kelamin
1 W-46D932C6 3279025011840002 ANI HERAWATI, ST., MM P

2 Q-B277F640 3207012105850001 IMAN BUDI LAKSANA, ST L
3 W-11CDD0F3 3279031503690001 ACENG NURSOBAH, ST L
4 W-6C272B2D 3207305006690004 SRI KURNIASARI, S.IP P
5 W-8B0CC012 3207300706790004 YADI SUDRAJAT, S.IP L
6 W-FC723AE1 3279012102900001 AGUNG NUGRAHA, S.Kom L
7 W-FC1BDDE7 3273196010920002 RIZKY DYAH AYU WULANDARY, S.ST P
8 W-DAC20E63 3207205906930003 DINI HANIFAH, S.T P
9 W-3E87FD19 3275040803900023 DIAN NUR HIDAYAT, ST L
10 3204063006920002 ENJANG SAMSUDIN, ST L
11 W-1787DC80 3279024810860001 SEPTY NOVIKA ARIFIN, S.T P
12 W-DA431781 32070111812910001 AGUNG RISTIANA, S.T L
13 W-DAA59E4D 3207032002950001 FIRMAN PRAYOGA, SST L
14 W-FCBF1AE0 3279014411840002 NOVIE DIANA KARTIKASARI, S.T P
15 W-17C59C35 3301091002840002 FEBRY SULISTIANA PUTRA, S.T L
16 W-6C338D6B 3301134808860004 ERI AGUSRINI, S.T P
17 W-7120E5C1 3279010209840004 RINO HADI SUSANTO, S.T L
18 W-1701A597 3279021803780001 ADAM EKA HARTANTO L
19 W-FC4C5EF7 3207300305820002 AGUS WANDA L
20 W-DAF25C6D 3207300105770001 KASIM L
21 W-71299F69 3279030211720001 UJANG SUPRIADI L
22 W-DA8F958F 3207031303750001 HENDI HERDIMAN L
23 W-D5E87D89 3207300305820002 WAWAN KURNIAWAN L
24 Q-8DA948FC 3279012303780001 NUR ALI YASIN L
25 W-D5D65848 3207012911800004 YADI MULYADI L
26 W-DA620849 3207011903730002 SUPRIADI L
27 W-DB16DAD4 3207300706790004 ACENG KARMAT L
28 3279010507820004 RICKY RAMDHANI RISWANTO L
29 W-CE375F40 3279031801860001 SANDI GUMILAR L
30 W-91A37C58 3301141805950002 FAJAR AGUNG WICAKSONO, A.Md.T L
31 W-FCFA792F 3279020202640001 SARNO L
32 W-05D13E68 3279040210660001 NGADNAN L
33 Q-1EA877C0 3301022811870001 AGUS LASTIYONO, ST L
34 3207014304980002 CIKA FERNANDA MAHDA RAHMAT, ST P
35 Q-C2493B46 3207012903860002 ADANG KISWA, ST L
36 Q-BC310B5C 3207100601940001 DEDE SUHENDAR, ST L
37 Q-F78F620A 3279011801940001 GIFAR NUANSA MUNAZIL, ST L
38 Q-8B747573 3279014703970001 AINNUR SYIFA MARDHIYYAH, S.T P
39 Z-8F641D8C 3301090307900002 ANGGORO YOSEPH PRIHANANTYO, S.T L
40 3207176502860001 PRATIWI HUTAMI. S.T P
41 Z-E6272D30 3206200107910003 EDE SUARSA, SE L
42 Z-87BC2C9F 3279015411960004 NOVIAMILIAH, ST P
43 Q-C302AAEA 3207060906890001 FAZAR AWALUDIN, ST L
44 Q-38B4D549 3279010605760002 Surya Suprihat L
45 Q-8B38E432 3301161708740001 Agus Waluyo Susanto, SE L
46 Q-FC8472A8 3279034911760002 Ai Maemunah, SE P
47 Q-B265BFD2 3207010802830002 Hendra Munawwar L
48 Q-8AE98A03 3301155709780002 Sri Mulyanti Retno Wulan, ST P
49 Q-B284AEAE 3207301008800003 Kusmana L
50 Q-04BDABD2 3279040907780002 Agus Hendrawanto Natadiraksa L
51 3279032603820001 Lalan L
52 330115270479001 Fredy Inta Herian, ST L
53 Q-FD2640F0 3279041802840001 Lukipan L
54 3279021101860003 Yudi Haryanto, S.IP L
55 Q-175AC003 3279041607830001 Mumu Muflihin L
56 Q-3785B246 327902250482002 Andri Nugroho, ST L
57 Q-185312D7 3279040702800002 Wahid Priantoro, ST L
58 Q-2AE007B2 3279011308800006 Enceng Hendri, ST L
59 Q-72D34552 3279021801780005 Rubi Paryandi, ST L
60 Q-FC08C11C 3279022310780003 Syarif Mubaroq L
61 3207010406750002 R. Moch Sulaeman L
62 Q-8AC7063C 3301155009850002 Indriyawati P
63 Q-8B16497E 3301160302710001 Opi Sopian, A.Md L
64 3279041308850001 Herdiyana, S.IP L
65 Q-38884705 3207306201880001 Yuyu Sri Rahayu P
66 Q-ED2C02E8 3279021605870002 Andri Awan L
67 Q-B4D84538 3279035602840001 Hepiani, ST P
68 Q-8DFE3071 3279041911850001 Nopikal Adif, ST P
69 3279022601810001 Evi Budianto, SE L
70 Q-389C5AA0 3207306305850001 Rini Sukmawati, SE P
71 Q-6F4C4851 3279032606930001 Suryana, S. IP L
72 Q-6F420E08 3279031303020001 SANDI DWI WISNUKAWIRIAN L
73 Z-4F7F9A1C 3172021204840009 Budi Raharjo L
FORMAT PENCATAT
TINGKAT PUSK
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)

TNI AL
Alamat
Dsn Randegan I rt.7 rw.3 Desa Raharja Kecamatan Purwaharja Kota Banjar
Dsn.Siluman RT 27/13 Purwaharja Banjar
Dsn Sengkong rt.1 rw.5 Ds. Wangunjaya Kec. Cisaga Kab. Ciamis
rt.004 rw.006 Kel.Babakan Ciamis Kec. Sumur Bandung
Nagrak RT/RW 006/003 Kel.Karangsari Kec.Padaherang
Sukarukun Rt 005 Rw 001 Sukatani Kab.Bekasi Jabar
Jl.Rumah sakit No.23 RT 01 Rw 18 Ciamis
Jl.Ciptomangunkusomo No.545 Kel.Ciamis Kec.Ciamis
Vila Selaras Kampus No.2 Jl.Arya Janggala RT/RW 003/004
Lingk.Banjarkolot RT/RW 004/012 Kel.banjar Kec.Banjar
KP.Karangiuh RT?RW 002/005 Ke.Rajamandala Kec.Rajapolah
Cileumeuh RT/RW 003/001 Kel.Rejodadi Kec.Cimanggu
Lingk Banjarkolot RT/RW 004/012 Kel.Banjar Kec.Banjar
Dsn Cikabuyutan Timur rt.4 rw.11 Ds. Hegarsari Kec. Pataruman Kota Banjar
Dsn Cibeka rt.37 rw.8 Ds. Karangkamulyan Kecamatan Cijeungjing Kab. Ciamis
Dsn.Sukaraja RT/RW 04/09 DS.Linggasari
Lingk. Kalapajajar rt.4 rw17 Ds.Ciamis Kec. Ciamis Kab. Ciamis
Dsn Cibentang rt.20 rw.8 Ds. Mekarharja Kec. Purwaharja Kota Banjar
Gg.Arjuna No.12 RT/RW 002/004 Kel. Cilopadang Kec.Majenang
Lingk. Pataruman rt.3 rw.12 Kel. Pataruman Kec. Pataruman Kota Banjar
Lingk. Bojongsari rt.1 rw.3 Kel. Bojongkantong Kec. Langensari Kota Banjar
Jl.Merpati No.07 02/02 Slarang Kesugihan Cilacap
Jl.Jend Sudirman 180 03/11 Sindangrasa Ciamis
Dusun Panyingkiran 04/01 Ciamis
Perum Baiturrohman Blok I 15 Dusun Ciwalung Baregbeg Ciamis
Lingk Cikabuyutan Timur 05/12 Hegarsari Pataruman
Dusun Cibeureum 04/02 Balokang Banjar
Dusun Kawunganten 02/02 Cilacap
Kp.Sindangsentra 19/04 Cisarua Cineam
Lingk Pintusinga 04/17 Banjar
Dusun Desa Cijulang 01/01 Cihaurbeuti Ciamis
Lingk. Pintusinga RT 01/19
Dsn siluman RT 25/12
Cisaar RT 09/03
Pakembaran RT 02/04
Sukamenak RT 10/11
Dsn.Purwodadi RT 13/04
Haurmukti Rt 02/01
Pakembaran Rt 02/04
Waringinsari Rt 08/06
Sukanagara RT 01/01
Dsn. Babakansari
Dsn. Sindanggalih
dsn. Pananjung Barat Rt 003/001
Lingk.Babakansari RT 008/011
Babakan 004/014
Lingk.Bojongsari
Dsn.Sukajaya
Linhk.Bojongsari RT 04/03
LINGK. SILUMAN RT 27 RW 13, PURWAHARJA
Pananjung Timur 30/07, Sinartanjung

kolom yang sesuai)
Nama/Jenis/Merek
Vaksin***
BPJS Non Non
BPJS PBI
PBI Anggota
085223860690 4/5/2021 VACCINE COVID-19

85223169006 4/5/2021 VACCINE COVID-19
82126629091 4/5/2021 VACCINE COVID-19
85314200791 4/5/2021 VACCINE COVID-19
85624391514 4/5/2021 VACCINE COVID-19
85323011121 4/5/2021 VACCINE COVID-19
8112092192 4/5/2021 VACCINE COVID-19
82126941281 4/5/2021 VACCINE COVID-19
8561550282 4/5/2021 VACCINE COVID-19
82120037882
82118425769 4/5/2021 VACCINE COVID-19
81214605022 4/5/2021 VACCINE COVID-19
82214020999 4/5/2021 VACCINE COVID-19
81323030264 4/5/2021 VACCINE COVID-19
81333878567 4/5/2021 VACCINE COVID-19
85712677288 4/5/2021 VACCINE COVID-19
85353018900 4/5/2021 VACCINE COVID-19
85323779077 4/5/2021 VACCINE COVID-19
82240224689 4/5/2021 VACCINE COVID-19
82116942119 4/5/2021 VACCINE COVID-19
85281111890 4/5/2021 VACCINE COVID-19
895333863361 4/5/2021 VACCINE COVID-19
85223564833 4/5/2021 VACCINE COVID-19
81321565052 4/5/2021 VACCINE COVID-19
82116416455 4/5/2021 VACCINE COVID-19
85223202616 4/5/2021 VACCINE COVID-19
85222907081 4/5/2021 VACCINE COVID-19
81222370560
81112701986 4/5/2021 VACCINE COVID-19
85726376763 4/5/2021 VACCINE COVID-19
85814622483 4/5/2021 VACCINE COVID-19
82318580832 4/5/2021 VACCINE COVID-19
85726547394 4/5/2021 VACCINE COVID-19
85723568593
82119149009 4/5/2021 VACCINE COVID-19
85318902094 4/5/2021 VACCINE COVID-19
85315720170 4/5/2021 VACCINE COVID-19
81313066517 4/5/2021 VACCINE COVID-19
85293539889 4/5/2021 VACCINE COVID-19
81223024025
85223935526 4/5/2021 VACCINE COVID-19
85353877455 4/5/2021 VACCINE COVID-19
82218848128 4/5/2021 VACCINE COVID-19
85317572442 4/5/2021 VACCINE COVID-19
87826225577 4/5/2021 VACCINE COVID-19
85352279475 4/5/2021 VACCINE COVID-19
85220482898 4/5/2021 VACCINE COVID-19
85227006317 4/5/2021 VACCINE COVID-19
85223476311 4/5/2021 VACCINE COVID-19
85756574637 4/5/2021 VACCINE COVID-19
85223202606
85223249090
81323759220 4/5/2021 VACCINE COVID-19
85322652200
85353953981 4/5/2021 VACCINE COVID-19
83130638777 4/5/2021 VACCINE COVID-19
81310180622 4/5/2021 VACCINE COVID-19
82321191191 4/5/2021 VACCINE COVID-19
81395242772 4/5/2021 VACCINE COVID-19
83827263427 4/5/2021 VACCINE COVID-19
81215067216
85228770013 4/5/2021 VACCINE COVID-19
82120846200 4/5/2021 VACCINE COVID-19
85223366868
85294253750 4/5/2021 VACCINE COVID-19
85320052600 4/5/2021 VACCINE COVID-19
85322448800 4/5/2021 VACCINE COVID-19
82320787000 4/5/2021 VACCINE COVID-19
85223691212
81323916585 4/5/2021 VACCINE COVID-19
85223531967 4/5/2021 VACCINE COVID-19
82126629191 4/5/2021 VACCINE COVID-19
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Vaksinasi Vaksinasi
4/5/2021 24001721 SELESAI

4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
TDK HADIR
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
TDK HADIR
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
HAMIL
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
SAKIT TDK HADIR
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
TDK HADIR
TDK HADIR
4/5/2021 24001721 SELESAI
TDK HADIR
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
TDK HADIR
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
TDK HADIR
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
TDK HADIR
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
4/5/2021 24001721 SELESAI
NAMA INSTANSI
DINAS PU
TNI AL
No No. Tiket NIK Nama Penerima Vaksin Jenis Kelamin
1 Q-4C8970AC 3279021806840002 Roni Suryana, ST Laki-Laki

2 Q-4122C003 3207020506860002 Edis Sugianto Laki-Laki
3 Q-C68AA5B6 3279022910840003 Devi Lastiana Laki-Laki
4 Q-9242574A 3279041911880001 Adi Herwanto Laki-Laki
5 Q-CEB846E5 3207016010880002 Restu Mulyanisari, SE Perempuan
6 Q-9B21E096 3279032203890002 Ade Irawan Laki-Laki
7 Q-9636D68A 3277031211880003 Ari Saeful Laki-Laki
8 Q-B992A77E 3279026103900003 Ai Rika Rohimah Perempuan
9 3279011604880002 Mumung Laki-Laki
10 Q-21C9D58A 3279012509840002 Sevi Saphadi Laki-Laki
11 Q-8858C3A1 3279014407820001 Rini Andriyani, ST Perempuan
12 Q-9F7D11F3 3207161005810001 Alan Wahyudi Laki-Laki
13 Q-B4DA20CF 3207282512850001 Deden Heryanto, SE Laki-Laki
14 Q-4E8F6084 3207302504880001 Bubun Rusmana Laki-Laki
15 Q-87D97BA7 3207302109760001 Ujang Endi Supendi Laki-Laki
16 3207142909910001 Hendar Kurniawan Laki-Laki
17 3279030706910001 Nursoleh, ST Laki-Laki
18 Q-24C3C0D5 3207036604890001 Nina Herlina A.Md Perempuan
19 Q-0686996D 3279011105910001 Wahyu Firmansyah Laki-Laki
20 Q-379C1D3D 3207151503780003 Iwan Ruswandi, ST Laki-Laki
21 Q-38950E4F 3279020909910004 Riki Rianto Laki-Laki
22 Q-68DC112F 3279031401890001 Tedi Laki-Laki
23 Q-868860AA 3279035904920001 Ani Apriani Perempuan
24 Q-E89F6036 3279026405920002 Alvi Meilani, S.IP Perempuan
25 Q-12FD2940 3279014410910001 Novita Nur Octaviani, S.IP Perempuan
26 Q-495410F4 3279040205860002 Elan Ramlan Laki-Laki
27 Q-C02B1546 3279045905840001 Titin Nurlina, SE P
28 Q-DD88F341 3279012808930002 Alfi Ilham Maulidin Laki-Laki
29 Q-82D1B4A5 3275032701860009 Yayan Sofyan Laki-Laki
30 Q-50F14362 3207190405870001 Dian Ramdhani Nugraha, SE Laki-Laki
31 Q-0C54069F 3279014404960002 Nia Herlina Perempuan
32 Q-6AA909D0 3279021503960003 Irfana Jamaludin, S.Kom Laki-Laki
33 Q-AB8C275E 3206220107810029 Dede Juandi Laki-Laki
34 Q-B229FB89 3279034711970001 Sofiatun Janah, SM Perempuan
35 Q-2D95A694 3207301309900001 Rizal Fahrizal Ma'mur Laki-Laki
36 Q-51136FDF 3301141804890004 Yatin Nursodiq Laki-Laki
37 3279032605980001 Akbar Fajar Pratama Laki-Laki
38 Q-63BEB500 3279020809860001 Adi Indra Laki-Laki
39 3301192012980002 Dendy Syiantoro Subekti Laki-Laki
40 3279042312860001 Dian Herdiana Laki-Laki
41 Q-78A35519 3207016312890002 DESY SUMANTI, ST P
42 3207011503930002 Wildan Wiraputra, ST Laki-Laki
43 3207312909770001 Heli Heliansah Laki-Laki
44 Q-65B97EFC 3279042005780001 Suwarno Laki-Laki
45 Q-C4810434 3207302110870001 Cucu Okta Triana Laki-Laki
46 Q-F55158E3 3279010812860001 Entis Sutisna, S.IP Laki-Laki
47 Q-F329A6F1 3207030606850003 Dani Iskandar Laki-Laki
48 Q-9ACD602C 3279020909780007 Akbar Maulana Laki-Laki
49 Q-03DD8B50 3279032804710001 Rohartono Laki-Laki
50 3207150211970002 Tedi Noviansah Laki-Laki
51 Z-9997AA68 3279010705850003 Ifan Ruchyana, S.IP Laki-Laki
52 Q-713206A8 3279044109010001 Ajeng Septi Dinanti Perempuan
53 Q-F21FD3BB 3279046808970002 Ragil Tria Agustin,S.IP Perempuan
54 Q-58319CA7 3279025408960001 Ina Karlina, SM Perempuan
55 3207030801650001 ASEP ROHANDI L
56 Q-734AD1F2 3207043110850002 Kiki Hamdani L
57 Q-1E4DCF49 3279022010970003 TRI MULYANA L
58 Q-AAF69FA6 3279010202850001 Asep Tata Herdiana L
59 Q-8D46C673 3207302311860001 Karis Sumandri L
60 Q-31239FBB 3279020608850004 Bayu Putra Agriyandi L
61 W-7B5D5534 3279020308830001 TURIMAN L
62 W-A057AB40 3279011503810001 WALUYO, A.Md L
63 3207301401870001 Handris Januar, S.IP L
64 3207171609730002 Sopino Priyatno L
65 3279011807770001 DEDE NURMANSYAH L
66 W-5F8B4A52 3279010507820004 RICKY RAMDHANI RISWANTO L
67 Q-6030EA9D 3279032603820001 Lalan L
68 Q-2DB9EDB1 3301152704790001 Fredy Inta Herian, ST L
69 W-2F8C8069 3204063006920002 ENJANG SAMSUDIN, ST L
70 Q-FBD006E8 3279021101860003 Yudi Haryanto, S.IP L
71 Q-FCC10802 3279041308850001 Herdiyana, S.IP L
72 Q-3B4DF3C2 3279022601810001 Evi Budianto, SE L
73 W-FCE2926A 3279014706940002 NADYA ITSNAINI, S.T P
74 Q-FC3ADE84 3279025605670001 NANI SUMARNI P
75 Q-F0E2CDD7 3279026211990003 NINA SUMIATI P
76 Q-C0800EF5 3279022004910002 ALFIAN ARIESTA L
77 Q-5F510E96 3279025411930001 NURHAYATI P
78 Q-77E7C229 3279021301820002 Hendri Gunawan L
79 3279043008820002 Asifudin L
80 3279042811930004 SAHRIR ALI MUSTOPA L
FORMAT PENCATATA
TINGKAT PUSKE
DOSIS 1
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)

PEGAWAI PEMERINTAH 0
TRAVEL 54 46-59
TRAVEL 22 18-30
TRAVEL 30 18-30
TRAVEL 28 18-30
GURU 39 31-45
GURU 38 31-45
GURU 28 18-30
DOSIS 1
Alamat
Cilewer Rt 01/01
Dsn.Margaluyu Rt 002/007
Dsn.Sindanggalih RT 008/005
Jln. Ottista Rt 02/01
Cibentang Rt 16/07
Lingk.Sukarame RT 004/014
Dsn Linggaharja RT 005/002
Dsn.Cibeureum RT 05/02
Mekarmulya Rt 09/04
Sukamenak Rt 05/10
Salegok Rt 39/09
Dsn.Citutut
Lingk.Banjarkolot RT 004/015
Dsn.Tarikolot RT 001/008
Lingk.Tanjungsukur RT 003/014
Lingk.Silumanbaru Rt 39/18
Dsn.Balokang RT 44/14
Dsn.Kalapasabrang
Dsn.Sidamukti 03/06
Karangpucung Rt 13/03
Cikabuyutan Timur RT04/011
Dsn.Pamarican RT 005/002
Lingk.Jelat RT 04/01
Kp Golonggong Rt 09/03
Dsn.Randegan RT 6/03
Dsn.Ciawi RT 002/002
Lingk.Lemburbalong RT 001/006
Kalenanyar Rt 03/11
Bantardawa Rt 05/02
Lingk.Sindanggalih RT 008/005
Dsn.Sukamenak
Sukarame 006/012
Lingjk.Sukarame RT 001/014
Cikabuyutan Timur

Dsn.Randegan II RT/RW 7/3 Desa Raharja Kec.Purwaharja
Sindanggalih RT 08/05 Rejasari
Desa Waringinsari RT/RW 03/05 Kec.Langensari
Dsn.Pananjung RT/RW 021/005 Desa Sinartanjung Kec.Pataruman
RT 01 RW 03
Cipariuk
Randegan 1 Rt 11/04
Haurmukti Rt 02/01
Pakembaran Rt 02/04
Lingk.Bojongsari
Lingk.Parunglesang RT/RW 003/009 Kel.Banjar Kec.Banjar
: lingk. sukamanah 1/18, PATARUMAN
DSN PANANJUNG RT 023 RW 005 DUSUN PANANJUNG RW 005
CIJUREY

Dosis I
kolom yang sesuai)
Nama/Jenis/Merek
Vaksin***
BPJS PBI
85314857097 4/6/2021 VACCINE COVID-19

81220507240 4/6/2021 VACCINE COVID-19
85320957828 4/6/2021 VACCINE COVID-19
85318838338 4/6/2021 VACCINE COVID-19
82119119220 4/6/2021 VACCINE COVID-19
82319179414 4/6/2021 VACCINE COVID-19
85283912426 4/6/2021 VACCINE COVID-19
85320998999
82130482078 4/6/2021 VACCINE COVID-19
85314813539 4/6/2021 VACCINE COVID-19
85861908766 4/6/2021 VACCINE COVID-19
85222578808 4/6/2021 VACCINE COVID-19
85318570934 4/6/2021 VACCINE COVID-19
82393082900 4/6/2021 VACCINE COVID-19
85212316460
85223305099
85323433026 4/6/2021 VACCINE COVID-19
82262028886 4/6/2021 VACCINE COVID-19
85294476732 4/6/2021 VACCINE COVID-19
82216644617 4/6/2021 VACCINE COVID-19
81322924462 4/6/2021 VACCINE COVID-19
859111423415 4/6/2021 VACCINE COVID-19
89698577172 4/6/2021 VACCINE COVID-19
85317217111 4/6/2021 VACCINE COVID-19
89662413376 4/6/2021 VACCINE COVID-19
8122083741 4/6/2021 VACCINE COVID-19
81320621139 4/6/2021 VACCINE COVID-19
88910696589 4/6/2021 VACCINE COVID-19
82240052847 4/6/2021 VACCINE COVID-19
81313246320 4/6/2021 VACCINE COVID-19
87848274443 4/6/2021 VACCINE COVID-19
85717885551 4/6/2021 VACCINE COVID-19
83827428630 4/6/2021 VACCINE COVID-19
82315837520
85318318103 4/6/2021 VACCINE COVID-19
87708307448
82113577414
85322422005 4/6/2021 VACCINE COVID-19
87898704296

82321045670 4/6/2021 VACCINE COVID-19
82118609088 4/6/2021 VACCINE COVID-19
82310819012 4/6/2021 VACCINE COVID-19

89664745626 4/6/2021 VACCINE COVID-19
82315850426 4/6/2021 VACCINE COVID-19
81323092085
812108817 4/6/2021 VACCINE COVID-19
81283150171 4/6/2021 VACCINE COVID-19
82376453428 4/6/2021 VACCINE COVID-19
85222870876 4/6/2021 VACCINE COVID-19
87828166747 4/6/2021 VACCINE COVID-19
82320472783 4/6/2021 VACCINE COVID-19
81323995858 4/6/2021 VACCINE COVID-19
82214782272
81323223468
82319753599
81222370560 4/6/2021 VACCINE COVID-19
85223202606 4/6/2021 VACCINE COVID-19
85223249090 4/6/2021 VACCINE COVID-19
82120037882 4/6/2021 VACCINE COVID-19
85322652200 4/6/2021 VACCINE COVID-19
85223366868 4/6/2021 VACCINE COVID-19
85223691212 4/6/2021 VACCINE COVID-19
81313598878 4/6/2021 VACCINE COVID-19
82118737383 4/6/2021 VACCINE COVID-19
83116907763 4/6/2021 VACCINE COVID-19
82219042858 4/6/2021 VACCINE COVID-19
81312317977 4/6/2021 VACCINE COVID-19
082123386810 4/6/2021 VACCINE COVID-19
081320288585
89662636272
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Vaksinasi
4/6/2021 24001021 SELESAI

4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
SAKIT
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
TDK HADIR
TDK HADIR
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
TDK HADIR
4/6/2021 24001021 SELESAI
TDK HADIR
TDK HADIR
4/6/2021 24001021 SELESAI
TDK HADIR
TDK HADIR
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
TDK HADIR
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
TDK HADIR
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
TDK HADIR
TDK HADIR
TDK HADIR
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
4/6/2021 24001021 SELESAI
TDK HADIR
TDK HADIR
NAMA INSTANSI
DINAS PU
TRAVEL CITRA
TRAVEL CITRA
SDN 3 PATARUMAN
SMK AL-AZHAR
SMK MUHAMMADIYAH
Jenis
Kelamin
1 3279011604880002 Mumung L
2 Q-5D2A90F4 3207142909910001 Hendar Kurniawan L
3 3279030706910001 Nursoleh, ST L
4 Q-F7A783AC 3279032605980001 Akbar Fajar Pratama L
5 Q-01E5ED20 3301192012980002 Dendy Syiantoro Subekti L
6 3279042312860001 Dian Herdiana L
7 Q-4F9F0C34 3207011503930002 Wildan Wiraputra, ST L
8 3207312909770001 Heli Heliansah L
9 Q-F32F7ED8 3207150211970002 Tedi Noviansah L
10 W-D7B9A13D 3207030801650001 ASEP ROHANDI L
12 Q-BFA9210E 3207171609730002 Sopino Priyatno L
13 W-AA949640 3279011807770001 DEDE NURMANSYAH L
14 Q-3154A398 3279021806860001 Uud Juarsa, SE L
15 Q-B255E0D1 3207010406750002 R. Moch Sulaeman L
16 W-201BF672 3207176502860001 PRATIWI HUTAMI. S.T P
1 Z-36CCE7D4 3279020403770002 HARUN AL RAYSID L
2 Z-A3479554 3279025605840002 WIWI WININGSIH P
3 3279041005880002 MUNTAZIM L
4 Z-A3709A7A 3279026603880002 YANTI SUPRIATIN P
5 Z-98161D7F 3279044701840001 Haniyati, S.Pd.I P
6 Z-BE4BF83F 3207192196900001 Abdul Mukhlisin, S.Pd.I L
7 3279014203900002 Ade Ratih P
8 Z-368A75AB 3279021810760001 Asep Deni, S.Pd.I,M.Pd. L
9 Z-389FC88E 3279022706950001 Syarif Munawar, S.Pd. L
10 Z-986270C9 3279045204950003 Siti Robingah,S.Pd.I P
11 Z-37025A7D 3279020501680001 Jujun Junaedi, S.Pd.I L
12 Q-6155F8F7 3279024709960001 Dara Mulya Santi, S.Pd. P
13 Z-38EB2E46 3279024903740001 Ani Anidah P
14 W-770D0E17 327901550660001 SUKAESIH, S.Pd P
15 W-F5A26FD1 3279026712650001 NUNUNG SURYANI P
16 W-C560EF50 3279011208700001 A. FAOZAN L
17 Q-39BB21C1 3279024605760000 NENI SUMARNI, S.Pd. P
18 Z-35E73B83 3279660266117902 RIKA RAHMAWATI, S.Pd. P
19 W-CD68590A 3279027105730001 NENI KUSMAWATI, S.Pd P
20 W-CC0F184F 3279036506890001 WINDA TRISWAHYUNI, S.Pd P
21 W-F606D2C3 3279025408650001 WATI HERAWATI, S.Pd P
22 W-09A03CF9 3207172505800003 AYATULLAH,S.Pd L
23 W-C4CDF03B 3205060706900006 SUGANDI, S.Pd L
24 W-86245752 3301184803860004 YULIARNI, S.Pd P
25 Q-1658D781 3207285408920001 SITI MARYATI HOBARIAH, S.Pd P
26 Z-9BBA00CF 3279010808790001 RISMAYADI,S.Pd L
27 Q-3605A400 3279025909760001 ANA SETIANA,S.Pd P
28 W-73A153F4 3279025108780003 DIAN RATNAYUWANGSIH P
29 W-99579AB9 3279024304610001 ENI HAPIDOH P
30 W-9964E9EB 3279024802640001 UKAMAH P
31 W-FFB50FE3 3279024310700001 NANI NURYANI P
32 S-5CC42120 3279034209830002 WIRDA HASTIKA P
33 W-C4AE114B 3211146608890006 TRI SUSILAWATI P
34 W-865936CF 3301185603870005 MIFTAHUL JANAH P
35 Q-10202C5F 3207185209880004 IRMA NOORMAHAENI P
36 Z-B6BB7696 3301131809890005 ARIF HIDAYAT L
37 Q-6B28A06A 3279036807720002 YELIS SUMIATI P
38 Z-7A0A25AD 3279022712830001 DENI KURNIA L
39 Q-1BA6EF1C 3279014405890001 BINA RAINA ANJANI P
40 Z-F8FC05D9 3279043008820002 Asifudin L
41 Q-A07ABA60 3279042811930004 SAHRIR ALI MUSTOPA L
58 S-056A6F2F 6310092102580001 MUHAMMAD SYA'I L
59 P-QV9P2UTK 6310095705630002 ENUNG HAYATI P
60 P-QVF6BJ0W 6310091803970004 RIZKY NURUL HAQIQI P
FO
Umur
Kelompok
Pekerjaan* (18-59 Umur
tahun)

GURU 43 31-45
GURU 36 31-45
GURU 32 31-45
GURU 32 31-45
GURU 37 31-45
GURU 31 18-30
GURU 30 31-45
GURU 45 18-30
GURU 26 18-30
GURU 26 18-30
GURU 53 46-59
GURU 25 18-30
GURU 47 46-59
GURU 55 46-59
GURU 56 46-59
GURU 51 46-59
GURU 45 31-45
GURU 42 31-45
GURU 48 46-59
GURU 32 31-45
GURU 56 46-59
GURU 41 31-45
GURU 31 31-45
GURU 35 31-45
GURU 28 18-30
GURU 42 31-45
GURU 45 31-45
GURU 43 31-45
GURU 59 46-59
GURU 57 46-59
GURU 50 46-59
GURU 37 31-45
GURU 31 31-45
GURU 33 31-45
GURU 32 31-45
GURU 31 31-45
GURU 48 46-59
GURU 38 31-45
GURU 31 31-45
GURU 38 31-45
GURU 28 18-30
CJH 63 >60
CJH 56 46-59
CJH 24 18-30
FORMAT PENCATATAN PELAKSANAAN VAKSINA
TINGKAT PUSKESMAS/FASYANKES/POS VA
DOSIS 1
Alamat
Salegok Rt 39/09
Kalenanyar Rt 03/11
Bantardawa Rt 05/02
Randegan 1 Rt 11/04
Lingk.Cikabuyutan Timur 002/013
DSN SUKAMAJU RT 009/005 DS MULYASARI-PATARUMAN
LING MARGASARI RT 005/006 DS BOJONGKANTONG-LANGENSARI
LING BAKANSARI RT 001/010 KEL/KEC PATARUMAN
Ling. Margasari RT 0002 RW 005 Bojongkatong
Dsn Kertajaga RT 008 RT 003 Desa Sukajaya
BANJAR
Lingk. Jelat RT.02 RW.03 Kel.Kec Pataruman
Dusun Kalapasabrang RT.04 RW.08 Kel.Kec Kujangsari Langensari
Cimenyan II Rt. 5 Rw. 8
Perum Dpbo Blok N7
Cikabuyutan Barat Rt 03 rw 09
Ling. Jadimulya Rt 03 rw 05
Lingk. Tanjung sukur rt 04 rw 14
Asrama Yonif 323 Rt. 29 Rw. 14
Lemburbalong Rt. 03 Rw. 08
LAKBOK
KP.BABAKANWETAN GARUT
JL. MT.HARYONO CILACAP
LINGK. PATARUMAN
LINGK. CIMENYAN
LINGK. PATARUMAN
LINGK. PATARUMAN RT 03 RW 12 KELURAHAN PATARUMAN KECAMATAN PATARUMAN KOTA BANJAR
DUSUN TANJUNGSUKUR RT.04/RW.17 DESA HEGARSARI KEC.PATARUMAN KOTA BANJAR
DUSUN CIBENTANG RT.017/RW.007 DESA MEKARHARJA KEC. PURWAHARJA KOTA BANJAR
JL.KIHAJAR DEWANTORO NO.17 RT.003 RW.006 DESA KUTASARI KEC.CIPARI KAB. CILACAP
PERUM GRIYA ASRI DUSUN PANANJUNG BARAT DESA SINARTANJUNG KEC.PATARUMAN KOTA BANJAR
DUSUN CIKONDANG RT.003 RW.001 DESA PANIMBANG KEC.CIMANGGU KAB CILACAP
LING.PATARUMAN RT.001 RW.014 DESA PATARUMAN KEC.PATARUMAN KOTA BANJAR
DUSUN RANCAKOLE RT.010 RW.002 DESA MULYASARI KEC.PATARUMAN KOTA BANJAR
DUSUN GARDU RT.016 RW.006 DESA BALOKANG KEC.BANJAR KOTA BANJAR
CIJUREY
SUNGEI KECIL NO. 53
SUNGEI KECIL NO. 53
SUNGEI KECIL NO. 53
AKSINASI COVID-19
POS VAKSINASI

kolom yang sesuai)
Tanggal
No. Hp Screening
Nama/Jenis/Merek Vaksin***
BPJS Non Non
BPJS PBI
PBI Anggota
85320998999
85212316460 4/7/2021 VACCINE COVID-19
85223305099
82315837520 4/7/2021 VACCINE COVID-19
87708307448 4/7/2021 VACCINE COVID-19
82113577414
87898704296 4/7/2021 VACCINE COVID-19

81323092085 4/7/2021 VACCINE COVID-19
82214782272
81323223468 4/7/2021 VACCINE COVID-19
82319753599 4/7/2021 VACCINE COVID-19
89662012892 4/7/2021 VACCINE COVID-19
81215067216 4/7/2021 VACCINE COVID-19
81223024025 4/7/2021 VACCINE COVID-19
085223906108 4/7/2021 VACCINE COVID-19
089644111487 4/7/2021 VACCINE COVID-19
081573453884
08990760891 4/7/2021 VACCINE COVID-19
081323654278 4/7/2021 VACCINE COVID-19
088223405038 4/7/2021 VACCINE COVID-19
081323314329 4/7/2021 VACCINE COVID-19

089652887553 4/7/2021 VACCINE COVID-19
085223694359 4/7/2021 VACCINE COVID-19
085223925168 4/7/2021 VACCINE COVID-19
08990758894 4/7/2021 VACCINE COVID-19
81910722482 4/7/2021 VACCINE COVID-19
085223807415 4/7/2021 VACCINE COVID-19
081323533433 4/7/2021 VACCINE COVID-19
082240060136 4/7/2021 VACCINE COVID-19
08985781700 4/7/2021 VACCINE COVID-19
085320945658 4/7/2021 VACCINE COVID-19
081214344633 4/7/2021 VACCINE COVID-19
08528766268 4/7/2021 VACCINE COVID-19
085324553430 4/7/2021 VACCINE COVID-19
081395201515 4/7/2021 VACCINE COVID-19
085974597450 4/7/2021 VACCINE COVID-19
082137460175 4/7/2021 VACCINE COVID-19
082130437230 4/7/2021 VACCINE COVID-19
085324825450 4/7/2021 VACCINE COVID-19
082315322843 4/7/2021 VACCINE COVID-19
8522317728 4/7/2021 VACCINE COVID-19
085223511909 4/7/2021 VACCINE COVID-19
0895370467676 4/7/2021 VACCINE COVID-19
081322322141 4/7/2021 VACCINE COVID-19
082127320983 4/7/2021 VACCINE COVID-19
089638708933 4/7/2021 VACCINE COVID-19
081327594781 4/7/2021 VACCINE COVID-19
08216917779 4/7/2021 VACCINE COVID-19
085643668173 4/7/2021 VACCINE COVID-19
089502532420 4/7/2021 VACCINE COVID-19
085223157587 4/7/2021 VACCINE COVID-19
085220219697 4/7/2021 VACCINE COVID-19
081320288585 4/7/2021 VACCINE COVID-19
89662636272 4/7/2021 VACCINE COVID-19
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Vaksinasi Vaksinasi
SAKIT
4/7/2021 24001021 SELESAI
TDK HADIR
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
TDK HADIR
4/7/2021 24001021 SELESAI
TDK HADIR
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
TDK HADIR
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
TDK HADIR
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
SAKIT
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 LANJUT DOSIS 2
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 SELESAI
4/7/2021 24001021 LANJUT DOSIS 2
4/7/2021 24001021 LANJUT DOSIS 2
4/7/2021 24001021 LANJUT DOSIS 2
NAMA INSTANSI
DINAS PU
MI PANATASAN
MI RANCAKOLE
SMP PATROMAN
MI JELAT
SDN 1 PATARUMAN
SDN 4 PATARUMAN
TK TUNAS BAKTI
SDN SINARTANJUNG
SMK AL-AZHAR
SMK MUHAMMADIYAH
CJH
Jenis
Kelamin
1 W-CBEE0203 3279035403800001 IRMAWATI, S.PD. P

2 W-76B3353C 3279016606700001 RUMIAH, S.PD. P
3 Z-A12DCD7D 3273025511830008 WINA SAPRIANA, S.Pd. P
4 W-C508C8C3 3207182408880002 RAHMATULLOH, S.Pd L
5 Q-79CD4010 3279020607710005 ANDANG L
6 W-C576E2B6 3279015402880001 NOERIDA MALIANTI, S.Pd.I P
7 Q-78FE3AEC 3279016503920002 LINDA MEGA APRILDA, S.Pd P
8 Z-99CABBB1 3279041408880004 Agus Sukmana L
9 Z-2F784FA1 3301123003870003 Angkat Subagyo L
10 Q-9A05A12B 3301154206780002 Ati Maria P
11 Q-9A43D3D7 3305052102930001 Barkah Al Amin L
12 W-D8A075F5 3207356505000001 Daryati P
13 Q-98D53179 3279015103860001 Dian Setyoningrum P
14 3279046907680001 Linatu Sofiyah P
15 W-8276F7DF 3207122905900002 Asep Kurnia L
16 Z-9957310D 3279025908860002 Risnawati Agustien P
17 W-82D494FA 3279024704640001 Heni Hernilah P
18 Q-99A16D42 3279026810830001 Iis Patimah P
19 W-82EBE7D4 3279025101690002 Karmanah P
20 W-828F0459 3279016406610001 Rasih P
21 W-830A7FA2 3279025207700001 Siti Khodijah P
22 W-D4547D1E 3279020804690001 USUP. S.Pd. L
23 W-D8A075F5 3207125304870001 MIRA YANI, S.Pd. L
24 Q-2F5CF28C 3279024502710001 IKAH ATIKAH, S.Pd. P
25 Z-1E2CD45D 3279024705920001 Arin Aryati P
26 Z-1E3B200F 3279045203760001 Dewi Rismayanti P
27 W-82C26B17 3279021207610002 NUR DARISMAN,S.Pd L
28 3279044905680002 Epi Sopiati P
29 Q-7359C79C 3207192006690001 Ajat Sudrajat L
30 W-9D90B8DF 3279014811670001 Siti Nurhayati Hotijah P
31 W-D526B1F1 3279045312710001 Nurhayati Rahayu P
32 W-A2C0F1E1 3310160701820001 Dadang Susilo L
33 Q-317081EE 3207185411940002 Isnarabani P
34 Q-C53FE02C 320 7112402940001 Eris Permana L
35 W-444F63E2 3206300502800001 Adang L
36 Q-CDBB3CD6 3207161506750001 Carsan L
37 W-9717FF41 3205191109990003 Yusril Hadi Sopyan L
38 W-1B364866 3207235412840001 Imas Cunayah P
39 3207195511680002 Dede Hernawati P
40 Z-95659260 3279025005720003 Oyoh. R P
41 3279026003740002 Emay Suryamah P
42 P-MDXEXINQ 3279025601680002 SUNITA P
43 3279021306740002 DEDE SAIDIN L
44 3207304301930003 Kinanti Laras Asih P
FORMAT PENC
TINGKAT P
Umur
Kelompok
tahun)
GURU 40 31-45
GURU 50 46-59
GURU 37 31-45
GURU 32 31-45
GURU 49 46-59
GURU 33 31-45
GURU 28 18-30
GURU 32 31-45
GURU 33 31-45
GURU 42 31-45
GURU 27 18-30
GURU 30 18-30
GURU 34 31-45
GURU 52 46-59
GURU 30 18-30
GURU 34 31-45
GURU 56 46-59
GURU 37 31-45
GURU 52 46-59
GURU 59 46-59
GURU 50 46-59
GURU 51 46-59
GURU 33 31-45
GURU 49 46-59
GURU 29 18-30
GURU 45 31-45
GURU 59 46-59
GURU 53 46-59
GURU 52 46-59
GURU 54 46-59
GURU 50 46-59
GURU 39 31-45
GURU 27 18-30
GURU 27 18-30
GURU 41 31-45
GURU 46 46-59
GURU 22 18-30
GURU 37 31-45
GURU 53 46-59
GURU 28 18-30
FORMAT PENCATATAN PELAKSANAAN VAKSINAS
TINGKAT PUSKESMAS/FASYANKES/POS VAKS
DOSIS 2
Alamat
LINGK. SILUMAN BARU RT35 RW16 PURWAHARJA

LINGK. PARUNGLESANG RT04 RW09 KEL. PATARUMAN
LINGK. CIKABUYUTAN TIMUR RT03 RW13 KEL. HEGARSARI
JLN. HANURA NOMOR 5 RT 04 RW 07 KEL. PANGLAYUNGAN KEC. CIPEDES KOTA TASIKMALAYA
LINGK. SUKAMANAH RT03 RW18 KEL. PATARUMAN, KEC. PATARUMAN
LINGK. CIMENYAN II RT02 RW09 KEL. MEKARSARI KEC. BANJAR
LINGK. CIMENYAN II RT05 RW08 KEL. MEKARSARI KEC. PATARUMAN
Jln. Mandalare / Panyingkiran RT/RW. 2/2 Desa Rejasari Kec. Langensari Kota Banjar
Padomasan RT/RW. 22/4 Desa Purwasari Kec. Banjarsari Kab. Ciamis
BANJAR WARU RT/RW. 2/2 Desa MADUSARI Kec. Wanareja Kab. Cilacap
Parto Atmojo RT/RW. 1/2 Desa Langensari Kec. Langensari Kota Banjar
Dusun Panyingkiran RT/RW. 28/13 Desa Ciharalang Kec. Cijeungjing
Dusun Kutasari, RT 11 RW 4, Desa Dayeuluhur, Kec. Jatinegara
Lingkungan Cikabuyutan Timur RT 1 RW 11, Desa Hegarsari, Kec. Pataruman
Jelat Rt/Rw: 2/2 Desa/Kel. Pataruman Kec. Pataruman Kota Banjar
Cikabuyutan Timur Rt/Rw: 6/12 Desa/Kel. Hegarsari Kec. Pataruman Kota Banjar
Gardu Rt/Rw: 6/16 Desa/Kel. Balokang Kec. Banjar Kota Banjar
Mulyasari RT. 06/05
Bayasari RT. 01/01
Mulyasari RT. 08/05
SUMANDING WETAN RT 02 RW 15, BANJAR
KP. Cilangla RT 08 RW 04, CIREUNGHAS, SUKABUMI
Dsn.Sinartanjung Rt 04 Rw 01
Lingk. Sukarame rt 05/ rw 12 Kel. Mekarsari Kec. Banjar Kota Banjar
Dsn.Sindangmulya rt02/ rw10 Kel. Kujangsari Kec. Langensari Kota Banjar
Dsn. Randegan I rt 07/ rw 03 Kel.Raharja Kec. Purwaharja Kota Banjar
Dsn. Sindangtawang rt 11/rw 03 Des. Sindanghayu Kec. Banjarsari Ciamis
Dsn Munjul rt 05/rw 015 Desa Buniseuri Kec. Cipaku Ciamis
Kp. Nanggewer rt 09/rw04 Des. Sukamulih Kec. Sariwangi Tasikmalaya
Tambaksari rt 03/ rw 01 des Tambaksari Kec Tambaksari Ciamis
Kp. Cimaragas rt 03/ rw 05 Des Ngamplangsari Kec. Ciawi Garut
LINGK. JELAT RT 03 RW 04, PATARUMAN
LINGK. JELAT RT 01 RW 02, PATARUMAN

SINDANGASIH
PELAKSANAAN VAKSINASI COVID-19
AS/FASYANKES/POS VAKSINASI
DOSIS 2

kolom yang sesuai)

BPJS Non Non
BPJS PBI
PBI Anggota
087735358485 4/8/2021 VACCINE COVID-19

089508092008 4/8/2021 VACCINE COVID-19
081318791236 4/8/2021 VACCINE COVID-19
082214519498 4/8/2021 VACCINE COVID-19
081394401153 4/8/2021 VACCINE COVID-19
085322628579 4/8/2021 VACCINE COVID-19
087767891241 4/8/2021 VACCINE COVID-19
085322650999 4/8/2021 VACCINE COVID-19
085747941095 4/8/2021 VACCINE COVID-19
081323272061 4/8/2021 VACCINE COVID-19
085232169160 4/8/2021 VACCINE COVID-19
085318839699 4/8/2021 VACCINE COVID-19
085318189899 4/8/2021 VACCINE COVID-19
081323696931
085295733309 4/8/2021 VACCINE COVID-19
085318822628 4/8/2021 VACCINE COVID-19
085220056757 4/8/2021 VACCINE COVID-19
082116955383 4/8/2021 VACCINE COVID-19
081323157970 4/8/2021 VACCINE COVID-19
082113653933 4/8/2021 VACCINE COVID-19
085294042120 4/8/2021 VACCINE COVID-19
0823 4966 3938 4/8/2021 VACCINE COVID-19
0852 2261 3636 4/8/2021 VACCINE COVID-19
0853 1465 5541 4/8/2021 VACCINE COVID-19
085321098286 4/8/2021 VACCINE COVID-19
085793292925 4/8/2021 VACCINE COVID-19
087886337506 4/8/2021 VACCINE COVID-19
81323123688
81220303807 4/8/2021 VACCINE COVID-19
085795138330 4/8/2021 VACCINE COVID-19
85223123633 4/8/2021 VACCINE COVID-19
85624475418 4/8/2021 VACCINE COVID-19
082120034113 4/8/2021 VACCINE COVID-19
081221391585 4/8/2021 VACCINE COVID-19
083826597680 4/8/2021 VACCINE COVID-19
087826909844 4/8/2021 VACCINE COVID-19
085222705752 4/8/2021 VACCINE COVID-19
085223522779
81323072834 4/8/2021 VACCINE COVID-19
81312518886
82119865400 4/8/2021 VACCINE COVID-19
082315531945
082318126405
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Vaksinasi Vaksinasi
4/8/2021 24001021 SELESAI

4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
IJIN TDK HADIR
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
SAKIT
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
4/8/2021 24001021 SELESAI
IJIN TDK HADIR
4/8/2021 24001021 SELESAI
TDK HADIR
4/8/2021 24001021 SELESAI
IJIN TDK HADIR
SAKIT
NAMA INSTANSI
SDN 2 PATARUMAN
SMK AL-AZHAR
SDN 5 PATARUMAN
SDN 3 PATARUMAN
SDN 1 MULYASARI
SMK MUHAMMADIYAH
SDN 3 MULYASARI
SLB NEGERI BANJAR

SLB NEGERI BANJAR
CJH
DESA SINARTANJUNG
SMP PATROMAN
1 Z-AEF3740F 3279020505520001 Darsono

2 Z-82351EE7 3279022807600001 Jajat Sudrajat
3 Q-1CFD4C96 3279021001610001 Odih Hadian
4 Z-655A2AB6 3279020406570004 Sujana
5 Z-B79C73CE 3279021504600004 Endang Syawa
6 3279020408560001 Tahirun
7 Z-71E1F005 3279020607590003 Ading
8 Z-7F39C3BD 3279021605410001 Ruhana
9 3279020111530001 Kardi
10 3279020727400003 Umar
11 3279021104480001 Sarko
12 P-STUYQFG5 Iswiyanto
13 P-SU3GV2FK Didin Muhyidin
14 S-1800C0B2 3279046907680001 Linatu Sofiyah
15 Q-2E3D44FC 3279026003740002 Emay Suryamah
16 Z-311A9905 3279024708680005 RATNANINGSIH
17 W-3EA3EF66 3205052402760003 SUGIARTO, S.H.
18 W-08C920FC 3207011006660004 ENDIS, S.H.
19 W-37F12798 3209201206850010 JUNIKO SIHOTANG, S.H.
20 Q-07DA70DC 3204101711650004 SAEFULLOH
21 W-60411D92 3206250407810001 KOKOK SETIO PRAKOSO YUWONO, S.E.
22 W-4E224F5E 3206221208810007 AGUS HERIANTO, S.H.
23 Q-3C5D9699 3315041812850004 DIA V RIANA SYAMSUATY, A.Md.I.P.
24 W-9C86D312 3207010810810002 SUTAN HASIBUAN, S.H.
25 W-FD3C3ED9 3207320506790002 DONNY IRAWAN
26 W-29600FC4 3279021210840002 DARWONO
27 Z-AA93B157 3273290602910001 JERY MUNAJAT
28 W-8FAC6D01 3209011510930001 DIDIN WAHYUDIN
29 Q-6C1CA6EB 3206200207980001 RIZAL SAEPUL AZIZ
30 Q-649BF04E 3302152501950003 EGI ALFIAN
31 Z-7E0DF241 3207040206970002 ANJAR JUNANDI
32 Z-6E69FF2A 3374132509970004 SEFTIAN GALIH ADHI PRATAMA
33 Z-0318EE5B 3279022606970001 KRISTIO WAHYUDI
34 Q-0DF9E4DF 3207220308010001 DONY DHARMAWAN
35 Q-33D849E9 3279022403800000 MOECHAMAD IRPAN
36 Q-D33EE075 3279011604880002 Mumung
37 Q-CEA39BE8 3279014203900002 Ade Ratih
F
Umur
Jenis Kelompok
Kelamin
tahun)
L PURNAWIRAWAN TNI 69 >60

L PURNAWIRAWAN TNI 58 46-59
P GURU 52 46-59
P JEMA'AH HAJI 47 46-59
P JEMA'AH HAJI 53 46-59
P GURU 30 18-30
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-
DOSIS 2
Alamat
Rancakole RT 10/2 Mulyasari-Kec Pataruman

Margaluyu RT 8/9 Mulyasari-Kec Pataruman
DSN SUKAMAJU RT 08 RW 05, MULYASARI, PATARUMAN
Babakansari RT 08 RW 11, Pataruman

PERUM CITRA JAYA GORDAH A 31 RT.02 RW.14 KEL.JAYAWARAS TAROGONG KIDUL GARUT
JL. JEND. SUDIRMAN NO.202 RT/RW 003/011 KEL. SINDANGRASA KAB. CIAMIS
JL.TERATAI NO.198 TEDENGDAYA RT.003 RW.004 KEL.KEDUNGJAYA KEC.KEDAWUNG KAB CIREBON
RSS SIDODADI A 240 RT.049 RW.015 KEL. PASIRKARUMBI KAB.SUBANG
PERUM PIR BLOK E NO.92 RT.002 RW.011 KEL. IMBANAGARARAYA,KEC.CIAMIS KAB.CIAMIS
DSN.DESA RT.003 RW.001 DESA SAGULING KEC.BAREGBEG KAB CIAMIS
LINGK. SUKAMANAH RT 001 RT 001/018 DS. PATARUMAN KEC. BANJAR
LINGK. CIKABUYUTAN BARAT RT/RW 003/009 KEL.HEGARSARI KEC. PATARUMAN KOTA BANJAR
DSN. KARANGPUCUNG KULON RT 015/004 DS. JAJAWAR KEC. BANJAR KOTA BANJAR
KP KERTAHARJA RT 004/003 DS. CIAMPANAN KEC. CINEAM TASIKMALAYA
DUSUN KEDUNGREJO RT/RW. 002/003 KEL. WONOHARJO KEL.PANGANDARAN KAB.PANGANDARAN
DUSUN SEDEKAN RT/RW 027/008 KEL.MEKARJADI KEC.SADANANYA KAB. CIAMIS
RIUNG ASIH RT/RW.002/011 KEL.TUGURAJA KEC.CIHIDEUNG KOTA TASIKMALAYA
DSN. SUKAMAJU RT.006 RW.005 KEL.MULYASARI KEC.PATARUMAN KOTA BANJAR
KARANG GEDANG RT/RE. 003/005 KEL.BABAKAN KEL.PANGANDARAN KAB.PANGANDARAN
LINGK.CIPADUNG RT.12 RW05 DESA PURWAHARJA KEC PURWAHARJA KOTA BANJAR
BANJAR
NASI COVID-19
VAKSINASI
2

Dosis I
kolom yang sesuai)
BPJS Non Non
BPJS PBI Pemberian
PBI Anggota
Vaksinasi
81321702482 4/9/2021 COVID-19 VACCINE

0852236969999 4/9/2021 COVID-19 VACCINE
81214557810 4/9/2021 COVID-19 VACCINE
4/9/2021 COVID-19 VACCINE
82121415178 4/9/2021 COVID-19 VACCINE
81313812718
81224200666 4/9/2021 COVID-19 VACCINE
0812610082170
0895803178745
081385335060
4/9/2021 COVID-19 VACCINE 4/9/2021
4/9/2021 COVID-19 VACCINE 4/9/2021
081323696931
81312518886 4/9/2021 COVID-19 VACCINE
81222940498 4/9/2021 COVID-19 VACCINE
081222868715 4/9/2021 COVID-19 VACCINE
082115588311 4/9/2021 COVID-19 VACCINE
08112414222 4/9/2021 COVID-19 VACCINE
82119842945 4/9/2021 COVID-19 VACCINE
085317323999
082120020304
087828483000 4/9/2021 COVID-19 VACCINE
08112123055 4/9/2021 COVID-19 VACCINE
081313169931 4/9/2021 COVID-19 VACCINE
085222226739 4/9/2021 COVID-19 VACCINE
088808111772 4/9/2021 COVID-19 VACCINE
082217683934 4/9/2021 COVID-19 VACCINE
082320389918 4/9/2021 COVID-19 VACCINE
085729747848 4/9/2021 COVID-19 VACCINE
085351372337 4/9/2021 COVID-19 VACCINE
081313370904 4/9/2021 COVID-19 VACCINE
081254141970 4/9/2021 COVID-19 VACCINE
083827492153 4/9/2021 COVID-19 VACCINE
082316969336 4/9/2021 COVID-19 VACCINE
85320998999 4/9/2021 COVID-19 VACCINE
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Vaksinasi
4/9/2021 24001021 SELESAI

4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI

4/9/2021 24001021 SELESAI

TUNDA HIPERTENSI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI

4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
4/9/2021 24001021 SELESAI
NAMA INSTANSI
PURNAWIRAWAN TNI
SMK AL-AZHAR
CJH
LAPAS BANJAR
DINAS PU
SMP PATROMAN
Jenis
Kelamin
1 Z-0C500B6D 3279026308650001 Neng Partini P

1 Q-B9676F61 3279025402910001 Tria Febrianti P
2 W-0A145A2D 3279025204680002 Turisna P
3 W-B0076297 3279021701620001 Wasidi L
4 3279026005770001 Yeti Sumiati P
5 W-A2129687 3279020401640001 Herman L
6 Z-36B5474A 3279036602850001 Inayatul Khoeriyah, S.Si p
7 Z-B7F87555 3279046407680001 Hj. Wati Hendrawati S.E P
8 Q-3E628158 3279026010850001 Annisa Tating Nurjanah P
9 Q-F6B05BCC 3279024305920002 Eem Emyati, S.M P
10 3279026711010002 Tasya Rohayanah P
11 327902430883000 1 Mimik Suparmika,S.Pd P
12 330217700884000 5 Puput Suharni, A.Ma P
13 Q-57732244 3279017011790002 Rohmita Utami P
14 Q-576BE5CA 3214124601820004 Vina Nurlaela P
15 Z-8DF630D2 3279015704730002 ELIS ROHANI P
16 W-00C1D66F 3279024505670004 Nuryeni P
17 Q-596CE2B2 3279024712850001 irna Riszi P
18 Q-2FF5124E 3279021310000001 Jajang Purnomo L
19 Z-ECE30673 3602196511790001 Novi Irmayanti P
20 W-97E6C2B3 3279016311880002 Nuna Nurhayati P
21 Q-FF4F04EA 3207202309940001 Ato Hartono L
22 Q-0EEF5356 3279044101950003 Vina Indriani P
23 32790462004820001 Santi Widya Hidayat P
24 Q-36B2B9B2 3279015105820001 Intan Rachmawaty P
25 Z-1018F814 3279020603840001 Wawan Setiawan 2 L
26 Z-BDA8A871 3279014804970002 NURUL IMAN APRILIA P
27 Q-318EABFF 3207304301930003 Kinanti Laras Asih P
28 S-F51F4B90 3279046907680001 Linatu Sofiyah P
30 Q-2E6E9818 3279025802870001 Neti Nadalia P
31 Q-2E900011 3279026209730003 IMAS SUMIATI P
FO
Umur Kelompok
Pekerjaan*
(18-59 tahun) Umur

GURU 30 18-30
GURU 52 46-59
GURU 59 46-59
GURU 43 31-45
GURU 57 46-59
GURU 36 31-45
GURU 52 46-59
GURU 35 31-45
GURU 28 18-30
GURU 19 18-30
GURU 37 31-45
GURU 36 31-45
GURU 42 31-45
GURU 39 31-45
GURU 48 46-59
GURU 53 46-59
GURU 35 31-45
GURU 21 18-30
GURU 42 31-45
GURU 33 31-45
GURU 27 18-30
GURU 26 18-30
GURU 39 31-45
GURU 39 31-45
GURU 37 31-45
GURU 24 18-30
GURU 28 46-59
GURU 52 31-45
PEDAGANG PASAR 48 0
FORMAT PENCATATAN PELAKSANAAN VAKSINASI CO
TINGKAT PUSKESMAS/FASYANKES/POS VAKSIN
DOSIS 2
Alamat
Pananjung Timur Rt/Rw: 27/6 Desa/Kel. Sinartanjung Kec. Pataruman Kota Banjar
Pananjung Barat Rt/Rw: 2/1 Desa/Kel. Sinartanjung Kec. Pataruman Kota Banjar
Pataruman Rt/Rw: 2/15 Desa/Kel: Pataruman Kec. Pataruman Kota Banjar
Dsn. Citangkolo Rt 02/ Rw 01, Kujangsari, Langensari, Banjar
Dsn. Pananjung Rt 14/ Rw 03, Sinartanjung, Pataruman, Banjar
lingk. Cimenyan II RT. 03 RW. 08 Mekarsari kota Banjar
lingk. Babakan Sari RT. 01 RW. 11 pataruman
Pananjung timur
Pananjung barat
Rancakole
Parung
CIBEREUM
Lingk. Siluman Baru rt 33/ rw 16 Purwaharja Banjar
Dsn. Sirnagalih rt 01/ rw02 Langensari Kota Banjar
Lingk. Cimenyan I rt 04/ rw 01 Des. Mekarsari Kec. Banjar
Lingk. Jadimulya rt 03/ rw 07 Kel. Hegarsari Kec. Pataruman Kota Banjar
SINDANGASIH
JADIMULYA RT 01 RW 07
LEMBUR BALONG RT 01 RW 05
KSANAAN VAKSINASI COVID-19
OSIS 2
Kepesertaan BPJS (tulis 'Ya'

pada kolom yang sesuai)
Nama/Jenis/Merek
Vaksin***
BPJS PBI BPJS Non
Non
PBI Anggota
81312769843 4/10/2021 VACCINE COVID-19

085294198223 4/10/2021 VACCINE COVID-19
0895375114744 4/10/2021 VACCINE COVID-19
082119508295 4/10/2021 VACCINE COVID-19
085320967877
082320585193 4/10/2021 VACCINE COVID-19
082136956919 4/10/2021 VACCINE COVID-19
085321390362 4/10/2021 VACCINE COVID-19
082216568341 4/10/2021 VACCINE COVID-19
082137158184 4/10/2021 VACCINE COVID-19
82123368440
0822 4058 2583
0812 2327 3159
081211306442 4/10/2021 VACCINE COVID-19
081394984150 4/10/2021 VACCINE COVID-19
85223060175 4/10/2021 VACCINE COVID-19
082316803026 4/10/2021 VACCINE COVID-19
87772833875 4/10/2021 VACCINE COVID-19
085320008042 4/10/2021 VACCINE COVID-19
082240185635 4/10/2021 VACCINE COVID-19
085283900722 4/10/2021 VACCINE COVID-19
081224286907 4/10/2021 VACCINE COVID-19
085799444828 4/10/2021 VACCINE COVID-19
082316895533
083825957140 4/10/2021 VACCINE COVID-19
087836284015 4/10/2021 VACCINE COVID-19
85321534832 4/10/2021 VACCINE COVID-19
082318126405 4/10/2021 VACCINE COVID-19
081323696931 4/10/2021 VACCINE COVID-19
85223995194 4/10/2021 VACCINE COVID-19
85793608973 4/10/2021 VACCINE COVID-19
Dosis I Dosis 2
Tanggal Tanggal
Vaksinasi Vaksinasi
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
4/10/2021 24001021
Keterangan
Diberikan/Lanjut)
SELESAI CJH
SELESAI
SELESAI
SELESAI SDN 3 MULYASARI
SAKIT
SELESAI
SELESAI
SELESAI
SELESAI MTs-AS Salam
SELESAI
SAKIT
IJIN
TK PGRI
IJIN
SELESAI
SELESAI RA HIMATUL ALIYAH
SELESAI
SELESAI
TK NANJUNGSARI
SELESAI
SELESAI
SELESAI SMK MUHAMMADIYAH
SELESAI
SELESAI
SELESAI
SAKIT SLB NEGERI BANJAR
SELESAI
SELESAI
SELESAI MI AL-KASYSYAF
SELESAI SMP PATROMAN
SELESAI SMK AL-AZHAR
SELESAI
PASAR BANJAR
SELESAI
Jenis
Kelamin
1 Q-699D83A4 3279021306740002 DEDE SAIDIN L

1 P-STEBWDNN 3279020708710004 IWAN SETIAWAN L
2 P-UDAZLCNF 3279021206700002 DIDI KARYADI L
3 P-UDRZK7KM 3279021209650003 DEDE SUKIN L
4 P-UDXEQARP 3279022506680004 UCA SUMANTRI L
5 P-UF04ZXVD 3279024605810001 MELIWATI P
6 P-UFFPKZGH 3279021610700001 PAIMUN L
7 P-UFWHCQEF 3279024205770001 ESIH P
8 P-UG3PAM6P 3279024908740002 ROSANAH P
9 P-UGGCE7NI 3279022606760001 NANA SUTISNA L
10 P-UGJT3GYE 3279021002810002 CARDIWAN L
11 P-UGNCHHZO 3279021508880005 ADI RADIANSYAH L
12 P-UGR6TTVT 3279021405630003 DEDE KURDIANA L
13 P-UHBEYO7T 3279020109680002 KIKIM SAKIM L
14 P-UITF2R4Q 3279025204750001 SRI INDRAWATI P
15 P-UKQNIAHG 3279020804900001 ADI MULYANTO L
16 P-UKV9F7RQ 3279021402690000 SAPTA SUPRATA L
17 P-ULFZ482B 3279020105750001 HENDARTO L
18 P-UM6KZMML 3279024503720003 AI NURHAYATI P
19 P-UODXGEIO 3279025808770002 DEDE SRI MULYATI P
20 P-UOIH9HU3 3204124103820013 ELIS LINA MARLINA P
21 P-UPC96OLA 3279026901930001 AYU ANDINA P
22 P-UPIATCSI 3279024104010001 PUSPA APRILIA TRIMILENA P
23 P-UQX2ENLE 3279026404820001 YATI HERLIANTI P
24 P-UQXQ8BDH 3279024101690015 ATIK SUSILAWATI P
25 S-C329097C 3279020307680001 YANTO DARYANTO L
1 S-023017AC 3279026011540001 EEN HAENAH P
2 S-0241C20C 3279025101610002 DEDE ATIKAH P
3 S-0DE49D33 3207175507570002 SAMINAH P
4 S-0E737E0D 3279026708500001 DARYATI P
5 S-0F4BF394 3279024107380001 UKA P
6 S-16745A7E 3279021102530001 ADE AMAR L
7 S-23A4069C 3279024707570003 NENENG YULIANI P
8 S-2596AB46 3279024508580004 WATI
9 S-26839620 3279025205480004 SOPIAH HAYATY P
10 S-386B141C 3279025506590004 ENAH P
11 S-39F070AE 3279021807550002 RITAM SYAHRUDIN L
12 S-3C3F498E 3279020610600001 ACE SOPIAN L
13 S-412AF477 3279024308450002 INAH SUTIASIH P
14 S-43D751BD 3279024208550001 TARWIYAH P
15 S-442C7039 3279021706580002 ENGKUS L
16 S-46F9B30F 3279020301580001 HERI DADANG L
17 S-4A76FD14 3279026311570001 NELAH P
18 S-4C75CA41 3279024802550002 MIMI P
19 S-4F58DDA0 3279025105510001 EJE P
20 S-5199907B 3279024101570021 PATONAH P
21 S-529E5B24 3279025007380001 MAERAHWATI P
22 S-556C9869 3279025107550004 TITING P
23 S-5C596C35 3279021404500003 EMAN TASMAN L
24 S-5DCC6FDA 3279022112550001 MAMAN SOMANTRI L
25 S-633E3CA5 3279022112550001 POPON P
26 S-635DC97A 3279025706550001 MIMIN MINTARSIH P
27 S-6940C1A0 3279020101520007 MAMAT L
28 S-699223D2 3279024711550001 KASINEM P
29 S-6CD2ACE5 3279021607600002 UBAD ABDUL HAMID L
30 S-720EE5D7 3279024107580006 TITI P
31 S-72208B31 3279020107440008 AJA L
32 S-7FDDB68A 3279021001580001 IJAN L
33 S-80C13ACA 3279024101470010 KHODIJAH P
34 S-83AA6A97 3279020612590003 ROSID L
35 S-8540B9AC 3273100504510001 ADE ROHMAT L
36 S-8792EAF4 3273100504510001 TITIK YUNTATI P
37 S-8B95A7F5 3279021405600002 ACIM L
38 S-90AB5C93 3279025008510002 IWI P
39 S-9339D522 3279024704560002 SUNARTI P
40 S-95F83256 3279021512600002 UJANG MAMAN L
41 S-99141028 3279021502580003 APAN ROPENDI L
42 S-9C330304 3279021005500001 SUDINTA L
43 S-9EC9132E 3279025502580001 AMINAH P
44 S-A076C8EC 3279022009590002 ADUT KASNO L
45 S-A48552B0 3279022009590002 WIWI P
46 S-A7CE0E83 3279025210550001 IRAH P
47 S-A913EF26 3279024404560001 SARINEM P
48 S-A91D4C51 3279020809490001 WIRYO L
49 S-B815F53C 3279021308590001 EEN SUPENDI L
50 S-B8A51B30 3279020610500002 HUSIN L
51 S-B95ABE60 3279021109540001 ROSID L
52 S-C01E1699 3279025508550003 MIMIN P
53 S-C20DB8C8 3279020107380006 DARMAN L
54 S-C5EA6991 3279020101420006 EWON SUPARMAN L
55 S-CD1847E7 3279026304530001 WIWI P
56 S-D1EB987E 3279025008550000 HADMIRAH P
57 S-D7D1D795 3279020510570001 ENTOY HERLIANA L
58 S-DA8A3815 3279026201590001 IKA SUPARMIKA P
59 S-DBB3FF4E 3279024501580002 ENDANG WAHYUNINGSIH P
60 S-DBBBC1BD 3279020107550009 AIP SARIP L
61 S-DC49E430 3279020108550003 HASIM L
62 S-DECDE653 3279025011600004 EDAH L
63 S-E17CDEE2 3279022105520001 TOHA L
64 S-E3740C09 3279024703550002 UUN UNASIH P
65 S-E5ECFEFB 3279022804510002 KOSIM
66 S-E6AFA749 3279020111600002 PARMAN L
67 S-F2C4B6D7 3279025608580001 MARYATI P
68 S-F43D393D 3279024511590003 YOYOH RODIAH P
69 S-F53D4E1B 3279022804540001 KUSMAN L
70 S-F6C0BCA0 3279020504590001 SAEPUDIN ZUHRI L
71 S-F89D8760 3279024512560004 ELA KARMILA P
72 S-FA3ACF72 3279020207590001 RASTAMAN L
73 S-FC9DD66E 6472021211590001 JUMARI L
74 Y-00002E6T 3279020103500002 DIDI EFENDI L
75 Y-00002E76 3279021011550001 ROSADI L
76 Y-00002E7N 3279022508400001 DARPI L
77 P-UDIQPODX 3279022508400001 AAN P
78 P-UDOM5F47 3279025205610002 TATI MARYANI P
79 P-UI0OEM3X 3279025205610002 HERI L
80 P-UJEUU88G 3279024503610001 RUWITA P
81 P-UQCWUMJV 3279024503610001 DJAMIAT PANJAITAN L
FOR
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)

TOKOH MASYARAKAT 50
TOKOH MASYARAKAT
TOKOH MASYARAKAT
TOKOH MASYARAKAT 53
TOKOH MASYARAKAT 40
TOKOH MASYARAKAT 51
TOKOH MASYARAKAT 44
TOKOH MASYARAKAT 44
TOKOH MASYARAKAT 45
TOKOH MASYARAKAT 40
TOKOH MASYARAKAT 33
TOKOH MASYARAKAT 58
TOKOH MASYARAKAT 53
TOKOH MASYARAKAT 46
TOKOH MASYARAKAT 30
TOKOH MASYARAKAT 52
TOKOH MASYARAKAT 46
TOKOH MASYARAKAT 49
TOKOH MASYARAKAT 44
TOKOH MASYARAKAT 39
TOKOH MASYARAKAT 28
TOKOH MASYARAKAT 20
TOKOH MASYARAKAT 39
TOKOH MASYARAKAT 52
TOKOH MASYARAKAT 51
LANSIA 67
LANSIA 60
LANSIA 63
LANSIA 71
LANSIA 83
LANSIA 68
LANSIA 64
LANSIA 63
LANSIA 73
LANSIA 62
LANSIA 66
LANSIA 61
LANSIA 76
LANSIA 66
LANSIA 63
LANSIA 63
LANSIA 64
LANSIA 55
LANSIA 70
LANSIA 64
LANSIA 83
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
LANSIA
FORMAT PENCATATAN PELAKSANAAN VAKSINASI C
TINGKAT PUSKESMAS/FASYANKES/POS VAKSIN
DOSIS 2
Alamat
DUSUN PANANJUNG TIMUR RT 31 RW 07, SINARTANJUNG
DUSUN PANANJUNG BARAT RT 08 RW 02, SINARTANJUNG
DSN PANANJUNG RT 018 RW 004
DUSUN SINARGALIH RT 41 RW 09, SINARTANJUNG

DUSUN PANANJUNG RT 21 RW 05, SINARATANJUNG
DUSUN SINARGALIH RT 33 R 08, SINARTANJUNG

ANAAN VAKSINASI COVID-19
ANKES/POS VAKSINASI
SIS 2

No. Hp
Screening Vaksin***
BPJS PBI BPJS Non
Non
PBI Anggota
082315531945 4/13/2021
81806355268 4/13/2021
4/13/2021
4/13/2021
82216568341 4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
4/13/2021
Dosis I Dosis 2
Tanggal Tanggal
Vaksinasi Vaksinasi
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
4/13/2021 24001021
Keterangan
Diberikan/Lanjut)
SELESAI DESA SINARTANJUNG

LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
TUNDA
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
TUNDA
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
Jenis
Kelamin
1 P-UYWNDAJH 3279020512850001 DEDE HAERUDIN L

2 P-UZWB3GOU 3279020607810001 YAYAN L
3 P-V10M5THK 3279025912800001 DESI DAMAYANTI P
4 P-V13WCD1S 3279026303890001 RENI RISMAYANTI P
5 P-V1IV3CNL 3279024711880001 LANI NOVIANI P
6 P-V2W73L2Z 3275085607800037 ANI HERLINA P
7 P-V2Z079G5 3279025005840001 UTI NURPAJAR P
8 P-V3397GEX 3279024805880002 NUNUNG NURLINA P
9 P-V3CUGETY 3279027006860001 ENUNG SULASTRI P
10 P-V3E8156W 3279024808830003 ETI SUHAETI P
11 P-V3GXR120 3279025809820004 NURLIA NINGSIH P
12 P-UZQ05G4P 3279025308820004 JEJEH PUSPITASARI P
13 S-93ACA469 3279024105760005 SITI AISAH P
14 S-A5AC090D 3279025906780001 LENI MARLINA P
15 S-A31C4D18 3279020303760001 LASIMAN L
16 P-V1S4LTS5 3206374701970003 AI CAHYANI P
17 P-V1UEVE7O 3207156711970001 IIN SITI NURJANNAH P
1 S-ECAF5BE9 3275031507590022 SUMARYONO L
2 S-56F3416E 3279021508450001 ONON RUKMAN L
3 S-4C5B52A1 3279021705580001 TISNA SUTISNA L
4 S-81C92C01 3279021506530001 DARSONO L
5 P-UYPODAIR 3279024801610003 CUCU P
6 S-7935C59D 3279024408510001 SOLIHAH P
7 S-CA3397D5 3279020907510001 KUSNADI L
8 S-92ECF459 2171036508531001 HAYATI P
9 S-400F8F0B 3279015901530001 ELI SURLIAH P
10 S-E1D05AB6 3279011203510002 DADI KARTADJUMHANA L
11 S-74CDCB0F 3279021612550001 IYUS L
12 S-55833036 3279010107480001 ENDANG HIDAYAT L
13 S-2D0617AC 3279025703540001 YAYUK LASMIYATIN P
14 S-B22586CF 3204314107561011 ENTIN P
15 S-1C3A3727 3279024504520001 LOMRAH P
16 S-69295171 3279021403540001 ELON L
17 S-5E1ACD30 3279020406580002 SAHDI L
18 S-0ABAB184 3279024808600002 YUHYATI P
19 P-UZYM9M6B 3279020806610001 YUDIMAN L
20 S-F80499EF 3279024610600001 ENOK PIPING HENDAYANI P
21 S-7090DB1F 3279015806430001 TASMINAH P
22 S-96DEF99B 3279020404600001 TOYO L
23 S-E0933BFD 3279026411580001 ENTIN P
24 S-773A5D68 3279021802530001 UKENG SUHERMAN L
25 S-CC5487DA 3279020804540001 HADI MULYO L
26 S-09297F95 3279021312530001 MULYONO HADISUSANTO L
27 P-V1F75NLS 3279024607610001 MARPUAH P
28 S-84945516 3279021805530001 MUMU L
29 S-6FB90162 3279020509590004 KUSWITO L
30 S-9C34B7E2 3279022503520001 KIRNO SUKIRJO L
31 S-E91A3A3C 3279024802580001 TIKA HASANAH P
32 S-13B66DCC 3279021903560001 HENDRAMANA L
FORMAT PENCATATAN PE
TINGKAT PUSKESMAS
Umur
Pekerjaan* (18-59 Kelompok Umur
tahun)
TOKOH MASYARAKAT 36
TOKOH MASYARAKAT 40
TOKOH MASYARAKAT 41
TOKOH MASYARAKAT 32
TOKOH MASYARAKAT 38
TOKOH MASYARAKAT 41
TOKOH MASYARAKAT 47
TOKOH MASYARAKAT 33
TOKOH MASYARAKAT 35
TOKOH MASYARAKAT 38
TOKOH MASYARAKAT 38
GURU PAUD 39
GURU PAUD 45
GURU PAUD 43
GURU PAUD 45
GURU PAUD 23
GURU PAUD 24
LANSIA 62
LANSIA 76
LANSIA 63
LANSIA 68
LANSIA 60
LANSIA 60
LANSIA 60
LANSIA 68
LANSIA 68
LANSIA 60
LANSIA 66
LANSIA 73
LANSIA 67
LANSIA 65
LANSIA 69
LANSIA 67
LANSIA 63
LANSIA 60
LANSIA 60
LANSIA 61
LANSIA 78
LANSIA 61
LANSIA 63
LANSIA 78
LANSIA 77
LANSIA 78
LANSIA 60
LANSIA 78
LANSIA 72
LANSIA 69
LANSIA 63
LANSIA 65
DOSIS 2

Alamat No. Hp
BPJS PBI BPJS Non
PBI
RANCAKOLE RT 12 RW 03 82121826313
RANCAKOLE RT 06 RW 02 82116028131
SUKAMAJU RT 07 RW 05 82320897121
SUKAMAJU RT 02 RW 04 82321050505
SUKAMAJU RT 05 RW 05 82320930392
RANCAKOLE RT 07 RW 02 82126545025
SUKAMAJU RT RT 01 RW 04 8987890855
RANCAKOLE RT 02 RW 01 85223535445
SUKAMAJU RT 14 RW 06 82219002405
SUKAMAJU RT 04 RW 04 81297621003
SUKAMAJU RT 03 RW 04 82217442152
SUKAMAJU RT 01 RW 04 81218131691
SUKAMAJU 10 RW 06 89644575192
SUKAMAJU RT 11 RW 06 82218821885
SUKAMAJU RT 05 RW 05
MARGALUYU RT 04 RW 08 0895332261876
SIDAMULYA RT 06 RW 13, CIAMIS 85321495397
PUP BLOK G3/18 RT 1 RW 11, BEKASI 081315737001
RANCAKOLE RT 13 RW 13
SUKAMAJU RT 09 RW 05 85223121699
MARGALUYU RT 08 RW 09
SIKAMAJU RT 03 RW 04
MARGALUYU RT 04 RW 08
OVID-19
ASI
rtaan BPJS (tulis 'Ya'

Dosis I
olom yang sesuai)
Nama/Jenis/Merek
Tanggal Screening Tanggal
Non Vaksin***
Anggota Vaksinasi
4/13/2021 VACCINE COVID-19 4/13/2021 24001021

4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021
4/13/2021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
4/13/2021 VACCINE COVID-19 4/13/2021 24001021
Dosis 2
Keterangan
Tanggal (Ditunda/Tidak NAMA INSTANSI
Pemberian No. Batch No. Serial Diberikan/Lanjut)
Vaksinasi
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
TUNDA KOMORBID
LANJUT DOSIS 2
LANJUT DOSIS 2 DESA MULYASARI
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2
TUNDA KOMORBID
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
Jenis
Kelamin
1 3279021608460001 ENDIN NASIR L

2 3279023107520001 NANA RUSMANA L
3 3279025408560001 EDEH P
4 3279024304580001 ICIH SUTARSIH P
5 3279021002590001 PENDI L
6 3279020103580001 SARDI L
1 3279044609890001 Farida P
2 3207202612920002 Andri Suryadi L
3 3279024808880003 Ristianti Agustini P
4 3279035407880001 Yeni Astuti P
5 3279022507850002 Yuli Setiyadi L
6 3301164507890001 Helga Nureka Navelani P
7 3207205408680001 Wiwin Widaningsih P
8 3279025705930002 Meriani Iswandini P
9 3205170904820005 Wawan Setiawan 1 L
10 3206352309950002 Sandi Wahyudi L
11 3207195511680002 Dede Hernawati P
12 32790462004820001 Santi Widya Hidayat P
13 3279044905680002 Epi Sopiati P
14 3279024112940002 SITI AMANAH,S.Pd.I P
15 3279024101870000 SITI MARYAM P
16 3279025103850002 DEVI DWIYANTI P
17 327902430883000 1 Mimik Suparmika,S.Pd P
18 330217700884000 5 Puput Suharni, A.Ma P
19 3204056311880003 DEDE RANI, S.Pd.I P
20 3279026005770001 Yeti Sumiati P
27 3206250407810001 KOKOK SETIO PRAKOSO YUWONO, S.E. L
28 3206221208810007 AGUS HERIANTO, S.H. L
29 3279030706910001 Nursoleh, ST L
30 3279042312860001 Dian Herdiana L
31 3207312909770001 Heli Heliansah L
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
PEDAGANG PASAR 75 >60

GURU 31 31-45
GURU 28 18-30
GURU 32 31-45
GURU 32 31-45
GURU 35 31-45
GURU 31 31-45
GURU 53 46-59
GURU 28 18-30
GURU 39 31-45
GURU 26 18-30
GURU 53 46-59
GURU 39 31-45
GURU 53 46-59
GURU 26 18-30
GURU 34 31-45
GURU 36 31-45
GURU 37 31-45
GURU 36 31-45
GURU 32 31-45
GURU 43 31-45
FORMAT PENCATATAN PELAKSANAAN VAKSIN
TINGKAT PUSKESMAS/FASYANKES/POS V
DOSIS 2
Alamat
JELAT, PATARUMAN
JELAT, PATARUMAN
JELAT, PATARUMAN
JELAT, PATARUMAN
JELAT, PATARUMAN
JELAT, PATARUMAN
Muktisari RT/RW. 5/2 Desa Muktisari Kec. Langensari Kota Banjar
Dusun Cipicung RT.15 RW.08 Desa Karangsari Kec. Padaherang Kab. Pangandaran
Ling Babakansari RT/RW. 3/11 Desa Pataruman Kec. Banjar Kota Banjar
Ling. Cikadu RT 18 RW 08 RT/RW. 18/8 Desa Karangpanimbal Kec. Purwaharja Kota Banjar
CITANGKOLO RT/RW. 5/1 Desa KUJANGSARI Kec. Langensari Kota Banjar
Cilulu RT/RW. 1/11 Desa Dayeuhluhur Kec. Dayeuhluhur Kab. Cilacap
Kp. Sindang serang rt 02/ rw 08 Des. Ciburuy Kec. Bayongbong Garut
Kp. Jamanis rt 01/ rw 05 Tanjung mekar kec. Jamanis Tasikmalaya
Pataruman RT. 03/09
Bantardawa Rt 05/02
Randegan 1 Rt 11/04
YANKES/POS VAKSINASI
S2

No. Hp
Screening Vaksin***
BPJS PBI BPJS Non
Non
PBI Anggota
85703143780 4/15/2021 VACCINE COVID

81391213604 4/15/2021
8121434953 4/15/2021 VACCINE COVID
81320053336 4/15/2021 VACCINE COVID
81320053336 4/15/2021 VACCINE COVID
81320053336 4/15/2021
081322322567 4/15/2021 VACCINE COVID
083814591128 4/15/2021 VACCINE COVID
085721698279 4/15/2021 VACCINE COVID
081394389550 4/15/2021 VACCINE COVID
081313978448 4/15/2021 VACCINE COVID
087725673307 4/15/2021 VACCINE COVID
085352388370
0895803178748 4/15/2021 VACCINE COVID
082117154562 4/15/2021 VACCINE COVID
08977737720 4/15/2021 VACCINE COVID
085223522779 4/15/2021 VACCINE COVID
082316895533
81323123688 4/15/2021 VACCINE COVID
081221826005 4/15/2021 VACCINE COVID
082113228605 4/15/2021 VACCINE COVID
082130175449 4/15/2021 VACCINE COVID
0822 4058 2583 4/15/2021 VACCINE COVID
0812 2327 3159 4/15/2021 VACCINE COVID
0895 6088 35239 4/15/2021 VACCINE COVID
085320967877 4/15/2021 VACCINE COVID
085317323999 4/15/2021 VACCINE COVID
082120020304 4/15/2021 VACCINE COVID
85223305099
82113577414 4/15/2021 VACCINE COVID
4/15/2021 VACCINE COVID
82214782272 4/15/2021 VACCINE COVID
Dosis I Dosis 2
Tanggal Tanggal
Vaksinasi Vaksinasi
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
4/15/2021 24001021
Keterangan
Diberikan/Lanjut)
SELESAI
TUNDA HT
SELESAI
PEDAGANG PASAR
SELESAI
SELESAI
TUNDA HT
SELESAI
SELESAI
SELESAI
SMK AL-AZHAR
SELESAI
SELESAI
SELESAI
TDK HADIR
SELESAI
SELESAI
SELESAI SLBN BANJAR
SELESAI
TDK HADIR
SELESAI
SELESAI
SELESAI RA RIYADU SHOLIHIN
SELESAI
SELESAI
TK PGRI
SELESAI
SELESAI SDN 1 MULYASARI
SELESAI SDN 3 PATARUMAN
SELESAI
LAPAS BANJAR
SELESAI
TDK HADIR
DINAS PU
SELESAI
DINAS PU
SELESAI
SELESAI
Jenis
Kelamin
1 P-X86XM6OF 3204284104650004 NYAI JUARIAH P

2 S-089FAE50 3279020604550003 SARAN L
3 S-1DB25431 3279024101430008 TONAH P
4 S-25855B7C 3279024101370002 SUPIAH P
5 S-25D003BF 3279025803560002 N WARLIAH P
6 S-2B85FB59 3279020112570002 HENARISMAN L
7 S-6A2DB04A 3279025406570003 NOORJANAH AR P
8 S-6A5D05FE 3279024912580001 N KESIH P
9 S-801FD16C 3279024106540001 DEDE HOTIMAH P
10 S-82DD5580 3279027011600002 ETI ROSTIAWATI P
11 S-8ED71B2B 3279022202550001 AAN ROHAENI SUPRIATNA L
12 S-D1924A8C 3279025207490001 SUMIRAH P
13 S-D5CC361C 3279026609560001 ADAH ARSIH P
14 S-E492093E 3279015006520001 TATI SITI CHOTIMAH P
15 S-EA0D8F7F 3279024708450005 UMAYA P
16 S-EA1A677C 3279020504540002 KODAR L
17 S-F6A90A0B 3279026606520001 TRESNASIH SUMITRA L
FORMAT PENCATATAN PELAKSAN
TINGKAT PUSKESMAS/FASYAN
Umur
Kelompok
Pekerjaan* (18-59 Alamat No. Hp
Umur
tahun)
LANSIA >60 PERUM DOBOKU LIGAR RT 08 RW 11

LANSIA >60 SUKAMANAH RT 01 RW 17
LANSIA >60 BABAKANSARI RT 02 RW 09
LANSIA >60 LEMBURBALONG RT 02 RW 17
LANSIA >60 RANCAKOLE RT 10 RW 02
LANSIA >60 LEMBURBALONG RT 03 RW 06
LANSIA >60 LINGK. JELAT RT 04 RW 01
CATATAN PELAKSANAAN VAKSINASI COVID-19
T PUSKESMAS/FASYANKES/POS VAKSINASI

Dosis I
Nama/Jenis/Merek
Vaksin***
BPJS PBI BPJS Non
Non
Pemberian
PBI Anggota
Vaksinasi
4/19/2021 VACCINE COVID-19 4/19/2021

4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
4/19/2021 VACCINE COVID-19 4/19/2021
Dosis I Dosis 2
Keterangan
Tanggal (Ditunda/Tidak
No. Batch No. Serial Pemberian No. Batch No. Serial Diberikan/Lanjut)
Vaksinasi

TUNDA HIPERTENSI
NAMA INSTANSI
LANSIA PATARUMAN
Jenis
Kelamin
1 S-64931E78 3279021909640001 DODI SUPARDI L

2 S-92EBDC60 3279026907630001 ANI MULYANI P
3 ELIS NURAENI P
4 P-XOCBIPF8 3279026801920001 YANI SURYANI P
5 S-D0AF7461 3279025506000003 SAYIDIANA LATIFAH P
6 P-XQ078QWP 3279026508770003 SUMIYATI P
7 P-XQEC0O91 3279025810940001 SUCI HERLINA P
8 P-XQNBWN19 3279026010650001 ETTY MUSLIHATI P
9 P-XTUCEFK0 3279025406660001 EUIS SRI HAYATI P
10 P-XUGOTATG 3279022104650005 DEDI RUSPENDI L
11 S-5FC45D02 3279024408790002 ERNI MURNIASIH P
12 S-4BF2938F 3279024203760003 IDA KARLINA P
13 S-9D5C9619 3279024604680004 ELAH HAYATI P
14 S-1F0CC689 3279025001850002 ENUNG NURHAYATI P
15 P-XLIKGAUN 3279024412870002 ENI NURHASANAH P
16 P-XLO5JNCW 3279024407760002 SRI BUDI ARYANI P
17 P-XM2MFVA8 3279016609750001 SUWARNI P
18 P-XM8DQUEP 3279026602760002 TATIEK HADIYANTI P
19 P-XMCO4N8A 3279036503870002 RENA RAHAYU NINGSIH P
20 P-XMHEPQW7 3279025709740002 SRI ASIH RUBIANTIKA P
21 P-XMLPVW87 3279025606850003 FIFIT WIDIANTINY P
22 S-ECDE03F4 3279026707710004 NURYANI P
23 S-606523F0 3279027004870001 IRMA NURHOLIS P
24 S-86B11F3D 3279015505760008 LIA MELIA P
25 S-70E716B6 3279025407740001 RD. HERYANI P
26 P-XOT56L3B 3279024811900001 NANI MARYANI P
27 S-40C6E8CB 3279026306850001 TRI MULYANI P
28 S-28C497A2 3279024504830002 LIA DAHLIA P
29 P-XP9DMPVQ 3279025111860001 ERNI SUPRIYATI P
30 S-A5C12C63 3279024110770001 ATIK SUPARTIKA P
31 NURCAHYATI P
32 S-E83E3080 3279016808720001 EUIS ROSIDA P
33 S-5D5FEE19 3279024706750001 NONOK TITI HARTILAH P
34 P-XPTIN3Y6 3279024311800002 UCU ASIAH P
35 S-89836FFA 3279024309750001 ELIS ROSYANTI P
36 P-XRPDJ6W9 3279024609690002 YENI YULIA P
37 P-XSCHEDYG 3279024209850003 NENG KURNIASIH P
38 Y-00002EA1 3279036605590001 NENNY SULASTRIANI P
39 P-XTZKQELP 3279026502710001 ENOK SRI KOMALA P
40 P-XUMB11ON 3279024907860002 SUDARYANTI P
41 S-A0BF525A 3279034704940002 DIANA GALIH P
TINGKAT PUSKESMAS/FASYANKES/POS
Umur
Kelompok
Umur
tahun)
GURU SD 57 JELAT 01/04 81318469964

GURU SD 58 CIKABUYUTAN TIMUR 05/11 82118257515
GURU PAUD 42 PANANJUNG BARAT 05/01
GURU PAUD 28 PANANJUNG BARAT 03/11 81223081771
GURU PAUD 21 PANANJUNG TIMUR 29/07 8985788868
GURU PAUD 27 PANANJUNG 20/05 82315275427
GURU PAUD 45 PATARUMAN 03/12 8999852999
GURU PAUD 34 BABAKANSARI 08/11 82119887714
GURU PAUD 46 SUKARAME 06/11 85220114131
GURU PAUD 45 TANJUNGSUKUR 03/15 85224214848
GURU PAUD 34 RANDEGAN 1 07/03 83129441666
GURU PAUD 45 LINGK. HAURMUKTI 41/02 85315708314
GURU PAUD 47 JELAT 03/03 89669604320
GURU PAUD 38 LEMBURBALONG 02/06 81222193099
GURU PAUD 35 LEMBUR BALONG 03/06 82321534540
GURU PAUD 22 PINTUSINGA 02/19
GURU PAUD 49 SUMANDING KULON 01/20 85315526783
GURU PAUD 46 PANATASAN 02/20 85294198940
GURU PAUD 40 SUKAMANAH 04/18 82220473599
GURU PAUD 62 JELAT 02/04 87717284180
AN PELAKSANAAN VAKSINASI COVID-19
SMAS/FASYANKES/POS VAKSINASI

Dosis I
BPJS PBI BPJS Non
Non
Pemberian No. Batch
COVID VACCINE 4/20/2021 24001021

COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021

COVID VACCINE 4/20/2021 24001021
COVID VACCINE 4/20/2021 24001021
sI Dosis 2
Keterangan
(Ditunda/Tidak
No. Serial Tanggal Pemberian No. Batch No. Serial Diberikan/Lanjut)
Vaksinasi
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
NAMA INSTANSI
SDN 2 PATARUMAN
SDN 5 PATARUMAN
PAUD SINARTANJUNG
PAUD PATARUMAN
PAUD PATARUMAN
Kabupaten/Kota
Provinsi
No No. Tiket NIK
1 N-200850B8 3207284109870002
2 N-53DF9DED 3205191903840005
3 3279014106920001
4 P-YEVBJNDW 3279021906660001
5 Y-0119LPXA 6106060212970001
6 Y-01199TYP 1671105402990002
7 P-94E39210 3279020208630002
8 P-YM0PM6XE 3279010411650001
9 P-YEHMLIHH 3207190503970004
10 P-YFUK4K55 3372042309840007
11 P-YHKD2P6O 3279011504950001
12 P-YE9WPUXF 3207150606960002
13 P-YMDGKXNS 3279024505750001
14 P-YD1ULNS6 3278011209690006
15 P-YDD3PEP0 3279030510870001
16 P-YDPYXV2S 3279026311960001
17 P-YG2L0KQ4 6409030909890006
18 S-2D609360 3279041206980001
19 S-431FBEB0 3205020802820003
20 S-2599C2F0 3207161608920001
21 S-52C2BC50 3027014807810002
22 3175102502670010
23 S-7EF82DF4 3279032709900001
24 S-A638EB31 3207010804920002
25 P-YGJBENBU 3301111501000002
26 P-YGUVR6R5 3207362304990001
27 S-AEE7D690 3279012503790001
1 P-YCUS74OC 3206190111940001
2 P-YD6HZQDY 3279031701780001
3 P-YDKQTV1L 3305170511730002
4 P-YEYVU943 3279021807880001
5 P-YFBF8BTV 3207180711820001
6 P-YFOW0WSB 3206341111930004
7 P-YHRWISXS 3207302307850001
8 P-YHXVI6RF 3207120503940001
9 P-YI8XRJ4H 3279011011950002
10 P-YIDZ7NB3 3279024406940002
11 P-YIJJ59JY 3207115002950001
12 P-YIOUOR0Q 3278045912970017
13 P-YJ2CRIWN 3279025805880001
14 P-YJ9HGDAM 3279025208950004
15 P-YK5NGXGA 3207013005810002
16 P-YKB6JWJQ 3278062604810008
17 P-YKE450LX 3279010501940004
18 P-YKJB5ICK 3279012805900001
19 P-YKP635JA 3207290811930001
20 P-YKUA37QZ 3207292002950001
21 P-YKYIGPOF 3279022410910002
22 P-YL4PSVVO 3279020507850001
23 P-YL8T5I2R 3279020609880001
24 P-YLDLMOFG 3279012503960001
25 P-YLGYJYPZ 3279010108920002
26 P-YLNOJHCO 3279022512830003
27 P-YLRMXJAX 3207030207000001
28 P-YLWNPTQS 3279026107910001
29 P-YM67XZIV 3207012912860002
30 P-YNYX5ZUZ 3279020705800003
31 P-YPOJ5DY6 3279022801960001
32 S-943E94E1 3205192909870002
60 P-YQMRJJAV 3279025010770003
61 Z-450626A0 3279020611580002
62 Z-9575CBC2 3279021006580002
63 Z-957F0C34 3279021602550001
64 Z-EBEBD5FF 3279025207600001
65 W-CCC2D519 3207205408680001
: KOTA BANJAR
: JAWA BARAT
Jenis
Nama Penerima Vaksin Pekerjaan*
Kelamin
EKA SRI ANGGARWATI P ASISTEN APOTEKER

WAGIE TRISWANDI L APOTEKER
SALLY HILDAWATY P ADMINISTRASI
TEGUH SUDARMONO L ADMINISTRASI
QADI MAQSHUDI L KOAS UMJ
TIVALEN P KOAS UMJ
SUPENDI L TRAVEL
MOCHAMMAD AGUS MUKARROM L TRAVEL
SIGIT RESTU DIANSAH L TRAVEL
MOHAMMAD ITSNAN FAIZ L TRAVEL
R. DARMAWAN ADIGUNA L TRAVEL
YOSEP HENDRA GUMELAR L TRAVEL
MIATI P TRAVEL
SENNO L KARYAWAN SWASTA
ASEP WAHYUDI L KARYAWAN SWASTA
NOVIYANTI P KARYAWAN SWASTA
MUHAMMAD FATHUL MAJID L KARYAWAN SWASTA
ANOM L PEGAWAI PEMERINTAH
ISAN NURHAKIM, S.I.P. L PEGAWAI PEMERINTAH
AGUS CHERAWAN L PEGAWAI PEMERINTAH
LULU NURYANI P PEGAWAI PEMERINTAH
ARYA PRASETYA UTAMA L PEGAWAI PEMERINTAH
YOGIE SEPTIAN HARTANTO L PEGAWAI PEMERINTAH
GANANG PURNOMO L PEGAWAI PEMERINTAH
FIKRI RAHMADAN NUGROHO L PEGAWAI PEMERINTAH
RIZAL APRIYADI MUHARRAM L PEGAWAI PEMERINTAH
R HADI SUPRIYATNA L DINAS PU
ARIF RUSMAN SUTIANA L KARYAWAN SWASTA
DENI SURATMAN L KARYAWAN SWASTA
YAYAN SURYANA L KARYAWAN SWASTA
Bambang Triasworo L KARYAWAN SWASTA
ASEP RONI L KARYAWAN SWASTA
ASEP HENDI L KARYAWAN SWASTA
ASEP SYAMSUL BAHRI L KARYAWAN SWASTA
MUHAMMAD RIZAL FAHMI L KARYAWAN SWASTA
PAHLEVI NOVIANDI UTAMA L KARYAWAN SWASTA
LENI SELVIANI P KARYAWAN SWASTA
WIDA NUR FEBRIANTI P KARYAWAN SWASTA
DIVA VADILA SARI P KARYAWAN SWASTA
INDRY FITRIA SUSSILOWATHY P KARYAWAN SWASTA
NOR AZIZAH P KARYAWAN SWASTA
SUBHAN ARIF FIRMANSYAH PRAWIRA L KARYAWAN SWASTA
HERDIANA APRIADI L KARYAWAN SWASTA
DANI SUMANTRIYANTO L KARYAWAN SWASTA
HENDRA SETIAWAN L KARYAWAN SWASTA
IAN MULYANA L KARYAWAN SWASTA
MOHAMAD RAMDANI L KARYAWAN SWASTA
DADI KUSNIADI L KARYAWAN SWASTA
SUTRISNO L KARYAWAN SWASTA
RICKI GUMILAR L KARYAWAN SWASTA
HIDAYAT L KARYAWAN SWASTA
AGUS SUTARMAN L KARYAWAN SWASTA
DEDE SUPRIADI L KARYAWAN SWASTA
FAJAR DWI MAULANA L KARYAWAN SWASTA
EKA TRISNA SAYEKTI P KARYAWAN SWASTA
ABUNG SARIFFUDIN L KARYAWAN SWASTA
YANA SURYANA L KARYAWAN SWASTA
HENDRI PERMANA L KARYAWAN SWASTA
Budi Lukman Halim L KARYAWAN SWASTA
NURLAELA HASANAH P TOKOH MASYARAKAT
Dudi Kurniadi, S.H L JEMA'AH HAJI
Undang Syam L JEMA'AH HAJI
Tubagus R L JEMA'AH HAJI
SULE YULIANA P JEMA'AH HAJI
Wiwin Widaningsih P GURU
FORMAT PENCATATAN PELAKSANAAN VA
Umur
Kelompok
(18-59
Umur
tahun)
34 31-45
37 31-45
29 18-30
55 46-59
24 18-30
22 18-30
58 46-59
56 46-59
24 18-30
37 31-45
26 18-30
25 18-30
46 46-59
52 46-59
34 31-45
25 18-30
32 31-45
22 18-30
39 31-45
29 18-30
39 31-45
33 31-45
30 18-30
29 18-30
21 18-30
22 18-30
42 31-45
27 18-30
43 31-45
48 46-59
33 31-45
39 31-45
28 18-30
36 31-45
27 18-30
26 18-30
27 18-30
26 18-30
24 18-30
33 31-45
26 18-30
40 31-45
40 31-45
27 18-30
30 18-30
26 18-30
26 18-30
30 18-30
36 31-45
33 31-45
25 18-30
21 18-30
38 31-45
21 18-30
30 18-30
35 31-45
40 31-45
25 18-30
34 31-45
44 31-45
63 0
63 0
66 0
61 0
53 46-59
Alamat

DUSUN PULAU PAGUNRT 04 RW 02, KAPUAS HULU
JL. RAWASARI NO. 138 BUKUT SANGKAL RT 48 RW Air Padang 30114
CIMENYAN II RT 02 RW 06
SUKAJADI RT 09 RW 03
CITANGKOLO RT 02 RW 01
BALOKANG RT 47 RW 15
PASIRLEUTIK RT 30 RW 12
RANCAKOLE RT 03 RW 01, MULYASARI
RANDEGAN RT 09 RW 05
RANDEGAN I RT 04 RW 02
DUSUN CIDEWA RT 05 RW 15
JL. SAKURA NO. 28 RT 06 RW 04, MAJENANG
DUSUN SINDANG RT 39 RW 06
LINGK. BANJAR RT 04 RW 02, BANJAR
KP BARANGBANG RT 03 RW 04
PEPUDUTAN RT 03 RW 02, KEBUMEN
KP. CIBURIAL RT 02 RW 01, LEMBANG
SUKAHURIP RT 04 RW 02, BANJARSARI
KP. IGOK, JAWA BARAT
DUSUN DESA RT 03 RW 05
DUSUN WETAN, JATINAGARA RT 20 RW 05
CIMENYAN I RT 04 RW 03
GIRIMULYA RT 01 RW 13, BINANGUN
DUSUN KIDUL RT 12 RW 07, CIPAKU
KP. PASANGGRAHAN RT 04 RW 08
DUSUN SUKAHURIP RT 02 RW 03, SUKAMUKTI
JADIMULYA RT 04 RW 08, HEGARSARI
PR. GRIYA AMERTA BLOK A.1
PANATASAN RT 01 RW 20, PATARUMAN
RAKSABAYA RT 10 RW 03, CIMARAGAS
RANCAGEDE RT 32 RW 12, CIMARAGAS
TANJUNGSUKUR RT 05 RW 14, HEGARSARI
CIKABUYUTAN TIMUR RT 04 RW 12
TANJUNGSUKUR RT 51 RW 04
PINTUSINGA RT 03 RW 19
CIKADU RT 24 RW 11, KARANGPANIMBAL
BABAKANSARI RT 01 RW 09
DUSUN KALER RT 06 RW 02, CIJEUNGJING
PABUARAN RT 05 RW 01
DUSUN RANDEGAN RT 06 RW 12, HEGARSARI
KP DAYEUH NANGGUNG RT 02 RW 03
LINGK. PATARUMAN RT 02 RW 15


Nama/Jenis/Merek
Vaksin***
BPJS PBI BPJS Non
Non
PBI Anggota
81224400087 4/21/2021 VACCINE COVID-19

82316104486 4/21/2021 VACCINE COVID-19
81222291515 4/21/2021 VACCINE COVID-19
81222291515 4/21/2021 VACCINE COVID-19
81388993477 4/21/2021 VACCINE COVID-19
82116161738 4/21/2021 VACCINE COVID-19
89601167203 4/21/2021 VACCINE COVID-19
85353238613 4/21/2021 VACCINE COVID-19
81221479147 4/21/2021 VACCINE COVID-19
82111222622 4/21/2021 VACCINE COVID-19
82119887606 4/21/2021 VACCINE COVID-19
85220208040 4/21/2021 VACCINE COVID-19
87789480929 4/21/2021 VACCINE COVID-19
81214348669 4/21/2021 VACCINE COVID-19
82321548336 4/21/2021 VACCINE COVID-19
85721477439 4/21/2021 VACCINE COVID-19
81903104860 4/21/2021 VACCINE COVID-19
082117383503 4/21/2021 VACCINE COVID-19
08112000185 4/21/2021 VACCINE COVID-19
81221996374 4/21/2021 VACCINE COVID-19
081323232910 4/21/2021 VACCINE COVID-19
087719825700 4/21/2021 VACCINE COVID-19
85223450900 4/21/2021 VACCINE COVID-19
81313008092 4/21/2021 VACCINE COVID-19
81215164463 4/21/2021 VACCINE COVID-19
87708665222 4/21/2021 VACCINE COVID-19
81214467325 4/21/2021 VACCINE COVID-19
83147456800 4/21/2021 VACCINE COVID-19
82316745007 4/21/2021 VACCINE COVID-19
87705030849 4/21/2021 VACCINE COVID-19
87833464448 4/21/2021 VACCINE COVID-19
8220184466 4/21/2021 VACCINE COVID-19
82218974944 4/21/2021 VACCINE COVID-19
82123019661 4/21/2021 VACCINE COVID-19
82120296044 4/21/2021 VACCINE COVID-19
81322865002 4/21/2021 VACCINE COVID-19
82214797003 4/21/2021
0895325339843 4/21/2021 VACCINE COVID-19
83827649262 4/21/2021 VACCINE COVID-19
87728111172 4/21/2021
81572496585 4/21/2021 VACCINE COVID-19
85320648234 4/21/2021 VACCINE COVID-19
85216353559 4/21/2021 VACCINE COVID-19
81248856780 4/21/2021 VACCINE COVID-19
85863074750 4/21/2021 VACCINE COVID-19
82315450563 4/21/2021 VACCINE COVID-19
82115512321 4/21/2021 VACCINE COVID-19
82218852164 4/21/2021 VACCINE COVID-19
81321380458 4/21/2021 VACCINE COVID-19
81222647690 4/21/2021 VACCINE COVID-19
82116136151 4/21/2021 VACCINE COVID-19
81313430682 4/21/2021 VACCINE COVID-19
87705310077 4/21/2021 VACCINE COVID-19
88218302997 4/21/2021 VACCINE COVID-19
82216751641 4/21/2021 VACCINE COVID-19
82320145772 4/21/2021 VACCINE COVID-19
85314179055 4/21/2021 VACCINE COVID-19
89506361700 4/21/2021 VACCINE COVID-19
85624453840 4/21/2021 VACCINE COVID-19
81222730203 4/21/2021 VACCINE COVID-19
4/21/2021
85324221676 4/21/2021 VACCINE COVID-19
085352388370 4/21/2021 VACCINE COVID-19
Dosis I Dosis 2
Tanggal Tanggal
Vaksinasi Vaksinasi
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
4/21/2021 24001021
Keterangan
Diberikan/Lanjut)
LANJUT DOSIS 2
NAKES PATARUMAN 3
LANJUT DOSIS 2
LANJUT DOSIS 2
NAKES RS PMC
LANJUT DOSIS 2
LANJUT DOSIS 2
KOAS UMJ
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 TRAVEL CITRA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
PT WINGS
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 LAPAS BANJAR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 DINAS PU
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA PROMIL
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA PROMIL
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
PT CNS MAYORA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 TOKOH MASYARAKAT
SELESAI
TUNDA HIPERTENSI
CJH
SELESAI
SELESAI
SELESAI SLBN BANJAR
Jenis
Kelamin
1 S-1982B5F3 3279025405530001 SRI SULASTRI P

2 S-31552F0D 3279022906510001 ENGKUS KUSMANA L
3 S-1527CB7D 3279025005580001 RODINCE SIHOMBING P
4 S-5FCA4A85 3215131210590002 ENDANG MULYANA L
5 S-96ECA458 3279034102410001 N ONENG GARMIPAH P
6 S-ECBF531C 3207055804590001 IMAS ROHIMAH P
7 S-CAEEF71D 3279024201500001 YAYAH UTIRAH P
8 S-FC8A43E9 3279025808550001 TITI ROHAETIN P
9 S-F64D5FAD 3279026010600001 ELIN HALIMAH P
10 S-4B968127 3279025407580002 PONIJAH P
11 S-0B84521F 3279020507410001 ABY SURAHMAN L
12 P-3Y88L72E 3301165508630004 IIS RATNA KURNIASIH P
13 P-3FBWNOG0 3404081801980001 ABDUL JABAR L
14 P-3FVA2ALE 3279021801030001 MUHAMMAD RAFLY PURNAMA L
15 P-3GBIJNUY 3279026312710002 RAJA JAHNIBAR P
16 P-3KXBGIBL 3279026204640001 MIMING HERMAWATI P
17 P-3Q9JDTMY 3279020909020003 AGRI SALVA SEFTIAN L
18 Z-BE71DC01 3279024312600005 N FARIDAH SPDI P
19 Q-6E4C75A7 3279011711790001 DANI HERDIANA L
20 Z-3702B379 3279026509540001 LOMRAH P
21 Z-066AB090 3279023107520001 NANA RUSMANA L
FORMAT PENCATATAN PELA
TINGKAT PUSKESMAS/FA
Umur
Kelompok
Pekerjaan* (18-59 Alamat
Umur
tahun)
LANSIA 68 0 BABAKANSARI RT 03 RW 09
LANSIA 69 0 LEMBURBALONG RT 03 RW 05
LANSIA 62 0 JELAT RT 02 RW 03
LANSIA 80 0 PARUNGSARI 10/05
LANSIA 62 0 BABAKANSARI 08/11
PELAYANAN PUBLIK 58 46-59 BABAKANSARI RT 03 RW 09
PELAYANAN PUBLIK 23 18-30 SEMBUNG SENDANG, DIY
PELAYANAN PUBLIK 56 46-59 JELAT RT 03 RW 02
PELAYANAN PUBLIK 19 18-30 BABAKANSARI 03/11
GURU 61 0
JAMAAH HAJI 42 31-45 AWILUAR RT 12 RW 04, SITUBATU
PEDAGANG PASAR 67 0 JELAT RT 02 RW 02
PEDAGANG PASAR 69 0 JELAT, PATARUMAN
MAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

No. Hp Screening Vaksin***
BPJS PBI BPJS Non
Non
PBI Anggota

81223857328 4/26/2021 VACCINE COVID-19
89657888792 4/26/2021 VACCINE COVID-19
82119581550 4/26/2021 VACCINE COVID-19
81222828518 4/26/2021 VACCINE COVID-19
85299250386 4/26/2021 VACCINE COVID-19
85854755343 4/26/2021 VACCINE COVID-19
85323002588 4/26/2021 VACCINE COVID-19
81317043486 4/26/2021 VACCINE COVID-19
81391213604 4/26/2021 VACCINE COVID-19
Dosis I Dosis 2
Tanggal Tanggal
Vaksinasi Vaksinasi
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
4/26/2021 24001021
Keterangan
Diberikan/Lanjut)
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
SELESAI
SELESAI
SELESAI
SELESAI
Jenis
Kelamin
1 P-70HU4WF3 3279026212760001 RINA HASANAH P

2 P-82EPVEXC 3279024506690001 RINI SUKINI SUSILAWATI P
3 P-844LMIC7 3279025011850002 SUSI SUSILAWATI P
4 P-878HNGP8 3279024402700002 ONAH P
5 P-896DHKM6 3279026308640001 ENOK ENGKAR P
6 P-8H9NPVP8 3279026206820002 sri wahyuni P
7 P-8WSCLQ4D 3279025702790003 ROHIMAH P
8 P-8YB0FC4C 3279022510780001 EDI SUYANTO L
9 Y-010G0IO2 3172025009651001 RANI SANTANI P
1 S-0A389920 3279025708580001 RAKISAH P
2 S-37570FA4 3279024409570001 NENDAH P
3 S-4A072B42 3279020906530003 KODIR L
4 S-74CDC0F7 3279022508570001 ABDUL AJID L
5 S-7586407A 3279025103520001 ENOH P
6 S-9F8EB3AC 3279022307530001 PATAH L
7 S-A46DAF6D 3279021002600002 AWANG DARMAWAN L
8 S-B7F09456 3279024610580001 ANTINAH P
9 S-C1A4F5CB 3279025208590001 ENING P
10 S-DA517811 3279025504600002 EJEN P
11 S-E9246D18 3279020107530011 HUSEN L
1 Z-06681880 3279020103580001 SARDI L
2 Z-ED3CDE61 3301167112470017 ROHATI P
3 Z-ED43E46B 3301160301480001 HARSO L
4 Z-ED69C5EA 3279026004600003 TITIN ROHANAH L
5 Z-ED788B0B 3279024101540030 ONAH ROHAENAH P
6 Z-ED807B80 3279021101500001 OLIH RUSPENDI L
7 Z-ED91D941 3279025006600005 UU MASUNAH P
8 Z-ED97E9A0 3279025010510003 EDAH DARIAH P
9 Z-EDD0AE1D 3279025606480001 IIR IRAH P
10 Z-EE01F607 3279020307490001 HADI HERJANA ISMAWIDJAJA L
11 Z-EE0A787F 3279020508380001 MADASRI L
12 Z-FBADB853 3279020711580003 ADANG DAUD RHAMLI L
13 Z-FBC65297 3279025208590003 NANI SURYANI P
14 P-83PCEKKX 3279024844770002 RAHWATI P
35 3301162908590001 KECO CARSO L
36 3279031601610001 MARYANA L
37 ATAM L
38 ESIH P
39 IROH P
40 OOH P
41 3279024808580002 HODIJAH P
42 3279024503600001 SITI MARIAM P
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
PELAYAN PUBLIK 45 31-45

LANSIA 63 0
LANSIA 64 0
LANSIA 68 0
LANSIA 64 0
LANSIA 69 0
LANSIA 68 0
LANSIA 61 0
LANSIA 63 0
LANSIA 61 0
LANSIA 61 0
LANSIA 64 0
LANSIA 74 0
LANSIA 73 0
LANSIA 61 0
LANSIA 68 0
LANSIA 70 0
LANSIA 61 0
LANSIA 70 0
LANSIA 83 0
LANSIA 72 0
LANSIA 83 0
LANSIA 63 0
LANSIA 62 0
PERANGKAT DESA 44 31-45
LANSIA 62 0
LANSIA 60 0
LANSIA 0
LANSIA 0
LANSIA 0
LANSIA 62 0
LANSIA 64 0
LANSIA 61 0

Alamat No. Hp
BPJS PBI BPJS Non
PBI
LEMBUR BALONG RT 04 RW 05 89527418008

PANANJUNG BARAT RT 02 RW 01 81222814981
PANANJUNG TIMUR RT 28 RW 06 81992420551
PATARUMAN RT 03 RW 12 082116740976
JL. SUNTER JAYA VI B NO 18 RT 3 RW 07 82210041001
PATARUMAN RT 01 RW 12 085223311534
PANANJUNG TIMUR RT 24 RW 06
PATARUMAN RT 01 RW 15 82116740976
GIRIMULYA RT 06 RW 14, BINANGUN 85323002588
PATARUMAN RT 01 RW 12 82316573700
PANANJUNG BARAT RT 02 RW 01
PATARUMAN RT 01 RW 15
PATARUMAN RT 01 RW 12 82316573700
JELAT, PATARUMAN 81320053336
DUSUN PEUNDEUY RT 01 RW 08, PANULISAN BARAT 82122730173
DUSUN PEUNDEUY RT 01 RW 08, PANULISAN BARAT 82122730173
BABAKANSARI RT 07 RW 11, PATARUMAN 85220319145
LEMBURBALONG RT 03 RW 05, PATARUMAN 083123915431
LEMBURBALONG RT 03 RW 05, PATARUMAN 083123915431
PANANJUNG TIMUR RT 26 RW 06, SINARTANJUNG 82117613565
PANANJUNG RT 23 RW 05, SINARTANJUNG 81321793844
PANANJUNG BARAT RT 01 RW 01, SINARTANJUNG 81222814981
PANANJUNG BARAT RT 01 RW 01, SINARTANJUNG 81222814981
MARGALUYU RT 09 RW 09, MULYASARI 87724874777
SUKAMANAH RT 01 RW 17, PATARUMAN 08122061538
VID-19
SI

Dosis I Dosis 2
olom yang sesuai)
Screening Vaksin*** Tanggal Tanggal
Non
Pemberian No. Batch No. Serial Pemberian
Anggota
Vaksinasi Vaksinasi
4/29/2021 COVID VACCINE 19 4/29/2021 24001021

4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021 24001021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
4/29/2021 COVID VACCINE 19 4/29/2021
Dosis 2
Keterangan
No. Batch No. Serial Diberikan/Lanjut)
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
TUNDA
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
24001021 SELESAI
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
POSITIF
TDK HADIR
Jenis
Kelamin
1 W-6A27803C 3279034209830002 WIRDA HASTIKA P

2 6310092102580001 MUHAMMAD SYA'I L
3 6310095705630002 ENUNG HAYATI P
4 6310091803970004 RIZKY NURUL HAQIQI P
5 Q-09C565F0 3279021203630001 Iswiyanto L
6 Didin Muhyidin
7 3301162908590001 KECO CARSO L
8 3279031601610001 MARYANA L
9 ATAM L
10 ESIH P
11 IROH P
12 OOH P
13 3279024503600001 SITI MARIAM P
14 3279021006580002 Undang Syam L
15 P-B3FHSE6Z 3279020907970003 ERVAN JULIANUS L
16 P-BD1K2MBO 3279020908990003 FAWWAZ NABIL KHRISYANA L
17 P-AZKI8POT 3279024810680001 ESIH KURNIASIH P
18 P-AZXRRPHI 3279022408710003 AGUS NUGRAHA L
19 P-B7D73W07 3279026111010001 MENTARI RAMADHINI P
20 P-B8A8EJVT 3279016306970001 MEGA ANITA RAHMAWATI P
21 P-B8S1OQFC 3279012310990001 YUSUF CHAERUL RAHMANSYAH L
22 P-CFBM14WT 3278042001720001 SYARIEF HENDRA DEWANTO L
FORM
TI
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
GURU 37 31-45
CJH 63 >60
CJH 56 46-59
CJH 24 18-30
LANSIA 62 0
LANSIA 60 0
LANSIA 0
LANSIA 0
LANSIA 0
LANSIA 62 0
LANSIA 61 0
JEMA'AH HAJI 63 0
48 46-59
FORMAT PENCATATAN PELAKSANAAN VAKSINASI
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI
Alamat

SUNGEI KECIL NO. 53
SUNGEI KECIL NO. 53
SUNGEI KECIL NO. 53
LINGK, PATARUMAN 01/03

JELAT 01/01, PATARUMAN
DUSUN PANANJUNG RT 20 RW 05
CIMENYAN I 04/05
LINGK. CIMENYAN 1 04/05
: JL. LIUNGGUNUNG RT 001 RW 006, DESA PANYINGKIRAN, INDIHIANG
ATATAN PELAKSANAAN VAKSINASI COVID-19
PUSKESMAS/FASYANKES/POS VAKSINASI

BPJS PBI BPJS Non
Non
PBI Anggota
082127320983 5/5/2021 COVID VACCINE-19
5/5/2021 COVID VACCINE-19
87724874777
81323328931
85223431375
89631891178 5/5/2021 COVID VACCINE-19

85894769140 5/5/2021 COVID VACCINE-19
85220247755 5/5/2021 COVID VACCINE-19
85224641176 5/5/2021 COVID VACCINE-19
82215349699 5/5/2021 COVID VACCINE-19
82218310684 5/5/2021 COVID VACCINE-19
87760827755 5/5/2021 COVID VACCINE-19
81323764320 5/5/2021 COVID VACCINE-19
Dosis I Dosis 2

Vaksinasi Vaksinasi
5/5/2021 24001021 5/5/2021 2410021
5/5/2021 24001021 5/5/2021 2410021
5/5/2021 24001021 5/5/2021 2410021

5/5/2021 24001021 5/5/2021 2410021
5/5/2021 24001021 5/5/2021 2410021
5/5/2021 24001021 5/5/2021 2410021
5/5/2021 24001021 5/5/2021 2410021
5/5/2021 24001021 5/5/2021 2410021
5/5/2021 24001021 5/5/2021 2410021
5/5/2021 24001021 5/5/2021 2410021
Keterangan
Diberikan/Lanjut)
SELESAI GURU
TDK HADIR
TDK HADIR CJH
TDK HADIR
SELESAI TNI PURAWIRAWAN
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
TDK HADIR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
Jenis
Kelamin
1 Q-14F2B0CF 3279020708710004 IWAN SETIAWAN L

2 Q-567827F7 3279021206700002 DIDI KARYADI L
3 Q-6AF51CCB 3279022506680004 UCA SUMANTRI L
4 Q-56823E90 3279024605810001 MELIWATI P
5 Q-A3F5D23A 3279021610700001 PAIMUN L
6 Q-7398676C 3279024908740002 ROSANAH P
7 Q-42770C08 3279022606760001 NANA SUTISNA L
8 Q-1FD7D20B 3279021002810002 CARDIWAN L
9 Q-BC286AA0 3279021508880005 ADI RADIANSYAH L
10 Q-8715264A 3279020109680002 KIKIM SAKIM L
11 Q-FFF0A258 3279025204750001 SRI INDRAWATI P
12 3279020804900001 ADI MULYANTO L
13 3279021402690000 SAPTA SUPRATA L
14 Q-35E25F91 3279020105750001 HENDARTO L
15 Q-0D1CB4C2 3279024503720003 AI NURHAYATI P
16 Q-8CAA839C 3279025808770002 DEDE SRI MULYATI P
17 Q-8C24948E 3204124103820013 ELIS LINA MARLINA P
18 Q-86B3FF1D 3279026901930001 AYU ANDINA P
19 Q-2ECF7AE4 3279024104010001 PUSPA APRILIA TRIMILENA P
20 Q-64204217 3279026404820001 YATI HERLIANTI P
21 Q-3CD00EA3 3279024101690015 ATIK SUSILAWATI P
22 W-F5DE3EC5 3279020307680001 YANTO DARYANTO L
1 W-F386C886 3279025101610002 DEDE ATIKAH P
2 3207175507570002 SAMINAH P
3 Z-E4DABD41 3279026708500001 DARYATI P
4 Z-169F0AED 3279021102530001 ADE AMAR L
5 Z-0EEC2119 3279024707570003 NENENG YULIANI P
6 Z-262A9834 3279024508580004 WATI P
7 Z-19A4BC7A 3279025205480004 SOPIAH HAYATY P
8 Z-62EAB68F 3279025506590004 ENAH P
9 Z-DAC5442B 3279020610600001 ACE SOPIAN L
10 Z-EB765E7E 3279024308450002 INAH SUTIASIH P
11 Z-26217648 3279024208550001 TARWIYAH P
12 Z-ED805044 3279021706580002 ENGKUS L
13 Z-24656AE3 3279024802550002 MIMI P
14 Z-F02A15B3 3279025105510001 EJE P
15 Z-A6F0460F 3279024101570021 PATONAH P
16 Z-1993A624 3279025007380001 MAERAHWATI P
17 3279025107550004 TITING P
18 Z-48BADE04 3279021404500003 EMAN TASMAN L
19 Z-F0C61A11 3279022112550001 MAMAN SOMANTRI L
20 Z-627C3376 3279022112550001 POPON P
21 Z-E2CFEAC7 3279025706550001 MIMIN MINTARSIH P
22 Z-976788CC 3279020101520007 MAMAT L
23 Z-0EF56456 3279024711550001 KASINEM P
24 Z-C2FFA9A7 3279021607600002 UBAD ABDUL HAMID L
25 Z-A6F84DA9 3279024107580006 TITI P
26 Z-2DD0B8F2 3279020107440008 AJA L
27 Z-C8DC76AF 3279021001580001 IJAN L
28 Z-8F0FDAD8 3279024101470010 KHODIJAH P
29 Z-F6401BB9 3279020612590003 ROSID L
30 Z-95570414 3273100504510001 ADE ROHMAT L
31 Z-627450D5 3273100504510001 TITIK YUNTATI P
32 Z-70A42651 3279021405600002 ACIM L
33 3279021512600002 UJANG MAMAN L
34 S-9E611370 3279021005500001 SUDINTA L
35 Z-A8148B9E 3279022009590002 ADUT KASNO L
36 Z-26B723CA 3279022009590002 WIWI P
37 Z-DF78E212 3279021308590001 EEN SUPENDI L
38 Z-9858B6B7 3279020610500002 HUSIN L
39 Z-127AAFBB 3279021109540001 ROSID L
40 Z-1A253494 3279025508550003 MIMIN P
41 Z-713C59D2 3279020101420006 EWON SUPARMAN L
42 Z-FEE8D682 3279026304530001 WIWI P
43 Z-E4ECC58C 3279025008550000 HADMIRAH P
44 Z-EB6CDEE8 3279020510570001 ENTOY HERLIANA L
45 Z-CB975E40 3279026201590001 IKA SUPARMIKA P
46 Z-BFEC2BB6 3279024501580002 ENDANG WAHYUNINGSIH P
47 Z-DAADE869 3279020107550009 AIP SARIP L
48 Z-101F6E35 3279020108550003 HASIM L
49 3279025011600004 EDAH L
50 Z-186431A5 3279022105520001 TOHA L
51 Z-ED8C1250 3279022804510002 KOSIM L
52 Z-DF8B5BE9 3279025608580001 MARYATI P
53 Z-6269631E 3279024511590003 YOYOH RODIAH P
54 Z-21F81503 3279022804540001 KUSMAN L
55 3279020504590001 SAEPUDIN ZUHRI L
56 Z-DF82DDB2 3279024512560004 ELA KARMILA P
57 6472021211590001 JUMARI L
58 Z-EB760149 3279020103500002 DIDI EFENDI L
59 Z-C8E883ED 3279021011550001 ROSADI L
60 Z-20CD4546 3279022508400001 DARPI L
61 Q-1A3209C7 3279022508400001 AAN P
62 Q-CA1DD2D0 3279025205610002 TATI MARYANI P
63 3279025205610002 HERI L
64 Q-C15F5D7D 3279024503610001 RUWITA P
65 Q-4820DD5F 3279024503610001 DJAMIAT PANJAITAN L
88 Q-643E67BB 3404081801980001 ABDUL JABAR L
FORMAT PENCATA
TINGKAT PUSK
S PATARUMAN 3
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
TOKOH MASYARAKAT 50
TOKOH MASYARAKAT 51
TOKOH MASYARAKAT 53
TOKOH MASYARAKAT 40
TOKOH MASYARAKAT 51
TOKOH MASYARAKAT 44
TOKOH MASYARAKAT 45
TOKOH MASYARAKAT 40
TOKOH MASYARAKAT 33
TOKOH MASYARAKAT 53
TOKOH MASYARAKAT 46
TOKOH MASYARAKAT 30
TOKOH MASYARAKAT 52
TOKOH MASYARAKAT 46
TOKOH MASYARAKAT 49
TOKOH MASYARAKAT 44
TOKOH MASYARAKAT 39
TOKOH MASYARAKAT 28
TOKOH MASYARAKAT 20
TOKOH MASYARAKAT 39
TOKOH MASYARAKAT 52
TOKOH MASYARAKAT 51
LANSIA 60
LANSIA 63
LANSIA 71
LANSIA 68
LANSIA 64
LANSIA 63
LANSIA 73
LANSIA 62
LANSIA 61
LANSIA 76
LANSIA 66
LANSIA 63
LANSIA 55
LANSIA 70
LANSIA 64
LANSIA 83
LANSIA
LANSIA 71
LANSIA 66
LANSIA 71
LANSIA 66
LANSIA 69
LANSIA 66
LANSIA 61
LANSIA 63
LANSIA 77
LANSIA 63
LANSIA 74
LANSIA 62
LANSIA 70
LANSIA 62
LANSIA 61
LANSIA
LANSIA 71
LANSIA 62
LANSIA 62
LANSIA 62
LANSIA 71
LANSIA 67
LANSIA 66
LANSIA 79
LANSIA 68
LANSIA 66
LANSIA 64
LANSIA 62
LANSIA 63
LANSIA 66
LANSIA 66
LANSIA
LANSIA 69
LANSIA 70
LANSIA 63
LANSIA 62
LANSIA 67
LANSIA
LANSIA 65
LANSIA
LANSIA 71
LANSIA 66
LANSIA 81
LANSIA 60
LANSIA 60
LANSIA
LANSIA 60
LANSIA 55
PELAYANAN PUBLIK 23 18-30
DOSIS 2
Kepesertaan BPJS (tulis 'Ya' pada ko

yang sesuai)
Alamat No. Hp
BPJS PBI BPJS Non
PBI
DUSUN PANANJUNG TIMUR RT 31 RW 07, SINARTANJUNG 81806355268

DUSUN PANANJUNG RT 14 RW 03, SINARTANJUNG 82216568341
DSN PANANJUNG RT 018 RW 004

DUSUN SINARGALIH RT 33 R 08, SINARTANJUNG

SEMBUNG SENDANG, DIY 89657888792
AN VAKSINASI COVID-19
ES/POS VAKSINASI
taan BPJS (tulis 'Ya' pada kolom

Dosis I
yang sesuai)
Non Anggota Pemberian No. Batch
Vaksinasi







5/10/2021
Dosis I Dosis 2
Keterangan
No. Serial Pemberian No. Batch No. Serial Diberikan/Lanjut)
Vaksinasi
5/10/2021 24001021 SELESAI

5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
TDK HADIR
TDK HADIR
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
TDK HADIR
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
TDK HADIR
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
TDK HADIR
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
TDK HADIR
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
TDK HADIR
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
TDK HADIR
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
5/10/2021 24001021 SELESAI
NAMA INSTANSI
DESA SINARTANJUNG
PELAYAN PUBLIK
Jenis
Kelamin
1 3279020512850001 DEDE HAERUDIN L

2 3279020607810001 YAYAN L
3 3279025912800001 DESI DAMAYANTI P
4 3279026303890001 RENI RISMAYANTI P
5 3279024711880001 LANI NOVIANI P
6 3275085607800037 ANI HERLINA P
7 3279025005840001 UTI NURPAJAR P
8 3279024805880002 NUNUNG NURLINA P
9 3279027006860001 ENUNG SULASTRI P
10 3279024808830003 ETI SUHAETI P
11 3279025809820004 NURLIA NINGSIH P
12 3279025308820004 JEJEH PUSPITASARI P
13 3279024105760005 SITI AISAH P
14 3279025906780001 LENI MARLINA P
15 3279020303760001 LASIMAN L
16 3206374701970003 AI CAHYANI P
17 3207156711970001 IIN SITI NURJANNAH P
18 3275031507590022 SUMARYONO L
19 3279021508450001 ONON RUKMAN L
20 3279021705580001 TISNA SUTISNA L
21 3279021506530001 DARSONO L
22 3279020907510001 KUSNADI L
23 2171036508531001 HAYATI P
24 3279015901530001 ELI SURLIAH P
25 3279011203510002 DADI KARTADJUMHANA L
26 3279021612550001 IYUS L
27 3279010107480001 ENDANG HIDAYAT L
28 3279025703540001 YAYUK LASMIYATIN P
29 3279024504520001 LOMRAH P
30 3279020406580002 SAHDI L
31 3279024808600002 YUHYATI P
32 3279020806610001 YUDIMAN L
33 3279024610600001 ENOK PIPING HENDAYANI P
34 3279015806430001 TASMINAH P
35 3279020404600001 TOYO L
36 3279026411580001 ENTIN P
37 3279021802530001 UKENG SUHERMAN L
38 3279020804540001 HADI MULYO L
39 3279021312530001 MULYONO HADISUSANTO L
40 3279024607610001 MARPUAH P
41 3279021805530001 MUMU L
42 3279020509590004 KUSWITO L
43 3279022503520001 KIRNO SUKIRJO L
44 3279024802580001 TIKA HASANAH P
45 3279021903560001 HENDRAMANA L
TARUMAN 3 DOSIS 2
Umur
Kelompok
Umur
tahun)
TOKOH MASYARAKAT 36 RANCAKOLE RT 12 RW 03

TOKOH MASYARAKAT 41 SUKAMAJU RT 07 RW 05
TOKOH MASYARAKAT 47 SUKAMAJU RT RT 01 RW 04
GURU PAUD 39 SUKAMAJU RT 01 RW 04
GURU PAUD 45 SUKAMAJU 10 RW 06
GURU PAUD 23 MARGALUYU RT 04 RW 08
GURU PAUD 24 SIDAMULYA RT 06 RW 13, CIAMIS
LANSIA 62 PUP BLOK G3/18 RT 1 RW 11, BEKASI
LANSIA 76 RANCAKOLE RT 13 RW 13
LANSIA 66 SUKAMAJU RT 03 RW 04
LANSIA 78 MARGALUYU RT 08 RW 09
LANSIA 78 SIKAMAJU RT 03 RW 04
LANSIA 78 MARGALUYU RT 04 RW 08
T PENCATATAN PELAKSANAAN VAKSINASI COVID-19
GKAT PUSKESMAS/FASYANKES/POS VAKSINASI
DOSIS 2

Dosis I
Nama/Jenis/Merek
No. Hp Tanggal Screening Tanggal
Vaksin***
BPJS PBI BPJS Non
Non
Pemberian
82121826313 5/11/2021 COVID VACCINE

82116028131 5/11/2021 COVID VACCINE
82320897121 5/11/2021 COVID VACCINE
82321050505 5/11/2021 COVID VACCINE
82320930392 5/11/2021 COVID VACCINE
82126545025 5/11/2021 COVID VACCINE
8987890855
85223535445 5/11/2021 COVID VACCINE
82219002405 5/11/2021 COVID VACCINE
81297621003 5/11/2021 COVID VACCINE
82217442152 5/11/2021 COVID VACCINE
81218131691 5/11/2021 COVID VACCINE
89644575192 5/11/2021 COVID VACCINE
82218821885 5/11/2021 COVID VACCINE
5/11/2021 COVID VACCINE
0895332261876
85321495397
081315737001


85223121699 5/11/2021 COVID VACCINE



Dosis I Dosis 2
Keterangan
Vaksinasi
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
TDK HADIR
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
TDK HADIR
TDK HADIR
TDK HADIR
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
TDK HADIR
5/11/2021 SELESAI DESA MULYASARI
5/11/2021 SELESAI
5/11/2021 SELESAI
TDK HADIR
TDK HADIR
5/11/2021 SELESAI
5/11/2021 SELESAI
TDK HADIR
5/11/2021 SELESAI
5/11/2021 SELESAI
5/11/2021 SELESAI
TDK HADIR
5/11/2021 SELESAI
TDK HADIR
TDK HADIR
5/11/2021 SELESAI
5/11/2021 SELESAI
TDK HADIR
5/11/2021 SELESAI
5/11/2021 SELESAI
TDK HADIR
5/11/2021 SELESAI
5/11/2021 SELESAI
1 Q-46B24005 3204284104650004 NYAI JUARIAH

2 3279020604550003 SARAN
3 3279024101430008 TONAH
4 Z-C3385C66 3279024101370002 SUPIAH
5 Z-1465DE09 3279025803560002 N WARLIAH
6 Z-3196F031 3279020112570002 HENARISMAN
7 Z-AA07E806 3279025406570003 NOORJANAH AR
8 Z-D3485332 3279024912580001 N KESIH
9 3279024106540001 DEDE HOTIMAH
10 Z-07102E20 3279027011600002 ETI ROSTIAWATI
11 Z-0708A8C8 3279022202550001 AAN ROHAENI SUPRIATNA
12 Z-6C384B11 3279025207490001 SUMIRAH
13 3279026609560001 ADAH ARSIH
14 Z-BB3B3755 3279015006520001 TATI SITI CHOTIMAH
15 Z-4CFF94C4 3279020504540002 KODAR
16 Z-209A9E3F 3279026606520001 TRESNASIH SUMITRA
17 Z-5C13C620 3279020307490001 HADI HERJANA ISMAWIDJAJA
18 Q-FF6F1E8B 3279020804900001 ADI MULYANTO
19 3279021402690000 SAPTA SUPRATA
20 Z-97F9C5CB 3207175507570002 SAMINAH
21 Z-1C8EC7DB 3279025107550004 TITING
22 Z-8E831EC8 3279021512600002 UJANG MAMAN
23 Z-C20ECCCB 3279025011600004 EDAH
24 Z-C96CA74F 3279020504590001 SAEPUDIN ZUHRI
25 3279025205610002 HERI
26 Q-599B1A5B 3279025010770003 NURLAELA HASANAH
FORMAT PENCATA
TINGKAT PUSK
Umur
Jenis Kelompo
Pekerjaan* (18-59
Kelamin k Umur
tahun)
P LANSIA >60
L LANSIA >60
P LANSIA >60
P LANSIA >60
P LANSIA >60
L LANSIA >60
P LANSIA >60
P LANSIA >60
P LANSIA >60
P LANSIA >60
L LANSIA >60
P LANSIA >60
P LANSIA >60
P LANSIA >60
L LANSIA >60
L LANSIA >60
L LANSIA 72 0
L TOKOH MASYARAKAT 30
L TOKOH MASYARAKAT 52
P LANSIA 63
P LANSIA
L LANSIA
L LANSIA
L LANSIA
L LANSIA
P TOKOH MASYARAKAT 44 31-45
DOSIS 2
Kepesertaan BPJS (tulis 'Ya

kolom yang sesuai)
Alamat No. Hp
BPJS PBI
PERUM DOBOKU LIGAR RT 08 RW 11

SUKAMANAH RT 01 RW 17
LEMBURBALONG RT 02 RW 17
LEMBURBALONG RT 03 RW 06
LINGK. JELAT RT 04 RW 01
LINGK. PATARUMAN RT 02 RW 15 81222730203
NASI COVID-19
AKSINASI

Dosis I
kolom yang sesuai)
Nama/Jenis/Merek
Tanggal Screening
BPJS Non Non Vaksin*** Tanggal Pemberian
No. Batch
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
5/17/2021
Dosis I Dosis 2
Keterangan
Vaksinasi
5/17/2021 24001021 SELESAI

TDK HADIR
TDK HADIR
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
TDK HADIR
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
TDK HADIR
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
TDK HADIR
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
5/17/2021 24001021 SELESAI
NAMA INSTANSI
TOKOH MASYARAKAT
Jenis
Kelamin
1 3279021909640001 DODI SUPARDI L

2 W-E4BDEF49 3279026907630001 ANI MULYANI P
3 W-E4B70B39 ELIS NURAENI P
4 Q-DB987877 3279026801920001 YANI SURYANI P
5 W-B5A04A78 3279025506000003 SAYIDIANA LATIFAH P
6 Q-FFBE79DA 3279026508770003 SUMIYATI P
7 3279025810940001 SUCI HERLINA P
8 Q-F68531DB 3279026010650001 ETTY MUSLIHATI P
9 Q-2C4171E5 3279025406660001 EUIS SRI HAYATI P
10 Q-7F34B8C2 3279022104650005 DEDI RUSPENDI L
11 Z-D573ED77 3279024408790002 ERNI MURNIASIH P
12 Q-3F2919EE 3279024203760003 IDA KARLINA P
13 Z-3F2FD44B 3279024604680004 ELAH HAYATI P
14 Q-3F391375 3279025001850002 ENUNG NURHAYATI P
15 Q-2D410780 3279024412870002 ENI NURHASANAH P
16 Q-1DD50924 3279024407760002 SRI BUDI ARYANI P
17 Q-812C0B40 3279016609750001 SUWARNI P
18 Q-AA1CC796 3279026602760002 TATIEK HADIYANTI P
19 Q-FCA983BA 3279036503870002 RENA RAHAYU NINGSIH P
20 Q-4DE57417 3279025709740002 SRI ASIH RUBIANTIKA P
21 Q-7774F3C3 3279025606850003 FIFIT WIDIANTINY P
22 Q-ADADE53A 3279026707710004 NURYANI P
23 Z-3A1F9893 3279027004870001 IRMA NURHOLIS P
24 Z-AF0A6B6D 3279015505760008 LIA MELIA P
25 Q-3A19CF47 3279025407740001 RD. HERYANI P
26 Q-021BCC03 3279024811900001 NANI MARYANI P
27 W-A1010774 3279026306850001 TRI MULYANI P
28 Q-250A1872 3279024504830002 LIA DAHLIA P
29 3279025111860001 ERNI SUPRIYATI P
30 Q-25C88AA5 3279024110770001 ATIK SUPARTIKA P
31 Q-5883EAFE NURCAHYATI P
32 W-580FE02D 3279016808720001 EUIS ROSIDA P
33 Q-2515D110 3279024706750001 NONOK TITI HARTILAH P
34 Q-4D17F385 3279024311800002 UCU ASIAH P
35 Q-BEB7F6D5 3279024309750001 ELIS ROSYANTI P
36 Q-A22F3D63 3279024609690002 YENI YULIA P
37 Q-9CEF4DCE 3279024209850003 NENG KURNIASIH P
38 Q-7796A86D 3279026502710001 ENOK SRI KOMALA P
39 Q-4E98130D 3279024907860002 SUDARYANTI P
40 3279034704940002 DIANA GALIH P
41 Z-0840C0B2 3279024101430008 TONAH P
TINGKAT PUSKESMAS/FASYANKES/P
Umur
Kelompok
Umur
tahun)
GURU SD 57 JELAT 01/04 81318469964

GURU SD 58 CIKABUYUTAN TIMUR 05/11 82118257515
GURU PAUD 42 PANANJUNG BARAT 05/01
GURU PAUD 46 SUKARAME 06/11 85220114131
GURU PAUD 34 RANDEGAN 1 07/03 83129441666
GURU PAUD 45 LINGK. HAURMUKTI 41/02 85315708314
GURU PAUD 47 JELAT 03/03 89669604320
GURU PAUD 38 LEMBURBALONG 02/06 81222193099
GURU PAUD 22 PINTUSINGA 02/19
GURU PAUD 49 SUMANDING KULON 01/20 85315526783
GURU PAUD 46 PANATASAN 02/20 85294198940
GURU PAUD 40 SUKAMANAH 04/18 82220473599
AN PELAKSANAAN VAKSINASI COVID-19
ESMAS/FASYANKES/POS VAKSINASI

Dosis I
BPJS PBI BPJS Non
Non
Pemberian No. Batch
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
COVID VACCINE
NAMA INSTANSI
osis I Dosis 2
Keterangan
Vaksinasi
TDK HADIR SDN 2 PATARUMAN

5/18/2021 24001021 SELESAI SDN 5 PATARUMAN
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
TDK HADIR PAUD SINARTANJUNG
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI PAUD PATARUMAN
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
TDK HADIR
PAUD PATARUMAN
5/18/2021 24001021 SELESAI

5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
5/18/2021 24001021 SELESAI
TDK HADIR
5/18/2021 24001021 SELESAI LANSIA PATARUMAN
Jenis
Kelamin
1 W-43591440 3207284109870002 EKA SRI ANGGARWATI P

2 W-14C52F47 3205191903840005 WAGIE TRISWANDI L
3 3279014106920001 SALLY HILDAWATY P
4 Q-54B05268 3279021906660001 TEGUH SUDARMONO L
5 Q-447A23B9 6106060212970001 QADI MAQSHUDI L
6 Q-975F3A06 1671105402990002 TIVALEN DWIRARA ANGGRAINI P
7 Q-DEB9C8B1 3279020208630002 SUPENDI L
8 Q-A07D74C3 3279010411650001 MOCHAMMAD AGUS MUKARROM L
9 Q-01A6C71F 3207190503970004 SIGIT RESTU DIANSAH L
10 3372042309840007 MOHAMMAD ITSNAN FAIZ L
11 Q-EB4EB11D 3279011504950001 R. DARMAWAN ADIGUNA L
12 Q-2BD847E5 3207150606960002 YOSEP HENDRA GUMELAR L
13 Q-1D3F0AFB 3279024505750001 MIATI P
14 Q-DAAE62B6 3278011209690006 SENNO L
15 Q-56EF33D6 3279030510870001 ASEP WAHYUDI L
16 3279026311960001 NOVIYANTI P
17 Q-F1076111 6409030909890006 MUHAMMAD FATHUL MAJID L
18 Q-83514F43 3279041206980001 ANOM YUSTISIA L
19 W-F96B878E 3205020802820003 ISAN NURHAKIM, S.I.P. L
20 Q-F975CAC5 3207161608920001 AGUS CHERAWAN L
21 W-2D56BB9C 3027014807810002 LULU NURYANI P
22 3175102502670010 ARYA PRASETYA UTAMA L
23 Q-F583EF3E 3279032709900001 YOGIE SEPTIAN HARTANTO L
24 Q-200CE6A2 3207010804920002 GANANG PURNOMO L
25 Q-1A9088B8 3301111501000002 FIKRI RAHMADAN NUGROHO L
26 Q-C2DD1C8B 3207362304990001 RIZAL APRIYADI MUHARRAM L
27 3279012503790001 R HADI SUPRIYATNA L
28 Q-DB0C8508 3206190111940001 ARIF RUSMAN SUTIANA L
29 Q-2E09535B 3279031701780001 DENI SURATMAN L
30 Q-2E0F23CD 3305170511730002 YAYAN SURYANA L
31 Q-FBA68955 3279021807880001 Bambang Triasworo L
32 Q-D0D571C0 3207180711820001 ASEP RONI L
33 Q-EF73B749 3206341111930004 ASEP HENDI L
34 Q-14579979 3207302307850001 ASEP SYAMSUL BAHRI L
35 Q-1452D8EF 3207120503940001 MUHAMMAD RIZAL FAHMI L
36 Q-90F3A97F 3279011011950002 PAHLEVI NOVIANDI UTAMA L
37 Q-DF9161A6 3207115002950001 WIDA NUR FEBRIANTI P
38 Q-B4CD5685 3278045912970017 DIVA VADILA SARI P
39 Q-5E2E581E 3279025208950004 NOR AZIZAH P
40 Q-DB4FEEDC 3207013005810002 SUBHAN ARIF FIRMANSYAH PRAWIRA L
41 Q-049BF667 3278062604810008 HERDIANA APRIADI L
42 3279010501940004 DANI SUMANTRIYANTO L
43 Q-2EEE56B3 3279012805900001 HENDRA SETIAWAN L
44 Q-D7A340A3 3207290811930001 IAN MULYANA L
45 Q-ACA363F1 3207292002950001 MOHAMAD RAMDANI L
46 Q-D4DDB07C 3279022410910002 DADI KUSNIADI L
47 Q-2BF8C418 3279020507850001 SUTRISNO L
48 Q-FE6DFEB7 3279020609880001 RICKI GUMILAR L
49 Q-D4D67E82 3279012503960001 HIDAYAT L
50 3279010108920002 AGUS SUTARMAN L
51 Q-A08324B0 3279022512830003 DEDE SUPRIADI L
52 Q-FA4912F8 3207030207000001 FAJAR DWI MAULANA L
53 Q-23A00C26 3279026107910001 EKA TRISNA SAYEKTI P
54 Q-23D83B61 3207012912860002 ABUNG SARIFFUDIN L
55 Q-3ADFBE14 3279020705800003 YANA SURYANA L
56 Q-2462243B 3279022801960001 HENDRI PERMANA L
57 Q-27C336E0 3205192909870002 Budi Lukman Halim L
58 Z-52983B91 3275031507590022 SUMARYONO L
FORMAT PENCATATAN
TINGKAT PUSKES
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
ASISTEN APOTEKER 34 31-45

APOTEKER 37 31-45
KOAS UMJ 24 18-30
KOAS UMJ 22 18-30
TRAVEL 58 46-59
TRAVEL 56 46-59
TRAVEL 24 18-30
TRAVEL 37 31-45
TRAVEL 26 18-30
TRAVEL 25 18-30
TRAVEL 46 46-59
KARYAWAN SWASTA 52 46-59
DINAS PU 42 31-45
KKQAAA3W7SDFMLZD 25 18-30
LANSIA 62
Alamat

KP MEKARSARI, GARUT
DUSUN PULAU PAGUNRT 04 RW 02, KAPUAS HULU
JL. RAWASARI NO. 138 BUKUT SANGKAL RT 48 RW Air Padang 30114
SUKAJADI RT 09 RW 03
CITANGKOLO RT 02 RW 01
PASIRLEUTIK RT 30 RW 12
RANCAKOLE RT 03 RW 01, MULYASARI
RANDEGAN RT 09 RW 05
RANDEGAN I RT 04 RW 02
DUSUN CIDEWA RT 05 RW 15
JL. SAKURA NO. 28 RT 06 RW 04, MAJENANG
DUSUN SINDANG RT 39 RW 06
LINGK. BANJAR RT 04 RW 02, BANJAR
KP BARANGBANG RT 03 RW 04
PEPUDUTAN RT 03 RW 02, KEBUMEN
KP. CIBURIAL RT 02 RW 01, LEMBANG
SUKAHURIP RT 04 RW 02, BANJARSARI
KP. IGOK, JAWA BARAT
DUSUN DESA RT 03 RW 05
DUSUN WETAN, JATINAGARA RT 20 RW 05
DUSUN KIDUL RT 12 RW 07, CIPAKU
KP. PASANGGRAHAN RT 04 RW 08
JADIMULYA RT 04 RW 08, HEGARSARI
PR. GRIYA AMERTA BLOK A.1
RAKSABAYA RT 10 RW 03, CIMARAGAS
RANCAGEDE RT 32 RW 12, CIMARAGAS
TANJUNGSUKUR RT 05 RW 14, HEGARSARI
CIKABUYUTAN TIMUR RT 04 RW 12
TANJUNGSUKUR RT 51 RW 04
PINTUSINGA RT 03 RW 19
CIKADU RT 24 RW 11, KARANGPANIMBAL
DUSUN KALER RT 06 RW 02, CIJEUNGJING
PABUARAN RT 05 RW 01
DUSUN RANDEGAN RT 06 RW 12, HEGARSARI
KP DAYEUH NANGGUNG RT 02 RW 03
PUP BLOK G3/18 RT 1 RW 11, BEKASI
KSANAAN VAKSINASI COVID-19
SYANKES/POS VAKSINASI

Dosis I
BPJS PBI BPJS Non
Non
Pemberian
81224400087 5/19/2021 VACCINE COVID-19

82316104486 5/19/2021 VACCINE COVID-19
81222291515 5/19/2021 VACCINE COVID-19
81222291515 5/19/2021 VACCINE COVID-19
81388993477 5/19/2021 VACCINE COVID-19
82116161738 5/19/2021 VACCINE COVID-19
89601167203 5/19/2021 VACCINE COVID-19
85353238613 5/19/2021 VACCINE COVID-19
81221479147 5/19/2021 VACCINE COVID-19
82111222622
82119887606 5/19/2021 VACCINE COVID-19
85220208040 5/19/2021 VACCINE COVID-19
87789480929 5/19/2021 VACCINE COVID-19
81214348669 5/19/2021 VACCINE COVID-19
82321548336 5/19/2021 VACCINE COVID-19
85721477439
81903104860 5/19/2021 VACCINE COVID-19
082117383503 5/19/2021 VACCINE COVID-19
08112000185 5/19/2021 VACCINE COVID-19
81221996374 5/19/2021 VACCINE COVID-19
081323232910 5/19/2021 VACCINE COVID-19
087719825700 5/19/2021 VACCINE COVID-19
85223450900 5/19/2021 VACCINE COVID-19
81313008092 5/19/2021 VACCINE COVID-19
81215164463 5/19/2021 VACCINE COVID-19
87708665222 5/19/2021 VACCINE COVID-19
81214467325 5/19/2021
83147456800 5/19/2021 VACCINE COVID-19
82316745007 5/19/2021 VACCINE COVID-19
87705030849 5/19/2021 VACCINE COVID-19
87833464448 5/19/2021 VACCINE COVID-19
8220184466 5/19/2021 VACCINE COVID-19
82218974944 5/19/2021 VACCINE COVID-19
82123019661 5/19/2021 VACCINE COVID-19
82120296044 5/19/2021 VACCINE COVID-19
81322865002 5/19/2021 VACCINE COVID-19
0895325339843 5/19/2021 VACCINE COVID-19
83827649262 5/19/2021 VACCINE COVID-19
81572496585 5/19/2021 VACCINE COVID-19
85320648234 5/19/2021 VACCINE COVID-19
85216353559 5/19/2021 VACCINE COVID-19
81248856780
85863074750 5/19/2021 VACCINE COVID-19
82315450563 5/19/2021 VACCINE COVID-19
82115512321 5/19/2021 VACCINE COVID-19
82218852164 5/19/2021 VACCINE COVID-19
81321380458 5/19/2021 VACCINE COVID-19
81222647690 5/19/2021 VACCINE COVID-19
82116136151 5/19/2021 VACCINE COVID-19
81313430682
87705310077 5/19/2021 VACCINE COVID-19
88218302997 5/19/2021 VACCINE COVID-19
82216751641 5/19/2021 VACCINE COVID-19
82320145772 5/19/2021 VACCINE COVID-19
85314179055 5/19/2021 VACCINE COVID-19
89506361700 5/19/2021 VACCINE COVID-19
85624453840 5/19/2021 VACCINE COVID-19
081315737001 5/19/2021 VACCINE COVID-19
Dosis I Dosis 2
Keterangan
Vaksinasi
5/19/2021 24001021 SELESAI

5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
TDK HADIR
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
TDK HADIR
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
KONTAK ERAT tunda
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
TDK HADIR
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
TDK HADIR
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
5/19/2021 24001021 SELESAI
NAMA INSTANSI
NAKES PATARUMAN 3
NAKES RS PMC
KOAS UMJ
TRAVEL CITRA
PT WINGS
LAPAS BANJAR
DINAS PU
PT CNS MAYORA
LANSIA MULYASARI
Jenis
Kelamin
1 P-CC47M6JQ 3279024103610003 ATMI P

2 S-1101BD93 3279025201590005 TUTI MULYATI P
3 S-280E763A 3279024608450005 ISAH P
4 S-2983D28F 3279024607600001 NURHAYATI P
5 S-6CF6B283 3279024709570002 RATMI P
6 S-79185F05 3279011911370001 AJID GANDA SUPENA L
7 S-844896C7 3279025012520002 RODIAH P
8 S-84D3F5CF 3279021204600002 ATENG L
9 S-A1AE6A7B 3279024509580002 EROH P
10 S-AEEE826B 3279026107470001 KARTIJAH P
11 S-B9A96CC7 3279016404450001 HURIPAHSARI P
12 S-C5B125E3 3279024510450001 RUSMINI P
13 S-E8A734CF 3279021012530001 KOSIM L
14 S-F046B3DD 3279025107480001 CUNONG P
15 S-F7747EAA 3279022304570001 JENAL ASIKIN P
16 Y-00002E8M 3279025508550004 TITI P
17 P-D7HLO13I 3279024202700002 ILAH WIDIANINGSIH P
18 P-GSYBZ9V4 3279025610750002 MUDIYAH P
19 P-GT57F0KA 3279026212720001 ENOK SURYANI P
20 P-GVFJ4NXN 3279025601650001 PUSPITASARI P
21 Q-85961B52 3279025005840001 UTI NURPAJAR P
Umur
Kelompok
Umur
tahun)
LANSIA 60 0 DUSUN SUKAMAJU, RT 06 RW 05, MULYASARI

LANSIA 62 0 DUSUN SUKAMAJU RT 06 RW 05, MULYASARI
MASYARAKAT UMUM 50 46-59 DUSUN SUKAMAJU RT 06 RW 05, MULYASARI
TOKOH MASYARAKAT 47 46-59 SUKAMAJU RT RT 01 RW 04, MULYASARI
PENCATATAN PELAKSANAAN VAKSINASI COVID-19
KAT PUSKESMAS/FASYANKES/POS VAKSINASI

BPJS PBI BPJS Non
Non
PBI Anggota

85294207596 5/21/2021 COVID VACCINE-19
8987890855 5/21/2021 COVID VACCINE-19
Dosis I Dosis 2
Tanggal Tanggal
Vaksinasi Vaksinasi
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
5/21/2021 24001021
Keterangan
Diberikan/Lanjut)
LANJUT DOSIS 2 LANSIA MULYASARI

LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
SELESAI TOMA
Jenis
Kelamin
1 Z-07DA989F 3279025405530001 SRI SULASTRI P

2 Z-B9F700EC 3279022906510001 ENGKUS KUSMANA L
3 Z-19F1B92E 3279025005580001 RODINCE SIHOMBING P
4 Z-19E3E574 3215131210590002 ENDANG MULYANA L
5 Z-A9289AE9 3279034102410001 N ONENG GARMIPAH P
6 3207055804590001 IMAS ROHIMAH P
7 Z-A01CE77B 3279024201500001 YAYAH UTIRAH P
8 3279025808550001 TITI ROHAETIN P
9 Z-1133ECDD 3279026010600001 ELIN HALIMAH P
10 Z-DBCC8421 3279025407580002 PONIJAH P
11 Z-0BD2176D 3279020507410001 ABY SURAHMAN L
12 Z-BB81F97E 3279025708580001 RAKISAH P
13 Z-55E6E69A 3279025208590001 ENING P
14 3279025504600002 EJEN P
15 Z-2E4D9DE8 3279020906530003 KODIR L
16 3279022307530001 PATAH L
17 3279020604550003 SARAN L
18 Z-DBF136B0 3279022508570001 ABDUL AJID L
19 Z-1E3BBD04 3279025103520001 ENOH P
20 Z-B7BAA648 3279024610580001 ANTINAH P
21 Z-843F68EA 3279020107530011 HUSEN L
22 Z-CAD418C2 3279024409570001 NENDAH P
1 Q-63AC140B 3301165508630004 IIS RATNA KURNIASIH P
2 Q-DD79EB12 3279021801030001 MUHAMMAD RAFLY PURNAMA L
3 Q-06F0EADD 3279026312710002 RAJA JAHNIBAR P
4 3279026204640001 MIMING HERMAWATI P
5 Q-F7B234D1 3279020909020003 AGRI SALVA SEFTIAN L
6 Q-73129AFE 3279026212760001 RINA HASANAH P
7 Q-1F11CD06 3279024506690001 RINI SUKINI SUSILAWATI P
8 Q-71F7E9B6 3279025011850002 SUSI SUSILAWATI P
9 Q-3AC6616F 3279024402700002 ONAH P
10 Q-BD08A72B 3279026308640001 ENOK ENGKAR P
11 Q-5E895B31 3279026206820002 sri wahyuni P
12 Q-95630C80 3279025702790003 ROHIMAH P
13 Q-0F11538E 3279022510780001 EDI SUYANTO L
14 Q-D31C3C53 3172025009651001 RANI SANTANI P
15 Q-59BF87BA 3279020907970003 ERVAN JULIANUS L
16 Q-4DB6B6A3 3279020908990003 FAWWAZ NABIL KHRISYANA L
17 Q-1D61C6CD 3279024810680001 ESIH KURNIASIH P
18 Q-6AC57837 3279022408710003 AGUS NUGRAHA L
19 Q-3BCEBC2A 3279026111010001 MENTARI RAMADHINI P
20 Q-D5356A14 3279016306970001 MEGA ANITA RAHMAWATI P
21 Q-5FBA191D 3279012310990001 YUSUF CHAERUL RAHMANSYAH L
22 Q-DE381D57 3278042001720001 SYARIEF HENDRA DEWANTO L
45 3279021909640001 DODI SUPARDI L
46 Q-CC66E07C 3279025810940001 SUCI HERLINA P
47 Q-B15D54D0 3279025111860001 ERNI SUPRIYATI P
48 3279034704940002 DIANA GALIH P
49 Q-F12D7EEB 3206374701970003 AI CAHYANI P
50 Q-C789DFA5 3207156711970001 IIN SITI NURJANNAH P
51 Q-B61DE1D1 3279021402690000 SAPTA SUPRATA L
52 Q-9BC93F21 3372042309840007 MOHAMMAD ITSNAN FAIZ L
53 3279026311960001 NOVIYANTI P
54 W-DE444FF6 3279012503790001 R HADI SUPRIYATNA L
55 Q-58B66570 3279010501940004 DANI SUMANTRIYANTO L
56 Q-283AB558 3279010108920002 AGUS SUTARMAN L
FORMAT PENCATATAN PELAKSANAAN
TINGKAT PUSKESMAS/FASYANKE
Umur
Kelompok
Umur
tahun)
LANSIA 80 0 PARUNGSARI 10/05
LANSIA 62 0 BABAKANSARI 08/11
LANSIA 63 0 PATARUMAN RT 01 RW 12
LANSIA 64 0 GIRIMULYA RT 06 RW 14, BINANGUN
LANSIA 69 0 PANANJUNG TIMUR RT 28 RW 06
PELAYANAN PUBLIK 56 46-59 JELAT RT 03 RW 02
PELAYANAN PUBLIK 19 18-30 BABAKANSARI 03/11
PELAYAN PUBLIK 45 31-45 LEMBUR BALONG RT 04 RW 05
PELAYAN PUBLIK 53 46-59 PANANJUNG BARAT RT 02 RW 01
PELAYAN PUBLIK 36 31-45 PANANJUNG TIMUR RT 28 RW 06
PELAYAN PUBLIK 38 31-45 PATARUMAN RT 03 RW 12
PELAYAN PUBLIK 56 46-59 JL. SUNTER JAYA VI B NO 18 RT 3 RW 07
PELAYAN PUBLIK 24 18-30 LINGK, PATARUMAN 01/03
PELAYAN PUBLIK 22 18-30 BABAKANSARI RT 03 RW 11, PATARUMAN
PELAYAN PUBLIK 53 46-59 BABAKANSARI RT 03 RW 09, PATARUMAN
PELAYAN PUBLIK 50 46-59 JELAT 01/01, PATARUMAN
PELAYAN PUBLIK 22 18-30 DUSUN PANANJUNG RT 20 RW 05
PELAYAN PUBLIK 24 18-30 CIMENYAN I 04/05
PELAYAN PUBLIK 22 18-30 LINGK. CIMENYAN 1 04/05
PELAYAN PUBLIK 48 46-59 : JL. LIUNGGUNUNG RT 001 RW 006, DESA PANYINGKIR
GURU SD 57 JELAT 01/04
GURU PAUD 27 PANANJUNG 20/05
GURU PAUD 35 LEMBUR BALONG 03/06
GURU PAUD 27 TANJUNGSUKUR 02/16
GURU PAUD 23 MARGALUYU RT 04 RW 08
GURU PAUD 24 SIDAMULYA RT 06 RW 13, CIAMIS
TOKOH MASYARAKAT 52 DUSUN PANANJUNG TIMUR RT 24 RW 06, SINARTANJUNG
TRAVEL 37 31-45 CITANGKOLO RT 02 RW 01
KARYAWAN SWASTA 25 18-30 RANCAKOLE RT 03 RW 01, MULYASARI
DINAS PU 42 31-45 LINGK. BANJAR RT 04 RW 02, BANJAR
KARYAWAN SWASTA 27 18-30 PANATASAN RT 01 RW 20, PATARUMAN
KARYAWAN SWASTA 21 18-30 CIKADU RT 24 RW 11, KARANGPANIMBAL
ATATAN PELAKSANAAN VAKSINASI COVID-19
PUSKESMAS/FASYANKES/POS VAKSINASI

Dosis I
No. Hp Tanggal
Screening Vaksin***
BPJS PBI BPJS Non
Non
Pemberian
PBI Anggota
Vaksinasi

81223857328 5/24/2021 VACCINE COVID-19
085223311534 5/24/2021 VACCINE COVID-19
82316573700 5/24/2021 VACCINE COVID-19
82116740976 5/24/2021 VACCINE COVID-19
82316573700 5/24/2021 VACCINE COVID-19
85323002588 5/24/2021 VACCINE COVID-19
85321389784 5/24/2021 VACCINE COVID-19
82119581550 5/24/2021 VACCINE COVID-19
81222828518 5/24/2021 VACCINE COVID-19
85299250386 5/24/2021 VACCINE COVID-19
85854755343 5/24/2021 VACCINE COVID-19
89527418008 5/24/2021 VACCINE COVID-19
81222814981 5/24/2021 VACCINE COVID-19
81992420551 5/24/2021 VACCINE COVID-19
85316719170 5/24/2021 VACCINE COVID-19
85223155514 5/24/2021 VACCINE COVID-19
082116740976 5/24/2021 VACCINE COVID-19
82116740976 5/24/2021 VACCINE COVID-19
85323985196 5/24/2021 VACCINE COVID-19
82210041001 5/24/2021 VACCINE COVID-19
89631891178 5/24/2021 VACCINE COVID-19
85894769140 5/24/2021 VACCINE COVID-19
85220247755 5/24/2021 VACCINE COVID-19
85224641176 5/24/2021 VACCINE COVID-19
82215349699 5/24/2021 VACCINE COVID-19
82218310684 5/24/2021 VACCINE COVID-19
87760827755 5/24/2021 VACCINE COVID-19
81323764320 5/24/2021 VACCINE COVID-19
81318469964 5/24/2021 VACCINE COVID-19
82315275427 5/24/2021 VACCINE COVID-19
82321534540 5/24/2021 VACCINE COVID-19
81993833207 5/24/2021 VACCINE COVID-19
0895332261876 5/24/2021 VACCINE COVID-19
85321495397 5/24/2021 VACCINE COVID-19
INARTANJUNG 5/24/2021 VACCINE COVID-19
82111222622 5/24/2021 VACCINE COVID-19
85721477439 5/24/2021 VACCINE COVID-19
81214467325 5/24/2021 VACCINE COVID-19
81248856780 5/24/2021 VACCINE COVID-19
81313430682 5/24/2021 VACCINE COVID-19
Dosis I Dosis 2
Keterangan
Vaksinasi
5/24/2021 24001021 SELESAI

5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 SELESAI
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 SELESAI
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 TDK HADIR
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
5/24/2021 24001021 SELESAI
NAMA INSTANSI
LANSIA PATARUMAN
LANSIA SINARTANJUNG
SDN 2 PATARUMAN
GURU PAUD
TOMA SINARTANJUNG
TRAVEL CITRA
PT WINGS
DINAS PU
PT MAYORA

Jenis
Kelamin
1 S-DCD486EB 3279025712590002 OOM P

2 P-IRVF1NJ6 3279020508610001 ACEP ALI AGUS L
3 S-052CB74A 3279021108500002 HANAN L
4 S-0D0E29F1 3279025202530001 EMEH P
5 S-2A0DBE35 3279020106420002 MAMUN L
6 S-CDA959E5 3279024107540020 IBOH P
7 S-EA753331 3279025811440001 IJOT P
8 P-IVNQW1JR 3279021205720002 JOJO L
9 P-IWLZM1DT 3279020505840002 YUSUF SIDIK L
10 P-IYRSYTRM 3279025405700001 ILAH P
11 P-J0NMFO8I 3279025007790001 NIA KURNIATIN P
Laporan Hasil Kegiatan Vaksinasi, Kamis, 27 Mei 2021

1 Sasaran di undang = 30 orang lansia dosis 1
2 Sasaran yg divaksin = 19 orang
Dosis 1 :
Lansia = 11 orang
Pendamping lansia = 4 orang
Nakes Penyintas Covid = 1 orang
Dosis 2 :
Lansia = 3 orang
3 Vaksin yg dipakai : 2 vial
4 Sisa Vaksin di PKM : 7 vial
Umur
Kelompok
Umur
tahun)
LANSIA 62 PANATASAN RT 03 RW 19, PATARUMAN

MASYARAKAT UMUM 48 PANATASAN RT 03 RW 20, PATARUMAN
PENCATATAN PELAKSANAAN VAKSINASI COVID-19
GKAT PUSKESMAS/FASYANKES/POS VAKSINASI

No. Hp
Screening Vaksin***
BPJS PBI BPJS Non
Non
PBI Anggota
5/25/2021 VACINE COVID-19

Dosis I Dosis 2
Keterangan
Tanggal Tanggal (Ditunda/Tidak
Pemberian No. Batch No. Serial Pemberian No. Batch No. Serial Diberikan/Lanjut)
Vaksinasi Vaksinasi
5/25/2021 24001021 LANJUT DOSIS 2

5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
5/25/2021 24001021 LANJUT DOSIS 2
NAMA INSTANSI
LANSIA PATARUMAN
Jenis
Kelamin
1 N-5CDEE4F0 3279041510930001 GALUH JATNIKA WAHYUDIN L

2 P-JETOMKIJ 3279025903830001 ELY SUWARSIH P
3 P-JK6QKTK6 3279023006780001 HERU SUNARYA L
4 P-JSIU3WRA 3207011006860002 FALMI FAJRI SHIDIQ L
5 P-JKIF4BNW 3279022509690001 ENDOS SUBAGJA L
6 P-JL2JBTWP 3279022168610001 IMIN L
7 P-JLM2RKSY 3279020501610001 PURWANTO L
8 S-019EAC9B 3207305205560002 ENGKAR KARTINI P
9 S-33E0A5BE 3279021101550001 ENDANG JUMSAN HERDI L
10 S-5869CD3D 3279020201460001 SUPARDI L
11 S-5E9CBC11 3279026805520001 TRI BUDI RAHAYU L
12 S-8210E48C 3279024311500001 NGADIYEM P
13 S-9ACA38B7 3279024107450013 MARIAH P
14 S-E1095A70 3278031012580003 OJO GUNAWIJAYA L
15 S-EF4DCD5E 3279024304530001 MARSINAH P
16 S-F83F8D40 3279020107570008 SARIMAN L
17 3279025807500002 ENTIN P
18 3279025609530002 TALIMAH P
19 Z-114DF923 3279025504600002 EJEN P
20 Z-18C621DB 3279022307530001 PATAH L
21 Z-E9C4CAF2 3278014509440005 TINTIN SETIASIH BA P
TINGKAT PUSKESMAS/FASYANKES/P
Umur Kelompok
Pekerjaan* Alamat
(18-59 tahun) Umur
NAKES 28 18-30 LANGEN 02/01, LANGENSARI

MASYARAKAT UMUM 38 31-45 BABAKANSARI 03/10, PATARUMAN
MASYARAKAT UMUM 35 31-45
LANSIA 62 0 BABAKANSARI 03/10, PATARUMAN
LANSIA 61 0 PATARUMAN 01/12, PATARUMAN
LANSIA 68 0 PATARUMAN 01/12, PATARUMAN
LANSIA 77 0 BUMI ASRI MEKARAHAYU 05/13
AT PENCATATAN PELAKSANAAN VAKSINASI COVID-19
INGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

No. Hp
Screening Vaksin***
BPJS PBI BPJS Non
Non
PBI Anggota

085223556300 5/27/2021 VACCINE COVID-19
082316382203 5/27/2021 VACCINE COVID-19
085223292405 5/27/2021 VACCINE COVID-19
082320172711 5/27/2021 VACCINE COVID-19
082117295850 5/27/2021 VACCINE COVID-19
081370094795 5/27/2021 VACCINE COVID-19
085223556300 5/27/2021 VACCINE COVID-19
085223931699 5/27/2021 VACCINE COVID-19
085321836857 5/27/2021 VACCINE COVID-19
5/27/2021
0895370380040 5/27/2021
082316573700 5/27/2021 VACCINE COVID-19
082316573700 5/27/2021 VACCINE COVID-19
Dosis I Dosis 2
Keterangan
Tanggal Tanggal (Ditunda/Tidak
Pemberian No. Batch No. Serial Pemberian No. Batch No. Serial Diberikan/Lanjut)
Vaksinasi Vaksinasi
5/27/2021 24001021 LANJUT DOSIS 2

5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
5/27/2021 24001021 LANJUT DOSIS 2
TUNDA
TUNDA
5/27/2021 24001021 SELESAI
5/27/2021 24001021 SELESAI
5/27/2021 24001021 SELESAI
NAMA INSTANSI
Jenis
Kelamin
1 P-KOFDG59H 3279025809740001 SITI HANI ROHANI P

2 P-KOHEC0OB 3279015909850001 LIA ANNISA P
3 P-KP35EHSW 3279025506680002 FATMAWATI P
4 P-KPE7L1V4 '3279035012650001 OTIMAH P
5 P-KRDK2CKZ 3279022206820002 SULAEMAN L
6 P-KSOZUB6Y 3279021411800001 PIPIT SURYAWAN P
7 P-KSW1G89Y 3279025509780003 ENDAH PRIYANTINI P
8 P-KP1E5DQY 3279025303610001 SITI AISAH P
9 S-08ADBF78 3279025212550001 SITI ROMLAH P
10 S-1F932C3D 3207351504400002 UMUH ALI MUCHTAR L
11 S-26751730 3279022205590001 YUSUP BUDIARDJO L
12 S-2B1CD1E6 3279021809470001 KOHAR L
13 S-3F40BB48 3279020402590001 DEDE RAHMAT L
14 S-7CF4D017 3279025001600002 NANIH P
15 S-8006ED4E 3279025607600001 DEDEH SURTIASIH P
16 S-9C49B615 3279020510540004 ADE RAHMAT KURNIAWAN L
17 S-A6673673 3279022612570002 SANYOTO L
18 S-B9184A90 3279025409310001 WARSIH P
19 S-F3F98D2E 3279020107570004 MARJONO L
20 S-FB20A54F 3279024909510001 NANI SUMARTINI MUSTOPA P
Umur
Kelompok
Umur
tahun)

MASYARAKAT UMUM 56 46-59 DUSUN KARANGMUKTI 05/06

Dosis I
No. Hp Tanggal
Screening Vaksin***
BPJS PBI BPJS Non
Non
Pemberian
081323777368 5/28/2021 COVID VACCINE 5/28/2021

081223146480 5/28/2021 COVID VACCINE 5/28/2021
085317169646 5/28/2021 COVID VACCINE 5/28/2021
082320470844 5/28/2021 COVID VACCINE 5/28/2021
085215124648 5/28/2021 COVID VACCINE 5/28/2021
085294323345 5/28/2021 COVID VACCINE 5/28/2021
5/28/2021 COVID VACCINE 5/28/2021
085215670263 5/28/2021 COVID VACCINE 5/28/2021
5/28/2021 COVID VACCINE 5/28/2021
081214174506 5/28/2021 COVID VACCINE 5/28/2021
089644535464 5/28/2021 COVID VACCINE 5/28/2021
5/28/2021 COVID VACCINE 5/28/2021
5/28/2021 COVID VACCINE 5/28/2021
5/28/2021 COVID VACCINE 5/28/2021
081213837117 5/28/2021 COVID VACCINE 5/28/2021
082116942978 5/28/2021 COVID VACCINE 5/28/2021
5/28/2021 COVID VACCINE 5/28/2021
082223851281 5/28/2021 COVID VACCINE 5/28/2021
5/28/2021 COVID VACCINE 5/28/2021
081323887447 5/28/2021 COVID VACCINE 5/28/2021
Dosis I Dosis 2
Keterangan
Vaksinasi

NAMA INSTANSI
Jenis
Kelamin
1 P-LAQ2SOBR 3279022503980001 DEIS RIZKYAN MARESTHA

2 P-CWS7XUFX 3279024510770005 RATNA KOMALA
3 P-DP5G16CW 3279025111690001 WATI
4 P-GPEIT48R 3279024101660006 EDENG KARNANI
5 P-D8Q41LPG 3279020810790001 IROM SUKIROM
6 P-GI5P0ADU 3279025006890002 ANI MARYATI
7 P-H8QIAMYI 3279025208000002 KHUSNUSYIVA
8 P-HJRBRES6 3279024601890002 SRI SUMARNI
9 P-JQT3NMLK 3279015707940001 LIA YULIANI
10 P-K81W6XDZ 3279045203970001 ELSA SULASTRI
11 P-L1XD4G4K 3279025605690001 MIMIN HASANAH
12 P-L161ZUPV 3279025806720002 CUCU MULYANI
13 P-L0S680RE 3279024106780003 LIS NURLIA
14 P-L4KAMSFK 3279020501940002 YANUALDY KOSWARA
15 S-453308C1 327902070200001 DEVIAN FEBIANTO
16 P-L59CSLZG 3279024710940002 REZA OCTAVIANTI
17 P-L5I0EB2Y 3279036908800002 AGUSTINA HERAWATI
18 P-L8OFXIYW 3279025808790004 TITIN SUKIATIN
19 P-L92IRKCJ 3279024805980004 RESTIANTI DWI PUTRI
20 P-L9E54HFE 3279025904820002 AI NUR RAHMAWATI
21 P-L9OKA6EK 3279025408950001 ADE SRI RAHAYU
22 P-L9RTD524 3279026609910001 SITI WAHYUNI
23 P-LAK4NPFT 3279024305870005 WIWIN LUSIANA
24 P-GTRR1Q4H 3279021110610001 OMAN
25 P-I3JV8JKC 3279025112650005 RATNA
26 P-IE25JNXC 3279026408620001 AI SRIWATI
27 P-ISDZOLGF 3279020808650002 ENDANG AHADI
28 P-JA9D5W21 3279024110610001 ACAH
29 P-L3HD62WK 3279020302650002 DARWIN
30 P-L8HSC60H 3279024301650001 NANI SURYANI
31 P-L8VPGRT0 3279020507650007 RASTUM
32 P-L9KPCGCU 3279024406700005 IIS KURNIASIH
33 S-021489A8 3279025507590003 SITI TOMIAH
34 S-2083A9BB 3271051205590010 DANI HERDIANSAH
35 S-2564CEE0 3279025002600002 ADE ROPIAH
36 S-2A25D45D 3279020511530002 SAKUM
37 S-2D44607A 3279020107570018 ADANG
38 S-3B31AEC6 3279024706580002 KIKI
39 S-4B49C232 3279024511540001 TUMINI
40 S-57C6D16D 3279024107520005 SARIAH
41 S-5D671304 3279020803530005 ENCON HASANUDIN
42 S-61467385 3279026706570001 HAERATI
43 S-7E54CE09 3204092009510004 TATANG KURNIA
44 S-9A584F4E 3279024805540001 OMAH
45 S-9E65F570 3279024404560001 SARINEM
46 S-DA21FD40 3279022103560001 EITH MAR SUMARNA
47 S-DB23C8B1 3279020101460005 KUNDANG MUTOLIB
48 S-E4ED7487 3279024406550002 IRAH
49 S-FE4776B6 3279021005540003 MAXI
50 S-FF2B88F2 3279024507470002 UAS
51 3279020804450002 DUDUNG ALIMIN L
52 3279026709500001 KARNI P
53 3279020809490001 WIRYO L
FORMAT PENCATATAN PELAK
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)

LANSIA 60 0
LANSIA 56 46-59
LANSIA 59 46-59
LANSIA 56 46-59
LANSIA 60 0
LANSIA 56 46-59
LANSIA 56 46-59
LANSIA 56 46-59
LANSIA 51 46-59
LANSIA 62 0
LANSIA 62 0
LANSIA 61 0
LANSIA 68 0
LANSIA 64 0
LANSIA 63 0
LANSIA 67 0
LANSIA 69 0
LANSIA 68 0
LANSIA 64 0
LANSIA 70 0
LANSIA 67 0
LANSIA 65 0
LANSIA 65 0
LANSIA 75 0
LANSIA 66 0
LANSIA 67 0
LANSIA 74 0
LANSIA 76 0
LANSIA 61 0
LANSIA 72 0

Alamat No. Hp
BPJS PBI BPJS Non
PBI
PANANJUNG BARAT 19/02, SINARTANJUNG 089670178227

PANANJUNG 23/05, SINARTANJUNG 083116907763
PANANJUNG TIMUR 25/06, SINARTANJUNG
PANANJUNG 19/04, SINARTANJUNG
PANANJUNG TIMUR 30/07
SINARGALIH 41/09, SINARTANJUNG
PANANJUNG BARAT 10/02, SINARTANJUNG
PANANJUNG TIMUR 26/06, SINARTANJUNG 089604272090
SINARGALIH 41/09, SINARTANJUNG 082357723232

KP. SEKELOA 02/09
COVID-19
NASI

Dosis I
olom yang sesuai)
Nama/Jenis/Merek
Non Vaksin***
Anggota
Vaksinasi
5/29/2021 COVID VACCINE-19 5/29/2021 24001021

5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021 COVID VACCINE-19 5/29/2021 24001021
5/29/2021
5/29/2021
5/29/2021
Dosis 2
Keterangan
Pemberian No. Batch No. Serial Diberikan/Lanjut)
Vaksinasi
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 LANSIA SINARTANJUNG
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA
TUNDA
TUNDA
Jenis
Kelamin
1 P-BZPI01HZ 3279026210750003 IDAH SAIDAH

2 P-R1W4RUNC 3279024702740001 SUMIATI
3 P-SZAY8261 3279024608740002 ANAH ROHANAH
4 P-SZZVJ3FQ 3279020101760007 ABDUL AZIZ
5 P-SZSIF6MF 3279025205850002 TRI SURYANI
6 P-T0DB2PBC 3279025710750001 LINA HERLINA
7 P-T0O6O2OL 3279022010740001 TONI FARINDO
8 P-T0VQ2JYN 3279024301800002 YETI
9 P-TINLPFJV 3279020805750001 ROHMAN
10 P-TK5SMWTZ 3279026406900001 RISMA AYU UTAMI
11 P-CGPYAIOT 3273151305920003 ALBERTUS GATOT HENDRASTO
12 P-TFY20Z5V 3279020701810002 NURDIN SUHENDAR
13 P-1N2XVZXD 3279020310730002 DIDI SUPRIYADI
14 P-N55ITDAB 3207094412740001 NUNUNG SITI NURJANAH
15 P-SZHVK0FM 3279024405010001 SINDI APRILIANI
16 P-T03RE1PN 3279040105970001 ADE ARIF HIDAYAT
17 P-SGTSBHPE 3201130412600004 DEDE RUHENDI
18 P-7MKZMO89 3279024511690005 ADE DARSIH
19 Y-0117P9HL 3279010204680002 AANG BUDI SETIAHANDRA
20 S-52777AAF 3279024505560002 NANI SUMARNI
21 S-6BCFB394 3279025506580005 SOPIAH
22 P-FBWPSWN1 3279026211630001 DEDEH KURNIASIH
23 S-6A9438C4 3279021206460001 DEDY RACHMAN
24 SAJUM
25 S-F1DDFCBA 3279020707570002 ENTIS SUTISNA
26 P-76WIG2OT 3279025608670009 ENOK NANI
27 P-LYSHHIP4 3279020812620002 DIDA HOLIDA
28 P-93IPE1YC 3279025608700006 ENTIN SUTINI
29 P-QLEXEP29 3279021407680001 MURIA
30 P-TCO0T8SX 3275035308640009 YENI AGUSTINI
31 S-10FC5212 3277020702600008 SUKSES SUPRAPTO
32 S-4786E22E 3279024107550014 PATIMAH
33 3279024106550002 EEM
34 3279024606490001 EEM SUTARSIH
35 P-HF0XDVBV 3279020507620002 RIYANTA
36 P-IGJR40DW 3279026305680001 HARES YANTI YULIANINGSIH
37 P-P1LZ2106 3279020811680002 NONO SUPRIATNO
38 P-PIKJ8PXZ 3279021710660001 PONIMAN
39 P-Q0GP8Y03 3279020101650006 RAKIMUN
40 P-T19ZDOAZ 3279020306680003 ASEP ROHMAN
41 P-T1NVLEDC 3279027006680001 TITI SUMIARTI
42 P-T1VOJUMF 3279021306650001 RADIMIN
43 S-EBAC96E9 3279025008520001 MAMAH
44 3279026112600001 SAMIAH
45 P-JC4CGBF6 3279025006630001 ATMI INDRAWATI
46 P-RHTZZAUL 3279020202690001 CARTAM
47 P-RZAZB2YY 3279025909610001 BAETI
48 P-SRGBZJRS 3279020312680002 YOYO HARTOYO
49 P-T2CDOYQH 3279024101660003 IIN SARINAH
50 S-074ABF1D 3279025212590002 SUNINGSIH
51 S-2D3FF9EB 3279025304460001 SURTATI
52 S-2E6B2B2A 3279024309400001 TUNIAH
53 S-442ABC0E 3279024107450021 NASIH
54 S-614C6EA4 3279025008550002 WARSIH
55 S-6E4BC344 3279024101450007 NESIH
56 S-8B1095D6 3279024711380001 SAMINAH
57 S-9E5B4710 3279020301580001 HERI DADANG
58 S-EB2F1A5D 3279020104470003 SARKO
59 S-EFD4961C 3279025008540001 KUSMIATI
60 3279024203610005 SAMINI
FORMAT PE
TINGKA
Umur
Kelompok
Pekerjaan* (18-59
Umur
tahun)
MASY. UMUM 46
MASY. UMUM 47
MASY. UMUM 47
MASY. UMUM 46
MASY. UMUM 36
MASY. UMUM 46
MASY. UMUM 47
MASY. UMUM 41
MASY. UMUM 46
MASY. UMUM 31
TOKOH AGAMA 29
MASY. UMUM 40
TENAGA KESEHATAN 47
PEDAGANG 47
PEDAGANG 20
PEDAGANG 24
LANSIA 55
LANSIA 52
LANSIA 53
LANSIA 65
LANSIA 63
LANSIA 58
LANSIA 75
LANSIA 60
LANSIA 64
LANSIA 54
LANSIA 59
LANSIA 50
LANSIA 53
LANSIA 57
LANSIA 61
LANSIA 66
LANSIA 66
LANSIA 72
LANSIA 59
LANSIA 58
LANSIA 53
LANSIA 55
LANSIA 56
LANSIA 53
LANSIA 53
LANSIA 56
LANSIA 69
LANSIA 61
LANSIA 58
LANSIA 52
LANSIA 60
LANSIA 53
LANSIA 55
LANSIA 62
LANSIA 75
LANSIA 81
LANSIA 76
LANSIA 66
LANSIA 76
LANSIA 83
LANSIA 63
LANSIA 74
LANSIA 67
LANSIA 59
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID
Alamat No. Hp

RANCAKOLE 03/01, MULYASARI 087828164406
SUKAMAJU 10/06, MULYASARI 082219661183
SUKAMAJU 10/06, MULYASARI 085314751874
JELAT 01/04 085222294868
LEMBURBALONG 01/07 08122139803
BANDUNG KULON 088223352363
KARANGSARI 14/04 082167025325
BABAKANSARI 03/11, PATARUMAN 085223030858
MEKARHARJA 11/03 082318323005
LEMBURBALONG 04/05, PATARUMAN 085722793263
DUSUN CIJUREY 03/04 089630922334
CIKABUYUTAN TIMUR 03/12
CIKABUYUTAN BARAT 04/10
CIKABUYUTAN BARAT 01/10 085220515551
CIKABUYUTAN TIMUR 04/12 082311608926
LINGK. GUDANG HEGARSARI
BABAKANSARI 02/09, PATARUMAN 081323364721
GUDANG 02/02
BINANGUN 02/03
TANJUNGSUKUR 04/14
PUP BLOK 53, BEKASI (DOMISILI RANCAKOLE 09/02) 081314027839
PERUM BUKIT SARIWANGI KAV. POLITEKNI 02/10 (DOMISILI RANCAKOLE ) 081394196999
PATARUMAN 02/15, PATARUMAN 08121480177
PATARUMAN 02/15, PATARUMAN 08132369236
LEMBURBALONG 01/05, PATARUMAN 085624224440
SUKAMANAH 03/16, PATARUMAN
SUKAMANAH 03/16, PATARUMAN 085326123466
JELAT 01/04, PATARUMAN 08122283806
JELAT 01/04 085351147608
SUKAMANAH 03/16, PATARUMAN
JELAT 01/04, PATARUMAN 085786723446
PATARUMAN 02/15 081323309971
SINARGALIH 37/08
SINARGALIH 37/08
PANANJUNG BARAT 01/01
PANANJUNG BARAT 01/01

Dosis I
Nama/Jenis/Merek
Tanggal Screening
Vaksin***
BPJS PBI BPJS Non
Non Tanggal Pemberian
6/11/2021 SINOVAC 6/11/2021

6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
6/11/2021 SINOVAC 6/11/2021
Dosis I Dosis 2
No. Batch No. Serial Tanggal Pemberian No. Batch No. Serial
Vaksinasi
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
24002521
Keterangan
Diberikan/Lanjut)
LANJUT DOSIS 2
LANJUT DOSIS 2
SINARTANJUNG
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
MULYASARI
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 ALUN-ALUN BANJAR
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2 MULYASARI
LANJUT DOSIS 2
LANJUT DOSIS 2
MULYASARI
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
PATARUMAN
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
SINARTANJUNG
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
Jenis
Kelamin
1 P-IRIRE6YK 3279024411790001 DIAH MARDIAH P

2 P-C9QOEN0F 3279025502730001 SARNI P
3 P-PCVRVFLS 3279022310770001 NANA SURYANA L
4 P-PVZNM848 7371111705850007 IRWAN KUSUMA L
5 P-SLIOZCSU 3301145608770006 SITI ROHIMAH P
6 P-U5Q0QEKK 3279026212730001 ROHAYATI P
7 P-U5TKW3MB 3279026902800002 CUCU MANINGSIH P
8 P-U6ITQP3J 3279021407730001 KASMIN NURYADIN L
9 P-U6VF1IIJ 3204255202830003 KUSTIYANAH P
10 P-U7G04FZT 3279024507820003 KARTINI P
11 P-K4VMHSBY 3279022809720001 TURMAN L
12 P-B03262C0 3279021405630003 DEDE KURDIANA L
13 P-DA7NBSEY 3602034304680001 NENI P
14 P-DS8E2ZQW 3279021901650002 LATUN SUDJONO L
15 P-EKK7YY7A 3175046011690001 SITI AMINAH P
16 P-FYRANEO1 3279024711660001 IAH RUBAIAH P
17 P-GFJ1PDG7 3279024305670004 DARTI P
18 P-HBQ4MDWB 3279020101670028 ADE SUHERMAN L
19 P-I090CRAQ 3279025611700001 ATY SUHERIAWATI P
20 P-M7NSFAVG 3279014101700004 EEN SUMARNI P
21 P-N70FCN8Q 3279025804630002 ERUK RUKIAH P
22 P-ORKQN9UL 3279027005640001 ENI SRI CAHYATI P
23 P-QER0ELJQ 3279025311640002 WIWI KURNIAWATI P
24 P-T7BOJXUB 3279025509620001 TITI P
25 P-TLVQF70Y 3279025202660003 MAYA KASMINAH P
26 P-U3KQNZ08 3279024208660001 ATING SUHERNAWATI P
27 P-U4Q61321 3279021204640006 KOSIM L
28 P-U6IEK9AK 3279024702670001 WATI ROHAETI P
29 P-U6YEIISH 3279022506610001 ENTIS SUTISNA L
30 P-U7PV3UY2 3279025806690001 KUSMAYANTI P
31 S-05CBB255 3279021403510001 HENKY HENDARIN L
32 S-0C6D6B54 3279025508500001 IPAH P
33 S-10F2BB35 3279025708450002 ENTIN P
34 S-1320888D 3279021904440001 MUSTARI L
35 S-18A5E0DC 3279021007530001 AHMAD L
36 S-19A31A8B 3205270912390001 SADWI L
37 S-2CC4269F 3279024406520001 SUKIAH P
38 S-3C1741B6 3279024101480002 MINLARSIH P
39 S-434943A9 3279024503450002 OJAH P
40 S-58D98E3A 3279021009520001 SADI L
41 S-5C165E30 3279021002600002 AWANG DARMAWAN L
42 S-5E857BC4 3279020208530001 M YUSUP L
43 S-64955322 3279024501540001 AMINAH P
44 S-6C048935 3279025506600001 SAKINEM P
45 S-8B26B0B0 3279024607570001 ROHATI P
46 S-9D5074D2 3279025202570001 YOYOH P
47 S-A7C49F9C 3279020101490002 KORI L
48 S-D1D3E8D5 3279020607600002 KASLIM L
49 S-D33705EA 3279024101400009 ROKAYAH P
50 S-D3436D67 3279024209580001 MAAH P
51 S-E7FB004B 3279024112540003 ENGKOM KOMARIAH P
52 S-EE4FB1F6 3279020309480001 IMING SUTARMAN P
53 JUJU P
54 KOMARIAH P
55 SITI SULASTRI P
56 SARWAN L
57 KIKING L
FORMAT PENCATATAN PELAKSAN
TINGKAT PUSKESMAS/FASYA
Umur
Kelompok
Umur
tahun)
MASY. UMUM 42 PANANJUNG 18/04, SINARTANJUNG

MASY. UMUM 46 PANANJUNG BARAT 06/02, SINARTANJUNG
MASY. UMUM 36 PANANJUNG TIMUR 32/07, SINARTANJUNG
MASY. UMUM 48 PANANJUNG BARAT 01/01, SINARTANJUNG
MASY. UMUM 40 SINARGALIH 34/08, SINARTANJUNG
LANSIA 58 PANANJUNG 18/04, SINARTANJUNG
LANSIA 52 PANANJUNG BARAT 07/02, SINARTANJUNG
LANSIA 57 PANANUUNG 31/07, SINARTANJUNG
LANSIA 54 PANANJUNG BARAT 09/02, SINARATNJUNG
LANSIA 58 SINARGALIH 39/09
LANSIA 56 PANANJUNG TIMUR 31/07, SINARTANJUNG
LANSIA 55 SINARGALIH 35/08, SINARTANJUNG
LANSIA 61 PANANJUNG TIMURN 24/06, SINARTANJUNG
LANSIA PANANJUNG BARAT 09/02, SINARATNJUNG
LANSIA PANANJUNG BARAT 11/02, SINARTANJUNG
LANSIA SINARGALIH 36/08, SINARTANJUNG
LANSIA PANANJUNG TIMUR 31/07, SINARTANJUNG
LANSIA PANANJUNG BARAT 05/01, SINARTANJUNG

Nama/Jenis/Merek
Vaksin***
BPJS PBI BPJS Non
Non
PBI Anggota
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021 SINOVAC
6/12/2021
6/12/2021
6/12/2021
6/12/2021
6/12/2021
Dosis I Dosis 2
Tanggal
Tanggal Pemberian
Vaksinasi Vaksinasi
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
6/12/2021 24002521
Keterangan
Diberikan/Lanjut)
LANJUT DOSIS 2 DESA SINARTANJUNG

LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA HIPERTENSI
TUNDA HIPERTENSI
TUNDA ASMA
TUNDA HIPERTENSI
TUNDA HIPERTENSI
Jenis
Kelamin
1 P-OT4PEOWO 3279026410740001 NURROHMAH P

2 P-ENLU41N0 3279020803800002 NURSIDIK L
3 P-F3CZ4SLX 3279020703720001 KARNA L
4 P-QK4PYYE4 3279021008770001 AMIR MAHMUD SARIPUDIN L
5 P-FXN368LY 3279021702740001 SOLIHIN L
6 P-J4QD4CII 3279021606800004 ENDUT HERMAWAN L
7 P-JLIVLUHJ 3279021009720002 ADE RUSMAN L
8 P-JVPBAX5F 3279023110750001 JAJA HARDADI L
9 P-M0CGVLPL 3279025412780001 LIA DAHLIA P
10 P-IYBSIQ8V 3279020301830001 NANA SUPRIATNA L
11 P-PBBFHQ54 3279021208720001 TOTO WARSONO L
12 P-QOZCE9LE 3279017108880002 ANI ROHAYANI P
13 P-T83PF77I 3279024709750001 ELAH P
14 P-U0D5W7TU 3301156105760003 IIS AISAH P
15 P-UQE6SPQK 3279025008780003 MAESAROH P
16 P-EEXEXQJU 3279021603650002 RUSMANA L
17 P-FEY8QQS7 3206020203620002 ROSMANA L
18 P-FNJFLRA1 3279021508700004 RUSTONO L
19 P-JFCWQNK0 3279020408700003 DEDI GANDA SAPUTRA L
20 P-KCTVGJMC 3279026608700001 ANA WIDYASTUTI P
21 P-KW8LD44M 3279025506640007 OTIH P
22 P-LCDYUQLH 3279021508660002 DIDING RUSTANDI L
23 P-OCGKMONQ 3279020407670001 MAMAT RAHMAT L
24 S-0538CEA7 3279021203480001 JUMADI L
25 S-2BFC910D 3213041103520002 ADE KUSMANA L
26 S-32BAC867 3279020709580003 KUSWARA L
27 S-7E0EB0C6 3279026007490002 IRAH P
28 S-93B34C13 3279022005540001 DANA SUNARYA L
29 S-A8C19AFA 3279021304590001 LILI L
30 S-BD1DC6BF 3279027103600001 MIMIN P
31 S-D8A83B0A 3279024808560001 CAHYATI P
32 3279020712620001 KARMA L
FORMAT PENCATATAN PELAKSANAAN VAKSI
Umur
Kelompok
Umur
tahun)
PELAYANAN PUBLIK 46 MARGALUYU 04/08, MULYASARI

PELAYANAN PUBLIK 49 RANCAKOLE 05/01, MULYASARI
PELAYANAN PUBLIK 44 SUKAMAJU 05/05, MULYASARI
MASY. UMUM 43 RANCAKOLE 07/02, MULYASARI
MASY. UMUM 46 SUKAMAJU 02/04, MULYASARI
LANSIA 56 RANCAKOLE 09/02, MULYASARI
LANSIA 59 MARGALUYU 04/08, MULYASARI
LANSIA 57 SUKAMAJU 03/04, MULYASARI

Dosis I
No. Hp Tanggal
Screening Vaksin***
BPJS PBI BPJS Non
Non
Pemberian
6/14/2021 SINOVAC 6/14/2021

6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
6/14/2021 SINOVAC 6/14/2021
Dosis I Dosis 2
Keterangan
Vaksinasi

NAMA INSTANSI
DESA MULYASARI
Jenis
Kelamin
1 Q-B1C0F9D5 3279024103610003 ATMI P

2 Z-4BB0E1B8 3279025201590005 TUTI MULYATI P
3 Z-D00E2C11 3279024608450005 ISAH P
4 Z-8233A4A5 3279024607600001 NURHAYATI P
5 Z-E0F505C5 3279024709570002 RATMI P
6 Z-8E520056 3279011911370001 AJID GANDA SUPENA L
7 Z-7FFC423D 3279025012520002 RODIAH P
8 Z-44AEAF13 3279021204600002 ATENG L
9 Z-2BB07F2C 3279024509580002 EROH P
10 3279026107470001 KARTIJAH P
11 Z-C895BF61 3279016404450001 HURIPAHSARI P
12 Z-05B21794 3279024510450001 RUSMINI P
13 Z-BF547F76 3279021012530001 KOSIM L
14 3279025107480001 CUNONG P
15 Z-93F3AA65 3279022304570001 JENAL ASIKIN P
16 Z-A9729B8E 3279025508550004 TITI P
17 Q-8383E68E 3279024202700002 ILAH WIDIANINGSIH P
18 3279025610750002 MUDIYAH P
19 Q-7F7DCBF8 3279026212720001 ENOK SURYANI P
20 Q-DF8097C8 3279025601650001 PUSPITASARI P
21 Z-140EA527 3279021612550001 IYUS L
22 Z-9E0CF3D2 3279022503520001 KIRNO SUKIRJO L
23 Z-6E77F770 3279010107480001 ENDANG HIDAYAT L
FORMAT PENCATATAN PELAKSANAA
TINGKAT PUSKESMAS/FASYANKE
TARUMAN 3
Umur
Kelompok
Umur
tahun)
LANSIA 60 0 DUSUN SUKAMAJU, RT 06 RW 05, MULYASARI


Dosis I
Nama/Jenis/Merek
Vaksin*** Tanggal
BPJS PBI BPJS Non
Non
Pemberian
6/19/2021 SINOVAC 5/21/2021

6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
85294207596 6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
6/19/2021 SINOVAC 5/21/2021
Dosis I Dosis 2
Keterangan
Vaksinasi
24001021 6/19/2021 24002521 SELESAI

24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 TDK HADIR
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 TDK HADIR
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 HADIR (SAKIT)
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
24001021 6/19/2021 24002521 SELESAI
NAMA INSTANSI
LANSIA MULYASARI
Jenis
Kelamin
1 P-59RQ3FGG 3279025312780001 ELIS SURYANI P

2 P-5CFTZWOV 3279021309780002 YAYAT HIDAYAT L
3 P-5DOR4AUH 3279020508860001 SURATMAN L
4 P-5Y3U0YO0 3279025704750003 PONIAH P
5 P-5PTOZY0C 3273221104770002 ACENG IWA L
6 P-4BIFV9X6 3279026609940001 YULI ANJANI P
7 P-49H4GYDB 3279024705710004 NANIH YUNINGSIH P
8 P-4DB803A7 3279026708660002 AKAY SETIAWATI P
9 P-4I063O5Q 3279024405700005 DEDE MULYATI P
10 P-4LNO2CI6 3279021810840002 JUJU JUNAEDI L
11 P-3M97HZMN 3602031405640001 SUARDI L
12 P-3R5ECY1G 3279026211680001 ICE RAHMAWATI P
13 P-3U8VOFK1 3279026509640002 DARPIAH L
14 P-3XD48XR7 3279021108670003 KUNDANG WAHYU L
15 P-4PHQ5F2T 3279021204640004 SAIN L
16 P-5HF9XP4P 3279024908670001 JUJU JULAEHA P
17 S-57738CB4 3279024604550001 ONOH P
18 S-69924B06 3279024909600001 ANAH P
19 S-EBA88EF6 3279024107490012 OMAH ROHMAH P
20 S-D39FB577 3279021805550001 EMON L
21 3279021605540004 SUPARNO L
22 3279021007680005 SARWAN L
23 P-4TDFY7QY 3279024304720003 ENOK SUHARYATI P
24 P-42EDKFQS 3279024808700001 TUTI NURBAETI P
25 P-4OYS7MT3 3279025401710001 NANI P
26 P-4XWUZ46S 3279025203620004 ETIN P
27 P-3KNQHPSU 3279024406610005 TATING P
28 P-5APFWAR5 3279020303650003 NANA SUDANA L
29 P-5HNAL72K 3279026505690002 SITI ROMLAH P
30 P-5KKDQ7AZ 3279021209700002 EMAN L
31 P-5QBIV561 3279026307670002 NUNUNG EPI DURI P
32 P-5TIN1ADZ 3279020808700007 AGUS L
33 P-5XN4CAEM 3203052401630004 RAHMAT L
34 P-67OAI6Z0 3279014311650001 TUSTINI P
35 P-6BG4BOKU 3279024306630007 PATONAH P
36 S-0AC03D9A 3279020507530001 SARKOSIH P
37 S-0BBB0861 3279024403400002 ICIH P
38 S-2047F5A9 3279024107520002 SUMIRAH P
39 S-215B7BA9 3279020306380001 UDIN L
40 S-33734B52 3279021112450001 KOMAR L
41 S-39E62436 3279024101590021 SUKILAH P
42 S-3B3933A4 3279020710550001 EWON L
43 S-3BC25E06 3279024907600003 ENGKAS P
44 S-43D5A73C 3279025606550001 SUKAESIH P
45 S-4BF39FED 3279020101580003 TOHIDIN L
46 S-4C4C56F9 3279021208510001 PARMAN L
47 S-571A316E 3279020306400001 UMAR L
48 S-7B17ED04 3279021504530002 WAWAN SETIAWAN L
49 S-7C3958A3 3279020308540002 ENDUT KARDI L
50 S-89038CCE 3279025208500005 NONOH P
51 S-972AC443 3279026003570002 MOMOH P
52 S-977C607A 3279024506560003 ISAH P
53 S-9D44F94B 3279020802400002 SUPANDI L
54 S-AED40D78 3279024507590003 PI'AH P
55 S-BB4B4BE4 3279025907400001 IJAH HODIJAH P
56 S-C36D9527 3279025602590001 WATI P
57 S-C947F174 3279025406580002 ENOH P
58 S-D6F4A287 3279024107510004 PARWITA P
59 S-DDDD0FE9 3279021704550001 HOPID L
60 S-DF5328B1 3279027005500001 ERAH P
61 S-E153C986 3279021002680002 NURHOLIQ L
62 S-F429FF71 3279027011500001 ENTIN P
63 3279025002450008 IRAH P
64 327902651167000 EHA P
65 3279020705550004 HENDRAYANA L
66 3279024705460002 ENAH P
67 7402370104540001 WASMAN L
68 3279024400510001 SOLIHAH P
FORMAT PENCATATAN PELAKSA
TINGKAT PUSKESMAS/FASY
Umur
Kelompok
Umur
tahun)

LANSIA 57 PANANJUNG TIMUR 29/07, MULYASARI
MASY. UMUM 49 SUKAMAJU 06/05, MULYASARI
LANSIA 54 SUKAMAJU05/05, MULYASARI
INGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

BPJS PBI BPJS Non
Non
PBI Anggota
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021
6/21/2021
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021 SINOVAC
6/21/2021
6/21/2021
6/21/2021
6/21/2021
6/21/2021
6/21/2021
Dosis I Dosis 2
Tanggal Tanggal
Vaksinasi Vaksinasi
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
6/21/2021 24002521
Keterangan
Diberikan/Lanjut)
LANJUT DOSIS 2 SINARTANJUNG

LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA HIPERTENSI
TUNDA HIPERTENSI
LANJUT DOSIS 2 MULYASARI
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
TUNDA HIPERTENSI
TUNDA HIPERTENSI
TUNDA HIPERTENSI
MENOLAK
MENOLAK
TUNDA HIPERTENSI
Jenis
Kelamin
Pekerjaan*
1 P-H5QM29BE 3279024801980002 TUTI APRIANTI P MASY.UMUM

2 3279025010660003 TITI WARSITI P LANSIA
3 3279020104600001 NANA DALI L LANSIA
4 3279024504700004 YANTI P LANSIA
5 3279021607540001 SUKARSO L LANSIA
6 3275031409720014 YUDI L MASY.UMUM
7 P-G8AXF1H7 3279027012650001 NENENG UTIH P LANSIA
8 P-H6XL2UW4 3279025010630001 ACU L LANSIA
9 P-5LDAJJ49 3279021708660001 UU SUBARI L LANSIA
10 P-7GSHA6SR 3207192508650003 OMON RUSTANDI L LANSIA
11 P-G7PNDQW5 3279025211650001 ETIH ROHAETI P LANSIA
12 P-G1KTI4SG 3279024306620002 YUYUN YUNARSIH P LANSIA
13 S-8255D9AD 3279025505590001 ESIH SUKAESIH P LANSIA
14 P-G3WFH3G4 3279026409660001 EPON KURNIATI P LANSIA
15 P-DTYAWHHB 3279024906660002 YEYET NURHAYATI P LANSIA
16 P-DMU9LMTS 3279022501680001 DODI L LANSIA
17 S-495B46F3 327902160458001 MAMAN SUPARMAN L LANSIA
18 P-DPL0NEC2 3279021502630002 OMID HERDIANA L LANSIA
19 S-ABEF7173 3279025205600001 TUMIJAH P LANSIA
20 S-FFF7A5BD 3279020203550003 KARSO L LANSIA
21 S-7D02D67D 3279022703580001 ENDANG SOLIHIN L LANSIA
22 P-GSNU85VA 3279022212060002 MUHAMMAD IMAM FIRDAUS L MASY.UMUM
23 P-H79PNQW1 3279021506070001 MUHAMMAD REIHAN L MASY.UMUM
24 P-H7JLH5X3 3279021311060002 HILMY HILMANIA L MASY.UMUM
25 P-FFIMHMR5 3279027005790001 ESTI SRI EKAWATI P MASY.UMUM
26 P-FGJPVZRJ 3279021604800002 NANA SUPRIATNA L MASY.UMUM
27 S-62ECFF2D 3279020809990001 FIKY NURRAHFI L MASY.UMUM
28 P-FCWJE8CQ 3279012604810001 ROMI HERMAWAN L MASY.UMUM
29 P-F9UORB52 3279020502960003 IMAN RAMDANI L MASY.UMUM
30 P-FBAVMIOA 3209201806850004 HENDRY RACHMAN FAUZI L MASY.UMUM
31 P-F67DQTM5 3278010908880001 AGUS PARID PERMANA L MASY.UMUM
32 P-ERZVND7N 3205023012710001 R.RUDI AGUSTIN P L LANSIA
33 P-EQUNNAMW 3301163110820002 YUDI L MASY.UMUM
34 P-E5HNPJFT 3279025501920002 RIDA KURNIATI P MASY.UMUM
35 P-ENNTGLNE 3279026805920003 SITI KURNIASIH P MASY.UMUM
36 P-EIIPU3US 3279012907860001 ENJANG JULIANA L MASY.UMUM
37 P-EIBNF7HX 3203054701930004 SITI SAADAH P MASY.UMUM
38 P-DS7Q70DW 3279024802810002 NY.ONENG SUARSIH P MASY.UMUM
39 P-EF75OBCN 3217070911890009 NOPAN ROESLI OKTARIAN P MASY.UMUM
40 P-E9QXOZUB 3279020505810006 DEDEN YUDI TANUBRATA L MASY.UMUM
41 P-DZEGRB1Z 3207094405800001 SITI RODIAH P MASY.UMUM
42 P-DQDX2YGL 3279020611000002 ABDUL ISMAIL L MASY.UMUM
43 P-DO9REIUR 3279020403010001 FARID RIZAL FADHILAH L MASY.UMUM
44 P-DLLWVIDP 3205120703920002 SETYO ANDI BRATA L MASY.UMUM
45 P-DXTL0RNS 3279021012810002 RONI L MASY.UMUM
46 P-FM1G1YVN 3279025804730002 ESIH P MASY.UMUM
47 P-FSOZORDA 3205285003840002 UCU L MASY.UMUM
48 Y-0131VWKK 3174070507820011 WAWAN GUNAWAN L MASY.UMUM
49 P-FW2YRIHQ 3279024711980001 SINTA RAHMA P MASY.UMUM
50 P-FUCVFMTY 3205281807810003 OMIN BUNYAMIN L MASY.UMUM
51 P-FINTEUNM 3279021201730002 MADRUHI L MASY.UMUM
52 P-GAM4R1Y1 3279020606020002 ANDRI MUSA MAULANA L MASY.UMUM
53 P-GA31G9NX 3279021410770002 ANDRE HAVID L MASY.UMUM
54 P-GBXBFI44 3279025605920003 UTIT HARTUTI P MASY.UMUM
55 P-DR3VIHSQ 3279026010800001 WAWAT P MASY.UMUM
56 P-FVXKXUDP 3279020505970007 RINALJI.S.HUM L MASY.UMUM
57 P-GJMSSYLD 3674064402780009 SYNORA YENI WICAKSANA P MASY.UMUM
58 S-3579D4D5 3279025606830001 CUCU RATNASARI P MASY.UMUM
59 P-1FHKXEM2 3279024611810002 SUYANTI P MASY.UMUM
60 P-2A14S0Q2 327902700784002 SITI ELI ZAKIYAH P MASY.UMUM
61 P-6NA3DNDA 3279021508770002 OLIH SOLIHIN L MASY.UMUM
62 P-9YXBHNSG 3279026304770002 YANI SRIMULYATI P MASY.UMUM
63 P-AB72O2OG 3279020402720001 DIAN HAERAWAN L MASY.UMUM
64 P-C6ODCS4W 3507025612820002 TINA ISMIANI P MASY.UMUM
65 P-9B0SV57Z 3279024308010002 IRMA TRI AMALIA P MASY.UMUM
66 P-FHNAR5PJ 3279024612970001 RESCHA THAMARA FUJA P MASY.UMUM
67 P-G3HIM2W0 3279024404740004 NANI NURLIAH P MASY.UMUM
68 Q-E1527F18 3279022705720001 NGADIYO L MASY.UMUM
69 P-H58YY2HK 3279021108020002 M.NUR FAUZAN P MASY.UMUM
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COV
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINAS
Kepesertaan BPJS (tuli

pada kolom yang sesu
Umur
(18-59 Kelompok Umur Alamat No. Hp
tahun) BPJS PBI
23 DUSUN CIGADUNG 03/03, PATARUMAN 85724700311

55 JELAT 001/002, PATARUMAN 85213878467
61 JELAT 002/002, PATARUMAN 81312769030
51 JELAT 002/002, PATARUMAN -
67 JELAT 004/002, PATARUMAN 81386071434
49 BEKASI. PATARUMAN 811930246
56 LINGK.SUKAMANAH, PATARUMAN 812148492
58 JELAT 001/001, PATARUMAN 8122221426
55 JELAT 003/001, PATARUMAN 82119595712
56 PAMARICAN 81283657472
56 JELAT 004/002, PATARUMAN 89657888792
59 JELAT 001/002, PATARUMAN 87870353258
62 JELAT 001/002, PATARUMAN 85324563131
55 JELAT 001/002, PATARUMAN 85324563131
55 JELAT 004/002, PATARUMAN 85221605100
53 DUSUN SUKAMAJU 14/06, MULYASARI 85223258253
63 BABAKANSARI 004/011, PATARUMAN 82218197889
58 JELAT 004/002, PATARUMAN 82216384365
61 JELAT 004/002, PATARUMAN 81368071434
66 JELAT 004/002, PATARUMAN 85624468892
63 JELAT 001/002, PATARUMAN 85213878467
15 JELAT 001/001, PATARUMAN 89503067947
14 LINGK.LEMBUR BALONG 003/007, PATARUMAN 895336264981
15 LINGK.LEMBUR BALONG 003/007, PATARUMAN 85703143741
42 JELAT 004/002, PATARUMAN 89637348369
41 JELAT 004/002, PATARUMAN 81222947844
22 JELAT 003/002, PATARUMAN 85722792024
40 JELAT 002/002, PATARUMAN 8990740555
25 JELAT 002/002, PATARUMAN 82316802910
31 JELAT 003/002, PATARUMAN 85962885200
50 KP.SUKATANI 003/001 81224034990
39 DUSUN BUNISEURI 001/005 85894304502
29 JELAT 004/002, PATARUMAN 81386071434
29 LEMBUR BALONG 002/007, PATARUMAN 89662021368
28 BANDUNG/JELAT,PATARUMAN 89611374251
40 JELAT 002/002, PATARUMAN 89657888729
32 BANDUNG/JELAT,PATARUMAN 89614401626
41 JELAT 004/002, PATARUMAN 85624468892
21 PANATASAN 003/019 0895335061811
20 DUSUN MULYASARI 014/006 89614659112
29 LINGK.PATARUMAN 002/015, PATARUMAN 88260260260
40 JELAT 002/001, PATARUMAN 89662347636
48 JELAT 004/002, PATARUMAN 85624468892
37 JELAT 001/002, PATARUMAN 82317281221
39 KEBAYORAN BARU 85216679615
23 JELAT 002/003, PATARUMAN 8882338078
40 JELAT 001/002, PATARUMAN 82317281221
48 JELAT 004/002, PATARUMAN 82217803684
44 JELAT 001/002, PATARUMAN 81809061920
29 JELAT 002/002, PATARUMAN 89687016777
41 JELAT 001/002, PATARUMAN 81312158161
43 TAMAN PONDOK CABE C, 008/006 82110925995
38 RANCAKOLE 012/003, MULYASARI 82124512328
40 JELAT 004/001, PATARUMAN 87826140424
37 JELAT 004/001, PATARUMAN 85353306458
44 JELAT 002/002, PATARUMAN 85223505272
49 JELAT 002/002, PATARUMAN 85223505272
39 DADAPAN 85738649442
20 JELAT 002/002, PATARUMAN 0895331173615
49 JELAT 004/001, PATARUMAN 85223046281
19 JELAT 004/002, PATARUMAN 081992166071
ANAAN VAKSINASI COVID-19

Dosis I
Tanggal Screening Nama/Jenis/Merek Vaksin*** Tanggal
BPJS Non Non
Pemberian No. Batch
PBI Anggota
Vaksinasi
7/5/2021 SINOVAC 7/5/2021 24200521

7/5/2021
7/5/2021
7/5/2021
7/5/2021
7/5/2021
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
7/5/2021 SINOVAC 7/5/2021 24200521
Dosis I Dosis 2
Tanggal Keterangan
Pemberia (Ditunda/Tidak NAMA INSTANSI
No. Serial No. Batch No. Serial Diberikan/Lanjut)
n
Vaksinasi
LANJUT DOSIS 2
TUNDA HIPERTENSI
TUNDA
TUNDA
TUNDA HIPERTENSI
TUNDA
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
Jenis
Kelamin
1 P-AC8C3E20 3279021209650003 DEDE SUKIN L

2 P-FNKGNGKB 3211115006840010 ROSNANI P
3 P-ICHNV4YB 3279025408610001 DEDE ROHAETI P
4 P-IDGG10MM 3279020508790003 RISMANTO L
5 P-IHQ0B7UN 3279025105830004 ASIH BUDIYARTI P
6 P-IIZW6LUV 3279026010680001 ENOK HOMSIH P
7 P-IJPUWTW7 3205330504640001 U. BENI ISKANDAR SUKMANA L
8 P-IKIJAHWK 3279020705640001 HODRI L
9 P-IL1GRLCM 3279022012010003 NUR ADI SAPUTRA L
10 P-ILS14Y4C 3279024205730002 NONAH HASANAH P
11 P-IN1ONVBM 3279020101640004 AGUS KUSWARA L
12 P-INQGQ5E2 327902440477004 NARYATI P
13 P-IOEA6NZS 3279026402940002 NUR FEBRIANTI P
14 P-IPXDF4W7 3279024101680007 DEDEH DARLIAH P
15 P-IRE9DNVX 3279024208820002 MAESAROH P
16 P-IS0XN4R7 3279020302730002 SUTOYO L
17 P-ISPB52RI 3279040411880001 YOGA PERMANA L
18 P-ITPDMIY6 3279025403930002 NIA KURNIA P
19 P-IUDEID68 3279024705790001 WIWI P
20 P-IV6W3DAQ 3279026710740001 SRI ENDANG WAHYUNINGSIH P
21 P-IVKDQPVY 3279025101030001 YUANISA VIDYA WAHYUNI P
22 P-IWH7D3A9 3279020107630012 ESO SUTARSO L
23 P-IX14EXC0 3279024909920001 NUR SUSAN SUSANTI P
24 P-IXTZ6LPN 3279020603780003 YANA L
25 P-IYE6Y4LC 3279026212010001 WIDIYANI AZULVA P
26 P-IYSE519I 3301136602970002 AFIFAH NUR FADIYAH P
27 P-J3ZW35ZA 33001161305680004 WARSA L
28 P-J4SYGN98 3279022510900001 DEDE KUSNANDAR L
29 P-J5PW1QAG 3279024311950003 DEWI NURAENI P
30 P-J6E0LYAL 3279021004890002 DEDE KUNDRAT L
31 P-J6FCVH1M 3279024209840001 AAD ANI ADMINI P
32 P-J6P0HDBI 3279020701760001 TAHYAN L
33 P-J6X96950 3279024707870005 NENI YUNINGSIH P
34 P-J6ZAHOKW 3279022612970002 SINGGIH ALI SUNAN L
35 P-J7B9O3NJ 3279020809940002 YUSUP HIDAYAT L
36 P-J7F73CRR 3279025405770002 ELIS HALIMAH P
37 P-J7KROWHN 327902070750001 RASIDI SHOLEH L
38 P-J7SVYQLV 3207031708820003 NANA SURYANA L
39 P-J7V65SAA 3279020405980001 REDI SETIADY L
40 P-J8INN2XM 3279020504960003 JATI PURNAMA L
41 P-J8QLSIEF 3279025711700001 SUDARYANTI P
42 P-J9C5LSRZ 3279017005740001 WIWIN WINARNI P
43 P-J9KUEAAI 3279022511760001 HARTOMAN L
44 P-J9LFKCLL 3205014211970003 RAISA DWIYANTI P
45 P-J9VRKAYH 3279026711690001 MAESAROH P
46 P-JA4D2B84 3279205402900001 EPON P
47 P-JALHHXP6 3174064607031002 SIVA VAUZIAH P
48 P-JBNS7BJ5 3279025009840004 ATI NURHAYATI P
49 P-JBVRKBU6 3279022207970005 DJOKO MAOLANA L
50 P-JC6DGQF1 3279024212770002 AAN DARWATI P
51 P-JCADHBUB 3279020708900001 AEP MULYONO L
52 P-JCJA4CH5 3279026804780004 YULIA P
53 P-JCQPQM59 3279026107950002 TIKA SULISTYAWATI P
54 P-JDIQE4OV 3279025105030001 SANTI SARTIKA P
55 P-JEEP7O3N 3279022700850001 TN. CAHYADI L
56 P-JEU0H1QZ 3279024304730002 NURAENI P
57 P-JFDQW0NE 3205070606950001 CEPI NUR HIDAYAT L
58 P-JFS9G3IW 3279021403810001 DEDE RUSMIN L
59 P-JGMQG4TE 3279024101890002 SUSILOWATI P
60 P-JHXIY22V 3205392512620001 ADE SUPARDI L
61 P-JID6NSMJ 3279021512940003 RIFKI RIANSYAH L
62 P-JISRTVTP 3279022404860001 ASEP KURNIA L
63 P-JK4AL73N 3279021101820002 TN. HENDRIK NURJAMAN L
64 P-JNTKKE71 3279025708020003 ANANDA FITRI NURFIIIAAH P
65 P-JO7MSTF1 3279022612790001 MAZMUDIN L
66 P-JRIKUKLH 3206374101000018 PIPIT PITRIANI P
67 P-JVYWA8QK 3279021904030004 RAIS RABBANI L
68 P-JWER6JWJ 3279026306000003 YETIK ROSIANA P
69 P-JWUDASKD 3310225109020004 AENI NUR FITRI HASANAH P
70 P-JYL8QBKZ 3279021005910004 ANDI NURHIDAYAT L
71 P-JZCV0IR1 3279026302800001 NURHASANAH P
72 P-K00PSHYJ 3279025110820001 ATIK P
73 P-K6UOHGI8 3279021205790002 DIANI L
74 P-P2F33RS5 3279022005700001 DEDE TOHA L
75 P-P3YPNMTW 3279026706830001 ELA NURLAELA P
76 P-P6W4PPI6 32790230050100001 ADE ARIF NURYANA L
77 P-P6ZKKG2W 3279024107630011 IHAT SOLIHAT P
78 P-P7CC1S8V 3279024610820003 ETIN P
79 P-P7LR2148 3279021001970001 RICKY RAMDANI L
80 P-P7PH2F1G 3279024801920001 SUSANTI MARYANI P
81 P-PZEYPP6X 3279026512700002 ENOK SURYATI P
82 P-QG9OLERZ 3279025706710002 ENDE INDRAWATI P
83 P-QIFM3OBL 3279025102710001 IIN SRI WAHYUNI P
84 P-QPAE9FZS 3279025708750006 SUNENGSIH P
85 S-3B488899 3279020407600001 DIKUN L
86 S-59458633 3279025212560003 AISYAH P
87 S-80753FA4 3279022512590002 SUHARSO L
88 S-93F794A2 3301160101590002 OTONG HERMANTO L
89 S-CD608597 3279020804500001 NONO SUHANA L
90 S-F26949CF 3207311210870001 HERA HERNALI P
91 3279025707410001 ANASIH P
92 3279021705540001 UU MAHPUDIN L
93 3279024905620002 NENENG SUCIYATI P
94 3279026006600002 EPON SUSANTI P
95 3279026610710001 SUMIATIN P
96 3279025504750001 HARTATI P
FORMAT PENCATATAN PELAKSANAAN VAKS
Umur
Pekerjaan* (18-59 Kelompok Umur Alamat
tahun)

MASY.UMUM 37 PANANJUNG TIMUR 031/007, SINARTANJUNG
MASY.UMUM 42 PANANJUNG 013/003, SINARTANJUNG
LANSIA 53 CILUBANG 001/001
MASY.UMUM 31 MARGALUYU 006/008
MASY.UMUM 23 PANANJUNG 012/003
MASY.UMUM 44 PANANJUNG 021/005
MASY.UMUM 40 PANANJUNG BARAT 011/002, SINARTANJUNG
MASY.UMUM 19 BABAKANSARI 001/009, PATARUMAN
LANSIA 50 JL.SETIONO RINGINSARI
MASY.UMUM 34 MEKARHARJA 004/001
NCATATAN PELAKSANAAN VAKSINASI COVID-19
T PUSKESMAS/FASYANKES/POS VAKSINASI

No. Hp BPJS Non Non Tanggal Screening Nama/Jenis/Merek Vaksin***

BPJS PBI
PBI Anggota
082315543087 7/6/2021 SINOVAC

085320523909 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
087836360688 7/6/2021 SINOVAC
081221301404 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
089609001167 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
081221301404 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
085794631786 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
081222814955 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
087718615143 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
087832272901 7/6/2021 SINOVAC
085223679738 7/6/2021 SINOVAC
082118223929 7/6/2021 SINOVAC
082118223929 7/6/2021 SINOVAC
087764070857 7/6/2021 SINOVAC
081214479346 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
085223975461 7/6/2021 SINOVAC
087736292965 7/6/2021 SINOVAC
081294760911 7/6/2021 SINOVAC
083116882277 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
085223903439 7/6/2021 SINOVAC
082216233837 7/6/2021 SINOVAC
083827075620 7/6/2021 SINOVAC
085959777892 7/6/2021 SINOVAC
08890730884 7/6/2021 SINOVAC
081992420551 7/6/2021 SINOVAC
081990723223 7/6/2021 SINOVAC
085222354700 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
087867530632 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
082119494461 7/6/2021 SINOVAC
081296229948 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
087874146809 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
089530050531 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
085900239224 7/6/2021 SINOVAC
089644246812 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
082129804213 7/6/2021 SINOVAC
08978535455 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
082117472253 7/6/2021 SINOVAC
087833587000 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
085318318336 7/6/2021 SINOVAC
085281886939 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
082117622389 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
085712125256 7/6/2021 SINOVAC
081224114151 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
085603986272 7/6/2021 SINOVAC
087312515535 7/6/2021 SINOVAC
0895335055868 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
087764031665 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
087894837496 7/6/2021 SINOVAC
082216585308 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
08210131625 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
081394011428 7/6/2021 SINOVAC
- 7/6/2021 SINOVAC
085223151616 7/6/2021 SINOVAC
- 7/6/2021
- 7/6/2021
- 7/6/2021
- 7/6/2021
081323511753 7/6/2021
085223037741 7/6/2021 SINOVAC
Dosis I Dosis 2
Tanggal Keterangan
Pemberia
Pemberian No. Batch No. Serial No. Batch No. Serial Diberikan/Lanjut)
n
Vaksinasi
Vaksinasi
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
7/6/2021 24200521 LANJUT DOSIS 2
TUNDA HIPERTENSI
TUNDA HIPERTENSI
TUNDA TIDAK FIT
TUNDA HIPERTENSI
TUNDA HIPERTENSI
7/6/2021 24200521
Jenis
Kelamin
Pekerjaan*
1 P-N7LPS2EA 3279020606700003 SURATMAN L LANSIA

2 P-N6PSBNM2 3279020803670001 UKIM L LANSIA
3 P-N4LH6A8I 3279021303670001 SARNO L LANSIA
4 P-N04PK9R7 3279021202700003 YAYA L LANSIA
5 P-LTMMETN1 3279025206650002 ENTIN P LANSIA
6 P-LVJSGO04 3279024101630009 RUMSIH P LANSIA
7 P-N5OCZ1V7 3279020210010001 RIO RAHMAN L MASY.UMUM
8 P-N5WIUSHJ 3279024101750006 DEWI P MASY.UMUM
9 P-N562YT5Y 3279025111020002 RINA RISMAYATI P MASY.UMUM
10 P-MTYJFY8H 3278926608000002 SINTA INDRIYANI P MASY.UMUM
11 Y-01174MLO 3207301503990001 YUSUP MULYADI L MASY.UMUM
12 P-MSVKF2AW 3279044604940001 DIANA LASATI P MASY.UMUM
13 P-MUBSU521 3301162505000001 DIKI SUPRIADI L MASY.UMUM
14 P-N3AE4F4Y 3279020101770005 MAMAN L MASY.UMUM
15 P-MT7GUCM6 3279024107980003 FITRIYANI P MASY.UMUM
16 P-M5FLYUMK 3279022705760001 EMAY SETIAWAN L MASY.UMUM
17 P-MCA8PRTI 3279021403880002 ARIEF PRAYOGO L MASY.UMUM
18 P-MCPYSKMX 3279025305870001 NOPI P MASY.UMUM
19 P-MDBQSAWJ 3279024404870001 ATI MULYANI P MASY.UMUM
20 P-MEZVFGZ0 3279025505770003 AYI IRAWATI P MASY.UMUM
21 P-MBNDJVLF 3279024402850001 KUSNIAH P MASY.UMUM
22 P-LULY56P2 3279020308990001 EZRA AGUSTINUS L MASY.UMUM
23 P-M04O8C0O 3279024703820006 SRI SULASTRI P MASY.UMUM
24 P-M5XSJGVX 3279024706800003 RANI MARLINA P MASY.UMUM
25 P-LYOO403O 3279021909030003 SENDI SETIAWAN L MASY.UMUM
26 P-LZOPACI7 3202112508910011 DEDIH ARIF MUSTOPA L MASY.UMUM
27 P-LMF8RMI9 3279026904040001 ALVIRA TRIA PADILA P MASY.UMUM
28 P-LLXYIMLY 3279025110700003 NANING DANINGSIH P LANSIA
29 P-LV1F83RJ 3279025603810002 LIDIAWATI P MASY.UMUM
30 P-LRXLE9KM 3279025610030003 CELANDINE MULAN IRIANIKA P MASY.UMUM
31 P-LR11DBJE 3279025006740005 KUSMAYATI P MASY.UMUM
32 P-LU8EEINO 3279021402820004 CAHYONO L MASY.UMUM
33 P-LXV9L8OD 3279024806820002 YANI SOPIANI P MASY.UMUM
34 P-M33I5SVB 3279020704810003 WAWAN HERMAWAN L MASY.UMUM
35 P-LSYWAYUG 3206186010930001 DEWI LAELASARI P MASY.UMUM
36 P-LVWNBIA3 3207361612010001 AJIS SUKMARA L MASY.UMUM
37 P-LWNIWHT1 3279022101920001 DADAN PERMANA L MASY.UMUM
38 P-MJY22P07 3279026507670001 EROH ROHAYATI P LANSIA
39 P-L7OLA4X3 3279021004790001 ARI L MASY.UMUM
40 P-L9E7GZ2U 3279021501800001 YAYAT L MASY.UMUM
41 P-LA2PGJ8U 3279024606790003 SUMIATI P MASY.UMUM
42 P-LAFJO3Q0 3279022205750002 UNTUNG SIMANUNGKALIT L MASY.UMUM
43 P-LAMF2YOA 3279021807800004 WAWAN JUWANDA L MASY.UMUM
44 P-LBPNTMV1 3279024104010003 DINI APRILIANI P MASY.UMUM
45 P-LB6NLGUE 3279036104980001 LINDA ROSMALIA P MASY.UMUM
46 P-N6PSBNM2 3279026006900001 NIRA WATI P MASY.UMUM
47 P-LDABLQAV 3279025904730001 ETI ROHAETI P MASY.UMUM
48 P-LC8HZUI0 3279026509820003 DEDE YUNINGSIH P MASY.UMUM
49 P-L842QLPP 3279024803810002 MARNI P MASY.UMUM
50 P-LFE2JXQI 3279021609770001 SUGIRI L MASY.UMUM
51 P-LFPR3ZQ4 3279020204790002 NINDA SETIAWAN L MASY.UMUM
52 P-LG2FP1J2 3279021911780003 SIWAN L MASY.UMUM
53 S-A2E80291 3279020307510001 IING L LANSIA
54 S-DFD97603 3279025106520001 UJI WATI P LANSIA
55 P-LCVDKHOP 3279022105620001 KUSWARA L LANSIA
56 P-LE0HDWYI 3279022404620001 SUKANTO L LANSIA
57 S-E7E2E824 3279025211550001 JUJU JULAEHA P LANSIA
58 P-LJB4AUV3 3279020711620001 KURDI L LANSIA
59 P-LGUKK5XA 3279025011620001 ECIN P LANSIA
60 P-LEQ9JEK8 3279024101640014 DAR'AH P LANSIA
61 S-037FF163 3279024101570006 ANAH P LANSIA
62 P-L8FLIY34 3279024209620002 KASIH SUTIARSIH P LANSIA
63 S-8C1C18BF 3279020806570002 SARJA L LANSIA
64 P-MOE94XQ7 3279024408690001 LILIS DARLIAH P LANSIA
65 S-154AF6BD 3278040109550005 MULYONO L LANSIA
66 P-MOPF840B 3279024307700007 RUSMIATI P LANSIA
67 S-4108D7D6 3279024206570002 UHA JUHATI P LANSIA
68 S-F5A387A3 3279021106600001 ENCENG SUHERMAN L LANSIA
69 P-MLKEIOTP 3279044407670005 JUBAEDAH P LANSIA
70 P-MIWPJN16 3279021307680001 MAMAN PERMANA L LANSIA
71 P-MHNXAM8V 3279020401650001 LILI SUARLI P LANSIA
72 P-MFYJHM4D 3279024706700003 DEDE HARTINI P LANSIA
73 P-MAUF5F3W 3279021707630001 UJANG SURYATMAN L LANSIA
74 P-M8BO0GWT 3279010501630001 AGUS HERANTO L LANSIA
75 P-M4E9T2HN 3279024202700001 PONIAH P LANSIA
76 P-LQCNIQ0E 3279022403680003 BA'I L LANSIA
77 P-LR3Y5NW0 3279022712020001 RIZKI RAHAYU L MASY.UMUM
78 P-MBAQR7D7 3279024207770004 IIS TUTI RASWATI P MASY.UMUM
79 P-M8WYLAHD 3279020107720014 SARMAN L MASY.UMUM
80 P-LXENHKVW 3279035908880001 EET GUNARTI P MASY.UMUM
81 P-M6XO2G5L 3279025201940005 UNEH P MASY.UMUM
82 P-M9LCSNTU 3279015811890003 RATNA JUWITA, S.H. P MASY.UMUM
83 P-MAFDJM4M 3279025902950002 MARNI P MASY.UMUM
84 P-M3XMXLIZ 3279021010790005 SUHARNO L MASY.UMUM
85 P-MFKHN393 3279045801910003 AYU DEVI P P MASY.UMUM
86 P-MGLNIYEU 3279026803020001 DISTI AULIA P MASY.UMUM
87 P-MH7G7HP5 3207266702970001 YUSI FITRIA P MASY.UMUM
88 P-MIL6Y14Q 3279021402800001 IWAN KURNIAWAN L MASY.UMUM
89 P-MHXODV0P 3279020306810004 JOKO SUSANTO L MASY.UMUM
90 P-MJ7TF3HE 3279020710730001 ENCENG NANO L MASY.UMUM
91 P-ME2KBJBQ 3279025004730005 CICIH MINTARSIH P MASY.UMUM
92 P-MJKLRH07 3279010808920001 AWALLUDIN L MASY.UMUM
93 P-MKQMFIZP 3279022204980002 ARIZKI IBNU ROHMAT L MASY.UMUM
94 P-MLZAOKQA 3279023009840001 YOSEF ARDIANSYAH L MASY.UMUM
95 P-MDMN7RNH 3279021201830005 AGUS SURIPTO L MASY.UMUM
96 P-MMEJPR3R 3279021402980001 ARDI NURDIN FADILAH L MASY.UMUM
97 P-MMUVREPN 3216065609740020 LIA WATI P MASY.UMUM
98 P-MNJYJAHC 3279024911840001 SITI ROBIAH P MASY.UMUM
99 P-MNR82GGA 3279025108910001 NURHALIMAH P MASY.UMUM
100 P-LGGJ1V7K 3279026908030002 NITA MUSRIANI P MASY.UMUM
101 P-LDNFOB75 3279025801010002 ERNASARI P MASY.UMUM
102 P-LCL5FZ83 3279021205980002 IVANDA NURDIANA L MASY.UMUM
103 P-LIV1DTP3 3279025112020002 REISHA RACHMI PRATIWI P MASY.UMUM
104 P-LJOVLNW5 3279022708940006 DAVID ANDIKA L MASY.UMUM
105 P-LLIYKZL0 3279020910720002 PAIMIN L MASY.UMUM
106 P-LO3MG3QX 3279024712790002 PIPIN SUPINI P MASY.UMUM
107 P-LOP9XBXK 3279020111760001 MAMAN SUDIAMAN L MASY.UMUM
108 P-LPKUWM2L 3279025903920001 RENI PARLIANI P MASY.UMUM
109 P-LP3AOWVF 3279024910980002 AYU FUJIANTI P MASY.UMUM
110 P-LPZDREU6 3279026505870001 YANI YULIANI P MASY.UMUM
111 P-LPQTZ3GL 3279025302860001 NANI NURYANI P MASY.UMUM
112 P-LQIQRLHT 3207035110960001 ANITA RAHAYU P MASY.UMUM
113 P-LQOUL6A8 3279021311960001 ERIS RISWANTO L MASY.UMUM
114 3279024112800002 YUYUN YUNINGSIH P MASY.UMUM
115 3279026112600001 SAMIAH P LANSIA
116 3279020101400021 MAMUN SUGANDA L LANSIA
117 3279020308690001 ABDUL ROHMAN L LANSIA
118 3279022002580001 PATAH L LANSIA
119 3279024510540001 OYOH P LANSIA
120 3279027108700001 AGUS DIANA L LANSIA
121 3279024101550005 HATIJAH P LANSIA
122 3279021012530002 SENTOT L LANSIA
123 3279024708560001 RATIAH P LANSIA
124 3279020611670002 PARMAN L LANSIA
125 3279021003530001 OJO SUPARJO L LANSIA
126 3279020101780003 ARI DARYANTO L MASY.UMUM
FORMAT PENCATATAN PELAKSANAAN VAKS

Umur Kelomp
(18-59 ok Alamat No. Hp BPJS Non
tahun) Umur BPJS PBI
PBI
51 PATARUMAN 004/014, PATARUMAN 085323306790

22 CISAGA 002/008 082115230389
21 PANULISAN 002/010 081219136612
66 PANYINGKIRAN 003/010, TASIKMALAYA 087825172586
54 TASIKMALAYA 003/010 087825172586
32 SUKAMANAH 001/016, PATARUMAN 085321019321
30 BOJONGKANTONG 008/005 085724245490
23 LEMPUNGAN 002/008 081575793119
N PELAKSANAAN VAKSINASI COVID-19
SMAS/FASYANKES/POS VAKSINASI

Dosis I Dosis 2
olom yang sesuai)
Tanggal
Non Pemberia
Anggota n
Vaksinasi
Vaksinasi
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021 SINOVAC 7/7/2021 24200251
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
7/7/2021
Dosis 2
Keterangan
No. Batch No. Serial Diberikan/Lanjut)
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
LANJUT DOSIS 2
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TUNDA HIPERTENSI
TUNDA
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TUNDA HIPERTENSI
Jenis
Kelamin
Pekerjaan*
1 P-31OMPQSE 3279022211940002 HENDRI WIBOWO L MASY.UMUM

2 P-85Y0PXW1 3279020509890002 ADE IRPAN SOPYANA L MASY.UMUM
3 P-8LKDIGZT 3212135204870002 ANGGRIANA P MASY.UMUM
4 P-AKCV4OED 3279034202950001 NENI RESTIANI P MASY.UMUM
5 P-AZEE1NEI 3279034605870001 NINGSIH PURWANINGSIH P MASY.UMUM
6 P-BMHM3SUK 3279036903720001 PARYANTI P MASY.UMUM
7 P-CCFSBIWY 3279034603030001 ANGGI DWI MARYAM P MASY.UMUM
8 P-EKBAGZ0Y 3279021502970001 DIAN FEBRIANA P MASY.UMUM
9 P-FHVJWYXK 3279036106040001 FITRI KOMALASARI P MASY.UMUM
10 P-GUHIERVS 3279035809000001 IKA SEPTIANI P MASY.UMUM
11 P-HE6TWDJM 3279032612960001 MUHAMMAD ILAL HAQIQI L MASY.UMUM
12 P-I9N87KRO 3279014203680001 YAYAN SRI MULYANI P LANSIA
13 P-ILI671NM 3279031606850001 SUGENG L MASY.UMUM
14 P-IX2MSBHP 3279016208890001 SITI MARYAM P MASY.UMUM
15 P-J7ZZRPIG 3279026607990001 FANI NURPADILA P MASY.UMUM
16 P-JA9QJ0Y8 3279014507930001 NURHAYATI P MASY.UMUM
17 P-JXVP85RW 3279030807870001 ARIS SETIAWAN L MASY.UMUM
18 P-L3EQJU4I 3279016607860002 ENUNG ROHIMA P MASY.UMUM
19 P-L3LNNLTJ 3279025208750003 TUTUR SUKAESIH P MASY.UMUM
20 P-LPPCULS7 3301157004940001 DEWI PURWANINGSIH P MASY.UMUM
21 P-LPQUDDVP 3279024608010003 INDAH IRMAWATI P MASY.UMUM
22 P-MCCYF9FW 3279035606020003 LUTVI TRIYANA P MASY.UMUM
23 P-MUNZG5H2 3279022909730002 RASMIN NURYADIN L MASY.UMUM
24 P-N99JYWCA 3279014502960002 febtiani asri rahmayani P MASY.UMUM
25 P-NE7MSN3R 3279025505860006 EVI DEWI MULYANI P MASY.UMUM
26 P-PV3HL80Q 3207180912760001 andre tyas gautama L MASY.UMUM
27 P-QDO9MQMV 3301161008960001 DEDI LESMANA L MASY.UMUM
28 P-QSCY5F9X 3279025504790003 SRI DARWATI P MASY.UMUM
29 P-R9WNBG8R 3279014906020002 TRI BUANA SEKAR BUDIARTI P MASY.UMUM
30 P-RVORKBMC 3279021504010001 DIMAS ERLANGGA PUTRA L MASY.UMUM
31 P-SA53QKUH 3217111307800015 NANA JUANSA, ST. L MASY.UMUM
32 P-SA6GEJJJ 3279014102840005 ELIN HERLINA P MASY.UMUM
33 P-SABRFPRQ 3279016707950002 ELA SARI P MASY.UMUM
34 P-SAH3KXL8 3207301401890001 YADI SUPRIADI L MASY.UMUM
35 P-SAQWTRVD 3279016505870003 YAYAH DWI PUSPITASARI P MASY.UMUM
36 P-SASBIAY5 3279022606790001 NANA MULYANA L MASY.UMUM
37 P-SBC0NX9W 3279024505780002 TITIN NURYATIN P MASY.UMUM
38 P-SBOPUOYM 3279014712740001 NURHAYATI P MASY.UMUM
39 P-SBQDPU99 3279021012850002 PONIMAN L MASY.UMUM
40 P-SBS2FLLJ 3279021204900001 IKIN ROSIKIN L MASY.UMUM
41 P-SBXOSVN1 327902050595003 YUDI MARYANA L MASY.UMUM
42 P-SC3S1ZKV 3279021803930001 TEDI LASTIADI L MASY.UMUM
43 P-SCEPNWZY 3279045508950002 ERMA IRMAYANTI P MASY.UMUM
44 P-SCIWLOL5 3279010809960001 RIZKYA TRADA PUTRA L MASY.UMUM
45 P-SCPPVR3P 3207171709970001 EDI PRASETYO L MASY.UMUM
46 P-SCS8MEZI 3279022601900001 ALI ABDUL AZIS L MASY.UMUM
47 P-SCVWZWHC 3279022505930009 SUTONO OKA L MASY.UMUM
48 P-SCY02NCU 3207072902960001 ARI FIRMANSYAH L MASY.UMUM
49 P-SD0OPXVR 3279024109880002 IRMA RAHMAWATI P MASY.UMUM
50 P-SD5BGMDR 3279012202940002 RAMADHAN INDRA KUSUMA L MASY.UMUM
51 P-SDASF7KZ 3279025604890002 EDAH ROSIDAH P MASY.UMUM
52 P-SDGOCH8P 3279021206880002 RUDI IRMANSYAH L MASY.UMUM
53 P-SDKITV2Z 3279026408770001 RIKA RASTIKA P MASY.UMUM
54 P-SDOHCHC3 3279020107780002 DUDUNG L MASY.UMUM
55 P-SDSZ4Y2G 3279024709940002 DESTY LUSIANY P MASY.UMUM
56 P-SE1WBHPZ 3279015207850001 YANI SURYANI P MASY.UMUM
57 P-SE30IOXH 3279010510820001 IFAN SUDRAJAT L MASY.UMUM
58 P-SE7J0K9I 3279026709920001 NUR INTAN SEPTIANI. SG P MASY.UMUM
59 P-SEFYKB2P **********0005 SAENAL L
60 P-SEGWNYSB 3279026412840002 IDA FARIDA P MASY.UMUM
61 P-SEOHYCFZ 3207191408840004 APIP PIANDI L MASY.UMUM
62 P-SEQBLYIK 3279024810790002 NINA MARLIANA P MASY.UMUM
63 P-SEYGCIJ6 3279030103970002 TIO SETIONO L MASY.UMUM
64 P-SEZ6DSK9 3279044908850002 LELA DURYANINGSIH P MASY.UMUM
65 P-SF3T6H8Z 3279011603800001 MAMAN ROHMAN L MASY.UMUM
66 P-SF54ZSAE 3273302105810005 BAYU NUGRAHA L MASY.UMUM
67 P-SF8JONME 3279022108740001 NANA ROWANA L MASY.UMUM
68 P-SFDOKX36 3279022106980001 KRISMAN GUMELAR L MASY.UMUM
69 P-SFI1NNP3 3279026005730002 HERLIN SUPRIATIN P MASY.UMUM
70 P-SFPKR16V 3279020508690002 WAWAN DARMAWAN L LANSIA
71 P-SFROK2TC 3279023008700001 SUHENDARNUR L LANSIA
72 P-SFUCJ43V 3279022011630001 SULAEMAN L LANSIA
73 P-SG361BM5 3279012311940001 ADITIA DARMAWAN L MASY.UMUM
74 P-SG44O3ND 3279020808700002 HERLIANA P LANSIA
75 P-SGDXNI73 3279025001910001 IIS SULASTRI P MASY.UMUM
76 P-SGFPGVHY 3279020306820002 HENDAR NUGRAHA L MASY.UMUM
77 P-SGH5IETR 3279021103850002 ASEP ANDRI SUWARSA L MASY.UMUM
78 P-SGMBSEYA 3279041203900002 HERLAN SUTISNA L MASY.UMUM
79 P-SGSNW0VD 3279020610760003 TATANG HIDAYAT L MASY.UMUM
80 P-SGX0PURS 3301152502780001 SUPANGATIN L MASY.UMUM
81 P-SGXT7ERN 3279022104860002 ANTO HERYANTO L MASY.UMUM
82 P-SGY5JTKJ 3279022810960004 YONA RAHMADI P MASY.UMUM
83 P-SH30XR2M 3279026012770001 YANI P MASY.UMUM
84 P-SH7HFQMQ 3279021601960001 ZAENUR MARJAN L MASY.UMUM
85 P-SHGAU5K6 3207191910920002 RIAN HIDAYAT L MASY.UMUM
86 P-SHKP7CJK 327902680675002 SUSI HERAWATI P MASY.UMUM
87 P-SHQUIS35 3279026206830001 SRI WAHYUNI P MASY.UMUM
88 P-SI0T298E 3279025812780002 ATI RUSMIATI P MASY.UMUM
89 P-SIBVQIKN 3273065205770001 NANI SUMIATI P MASY.UMUM
90 P-SICM615G 3279036411820002 YENI YUNINGSIH P MASY.UMUM
91 P-SIQJPIFL 3279010307680003 U. NUR'ALAM L LANSIA
92 P-SISL8RXO 3279023009670001 HAMIDDUDIN L LANSIA
93 P-SJ5HR03H 3279011005740003 ANDANG RAHMAT L MASY.UMUM
94 P-SJDOMWSE 3279020102740001 HENDRI L MASY.UMUM
95 P-SJHGKOOD 3341150608690005 KHOMSIN L LANSIA
96 P-SJMDIEHQ 3301150101850026 SUHERMAN L MASY.UMUM
97 P-SJRWG0ON 3279014112660001 EDAH SITI JUBAEDAH P LANSIA
98 P-SJSHKTVN 3301154805990002 WARYANTI P MASY.UMUM
99 P-SJZVGA15 3279024803690002 RANTI ASTUTI P LANSIA
100 P-SKENUG52 3279034610930001 CHOERUNISA P MASY.UMUM
101 P-SKIIUY7U 3279015503800001 ENTIN KARTINI P MASY.UMUM
102 P-SKZ6RP3Y 3279022005840005 HERYANA L MASY.UMUM
103 P-SL5F6NRS 3279025508850002 ISAH P MASY.UMUM
104 P-SL66FHQU 3279021708840006 AGUS RIYANTO L MASY.UMUM
105 P-SLABO4NH 3279025405790001 SARI SULISTIANI P MASY.UMUM
106 P-SLCUIIYP 3207192002680001 SUGIANTO L LANSIA
107 P-SLDBKO7U 3279026509740002 AAS SITI NURJANAH P MASY.UMUM
108 P-SLHFIUPZ 3279020212740001 MAMAN L MASY.UMUM
109 P-SLO2GHF7 327901661810002 YULI YULIANTINI P MASY.UMUM
110 P-SLS0KWFH 3279026107730001 TETI HERAWATI P MASY.UMUM
111 P-SLUWKKLL 3279021003730005 TRISNA P MASY.UMUM
112 P-SLXDIGJN 3279022512800001 DEVIANA KURNIAWAN P MASY.UMUM
113 P-SM21V84K 3279025302720001 RUMINAH P MASY.UMUM
114 P-SMBVJSLV 3279025004660003 MAMAY MARYAMAH P LANSIA
115 P-SMDLV2AN 3279024706870001 NIA KHAERUNNISA P MASY.UMUM
116 P-SME3P1RW 3279021703940001 DARUS L MASY.UMUM
117 P-SMRLV38A 3279021101640026 WAWAT P LANSIA
118 P-SN2KUQGD 3279022402610001 JUHANA L LANSIA
119 Q-0000TPXO 3279014409010001 RESA NURHASANAH P MASY.UMUM
120 S-0727D6A7 3279022010600001 TUJAN ARSAN L LANSIA
121 S-450ED857 3279022804600001 NANANG SURYANA L LANSIA
122 S-D6F45337 3279020705580001 EMON MAMAN L LANSIA
123 WAWAN RUSWANDI L MASY.UMUM
124 3279015609780001 NINING KURNIA P MASY.UMUM
125 32790209720001 KUSNADI L MASY.UMUM
126 WIWI WIYARSIH P MASY.UMUM
127 3279014209780002 IDA FITRI KUSMAWATI P MASY.UMUM
128 3279031006800001 KARMIN L MASY.UMUM
129 3525132907860001 DANNY YULIANTO L MASY.UMUM
130 3279025206720001 EMIN P MASY.UMUM
131 3279025503750001 AI.JUARIAH P MASY.UMUM
132 3279020708730001 RUSNA SURYANA L MASY.UMUM
133 3279022207830001 YANA SURYANA L MASY.UMUM
134 3279021111750001 HENDI JUHAENDI L MASY.UMUM
135 3279011012890002 RUDIANA SETIA GUNAWAN L MASY.UMUM
136 3279041207720023 ASEP SUPRIATNA L MASY.UMUM
Kolom1
FORMAT PENCATATAN PELAK
Umur
(18-59 Kelompok Umur Alamat No. Hp
tahun)
27 TEMBANGKERTA 005/010, SUKAMUKTI 089625133736

23 CIMANGGU, RT/RW 08/02 08813017727
34 JL.MALABAR NO 40, CIREBON 089661294877
26 SILUMAN BARU, 035/016 085722721539
34 LINGK.PARUNGSARI, 008/009 085320577024
49 LINGK.PARUNGSARI, 12/04 089656675521
18 LINGK.PARUNGSARI 012/004 085861191472
24 SUKAHURIP, 006/004 SUKAMUKTI 081224816886
25 CIKADU, 020/009 085281741996
53 LINGK.PINTU SINGA RT/RT 005/018 083116727067
36 LINGK.WARGAMULYA 015/007, PURWAHARJA 085220600853
32 LINGK.WARGAMULYA 015/007, PURWAHARJA 085220600853
23 GIRIMUKTI, 004/008, SUKAMUKTI 081222819913
28 LINGK.SUMANDING KULON 003/021 085221305604
34 PURWAHARJA 083154840048
35 CIBEUREUM 042/003, BALOKANG 089655874644
46 LEMBUR BALONG 001/006 082315013190
27 MAJENANG 083844414080
19 LINGK.LEMBUR BALONG 002/06 085161631006
19 LINGK.CIKADU, 021/009, KARANGPANIMBAL 087735495712
42 CIKABUYUTAN TIMUR 005/011 087764097141
25 LINGK.CIBULAN 003/006 08971882767
35 LINGK.CIKABUYUTAN BARAT 003/010 082317667321
42 KARANGTENGAH 027/009, BALOKANG 085352239122
25 LINGK.SUKARAME 082317742207
42 PABUARAN 013/002 082320586085
19 SUKARAME 005/014 087742090441
20 CIKABUYUTAN TIMUR 089630914700
41 BANJAR KOLOT 001/013 082121095595
37 BANJAR KOLOT 0895358540300
26 BANJAR KOLOT 089665012246
32 BINANGUN 088809567040
34 SUMANDING KULON 001/019 085320170636
42 LEMBUR BALONG 004/005 089527418008
43 TANJUNG SUKUR 005/016 0895370379100
47 SUKARAME 005/014 087725990797
36 SUKAMAJU 009/005 0895386619070
31 JELAT, PATARUMAN 0895803164494
26 PANATASAN 001/019 08980006630
28 MARGALUYU 002/007, MULYASARI 089680790882
26 SUKAMAJU 009/005 0895386619070
24 CIMENYAN 1, 002/004 081807348643
24 CILENGKRANG 009/005.NEGLASARI 083823283539
31 LEMBUR BALONG 0812121946270
28 JELAT 081313088325
24 NEGLASARI 003/002 087858150561
33 TANJUNG SUKUR 005/015 089668103871
27 PATARUMAN 003/013 087717414754
32 PANGADEGAN 005/018 088229110577
33 TANJUNG SUKUR 005/017 089505869404
44 TANJUNG SUKUR 004/017 0895613979687
43 TANJUNG SUKUR 003/17 085211948044
27 JELAT 088809448120
36 BANJAR KOLOT 004/015 089530046376
39 BANJAR KOLOT 004/015 0895389830008
29 CIKABUYUTAN BARAT 003/010 085221683251
37 TANJUNG SUKUR 005/016 081315847784

37 TANJUNG SUKUR 005/016 08574972
42 TANJUNG SUKUR 004/015 081320213098
24 PARUNGSARI -
36 SINDANGMULYA 002/010, KUJANGSARI 082320470684
41 CIMENYAN 1 004/005 085316167434
47 SUKAMAJU 009/005, MULYASARI 085321199577
23 LEMBUR BALONG 089663287223
48 TANJUNG SUKUR 002/014 085223561850
52 TANJUNG SUKUR RT/RW 002/014, HEGARSARI 081220348928
51 MULYASARI 04/06 082119390174
57 LINGK.CIKABUYUTAN TIMUR, RT/RW 003/012 085221200407
27 SUKAMANAH 001/017 0895344839577
51 CIKABUYUTAN TIMUR 08990475280
39 CIKABUYUTAN BARAT 005/010 082240952424
31 SINARGALIH, 001/004 088222348136
43 ADIMULYA, WANAREJA -
35 PABUARAN 001/001 083103532987
35 SUKAMANAH 004/017 089510396203
44 LEMBUR BALONG 003/008 085294589227
25 SUKAMANAH 001/018 085280154439
46 SUKAMANAH,PATARUMAN 087896076257
38 TANJUNG SUKUR 004/015 081323313204
43 TANJUNG SUKUR 085294151460
39 HEGARSARI 004/007 08985714800
53 LINGK.CIMENYAN 2 082124895387
54 TANJUNG SUKUR, RT/RW 001/015 081318486510
47 BANJAR KOLOT 0852210772299
47 TANJUNG SUKUR, RT/RW 004/015, HEGARSARI 082116218941
51 LIH LOR, RT/RW 001/001, WANAREJA 087724126802
36 WANAREJA 005/003 081215925067
55 PERUM BALOKANG 081321026968
22 MADURA, WANAREJA 085602930965
52 TANJUNG SUKUR, RT/RW 001/014, HEGARSARI 089514248081
28 KARANGPUCUNG 33/11 085314099787
41 KARANGPUCUNG 32/11 089668585036
36 PANGADEGAN 002/019 085624313673
36 PANGADEGAN 004/019 083130582872
37 LINGK.PANGADEGAN 001/019 -
42 CIKABUYUTAN BARAT 085323178993
53 SUKAJADI, PAMARICAN, CIAMIS -
47 CIKABUYUTAN TIMUR -
40 SUMANDING KULON 001/20 081220704979
48 TANJUNG SUKUR 004/016 -
48 CIKABUYUTAN TIMUR 004/013 -
49 PANGADEGAN 081290588074
55 LINGK.CIKABUYUTAN TIMUR -
27 PANGADEGAN 001/018 08815750069
57 TANJUNG SUKUR -
60 CIKABUYUTAN TIMUR -
20 CIMENYAN 2 003/008 0895619611565
61 CIKABUYUTAN TIMUR, RT/RW 003/021, HEGARSARI 085320415100
61 JELAT, RT/RW 002/002, PATARUMAN -
63 LINGK.GUDANG 0895335083897
41 SUMANDING KULON 002/019 -
43 TANJUNGSUKUR RT/RW 003/007 087753908633
49 TANJUNGSUKUR RT/RW 005/010 0895370379100
45 CIK.TIM 04/11 082319903599
43 CIMENYAN RT/RW 002/009 089615636736
41 RANDEGAN 1, RT/RW 017/007 081909761918
34 TUNGGAL RAHAYU RT/RW 011/004 081229805798
49 CIKABUYUTAN BARAT -
46 CIK.TIM -
48 PANGADEGAN RT/RW 002/019 -
38 TANJUNGSUKUR RT/RW 005/014 -
46 CIK.TIM 003/011 081554513832
32 SUKAMANAH RT/RW 004/007, PATARUMAN 085316775498
49 BANJAR KOLOT -

Dosis I
kolom yang sesuai)
BPJS Non Non
BPJS PBI Pemberian
PBI Anggota
Vaksinasi
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Dosis I Dosis 2
Tanggal Keterangan
Pemberia NAMA INSTANSI
No. Batch No. Serial No. Batch No. Serial (Ditunda/Tidak Diberikan/Lanjut)
n
Vaksinasi
- -
- TUNDA TIDAK SEHAT
- TUNDA TIDAK SEHAT
- TUNDA HIPERTENSI
- TUNDA TIDAK SEHAT
- TUNDA ALERGI
- TUNDA TIDAK SEHAT
- TUNDA ASMA TDK TERKONTROL

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Nama Puskesmas/Fasyankes/Pos

Nama Penerima Vaksin

yang diterima Puskesmas/Faskes)

LINGK. JELAT 1/3 KEL.PATARUMA

DUSUN CIJUREY 03/04 DESA KUJ

1 P-46LX3HKN 3175075707840013 RISA ROSNELITA P

TENAGA KESEHATAN LAINNYA 26 18-30

TENAGA KESEHATAN LAINNYA 26 18-30

DUSUN PANGASINAN RT 002 RW 007, DESA BINANGUN, KEC. PATARUMAN

Kepesertaan BPJS (tulis 'Ya' pada

081223024111 YA 2/26/2021 COVID-19 VACCINE 2/26/2021

082123717190 YA 2/26/2021 COVID-19 VACCINE 2/26/2021

082218810113 YA 2/26/2021 COVID-19 VACCINE 2/26/2021

1 P-EUZZ39TT 3207176002710002 NURUL ZULFANI'MAH P

Kepesertaan BPJS (tulis 'Ya' pada

YA 2/27/2021 COVID 19 VACCINE 2/27/2021 24000421

1 S-ECC2540F 3279012712850001 Erik Kiswanto L

Lurah Kelurahan Pataruman 36 31-45

Perangkat Desa 30 18-30

Kepala Desa Sinartanjung 37 31-45

Perangkat Desa 47 46-59

Perangkat Desa 50 46-59

Perangkat Desa 47 46-59

Perangkat Desa 31 31-45

Perangkat Desa 27 18-30

Perangkat Desa 33 31-45

Perangkat Desa 31 31-45

Perangkat Desa 39 31-45

Perangkat Desa 35 31-45

Perangkat Desa 59 46-59

Perangkat Desa 31 31-45

Perangkat Desa 30 18-30

Perangkat Desa 50 46-59

Perangkat Desa 38 31-45

DUSUN RANCAKOLE RT 013/ RW 03 DESA MULYASARI KEC. PATARUMAN

DUSUN CISAGA KOTA 01/05, CISAGA

LINGK. BABAKANSARI RT 003/ RW 009 KEL. PATARUMAN, KEC. PATARUMAN

LINGK. LEMBURBALONG RT 003/ RW 006 KEL. PATARUMAN, KEC. PATARUMAN

Kepesertaan BPJS (tulis 'Ya' pada

08112110242 YA 3/1/2021 3/1/2021

24000421 LANJUT DOSIS 2

No No. Tiket NIK Nama Penerima Vaksin

1 S-F7A11951 3276060906690009 MOHAMAD MAOLANA, A.Md.I.P., S.H., M.Si.

26 S-26B0D832 3211136910900002 TINA ARDHYANIE

L KEPALA LAPAS 51 46-59

L LAPAS BANJAR 51 46-59

L LAPAS BANJAR 34 31-45

L LAPAS BANJAR 38 31-45

L LAPAS BANJAR 41 31-45

L LAPAS BANJAR 36 31-45

L LAPAS BANJAR 27 18-30

L LAPAS BANJAR 27 18-30

P LAPAS BANJAR 30 18-30

L LAPAS BANJAR 29 18-30

L LAPAS BANJAR 28 18-30

L LAPAS BANJAR 28 18-30

L LAPAS BANJAR 27 18-30

L LAPAS BANJAR 25 18-30

L LAPAS BANJAR 23 18-30

L LAPAS BANJAR 23 18-30

L LAPAS BANJAR 23 18-30

P LAPAS BANJAR 22 18-30