FORMULIR PENDATAAN BY NAME IMUNISASI

: POLIKLINIK IKA RSPAD GATOT SOEBROTO

ulan : DESEMBER 2021

No Tgl Kunjungan Nama Bayi JK Nama Ibu Tempat Lahir RM NIK

1 11/29/2021 BY NY SABRINA NEWBORN NY SABRINA RSPAD 01062706 3216076909950004

2 11/24/2021 BY NY JUMIYAH SATAR NEWBORN NY JUMIYAH SATAR RSPAD 01078331 3327135009930007

NY ENDAH KUSUMA
3 11/25/2021 BY NY ENDAH KUSUMA WARDHANI NEWBORN RSPAD 01078376 3402104305930001
WARDANI

4 11/24/2021 BY NY UTARI SETYANINGSIH NEWBORN NY UTARI SETYANINGSIH RSPAD - 3215014707880010

5 11/8/2021 BY NY ANNISA NEWBORN NY ANNISA RSPAD - -

6 10/29/2021 BY NY INDAH YUNITA NEWBORN NY INDAH YUNITA RSPAD - 3175034206890006
7 10/29/2021 BY NY LUSIANAH NEWBORN NY LUSIANAH RSPAD 01073568 3173020206100049

8 11/3/2021 BY NY INDAH ARINA MIA MUSTADZAH NEWBORN NY INDAH ARINA MIA RSPAD - 3374096504960003
MUSTADZAH
9 11/3/2021 BY NY DIANA ANGGRAINI NEWBORN NY DIANA ANGGRAINI RSPAD - 3276027005930001

10 10/29/2021 BY TN SUPARNO NEWBORN TN SUPARNO RSPAD 01073571 1805220708770001

11 11/18/2021 BY TN KHARISMA NICO F NEWBORN TN KHARISMA NICO F RSPAD - 3171082712900001

12 11/1/2021 BY NY TIKA NEWBORN NY TIKA RSPAD 902257 3174016110920001

13 11/15/2021 BY NY KUMALA DEWI NEWBORN NY KUMALA DEWI RSPAD 01076771 3171045309820001

14 11/15/2021 BY NY YANI BLEGUR NEWBORN NY YENI BLEGUR RSPAD 01076694 5305014205940005

15 11/13/2021 BY NY HESTI KUSUMANINGRUM NEWBORN NY HESTI KUSUMANINGRUM RSPAD 01076479 3173064209840010

16 11/12/2021 BY NY ARINI NEWBORN NY ARINI RSPAD 01076414 -

17 11/12/2021 BY NY TITIN PRIHATIN NEWBORN NY TITIN PRIHATIN RSPAD 01076405 -
18 11/12/2021 BY NY SABRINA IMAWATI NEWBORN NY SABRINA IMAWATI RSPAD 819056 3171025303890001
19 11/6/2021 BY NY NURFISKA SISMIATI NEWBORN NY NURFISKA SISMIATI RSPAD - 3175077007980010
20 11/5/2021 BY NY RAHAYU ISTIQOMAH NEWBORN NY RAHAYU ISTIQOMAH RSPAD 01075115 3175064105001005

21 11/4/2021 BY NY KELLA OKTAV ADIMIYA NEWBORN NY KELLA OKTAV ADIMIYA RSPAD 3324116210930003
-
22 10/23/2021 BY NY CIWIDARTI NEWBORN NY CIWIDARTI RSPAD 01072439 3171015010790006
23 11/5/2021 BY NY MUJAIRAH NEWBORN NY MUJAIRAH RSPAD - -
24 11/5/2021 BY NY ANNISA MIRANDA NEWBORN NY ANNISA MIRANDA RSPAD 01074492 3276045810990004
25 11/9/2021 BY NY DWI YUNIARTI NEWBORN NY DWI YUNIARTI RSPAD 431572 3175105406880006
26 11/20/2021 BY NY ROBIATUL ADAWIYYAH NEWBORN NY ROBIATUL ADAWIYYAH RSPAD 911789 3276027004930013
27 11/20/2021 BY NY FIKA TIARA PURI AYU NEWBORN NY FIKA TIARA PURI AYU RSPAD 01077639 3201045903880002
28 12/31/2021 BY NY FITRIYANI NEWBORN NY FITRIYANI RSPAD 01083950 3173064802970004
29 12/31/2021 BY NY YOVIN YERAH BUTAR BUTAR NEWBORN NY YOVIN YERAH BUTAR BUTARRSPAD 01084620 36730635309860002
30 12/31/2021 BY NY NINA PUTRIYANA NEWBORN NY NINA PUTRIYANA RSPAD - 3171084604910003
31 NEWBORN RSPAD 3174055502871001
12/31/2021 BY NY ANISA PERTIWI S.PD NY ANISA PERTIWI S.PD 432406
32 12/29/2021 BY NY ERNA RATNAWATI S,TH,I NEWBORN NY ERNA RATNAWATI RSPAD 3172025204810004
33 12/28/2021 BY NY SAFITRI NEWBORN NY SAFITRI RSPAD 01081856 -
34 12/24/2021 BY NY EVIE WIDIYAHWATI NEWBORN NY EVIE WIDIYAHWATI RSPAD - 3171015709970002
35 12/31/2021 BY NY NI KADEK SILVIA AGUSTINI NEWBORN NY NI KADEK SILVIA AGUSTINI RSPAD - 5103034808970006
36 12/21/2021 BY NY FIVI KARVINA SARI NEWBORN NY FIVI KARVINA SARI RSPAD 01082906 3175045901840005
37 12/16/2021 BY NY TRI WAHYUNI NEWBORN NY TRI WAHYUNI RSPAD - -
38 11/16/2021 BY NY MURTINI NEWBORN NY MURTINI RSPAD 01076911 3201135103810006
39 12/2/2021 BY NY UMUL SYARIFAH NEWBORN NY UMUR SYARIFAH RSPAD 01079768 1306075003910001
40 12/1/2021 BY NY FITROTUL IZZAH NEWBORN NY FITROTUL IZZAH RSPAD - 3329035004910006
41 12/1/2021 BY NY MEIHAYATI NEWBORN NY MEIHAYATI RSPAD - 3173025105850006
42 12/1/2021 BY NY USNIAH NEWBORN NY USNIAH RSPAD 01079508 3301016808870004
43 12/2/2021 BY NY RACHMAH KURNIASARI NEWBORN NY RACHMAH KURNIASARI RSPAD - 3275067006910009
44 12/2/2021 BY NY WINDA LUVITA DHEVI NEWBORN NY WINDA LUVITA DHEVI RSPAD 3328014308960003
45 12/7/2021 BY NY NUR FADILLAH NEWBORN NY NUR FADILLAH RSPAD - -
46 12/7/2021 BY NY CHYNTIA LINA OCTORIANA NEWBORN NY CHYNTIA LINA OCTORIANA RSPAD - 1671105410900011
47 12/7/2021 BY NY FITRIAH PUJIASTUTI NEWBORN NY FITRIAH PUJIASTUTI RSPAD 3172056205880003
48 12/10/2021 BY NY WIDA LAGVIA HERA NEWBORN NY WIDA LAGIVA HERA RSPAD 01060630 3202096403970004
49 12/10/2021 BY NY DWI MURGIYATI NEWBORN NY DWI MURGIYATI RSPAD - 3175014109850009
50 12/10/2021 BY NY MARLIANA NEWBORN NY MARLIANA RSPAD - 3275035803880020

51 NEWBORN NY ENI RAHAYU SUSILOWATI RSPAD 3171037009780006

12/10/2021 BY NY ENI RAHAYU SUSILOWATI S.PD S.PD -
52 12/15/2021 BY TN MUHAMMAD RAFI NEWBORN TN MUHAMMAD RAFI RSPAD - 1404132806960002
53 12/15/2021 BY TN MAHARDIKA L TN MAHARDIKA - - -
54 12/15/2021 BAYI VITA P TN RUDI DAN NY VITA - - -
55 12/15/2021 BY WINDA P TN BINTANG DAN NY WINDA RSPAD - -
56 12/15/2021 BY TN FIAN L TN FIAN DAN NY FITRA - - -
57 12/22/2021 BY NY MEILIA L NY MEILIA - - -
58 12/22/2021 BY NY NOVI P TN PANJI DAN NY NOVI RSPAD - -
59 12/22/2021 BY TN ILHAM L TN ILHAM DAN NY NURLIYATI - - -
NAME IMUNISASI

Ditolong oleh Tanggal lahir ALAMAT RT RW IMUNISASI YANG DIBERIKAN

ALAMAT KELURAHAN KECAMATAN VAKSIN EXPIRED BATCH
PERMATA REGENSI BLOK H2 NO
DOKTER 11/29/2021 19 WANASARI 007 022 HEPATITIS B Apr-24 3650721
CIBITUNG
DOKTER 11/24/2021 CEMPAKA WANGI III NO 42 HARAPAN MULIA KEMAYORAN 016 009 HEPATITIS B Apr-24 3650721

DOKTER 8/19/2021 ASR YONBEKANG 3 RAT 009 010 HEPATITIS B Apr-24 3650721
BUNGUR SENEN
PERUM SAMUDRA RESIDENCE
DOKTER 11/24/2021 BLOK B 54/03 TAJURHALANG TAJURHALANG 001 025 HEPATITIS B Apr-24 3650721

DOKTER 11/8/2021 - - - - - HEPATITIS B Apr-24 3650721

DOKTER 11/1/2021 CIPINANG MUARA NO 52 CIPINANG MUARA JATINEGARA 006 001 HEPATITIS B Apr-24 3650721
DOKTER 10/29/2021 - - - - - HEPATITIS B Apr-24 3650721

DOKTER 11/3/2021 JL WIJAYA KUSUMA II BLOK Q 245 REMPOA 003 011 Apr-24 3650721
MABAD HEPATITIS B
CIPUTAT TIMUR
DOKTER 11/3/2021 JL KWITANG TIMUR NO 24 BUNGUR SENEN 005 010 HEPATITIS B Apr-24 3650721

DOKTER 11/1/2021 DUSUN VIII SRIPENDOWO BANDAR 033 016 HEPATITIS B Apr-24 3650721
SRIBHAWONO
DOKTER 11/18/2021 JL INTAN NO 6 GALUR JOHAR BARU 006 001 HEPATITIS B Apr-24 3650721

DOKTER 11/1/2021 MENTENG BATA PASAR MANGGIS 014 007 HEPATITIS B Apr-24 3650721
SETIABUDI
DOKTER 11/15/2021 ASR YON ANGRAT BUNGUR SENEN 010 010 HEPATITIS B Apr-24 3650721
ASR PASPAMPRES JL TANAH
DOKTER 11/15/2021 PETOJO SELATAN 009 008 HEPATITIS B Apr-24 3650721
ABANG II / 6 GAMBIR

DOKTER 11/13/2021 JL N PERINTIS IV TEGAL ALUR 002 005 HEPATITIS B Apr-24 3650721
KALIDERES
DOKTER 11/12/2021 - - - - - HEPATITIS B Apr-24 3650721
- - - - - - - HEPATITIS B Apr-24 3650721
DOKTER 11/12/2021 JL RAJAWALI SELATAN I NO 17B GUNUNG SAHARI UTARA SAWAH BESAR 004 002 HEPATITIS B Apr-24 3650721
DOKTER 11/6/2021 JL KWITANG KEBUN SAYUR 20 KWITANG SENEN 006 008 HEPATITIS B Apr-24 3650721
DOKTER 11/5/2021 JL PUSKESMAS JATINEGARA CAKUNG 006 003 HEPATITIS B Apr-24 3650721
PERUM PESONA PALAD BLOK OO
DOKTER 11/4/2021 NO 16 CIKAHURIPAN 004 013 HEPATITIS B Apr-24 3650721
KLAPANUNGGAL
DOKTER 11/1/2021 JL PEJAMBON I NO 1B GAMBIR GAMBIR 001 001 HEPATITIS B Apr-24 3650721
DOKTER - - - - - - Apr-24 3650721
DOKTER 11/5/2021 JL KEBIN JERUK RAYA NO 77 KEBON JERUK KEBON JERUK 003 009 HEPATITIS B Apr-24 3650721
DOKTER 11/9/2021 JL TELUK RATAI II NO 41 KELAPA GADING BARAT KELAPA GADING 003 010 HEPATITIS B Apr-24 3650721
DOKTER 11/20/2021 JL BAKTI II NO 54 BARU PASAR REBO 004 009 HEPATITIS B Apr-24 3650721
DOKTER 11/20/2021 KP KEBON PALA CIMANDALA SUKARAJA 001 004 HEPATITIS B Apr-24 3650721
DOKTER 12/31/2021 KALIDERES KALIDERES KALIDERES 009 003 HEPATITIS B Apr-24 3650721
DOKTER 12/31/2021 JL SATYA 4 NO 7 BARU PASAR REBO 002 003 HEPATITIS B Apr-24 3650721
DOKTER 12/31/2021 KEBON KACANG XI BLOK 5/2/20 KEBON KACANG TANAH ABANG 010 001 HEPATITIS B Apr-24 3650721

DOKTER 12/31/2021 HEPATITIS B Apr-24 3650721

KOMPLEK KOSTRAD KEBAYORAN LAMA SELATAN KEBAYORAN LAMA 010 007
DOKTER 12/29/2021 JL ANCOL SELATAN SUNTER AGUNG TJ PRIOK 010 002 HEPATITIS B Apr-24 3650721
DOKTER 12/28/2021 - - - - - HEPATITIS B Apr-24 3650721
DOKTER 12/24/2021 JL PUALAM RAYA NO 32 SUMUR BATU KEMAYORAN 009 004 HEPATITIS B Apr-24 3650721
DOKTER 12/31/2021 ASR YONBEKANG 3 RAT BUNGUR SENEN 012 010 HEPATITIS B Apr-24 3650721
DOKTER 12/21/2021 KOMP PUSDIKKES II CILILITAN KR JATI 004 011 HEPATITIS B Apr-24 3650721
DOKTER 12/16/2021 - - - - - HEPATITIS B Apr-24 3650721
DOKTER 11/16/2021 PERUM PUSPA RAYA BLOK ED/11 BOJONGBARU BOJONG GEDE 001 012 HEPATITIS B Apr-24 3650721
DOKTER 12/2/2021 DHARMA 8 NO 22 BARU PASAR REBO 007 004 HEPATITIS B Apr-24 3650721
DOKTER 12/1/2021 BALI MATRAMAN NO 46 MANGGARAI SELATAN TEBET 012 005 HEPATITIS B Apr-24 3650721
DOKTER 12/1/2021 JL TANAH KOJA NO 134 DURI KOSAMBI CENGKARENG 011 002 HEPATITIS B Apr-24 3650721
DOKTER 12/1/2021 GG DAMAI III CIPINANG MUARA CIPINANG MUARA JATINEGARA 001 001 HEPATITIS B Apr-24 3650721
DOKTER 12/2/2021 KP RAWA BAMBU KALIBARU MEDAN SATRIA 004 007 HEPATITIS B Apr-24 3650721
DOKTER 12/2/2021 ASR YON POMAD SIRNAGALIH JONGGOL 011 006 HEPATITIS B Apr-24 3650721
DOKTER 12/7/2021 - - - - - HEPATITIS B Apr-24 3650721
DOKTER 12/7/2021 JL PURWOSARI SIMANAMPANG NO BUKIT SANGKAL KALIDONI 049 010 HEPATITIS B Apr-24 3650721
DOKTER 12/7/2021 KP MUKA ANCOL PADEMANGAN 002 004 HEPATITIS B Apr-24 3650721
DOKTER 12/10/2021 KP CILANDAK SIRNAJAYA WARUNG KIARA 004 006 HEPATITIS B Apr-24 3650721
DOKTER 12/10/2021 JL KESATRIAAN IV KEBON MANGGIS MATRAMAN 024 003 HEPATITIS B Apr-24 3650721
DOKTER 12/10/2021 JL DANAU POSO BLOK AC 9 NO 22 HARAPAN JAYA BEKASI UTARA 005 011 HEPATITIS B Apr-24 3650721

DOKTER 12/10/2021 HEPATITIS B Apr-24 3650721

JL UTANG PANJANG III UTAN PANJANG KEMAYORAN 013 006
DOKTER 12/15/2021 JL DIPONEGORO TEMBILAHAN KOTA TEMBILAHAN 003 001 HEPATITIS B Apr-24 3650721
PERAWAT 10/11/2021 MESS PAMEN DENMA MABESAD KP GEDONG PASAR REBO 012 010 BCG Feb-23 0371G014
PERAWAT 12/15/2021 JL KESATRIAAN IV SAWUNGGALIH WONOKROMO 007 010 DPT Mar-23 5010121
PERAWAT 12/15/2021 MESS PAMEN KARTIKA PATRIA LUBANG BUAYA CIPAYUNG 002 004 DPT Mar-23 5010121
PERAWAT 12/15/2021 CITY PARK TOWER CIBUBUR - - - M.R Aug-22 012ONO33
PERAWAT 12/22/2021 JL KAYU II KAYUPUTIH PULOGADUNG 007 005 DPT Mar-23 5010121
PERAWAT 12/22/2021 BLOK UNGU CIBUBUR CIBUBUR - 09 03 DPT Mar-23 5010121
- 12/22/2021 JL CIPINANG CIPINANG BESAR JATINEGARA 014 013 BCG Feb-23 0371G014
VAKSIN EXPIRED BATCH
POLIO Feb-23 2051221
POLIO Feb-23 2051221

POLIO Feb-23 2051221

POLIO Feb-23 2051221
POLIO Feb-23 2051221
 REKAPITULASI HASIL
Bul

Fasyankes : POLIKLINIK
BAYI
HbHib HbHi HbHib POLIO POLIO IV
NO HASIL VACINASI BCG POLIO II POLIO III
1 b2 3 I
L P L P L P L P L P L P L P L
1 POSYANDU
KIA
PUSKE
2
SMAS SCREE NIHIL TIDAK ADA PASIEN IMUNISASI
NING
3 SEKOLAH
RUMAH
4 BERSALIN
BIDAN SWASTA
5 PKM SENEN
…………………
…UMUM
6 DOKTER
ANAK
7 KINARA CLINIC
BALKESMAS /
8
Klinik …
9 KUA / CATEN
JUMLAH
REKAPITULASI HASIL LAPORAN BULANAN IMUNISASI
Bulan JUNI 2020

BALITA asi TT WUS HAMIL

DPTH Dasar
POLIO IV < HB O ak
IPV CAMPAK bHib
IV 24JA > 07 hr 24 Lengk TT 1 TT 2 TT 3 TT 4 TT 5
P L P L P L P L P 18L bln
P L P L P

Jakarta, 2020
Mengetahui,

Wiwik Seytaningsih Amd Kep

 TT WUS TIDAK HAMIL
TT KET
TT 1 TT 2 TT 3 TT 4 TT 5 CATEN
TEMPAT PELAKSANAAN *)
KABUPATEN / KOTA
PROVINSI
BULAN / TAHUN : Januari 2020
KLINIK :..Kinara Klinik/ Bungur
IDENTITAS
NO JENIS KELAMIN
NAMA ANAK TANGGAL LAHIR
L/P
1 2 3 4

1 BY NY SABRINA NEWBORN 11/29/2021

2 BY NY JUMIYAH SATAR NEWBORN 11/24/2021

3 BY NY ENDAH KUSUMA WARDHANI NEWBORN 8/19/2021

4 BY NY UTARI SETYANINGSIH NEWBORN 11/24/2021

5 BY NY ANNISA NEWBORN 11/8/2021

6 BY NY INDAH YUNITA NEWBORN 11/1/2021

7 BY NY LUSIANAH NEWBORN 10/29/2021

8 BY NY INDAH ARINA MIA MUSTADZAH NEWBORN 11/3/2021

9 BY NY DIANA ANGGRAINI NEWBORN 11/3/2021

10 BY TN SUPARNO NEWBORN 11/1/2021

11 BY TN KHARISMA NICO F NEWBORN 11/18/2021

12 BY NY TIKA NEWBORN 11/1/2021

13 BY NY KUMALA DEWI NEWBORN 11/15/2021

14 BY NY YANI BLEGUR NEWBORN 11/15/2021

15 BY NY HESTI KUSUMANINGRUM NEWBORN 11/13/2021

16 BY NY ARINI NEWBORN 11/12/2021

17 BY NY TITIN PRIHATIN NEWBORN -

18 BY NY SABRINA IMAWATI NEWBORN 11/12/2021

19 BY NY NURFISKA SISMIATI NEWBORN 11/6/2021

20 BY NY RAHAYU ISTIQOMAH NEWBORN 11/5/2021

21 BY NY KELLA OKTAV ADIMIYA NEWBORN 11/4/2021

22 BY NY CIWIDARTI NEWBORN 11/1/2021

23 BY NY MUJAIRAH NEWBORN -

24 BY NY ANNISA MIRANDA NEWBORN 11/5/2021

25 BY NY DWI YUNIARTI NEWBORN 11/9/2021

26 BY NY ROBIATUL ADAWIYYAH NEWBORN 11/20/2021

27 BY NY FIKA TIARA PURI AYU NEWBORN 11/20/2021

28 NEWBORN 12/31/2021
BY NY FITRIYANI

29 NEWBORN 12/31/2021
BY NY YOVIN YERAH BUTAR BUTAR

30 NEWBORN 12/31/2021
BY NY NINA PUTRIYANA

31 NEWBORN 12/31/2021
BY NY ANISA PERTIWI S.PD
32 NEWBORN 12/29/2021
BY NY ERNA RATNAWATI S,TH,I

33 NEWBORN 12/28/2021
BY NY SAFITRI

34 NEWBORN 12/24/2021
BY NY EVIE WIDIYAHWATI

35 NEWBORN 12/31/2021
BY NY NI KADEK SILVIA AGUSTINI

36 NEWBORN 12/21/2021
BY NY FIVI KARVINA SARI

37 NEWBORN 12/16/2021
BY NY TRI WAHYUNI

38 NEWBORN 11/16/2021
BY NY MURTINI

39 NEWBORN 12/2/2021
BY NY UMUL SYARIFAH

40 NEWBORN 12/1/2021
BY NY FITROTUL IZZAH

41 NEWBORN 12/1/2021
BY NY MEIHAYATI

42 NEWBORN 12/1/2021
BY NY USNIAH

43 NEWBORN 12/2/2021
BY NY RACHMAH KURNIASARI

44 NEWBORN 12/2/2021
BY NY WINDA LUVITA DHEVI

45 NEWBORN 12/7/2021
BY NY NUR FADILLAH

46 NEWBORN 12/7/2021
BY NY CHYNTIA LINA OCTORIANA

47 NEWBORN 12/7/2021
BY NY FITRIAH PUJIASTUTI

48 NEWBORN 12/10/2021
BY NY WIDA LAGVIA HERA

49 NEWBORN 12/10/2021
BY NY DWI MURGIYATI

50 NEWBORN 12/10/2021
BY NY MARLIANA

51 NEWBORN 12/10/2021
BY NY ENI RAHAYU SUSILOWATI S.PD

52 NEWBORN 12/15/2021
BY TN MUHAMMAD RAFI

53 L 10/11/2021
BY TN MAHARDIKA

54 P 12/15/2021
BAYI VITA

55 P 12/15/2021
BY WINDA
 56 L 12/15/2021
BY TN FIAN

57 L 12/22/2021
BY NY MEILIA

58 P 12/22/2021
BY NY NOVI

59 L 12/22/2021
BY TN ILHAM

NO VAKSIN V1 V2
1 HEPATITIS B 52 0
2 DPT 4 0
3 BCG 2 0
4 M.R 1 0
5 POLIO 0 5
6 ROTAVIRUS 0 0
JUMLAH

Jika ditemukan gejala-gejala berikut :

1. Tidak mau menetek/minum
2. Kejang
3. Pucat/biru
4. Sesak nafas
5. Muntah berlebihan
6. Demam tinggi (>39) lebih 1 hari
7. Menangis terus menerus lebih dari 3 jam
8. Kesadaran menurun
9. Anafilaktik
10. Abses

Lanjutkan ke Formulir Pelaporan KIPI Serius

AN VAKSIN DI KAMAR BERSALIN BERDASARKAN RESEP YANG DI TERIMA FARMASI RAWAT INAP.
TERTULIS JENIS KELAMIN DAN BEBERAPA DI ANTARA MENGGUNAKAN K.T.A DINAS YANG SECARA SPESIFI
TIDAK MENCANTUMKAN ALAMAT DOMISILI
 LAPORAN KEJADIAN IKUTAN

IDENTITAS
TANGGAL
UMUR (bln) NAMA ORTU ALAMAT
SEKARANG
5 6 7

PERMATA REGENSI BLOK

1/4/2022 1 NY SABRINA
H2 NO 19

1/4/2022 1 NY JUMIYAH SATAR CEMPAKA WANGI III NO 42

1/4/2022 4 NY ENDAH KUSUMA WARDANI ASR YONBEKANG 3 RAT

PERUM SAMUDRA
1/4/2022 1 NY UTARI SETYANINGSIH
RESIDENCE BLOK B 54/03

1/4/2022 1 NY ANNISA -

1/4/2022 2 NY INDAH YUNITA CIPINANG MUARA NO 52

1/4/2022 2 NY LUSIANAH -

NY INDAH ARINA MIA JL WIJAYA KUSUMA II BLOK

1/4/2022 2 MUSTADZAH Q 245 MABAD

1/4/2022 2 NY DIANA ANGGRAINI JL KWITANG TIMUR NO 24

1/4/2022 2 TN SUPARNO DUSUN VIII

1/4/2022 1 TN KHARISMA NICO F JL INTAN NO 6

1/4/2022 2 NY TIKA MENTENG BATA

1/4/2022 1 NY KUMALA DEWI ASR YON ANGRAT

ASR PASPAMPRES JL
1/4/2022 1 NY YENI BLEGUR
TANAH ABANG II / 6

1/4/2022 1 NY HESTI KUSUMANINGRUM JL N PERINTIS IV

1/4/2022 1 NY ARINI -

1/4/2022 #VALUE! NY TITIN PRIHATIN -

JL RAJAWALI SELATAN I NO
1/4/2022 1 NY SABRINA IMAWATI
17B

JL KWITANG KEBUN SAYUR

1/4/2022 1 NY NURFISKA SISMIATI
20

1/4/2022 1 NY RAHAYU ISTIQOMAH JL PUSKESMAS

PERUM PESONA PALAD

1/4/2022 2 NY KELLA OKTAV ADIMIYA
BLOK OO NO 16

1/4/2022 2 NY CIWIDARTI JL PEJAMBON I NO 1B

1/4/2022 - NY MUJAIRAH -

JL KEBIN JERUK RAYA NO

1/4/2022 1 NY ANNISA MIRANDA
77

1/4/2022 1 NY DWI YUNIARTI

JL TELUK RATAI II NO 41

1/4/2022 1 NY ROBIATUL ADAWIYYAH

JL BAKTI II NO 54

1/4/2022 1 NY FIKA TIARA PURI AYU KP KEBON PALA

1/4/2022 0
NY FITRIYANI KALIDERES

1/4/2022 0
NY YOVIN YERAH BUTAR BUTAR JL SATYA 4 NO 7

1/4/2022 0
NY NINA PUTRIYANA KEBON KACANG XI BLOK 5/2

1/4/2022 0
NY ANISA PERTIWI S.PD KOMPLEK KOSTRAD
1/4/2022 0
NY ERNA RATNAWATI JL ANCOL SELATAN

1/4/2022 0
NY SAFITRI -

1/4/2022 0
NY EVIE WIDIYAHWATI JL PUALAM RAYA NO 32

1/4/2022 0
NY NI KADEK SILVIA AGUSTINI ASR YONBEKANG 3 RAT

1/4/2022 0
NY FIVI KARVINA SARI KOMP PUSDIKKES II

1/4/2022 0
NY TRI WAHYUNI -

1/4/2022 1
NY MURTINI PERUM PUSPA RAYA BLOK E

1/4/2022 1
NY UMUR SYARIFAH DHARMA 8 NO 22

1/4/2022 1
NY FITROTUL IZZAH BALI MATRAMAN NO 46

1/4/2022 1
NY MEIHAYATI JL TANAH KOJA NO 134

1/4/2022 1
NY USNIAH GG DAMAI III CIPINANG MU

1/4/2022 1
NY RACHMAH KURNIASARI KP RAWA BAMBU

1/4/2022 1
NY WINDA LUVITA DHEVI ASR YON POMAD

1/4/2022 0
NY NUR FADILLAH -

1/4/2022 0
NY CHYNTIA LINA OCTORIANA JL PURWOSARI SIMANAMPA

1/4/2022 0
NY FITRIAH PUJIASTUTI KP MUKA

1/4/2022 0
NY WIDA LAGIVA HERA KP CILANDAK

1/4/2022 0
NY DWI MURGIYATI JL KESATRIAAN IV

1/4/2022 0
NY MARLIANA JL DANAU POSO BLOK AC 9

1/4/2022 0 NY ENI RAHAYU SUSILOWATI

S.PD JL UTANG PANJANG III

1/4/2022 0
TN MUHAMMAD RAFI JL DIPONEGORO

1/4/2022 2
TN MAHARDIKA MESS PAMEN DENMA MABE

1/4/2022 0
TN RUDI DAN NY VITA JL KESATRIAAN IV

1/4/2022 0
TN BINTANG DAN NY WINDA MESS PAMEN KARTIKA PATR
 1/4/2022 0
TN FIAN DAN NY FITRA CITY PARK TOWER

1/4/2022 0
NY MEILIA JL KAYU II

1/4/2022 0
TN PANJI DAN NY NOVI BLOK UNGU CIBUBUR

1/4/2022 0
TN ILHAM DAN NY NURLIYATI JL CIPINANG

JUMLAH

RMASI RAWAT INAP.

DINAS YANG SECARA SPESIFIK
EJADIAN IKUTAN PASCA IMUNISASI (KIPI)

No Batch / Exp No Batch / Exp PEMBERI

JENIS VAKSIN 1 JENIS VAKSIN 2
Date Vaksin 1 Date Vaksin 2 IMUNISASI

8 9 10 11 12

3650721 ED dr YENNY
HEPATITIS B 04/2024 - - PURNAMA SpA,
Mkes

3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR

3650721 ED DR ULFAH
HEPATITIS B 04/2024 - -
MASFUHAH

3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR

3650721 ED dr NOVITA
HEPATITIS B 04/2024 - -
DAVIYANTI

3650721 ED DR CARINA
HEPATITIS B 04/2024 - - ESTEFANI
JACOBS

3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR

3650721 ED DR
HEPATITIS B 04/2024 - - FEBRIYANSAH
DARUS SpOG
3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR
 3650721 ED DR ROSTINE
HEPATITIS B 04/2024 - -
NURYAKIN
3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR

3650721 ED DR DWI YUNITA

HEPATITIS B 04/2024 - - ANGGOOROWA
TI
3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR
3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR
3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR
3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR
3650721 ED DR GUNAWAN
HEPATITIS B 04/2024 - -
DWI

3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR

3650721 ED DR WINDHI
HEPATITIS B 04/2024 - - KRESNAWATI,
SPA
3650721 ED dr DIANA
HEPATITIS B 04/2024 - -
CHAIDIR
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
 3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
3650721 ED
HEPATITIS B 04/2024
0371G014 ED
BCG
02/2023
5010121 ED 2051221 ED
DPT POLIO
03/2023 03/2023
5010121 ED 2051221 ED
DPT POLIO
03/2023 03/2023
 012ONO33 ED
M.R
08/2022
5010121 ED 2051221 ED
DPT POLIO
03/2023 03/2023
5010121 ED 2051221 ED
DPT POLIO
03/2023 03/2023
0371G014 ED 2051221 ED
BCG POLIO
02/2023 03/2023
 GEJALA YANG DIALAMI
TEMPAT
TANGGAL
PELAYANAN DEMAM BENGKAK MERAH
IMUNISASI
IMUNISASI
Jika ya di tandai ü
13 14 15 16 17

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN
R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN
R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN
R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN
R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN
R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN
R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN

R.TINDAKAN
1/4/2022 0-Ya
PERSALINAN
………… ………., ….. - …………. - …………
Mengetahui,
Kepala Puskesmas,

(……………………………………………)
 Form KIPI Non Serius

ANG DIALAMI
MUNTAH LAIN-LAIN
ü (SEBUTKAN)
18 19
… ………., ….. - …………. - …………

……………………………………)