FORMAT PENCATATAN HASIL PELAYANAN

Posyandu/Pos layanan BIAN lainnya :

Desa/kelurahan :
Tanggal :

Jenis Kelamin
No. Nama Anak Tgl lahir Umur Nama orang tua Alamat
(L/P)

a b c d e f g
1 Retha faradina mecca 9/6/2017 56 P Wiwin/Jalil DAWUHAN RT 1 RW 1
2 M Safii Abdilah 9/30/2017 55 L Halimatus/saadah DAWUHAN RT 2 RW 1
3 Viona Via Putri 11/1/2017 54 P Khusnul amalia/febri DAWUHAN RT 2 RW 2
4 Atharaza Fayrel Farzana 12/23/2017 53 L yati/sahmul DAWUHAN RT 2 RW 1
5 Alifiah qurata aini 12/24/2017 53 P st amina/subari DAWUHAN RT 1 RW 1
6 M Dani 1/13/2018 52 L Raodatul/Tosan DAWUHAN RT 1 RW 1
7 alifia kinan 3/21/2018 50 P st fatimah/kiki DAWUHAN RT 2 RW 1
8 M Faeza Alfariki 3/2/2018 50 L tyas/didik DAWUHAN RT 1 RW 1
9 Aprilia kanaya putri andriansya 4/23/2018 49 P hidayatul/andrian DAWUHAN RT 2 RW 1
10 Arif Bilah Al Ansori 5/25/2018 48 L usisah/fiki DAWUHAN RT 1 RW 1
11 M Iqbal Nur Ridwan 6/16/2018 47 L Fitriyah/ M Halik DAWUHAN RT 2 RW 1
12 Riski Malik 7/20/2018 46 L Tutik soimah/Ahmad DAWUHAN RT 1 RW 1
13 M. Gibran Julio Ibrahim 7/23/2018 46 L fitria/rohim DAWUHAN RT 1 RW 1
14 Ahza Danish Sholihin 7/20/2018 46 L eka mariatul/m solihi DAWUHAN RT 2 RW 1
15 M. Dafa alfarisi 8/5/2018 45 L sumyana/junaedi DAWUHAN RT 2 RW 1
16 Nadwa Dawiyatus Zahra 8/8/2018 45 P tirta/rudi DAWUHAN RT 2 RW 1
17 M Jiyaad Abdilah 10/9/2018 43 L Lutfiah/adrian DAWUHAN RT 3 RW 1
18 Khalisa Wardana 10/24/2018 43 P Halimatus/misnawi DAWUHAN RT 2 RW 1
19 Aida 3/24/2018 50 P Fatimah/Jamhuri DAWUHAN RT 1 RW 1
20 Nur Imamah Q Nada 2/12/2019 39 P Rini/ Budianto DAWUHAN RT 2 RW 1
21 Misbahur Rohman 7/20/2018 46 L Nur/ Beni DAWUHAN RT 1 RW 1
22 Zulfa Faidatul marfuah 3/2/2019 38 P Halimatus/Surianto DAWUHAN RT 2 RW 1
23 M Azka Alfarisi 3/18/2019 38 L Riski/Harisal DAWUHAN RT 3 RW 1
24 Nurul Faiqoh 4/13/2019 37 P Nuraini/jaib DAWUHAN RT 1 RW 1
25 Naura Fitria R 5/13/2019 36 P Susi/Mastuki DAWUHAN RT 3 RW 1
26 M. Azzam Sauqi Ramadhan 5/28/2019 35 L Nurmantika/artasun DAWUHAN RT 1 RW 1
27 M Akmal Saifullah 6/23/2019 35 L Khusnul/febri DAWUHAN RT 2 RW 1
28 Raihana Jihan 9/2/2019 32 P Nur sariah DAWUHAN RT 1 RW 1
29 Naura Jasmin ayudia 9/28/2019 31 P Inayatul/Faisol DAWUHAN RT 2 RW 1
30 Imam Bima Wijaya 3/14/2020 26 L Desi/Imam Tabrani DAWUHAN RT 1 RW 1
31 M. Evandra Maulana Hakim 12/20/2019 29 L St Marina/lukman DAWUHAN RT 1 RW 1
32 M Hoiril Anam 10/4/2019 31 L indah novianti/junaedDAWUHAN RT 3 RW 1
33 Elvina Nor havifah 1/31/2020 28 P Mariana/Haris DAWUHAN RT 1 RW 1
34 Syafiqoh Kamila Inaroh 2/18/2020 27 P Sulistyo/Aminullah DAWUHAN RT 2 RW 1
35 Khaila Serly Sivabela 2/17/2020 26 P St.Hanifah/Saiful DAWUHAN RT 3 RW 1
36 Aqlan Harith Ridaudin 3/19/2020 26 L Susiwati/Subairi DAWUHAN RT 4 RW 2
37 Amira Meidina masruroh 4/6/2020 25 P Tutik soimah/Ahmad DAWUHAN RT 1 RW 1
38 Sagita meisya fitriasari 5/29/2020 23 P Rofiah/Feri DAWUHAN RT 2 RW 1
39 Muhamad Adnan Yusuf Ibrahim 7/25/2020 22 L Rifatul mahmuda/Sof DAWUHAN RT 1 RW 1
40 Muhammad Rahman 8/15/2020 21 L Nur Azizah/ Fathor DAWUHAN RT 1 RW 1
41 Muhammad Akbar Rizky Jalil 8/23/2020 21 L wiwin/Jalil DAWUHAN RT 1 RW 1
42 muhammad Azaim Ibrohim 11/28/2020 18 L ana jamila/wahyudi DAWUHAN RT 3 RW 2
43 ahmad agam f 12/16/2020 17 L Holifatul/Alis ade DAWUHAN RT 2 RW 1
44 brilliant adiba silva anjani 2/23/2021 15 P hafifatul/fatir DAWUHAN RT 2 RW 1
45 teguh ahmad irsyad maulana 2/28/2021 15 L nofinda/fawait DAWUHAN RT 1 RW 1
46 chanina qothrunnada al anshor 3/2/2021 14 P usisah/fiki DAWUHAN RT 1 RW 1
47 m. Fathan ghufronullah 4/11/2021 13 L siti azizah/budianto DAWUHAN RT 2 RW 1
48 ahmad kiflan zen 4/16/2021 13 L felia nur/m.rosi DAWUHAN RT 1 RW 1
49 shalahudin alayubi 5/27/2021 12 L luluk/mustafa DAWUHAN RT 1 RW 1
50 Kirana ardani ilham 11/6/2019 30 P Eki diah/Ilham DAWUHAN RT 1 RW 1
51 Kanza Maharani 6/15/2021 11 P haoiriyah/jamal DAWUHAN RT 2 RW 1
52 alisha zea zaida 6/26/2021 11 P evi handayani/fendi DAWUHAN RT 2 RW 1
53 Raihan 12/7/2017 53 L ika/efendi DAWUHAN RT 4 RW 2
54 Alfiatun H 12/12/2017 53 P Rokaya/Ridwan DAWUHAN RT 4 RW 2
55 Aisyah 1/3/2018 52 P desi/sukron DAWUHAN RT 4 RW 2
56 m Angga Isnaini 7/23/2018 46 L Yulia/Asmuni DAWUHAN RT 3 RW 2
57 Ila Masrurah 2/1/2019 39 P marwiyatul/iwan DAWUHAN RT 4 RW 2
58 Siti Fatimah 4/27/2019 37 P Wuryati/wafi DAWUHAN RT 4 RW 2
59 Naura Fitriah Rahmadani 5/13/2019 36 P susi DAWUHAN RT 4 RW 2
60 M Zidan Fatoni 7/28/2019 34 L rofiatul hasimah DAWUHAN RT 5 RW 2
61 Hifsa Hafisah 9/2/2019 32 P Ainul Kudra DAWUHAN RT 4 RW 2
62 m Diko F 9/4/2019 32 L sarifah/ sofyan DAWUHAN RT 5 RW 2
63 Riskiyatul Hasanah 12/5/2019 29 P museyaroh/hasan DAWUHAN RT 5 RW 2
64 Kafa Syaifi 1/1/2020 28 L ika/fendi DAWUHAN RT 4 RW 2
65 Juwita Dzakiatul F 1/3/2020 28 P komariyah/subawi DAWUHAN RT 4 RW 2
66 Keysa Nadiya Putri 1/4/2020 28 P maulidia/nasrul DAWUHAN RT 4 RW 2
67 M Arka Ainul Y 4/7/2020 25 L bilgis basri DAWUHAN RT 4 RW 2
68 M Agil Ramadani 5/7/2020 24 L ita/ansori DAWUHAN RT 4 RW 2
69 Ramadan Malik 5/23/2020 24 L anis/agus DAWUHAN RT 4 RW 2
70 Citra Dwi Permatasari 7/14/2020 22 P siti nurhasanah/ bahaDAWUHAN RT 3 RW 2
71 Muhammad sobirin 12/19/2020 17 L Syamsiah/Syaifullah DAWUHAN RT 5 RW 2
72 M Rafasa Sofa 1/22/2021 16 L Amelia/ Subahan DAWUHAN RT 3 RW 2
73 M Robbit 1/27/2021 16 L Mamluahg/Dianto DAWUHAN RT 4 RW 2
74 Khumaira Fitri Aulia 5/13/2021 12 P Citra-Farid DAWUHAN RT 4 RW 2
75 Nilam 9/23/2017 56 P Wasila/Baihaki DAWUHAN RT 10 RW 4
76 Alya Maqfirah 9/19/2017 55 P Indahsari/Nawawi DAWUHAN RT 10 RW 4
77 A Holid F 12/27/2017 53 L Mualimatus/Zaenal DAWUHAN RT 6 RW 3
78 Febiana Nauril 12/18/2017 53 P Vivin Puji/A Rahman DAWUHAN RT 8 RW 3
79 M Tanzilul 1/9/2018 52 L Ita/Bari DAWUHAN RT 7 RW 3
80 M Husnul Fariki 2/7/2018 51 L Anis pipih/Basri DAWUHAN RT 9 RW 3
81 A Ainur Rofiki 2/7/2018 51 L Anis pipih/Basri DAWUHAN RT 9 RW 3
82 Nabilatul Aslih 6/25/2018 47 P Pathiyah/Abu Bakar DAWUHAN RT 6 RW 3
83 M Muhbid 6/25/2018 47 L Munasila/Sanuris DAWUHAN RT 10 RW 4
84 Arini Arista 9/21/2018 45 P Wiwid/Sugianto DAWUHAN RT 6 RW 3
 85 Savira solehatun nisa 9/21/2018 44 P Fitriayu/Hamdi DAWUHAN RT 10 RW 4
86 Najwatul bariroh 9/29/2018 44 P Supiya/Lutfiah DAWUHAN RT 10 RW 4
87 Aulia Izzatun nisa 1/21/2019 40 P Komariyah/Fathor DAWUHAN RT 10 RW 4
88 Mia Kalesa 1/25/2019 40 P Diah/Eko DAWUHAN RT 9 RW 3
89 Ulil Makrifah 2/20/2019 39 P Lutfiah/Absan DAWUHAN RT 7 RW 3
90 Maretta 3/1/2019 38 P St Hotimatul/Wafi DAWUHAN RT 8 RW 3
91 M Farel Rafada 4/26/2019 37 L Evi Susanti/Hendri DAWUHAN RT 8 RW 3
92 Nasita Shafwatun nisa 6/10/2019 35 P hamidah/yudi DAWUHAN RT 10 RW 4
93 Aura Zafarani 7/20/2019 34 P Rahma DAWUHAN RT 6 RW 3
94 Nur M Zahir romli 9/11/2019 32 L Sakinah/Romli DAWUHAN RT 10 RW 4
95 M Alfan Ibrohimi 9/11/2019 32 L St Hidayatul DAWUHAN RT 9 RW 4
96 Sinta 11/7/2019 30 P St Nur halisa DAWUHAN RT 7 RW 3
97 M Riski Maulana 11/17/2019 30 L Mintaatul DAWUHAN RT 7 RW 3
98 Cyntya Carolina Putri 4/21/2020 25 P makrifatul hasim DAWUHAN RT 7 RW 3
99 Farhan Alfa Karomi 4/16/2020 25 L Rokiah DAWUHAN RT 10 RW 4
100 Rayyan Bagas 5/16/2020 24 L suci/sutrisno DAWUHAN RT 6 RW 3
101 M Nur Hafidz 5/22/2020 24 L sofi/sujatmo DAWUHAN RT 7 RW 3
102 Adeva Khumairo Putri 6/4/2020 23 P suryati babun DAWUHAN RT 9 RW 4
103 Siti Zahro 7/4/2020 22 P Rahmawati/Zaini DAWUHAN RT 8 RW 3
104 Ahmad faiz wibowo 9/19/2020 20 L Maulidatul lurifah/jofaDAWUHAN RT 9 RW 4
105 Farel Nur Zuhaeri 10/1/2020 19 L Fitriatul h-Hasan DAWUHAN RT 10 RW 4
106 Alvino Dafa Muwafaq 10/15/2020 19 L Samsul a- Dian R DAWUHAN RT 7 RW 4
107 Wahdatul Unsiyah 1/14/2021 16 P Kuratul uyun/m halil DAWUHAN RT 10 RW 4
108 indah n azahra 3/18/2021 14 P holifatul zahro/fawaidDAWUHAN RT 9 RW 4
109 siti mualimatus diniyah 4/2/2021 13 P sarifah/ahmad hadi DAWUHAN RT 8 RW 4
110 putri aprilia ramadani 4/13/2021 13 P ulfatus sabaniyah/ah DAWUHAN RT 10 RW 4
111 muhamad riski alfarisi 6/16/2021 11 L nadatul umroh/juhari DAWUHAN RT 6 RW 3
112 M. Akbar Agung Riski 8/11/2021 9 L anisa/rizal DAWUHAN RT 8 RW 4
113 M. Fahmi Aly bilah 8/17/2021 9 L zahro/aliwafa DAWUHAN RT 8 RW 4
114 Nauril Iza F 9/1/2021 8 P sunrotul/abdul latif DAWUHAN RT 9 RW 4
115 Khayla amira m 9/6/2017 56 P Sifa/Candra DAWUHAN RT 11 RW 5
116 M Wafilul Zidan 12/1/2017 53 L Meri/Fendi DAWUHAN RT 14 RW 5
117 Yuda Hartono 1/20/2018 52 L Maulida/Edi DAWUHAN RT 15 RW 5
118 M Fakhrun Qolbi 2/2/2018 51 L Wahyul DAWUHAN RT 11 RW 4
119 Maufidah Makrufah/mufidatul 2/5/2018 51 P Wiwin/Samsul DAWUHAN RT 11 RW 5
120 Aprilia mulyani 4/10/2018 49 P Hasilah/Saiful DAWUHAN RT 12 RW 5
121 Azril Arkan 5/16/2018 48 L Saniyah/Imron DAWUHAN RT 12 RW 5
122 Niken Fradela D 5/4/2018 48 P Mila/Beni DAWUHAN RT 11 RW 4
123 Arista Azahra Ramadani 5/20/2018 48 P Mariatul/Imron DAWUHAN RT 11 RW 4
124 Siti Rifatul Maula 7/25/2018 46 P Halimah/Junaedi DAWUHAN RT 15 RW 5
125 M Hasan Yordaniah 8/24/2018 45 L ida/Junaedi DAWUHAN RT 12 RW 5
126 Naila Naretta 10/16/2018 43 P Rofiqoh/Agus DAWUHAN RT 12 RW 5
127 M Amar afka 10/18/2018 43 L Azizah/Jamian DAWUHAN RT 12 RW 5
128 Gibran 12/18/2018 41 L Novia/Sodikin DAWUHAN RT 14 RW 5
129 St Fatimah 12/18/2018 41 P Hasiseh/Fathola DAWUHAN RT 14 RW 5
130 Devi Faradina 1/20/2019 40 P Sunatus/Heriyanto DAWUHAN RT 11 RW 5
131 Aurelia 12/11/2018 41 P Hidayah/suudi DAWUHAN RT 12 RW 5
132 Anindita Keysa 8/28/2018 44 P Zahro/Junaedi DAWUHAN RT 14 RW 5
133 Sauqi 3/2/2019 37 L Sunatut/Irfandi DAWUHAN RT 11 RW 5
134 Bunga Safirah 4/13/2019 36 P imamah/Edi DAWUHAN RT 16 RW 5
135 Aurelia Nur Rahmaniah 5/30/2019 35 P Mutmainah DAWUHAN RT 15 RW 5
136 Arsila Nurul Fitriah 6/5/2019 34 P Maqfiroh DAWUHAN RT 15 RW 5
137 Alreska Danish F 1/12/2019 39 L Afdiana/Firman DAWUHAN RT 15 RW 5
138 Nuraisa Aska Rubina 9/11/2019 31 P Nurkomariah DAWUHAN RT 13 RW 5
139 Adelia Salsabila 11/30/2019 29 P St Fatimah DAWUHAN RT 14 RW 5
140 M Nando Danindra 12/20/2019 28 L Diana Nurhayati DAWUHAN RT 12 RW 5
141 Sausan Wafiah 12/21/2019 28 P Maisura/Yamin DAWUHAN RT 14 RW 5
142 Faisa Almira 1/13/2020 27 P Umi Kulsum DAWUHAN RT 16 RW 5
143 M. Ghani 1/21/2020 27 L Nurmantika/Aliwafa DAWUHAN RT 15 RW 5
144 Kalila Azra Fauziyah 3/6/2020 25 P sulastri/Fausi DAWUHAN RT 12 RW 5
145 zainina Hilna Zaharini 3/26/2020 25 P Luluk H/ Harsono DAWUHAN RT 11 RW 5
146 Talita Hasna K 4/11/2020 24 P ira hidayat DAWUHAN RT 11 RW 5
147 Putri Arza Rama 5/8/2020 23 P uswatun/mashudi DAWUHAN RT 15 RW 5
148 khayla ainul nadwa 4/13/2020 24 P yuliatul ibrahim DAWUHAN RT 15 RW 5
149 M ramzi kamil 9/3/2020 19 L Quratu ayuni/K.uma DAWUHAN RT 16 RW 5
150 Fatan darma purta 9/19/2020 19 L Lutfiah/ibnu DAWUHAN RT 13 RW 5
151 M Atwa Habibi Rizqi 9/27/2020 19 L ilmi sofiah/sugianto DAWUHAN RT 11 RW 5
152 Riska Kayla Khoirulnisa 1/13/2021 15 P Alfiatus/M Basit DAWUHAN RT 15 RW 5
153 M. Azzka Athoillah 4/1/2021 12 L halimatus-juharaman DAWUHAN RT 11 RW 5
154 Ahkam Malik Ramadan 4/28/2021 12 L Ulfatul hasanah/solihiDAWUHAN RT 11 RW 5
155 nur athiyah barikatul majidah 5/24/2021 11 P Ismi mufarohah/faisolDAWUHAN RT 12 RW 5
156 Kinan Dita Al Mahira 7/15/2021 9 P Muhibatin/ilyasin yusuDAWUHAN RT 11 RW 5
157 galena aunatulah ichima 9/25/2021 7 P fenti/idrus DAWUHAN RT 15 RW 5
158 m. Nasril aska 6/9/2018 43 l sofi/imam dawuhan rt 9 rw 4
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TATAN HASIL PELAYANAN
Nama petugas :
Puskesmas :
Kabupaten :
Imunisasi Kejar
(Ya = 1, Tidak=0) Ket** (bila anak
mendapatkan dosis
Campak
kedua/keetiga/keempat
Rubela
No.Hp NIK OPV/Penta saat BIAN,
(Ya=1,
Tidak=0) maka tetap dicatat namun
OPV IPV DPT-HB-Hib tidak dimasukkan sebagai
cakupan BIAN)

h i j k l m n
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81246514054 3511086509210000 1 0 0 0
81246514054 3511080906180001 1 0 0 0
 FORMAT REKAPITULASI HASIL PELAYANAN BULAN IMUNISASI ANAK NASIONAL
Desa/kelurahan :
Puskesmas :
Isilah pada kolom yang berwarna

Sasaran dan Cakupan Imunisasi Kejar Sasaran dan cakupan

imunisasi campak rubela
Usia 12 - 59 bulan Usia 9-59 bulan
NO Posyandu/Pos layanan
BIAN lainnya OPV IPV DPT-HB-Hib Campak Rubella
Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah
Jumlah sasaran % % % %
diimunisasi sasaran diimunisasi sasaran diimunisasi sasaran diimunisasi

a b c d e f g h i j k l m n
200 50 25.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
0.0% 0.0% 0.0% 0.0%
Total 200 50 25.0% 0.0% 0.0% 0.0%
Nama Provinsi :

Nama Kabupaten :
Nama Puskesmas :

Isilah Kolom yang berwarna!

OPV IPV
Posyandu/Pos Imunisasi
No. lainnya
Jumlah diimunisasi Jumlah Vial Indeks Pemakaian Jumlah diimunisasi
digunakan Vaksin

a b c d e f
1 Mawar 10 2 5 20
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
TOTAL 10 2 5 20

Catatan :
IP = Jumlah yang diimunisasi/jumlah vial vaksin yang digunakan
 FORMAT REKAPITULASI LOGISTIK PUSKESMAS

h Kolom yang berwarna!

IPV DPT-HB-Hib Campak Rubela

Jumlah Vial Indeks Jumlah Jumlah Vial

Pemakaian IP Jumlah diimunisasi Jumlah Vial IP
digunakan Vaksin diimunisasi digunakan

g h i j k l m n
5 4 40 10 4 40 5 8
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0!
5 4 40 10 4 40 5 8
 Jumlah Logistik yang digunakan

Pelarut Dropper ADS 0,5 ML ADS 5 ML Safety Box Pen Marker

o p q r s t
5 2 100 5 1
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
5 2 100 5 1 0