FORMAT PENCATATAN HASIL

Posyandu/Pos ayanan BIAN lainnya : SDN 173672 HORSIK , Parsaoran Sibisa, Posyandu Dos Roha I, Posyandu Dosroha II, Posyandu Mawa
Desa/kelurahan : Horsik, Parsaoran Sibisa, Pardomuan Ajibata
Tanggal : 20 Juni 2022

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

a b c d e
1 Harlen Michael Sidabalok 9/21/2013 9 L
2 Aldo Imanuel Sijabat 1/22/2015 8 L
1 3 Gideon Lumbanraja 1/20/2010 13 L
2 4 Hanna Monalisa Lumbanraja 11/3/2012 10 P
3 5 Rinche Anastasya Situmorang 5/2/2010 13 P
4 6 Fransisco Situmorang 7/2/2013 10 L
5 7 Gomgom Parulian Siallagan 3/16/2015 8 L
6 8 Diana Nathania Samosir 1/15/2015 8 P
7 9 Dodi A.N Siahaan 2/18/2010 13 L
8 10 Desi Delima Siahaan 11/8/2014 8 P
9 11 Bimo Harapan Siallagan 7/24/2010 13 L
10 12 Hanna Manuella Siallagan 4/18/2013 10 P
11 13 Bethuel Imanuel Sinambela 4/28/2011 12 L
12 14 Septi Novelina Sinambela 11/6/2013 9 P
13 15 Trimanda Sari Situmorang 12/18/2012 10 P
14 16 Giovani Pandapotan Padang 6/17/2009 14 L
15 17 Ridho Jeremia Sijabat 12/11/2012 10 L
16 18 Selvyana Situmorang 1/30/2014 9 P
17 19 Seven Tina Lase 9/10/2011 11 8
18 20 Delova Helena Sitorus 11/4/2016 6 P
19 21 Princess Nowela Sitorus 1/1/2015 8 P
20 22 Alvaro Moratta Simatupang 2/27/2017 6 L
21 23 Valencia Sihombing 2/12/2017 6 P
22 24 Davit Gultom 2/19/2010 13 L
23 25 Miranda Gultom 10/15/2014 8 P
24 26 Marco Alpiando Gultom 8/25/2019 3 L
25 27 Jeremi Moratta Siahaan 12/25/2018 4 L
26 28 Yemima Gok Asih Siahaan 6/25/2020 3 P
27 29 Alfred Reymon butarbutar 11/7/2016 6 L
28 30 Nowela Aulani Manurung 12/26/2016 6 P
29 31 Fivegus Manik 8/5/2021 2 L
30 32 Jeliana Manik 1/7/2019 4 P
31 33 Masrina Situmorang 6/25/2018 5 P
32 34 Mattew Sirait 5/21/2019 4 L
33 35 Novela artha manik 4/25/2017 6 P
34 36 Kim Jong Un Sirait 6/17/2020 3 L
35 37 Bintang Sirait 1/17/2017 6 P
36 38 Emilia Manurung 7/28/2021 2 P
37 39 Laura Eva Ruth Maharani Manik 4/13/2010 13 P
38 40 Dean Bayangkara Siallagan 6/2/2021 2 L
39 41 Eyetha Dearni Manik 3/16/2020 3 P
40 42 Tristan Gidean Sirait 2/7/2016 7 L
41 43 Talitha Amanda Sirait 9/7/2021 1 P
42 44 Vera Lusiana Manik 9/15/2017 5 P
43 45 Sofia Siallagan 10/27/2019 3 P
44 46 Novri Siallagan 11/20/2012 10 P
45 47 Ernest Aristo Siregar 8/20/2021 1 L
46 48 Yudha Seproniel Siallagan 9/25/2010 12 L
47 49 Vayehi Gibor Sirait 7/31/2021 2 L
48 50 Fleshly Noela Sirait 9/11/2019 3 L
49 51 Gideon Pratama Silalahi 6/6/2018 5 L
50 52 Agustinus Alpino Pakpahan 8/15/2009 13 L
51 53 Alvano Zega 10/27/2020 2 L
52 54 Anggita Zega 7/16/2018 5 P
53 55 Gracia Victoria Silalahi 10/31/2020 2 P
54 56 Wendi Apriando Tampubolon 4/2/2019 4 P
55 57 Dherey Valen Sirait 2/14/2018 5 L
56 58 Juan Tristan Samosir 9/2/2018 4 L
57 59 Rachel Clarisa Samosir 4/19/2017 6 P
58 60 Albert Samuel Samosir 7/1/2012 11 L
59 61 Mishela Nathania Sirait 7/18/2019 4 P
60 62 Aqine Gracelya Sirait 6/26/2020 3 P
61 63 Argya Romanda Sihaloho 4/23/2018 5 L
62 64 Yoselin Retta Rumahorbo 7/23/2020 3 P
63 65 Godwin Gibeon Rumahorbo 9/3/2017 5 L
64 66 Boy Tri Putra Sirait 6/22/2017 6 L
65 67 Giselle Nababan 3/29/2017 6 P
66 68 Vader Ozora Manurung 5/2/2018 5 L
67 69 Bulan Charista Sidabutar 12/15/2016 6 P
68 70 Chloe Ivana Samosir 11/2/2021 1 P
69 71 Juita Frisilia Manik 11/15/2016 6 P
70 72 Mora Sirait 2/28/2019 4 P
71 73 Merika Sirait 5/21/2017 6 P
72 74 anggi tamara sitindaon 5/31/2021 2 P
73 75 Rafael Sirait 4/9/2018 5 L
74 76 Samuel Sirait 2/8/2021 2 L
75 77 Pudan Riski Panjaitan 8/21/2016 6 L
76 78 Morgan Ramoscell Ambarita 8/14/2015 7 L
77 79 Marvel Jendrico Ambarita 5/14/2015 8 L
78 80 Mita Ambarita 4/7/2019 4 P
79 81 Adriel Boido Sidabalok 12/30/2020 2 L
80 82 Nagita Sirait 2/22/2018 5 P
81 83 Robinson Hamonangan Sinaga 11/20/2016 6 L
82 84 Marnala Sinaga 12/18/2017 5 P
83 85 Putri Imanuela Sinaga 11/6/2019 3 P
84 86 Saputra L A Lubis 11/16/2016 6 L
85 87 Emorinho Sinaga 6/24/2017 6 L
86 88 Aldiano Sinaga 9/27/2020 2 L
87 89 Ruth Priskila Manurung 2/12/2016 7 P
88 90 Ulima Manurung 1/29/2019 4 P
89 91 Deswan Yosafat Sirait 12/1/2016 6 L
90 92 Citrani Clarissa Sirait 3/13/2021 2 P
91 93 Luhut Binsar Simbolon 5/25/2018 5 L
92 94 Area Tamaro Sirait 3/2/2021 2 L
93 95 Debby Chalista Aryati Sirait 12/9/2019 3 P
94 96 Febriyani Sipahutar 2/6/2019 4 P
95 97 Dileanro Togihon Sirait 7/24/2021 2 L
96 98 Viola Stevany Manurung 12/20/2016 6 P
97 99 Togi Marito Manurung 10/19/2018 4 P
98 100 Desvina Sirait 5/5/2010 13 P
99 101 Celyn Pasnaulina Simanjuntak 12/21/2016 6 P
100 102 Queen Marisa Sirait 11/21/2015 7 P
101 103 Coky Sirait 4/17/2018 5 P
102 104 Karin Lyora Manurung 5/6/2020 3 P
103 105 Revandi 6/6/2017 6 L
104 106 Putri Relita Tindaon 8/10/2018 5 P
105 107 Anggun Aretha Gultom 6/7/2020 3 P
106 108 Cahaya Amora Nababan 1/22/2020 3 P
107 109 Andika Singga 123 L
108 110 Gresya Sinaga 3/7/2019 4 P
109 111 Aulia Putri Sijabat 8/28/2007 15 P
110 112 Fitri Sitinjak 8/15/2017 5 P
111 113 Mesakh Kamora Siadari 5/31/2018 5 L
112 114 Noval Sitorus 11/8/2017 5 L
113 115 Braian Sotarduga Manurung 5/31/2018 5 L
114 116 Valentino Manurung 2/14/2019 4 L
115 117 Anggi Desmona Manurung 5/19/2020 3 L
116 118 Kyriake Manurung 5/6/2017 6 P
117 119 Abigail Manurung 10/14/2018 4 P
118 120 Ashyana Venelape Manurung 8/15/2018 4 L
119 121 Aslan Basar Manurung 2/4/2020 3 P
120 122 Lamhot P Marbun 3/17/2017 6 L
121 123 Desta Manurung 12/29/2017 5 P
122 124 Neisi Manurung 11/24/2019 3 P
123 125 Sesilia Silaban 1/12/2017 6 P
124 126 Roma Putra Silaban 7/27/2019 4 P
125 127 Adriella Sirait 10/1/2018 4 P
126 128 Hillary Helena Yoveli Napitu 16-03-2019 #VALUE! PR
127 129 Jovanro Mora Yudimas Napitu 3/3/2021 1 LK
128 130 Juaratua Manurung 1/7/2017 6 LK
129 131 Michelle Aurora Manurung 9/12/2017 5 PR
130 132 Brylian Manurung 28/11/2015 #VALUE! LK
131 133 Likardo Albertus Simalango 16/11/2016 #VALUE! LK
132 134 Klara Aurylia Manurung 20/02/2020 #VALUE! PR
133 135 Kasih Cecilia Manurung 28/04/2017 #VALUE! PR
134 136 Kornelius Bintang Manurung 16/09/2015 #VALUE! LK
135 137 Diwan Carlin Nadapdap 6/5/2018 5 LK
136 138 Marcelino Sianturi 4/2/2017 6 LK
137 139 Revaulina Manurung 4/7/2017 6 PR
138 140 Johan Manurung 23/05/2018 #VALUE! LK
139 141 Caira Fayola Manurung 12/1/2020 2 PR
140 142 Marnala Natali Samosir 29/04/2019 #VALUE! PR
141 143 Aries Okto P Sibagariang 30/10/2017 #VALUE! LK
142 144 Juni Andro Sibagariang 7/6/2020 3 LK
143 145 Pazio Barakiel Manullang 16/05/2009 #VALUE! Lk
144 146 Phoebe Ecinaceah Manullang 24/08/2021 #VALUE! PR
145 147 Moh Faiz 5/3/2018 5 LK
146 148 Nabila Arumi 25/03/2019 #VALUE! PR
147 149 Maulana Ramadhani 18/05/2020 #VALUE! LK
148 150 Aprillia Ambarita 30/04/2017 #VALUE! PR
149 151 Filipi Ambarita 29/05/2019 #VALUE! LK
150 152 Rachel Sinaga 7/20/2018 5 P
151 153 Rafael Arensius 12/28/2019 3 L
152 154 Albery Marulitua Sirait 4/8/2020 3 L
153 155 Gracia Maranggi Marpaung 9/5/2019 3 P
154 156 Alvaro Trito P Manurung 9/6/2019 3 L
155 157 Juan Harahap 6/13/2015 8 L
156 158 Rahel Nomensen Harahap 6/10/2021 2 P
157 159 Glen Rafristen Sirait 2/10/2016 7 L
158 160 Triven Octhur Sirait 10/11/2018 4 L
159 161 Sean Napitupulu 6/1/2021 2 P
160 162 Leo Sitompul 3/3/2020 3 L
161 163 Zidea Adian Sitompul 6/26/2018 5 L
162 164 Ryndu Lumbangaol 1/11/2017 6 P
163 165 Andreas 9/19/2018 4 L
164 166 Brian Kastano Sirait 3/19/2017 6 L
165 167 Balena Hutri Sirait 8/17/2018 4 P
166 168 Yonathan Sitorus 5/25/2018 5 L
167 169 Lita Natalya Sidabutar 12/26/2016 6 P
168 170 Sammy Kristosim Sirait 8/6/2019 4 L
169 171 Felicia Kimora Sinaga 5/26/2018 5 P
170 172 Cleora Deomora Sinaga 10/13/2021 1 P
171 173 Crisan Aquino Samosir 1/28/2018 5 L
172 174 Riyan Hasian Sirait 5/28/2016 7 L
173 175 Puan Rodearny Silaban 9/19/2017 5 P
174 176 Dareen Gracio Paltua Sinaga 7/20/2020 3 L
175 177 Felix Christian Simanjuntak 2/12/2016 7 L
176 178 Geby Simanjuntak 9/20/2020 2 P
177 179 Clowi Fayola Simanjuntak 6/26/2017 6 P
178 180 Alvaro Micael Simangunsong 6/8/2017 6 L
179 181 Masta Sirait 2/6/2018 5 P
180 182 Markus Alfaro Sitinjak 7/4/2016 7 L
181 183 Alan Bonatua Ambarita 11/1/2021 1 L
182 184 Rizky Folando Sitorus 6/2/2012 11 L
183 185 Gio Alvaro Sitorus 4/4/2017 6 L
184 186 Abrina Putri Sidabutar 12/18/2020 2 P
185 187 Maykel Tamora 5/18/2020 3 L
186 188 Shandi Cartenzo Rylichiro Sitorus 9/5/2019 3 L
187 189 Gloria Eventina Nainggolan 11/30/2015 7 P
188 190 Febri Maria Nainggolan 2/15/2017 6 P
189 191 Menkeu Sitorus 9/10/2019 3 P
190 192 Butet Sitorus 6/16/2021 2 P
191 193 Gabriel Binsar Simanungkalit 1/18/2016 7 L
21
Jenis logistik OPV IPV DPT-HB-HIB
Jumlah 0 0 0
Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
 FORMAT PENCATATAN HASIL PELAYANAN
sa, Posyandu Dos Roha I, Posyandu Dosroha II, Posyandu Mawar Motung, Posyandu Simarata, Pardamean Sibisa Nama petugas : Eni Lase
Puskesmas : Ajibata
Kabupaten : Toba

Imunisasi Kejar
(Ya = 1, Tidak=0)

Campak
Rubela
Nama orang tua Alamat No.Hp NIK
(Ya=1,
Tidak=0)
OPV IPV DPT-HB-Hib

f g h i j k l m
Mian Magdalena Sinaga Horsik 1212082109130001 1
Mariana Sinaga Horsik 1212082201150001 1
Martha Hasibuan Horsik 1212882001100001 1
Martha Hasibuan Horsik 1212084311120001 1
Helena Simanullang Horsik 1216080207130002 1
Helena Simanullang Horsik 1216080207130002 1
Elida Simatupang Horsik 1212081603150001 1
Gelora Sidabutar Horsik 1212085501150001 1
Hotmaria Samosir Horsik 1212081802100002 1
Hotmaria Samosir Horsik 1212084811140001 1
Elida Simatupang Horsik 1212082407100001 1
Elida Simatupang Horsik 1212085804130001 1
Mesna Sitorus Horsik 1212082804110001 1
Mesna Sitorus Horsik 1212084611130001 1
Novita Sitanggang Horsik 1212085212120003 1
Lidia Sijabat Horsik 1
Mariana Sinaga Horsik 121208112120001 1
Novita Sitanggang Horsik 1212087001140001 1
Ramsi Simamora Horsik 1212085309110001 1
Eka Sitio Parsaoran Sibisa 1212084411160001 1
Eka Sitio Parsaoran Sibisa 1212084411160001 1
Eka Sitorus Parsaoran Sibisa 1212012006170001 1
Repida Hutajulu Parsaoran Sibisa 1202101202170001 1
Mediana Siahaan Parsaoran Sibisa 1212082201100001 1
Mediana Siahaan Parsaoran Sibisa 1212085610140001 1
Mediana Siahaan Parsaoran Sibisa 1
Irma Purnama Sinaga Sipangan Bolon 1208042812180001
Irma Purnama Sinaga Sipangan Bolon 1208041606200001
Rodesta Lumbangaol Parsaoran Sibisa 1212080711160002 1
Febriani Sinaga Pardomuan Ajibata '1212082612150001 1
Suryati Sinaga Pardomuan Ajibata 1
Suryati Sinaga Pardomuan Ajibata 1
Rika Siregar Pardomuan Ajibata 1
Lastarina Sitanggang Pardomuan Ajibata 1212081009140001 1
Tety Sidabutar Pardomuan Ajibata 1
Masniari Hutagaol Pardomuan Ajibata 1
Masniari Hutagaol Pardomuan Ajibata 1
Febriani Sinaga Pardomuan Ajibata 1
Heni Ida Rauli Pardomuan Ajibata 1212085304100001 1
Purnama Damanik Pardomuan Ajibata 1212080206210001 1
Amran Manik Pardomuan Ajibata 1212085603200001 1
Lamtiur Simanjuntak Pardomuan Ajibata 1
Lamtiur Simanjuntak Pardomuan Ajibata 1
Jenti Silitonga Pardomuan Ajibata 1212085509170001 1
Eni Situmorang Pardomuan Ajibata 1212086710190001 1
Normaida Sirait Pardomuan Ajibata 1212086011120001 1
Rosdian Damanik Pardomuan Ajibata 1212082008210001 1
Purnama Damanik Pardomuan Ajibata 1212082509100001 1
Elsa Samosir Pardomuan Ajibata 1212083107210001 1
Elsa Samosir Pardomuan Ajibata 1212085109190001 1
Lamria Situmorang Pardomuan Ajibata 1
Maria Simarmata Pardomuan Ajibata 1212081508090001 1
Erawati Situmorang Pardomuan Ajibata 1212082710200001 1
Erawati Situmorang Pardomuan Ajibata 1212085607180001 1
Lamria Situmorang Pardomuan Ajibata 1212087110200001 1
Lena Damanik Pardomuan Ajibata 1212080204190001 1
Lenni Mariana Malau Pardomuan Ajibata 1212081402180002 1
Helena Sianipar Pardomuan Ajibata 1212080209180001 1
Helena Sianipar Pardomuan Ajibata 1212085904170001 1
Fransiska Napitu Pardomuan Ajibata 1
Septyna Ace Silalahi Pardomuan Ajibata 1212085507190001 1
Septyna Ace Silalahi Pardomuan Ajibata 1212086606200001 1
Larina Sagala Pardomuan Ajibata 1212082304180001 1
Rosmelia Manik Pardomuan Ajibata 2171106307200003 1
Rosmelia Manik Pardomuan Ajibata 2171100309170001 1
Nurmida Siagian Pardomuan Ajibata 1212082206170001 1
Mei Pakpahan Pardomuan Ajibata 3273146903170003 1
Maya Hasrina Pardomuan Ajibata 1212080205180001 1
Mitra Sirait Pardomuan Ajibata 1212085512160001 1
Artha Sinaga Pardomuan Ajibata 1212085902190001 1
Masdiana Pardosi Pardomuan Ajibata 1212085511160001 1
Jenni Sirait Pardomuan Ajibata 1208096802190001 1
Jenni Sirait Pardomuan Ajibata 1208096105170001 1
Lorenta Harianja Pardomuan Ajibata 1
Nomy Vera Hutabarat Pardamean Ajibata 1212080904190001 1
Nomy Vera Hutabarat Pardamean Ajibata 1212080802210001 1
Wida Sartika Manik Pardamean Sibisa 1212082108180001 1
Midian Ambarita Pardamean Sibisa 1212082910130001 1
Midian Ambarita Pardamean Sibisa 1212085408150001 1
Midian Ambarita Pardamean Sibisa 1212084704190001 1
Ninsih Justina Hutagalung Pardamean Sibisa 1212080312200001 1
Saut S Pardamean Sibisa 1212086202180001 1
Nurhayati Maharaja Pardamean Sibisa 1212082011160001 1
Nurhayati Maharaja Pardamean Sibisa 1212085812170001 1
Nurhayati Maharaja Pardamean Sibisa 1212084611190002 1
Sofyan R Lubis Pardamean Sibisa 1212021611160001 1
Egorider Sinaga Pardamean Sibisa 1212082406170001 1
Egorider Sinaga Pardamean Sibisa 1212082709200001 1
Tohap Manurung Pardamean Sibisa 1212085202860001 1
Tohap Manurung Pardamean Sibisa 1
Nurayani Sidabutar Pardamean Sibisa 1208214112160002 1
Nurayani Sidabutar Pardamean Sibisa 1212085103210001 1
Erbin Simbolon Pardamean Sibisa 1212082505180002 1
Arina Gultom Pardamean Sibisa 1212080203210001 1
Melita Marpaung Pardamean Sibisa 1212084912190001 1
Ida Siburian Pardamean Sibisa 1212084802190001 1
Lambok Manurung Pardamean Sibisa 1212082407210001 1
Perawaty Sihombing Pardamean Sibisa 1212088012160001 1
Perawaty Sihombing Pardamean Sibisa 1212085910180001 1
Damaria Sidabutar Pardamean Sibisa 1
Marianti Sijbat Parsaoran Sibisa 1212066112160001 1
Mega Natalia Pardamean Sibisa 1212086111150001 1
Siska Manalu Pardamean Sibisa 1212081704180001
Sumiharti Sinaga Pardamean Sibisa 1212084605200001
Lamrika Rajagukguk Parsaoran Sibisa 1
Lamrika Rajagukguk Parsaoran Sibisa 1
Agum Gultom Pardamean Sibisa 121208476200002 1
Junaeda Sitanggang Pardamean Sibisa 1
Lastiar Sijabat Parsaoran Sibisa 1
Irama Ria Hutahaean Motung 1212084703190001 1
Lasta Sinaga Motung 1212086808070001 1
Lasta Sinaga Motung 1212085508170001 1
Berliana Panjaitan Motung 1212083105180001 1
Dina Sinaga Motung 1212080811170001 1
Bergiat Manurung Motung 1212083105180002 1
Mayer Sirait Pardomuan Motung 1212081402190001 1
Mayer Sirait Pardomuan Motung 1212085905200002 1
Natalina Tambunan Motung 1212084605170001 1
Natalina Tambunan Motung 1212085410180001 1
Sovia Sirait Motung 1212081508180001 1
Sovia Sirait Motung 1212084402200001 1
Ramaida Sinaga Motung 1212081703170001 1
Hotria Sinaga Motung 1212086912170001 1
Hotria Sinaga Motung 1212086411190001 1
Tety Tindaon Motung 1212085201170001 1
Tety Tindaon Motung 1212082707190001 1
Agustika Purba Motung 1212084110180001 1
Yenny Lestari Manurun Motung 121208560319001
Yenny Lestari Manurun Motung
Desmanata Simorangkir Motung 1212080107170000
Magdalena Sofia Lorina Gultom Motung 1212084912170001
Sherliana Munthe Motung 1212082811150001
Leni Marlina Sinaga Motung 1208141611160001
Rengsi Meliaki Pardede Motung 121208600200001
Rengsi Meliaki Pardede Motung 1212086804170000
Rengsi Meliaki Pardede Motung 1212081609150001
Agusti Samosir Motung 1212080605180001
Emma Sihotang Motung 1212080402170001
Mesriana Manik Motung 1212084704170001
Elfis Nadeak Motung 1212082305180002
Mei Arny Samosir Motung 1212085201200001
Marlise Maryones Simanungkalit Motung 1212086904190001
Rayun Irawati Tumanggor Motung 1212083010170002
Rayun Irawati Tumanggor Motung 1212084706200001
Fatimah Manurung Motung 1212081605190001
Fatimah Manurung Motung 1212086408210001
Raun Insani Sinaga Motung 1212080503160001
Raun Insani Sinaga Motung 1212086503190001
Raun Insani Sinaga Motung 1212081905200001
Irawati Elisabeth Sitorus Motung 1212087004170001
Irawati Elisabeth Sitorus Motung 1212082905190001
Delta Sirait Motung 1212087004170001
Delta Sirait Motung 1212082905190001
Agustika Purba Motung 1212080804200001 1
Dewi Purba Pardomuan Motung 6402074509190001 1
Elperida Situmorang Motung 1212080609190001 1
Tiar Napitu Motung 1212091306150001 1
Tiar Napitu Motung 1
Parmiwaty Panjaitan Motung 1212081002160002 1
Parmiwaty Panjaitan Motung 1212081110180001 1
Lilis Pardosi Motung 1
Emmi Eliana Motung 1212082605180001 1
Emmi Eliana Motung 1
Winarty Motung 1212105101120001 1
Meta Indiana Munte Motung 1212081909180001 1
Siti Maesaroh Motung 2171041903170012 1
Siti Maesaroh Motung 2171045708180002 1
Swarlina Sihotang Motung 1212082505180001 1
Parasian Gultom Motung 1208136612160001 1
Tetty Sinaga Motung 1212080609190002 1
Emmania Hosianna Simanjuntak Motung 1
Emmania Hosianna Simanjuntak Motung 1
Ropenni Sinaga Motung 1212082801180001
Robina Ambarita Motung 1212082805160001
Hormalumaitan Sidabutar Motung 1212085909170001
Ida Yunita Ambarita Motung 1212082007200001
Lisda Napitu Motung 1212081202160001
Lisda Napitu Motung
Saudurlina Manurung Motung 1212086608170001
 Renta Simanjuntak Motung 1209290806170001
Serdi Nainggolan Motung 1212084602180001
Tota Ristauli Silalahi Motung 1212080407160001
Juniati Sinaga Motung 1212084111210001
Suryani Sibarani Motung 1212080206120001
Suryani Sibarani Motung 1212080404170001
Rosintan Ambarita Motung
Berta Ambarita Motung
Yuliana Efriani Motung 1212080008100001
Astuti Marini Ambarita Motung 1212087011500001
Astuti Marini Ambarita Motung 1212085502170001
Evi Ambarita Motung 1212085009190001 1
Evi Ambarita Motung 1
Nani Rahayu Pardamean Ajibata 1212081801160001 1
21
CAMPAK RUBELA Pelarut Campak Rubela Dropper ADS 0,5 ML ADS 5 ML Safety Box Pen Marker
193 20 193 20 4 4

asi susulan pada kolom keterangan

Ket** (bila anak mendapatkan
dosis kedua/keetiga/keempat
OPV/Penta saat BIAN, maka
tetap dicatat namun tidak
dimasukkan sebagai cakupan
BIAN)

n
 FORMAT REKAPITULASI HASIL PELAYANAN BULAN IMUNISASI ANAK NASIONAL
Desa/kelurahan : Pardamean Ajibata dan Parsaoran Ajibata
Puskesmas : Ajibata
Isilah pada kolom yang berwarna

Sasaran dan Cakupan Imunisasi Kejar Sasaran dan cakupan imunisasi ca

Usia 12 - 59 bulan Usia 9-59 bulan Usia 5 - <7 thn
Posyandu/Pos layanan
NO OPV IPV DPT-HB-Hib Campak Rubella Campak Rubela
BIAN lainnya
Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah
% % diimuni % % %
sasaran diimunisasi sasaran diimunisasi sasaran sasi sasaran diimunisasi sasaran diimunisasi
a b c d e f g h i j k l m n o p q
1 SDN 173672 HORSIK 0 0 0.0% 0 0 0.0% 0 0 0.0% 0 0 0.0% 0 0 0.0%
2 Parsaoran Sibisa (Sweaping) 0 0 0.0% 0 0 0.0% 0 0 0.0% 0 5 0.0% 0 4 0.0%
3 Posyandu Dos Roha I 0 0 0.0% 0 0 0.0% 0 0 0.0% 23 20 87.0% 10 5 50.0%
4 Posyandu Dos Roha II 0 0 0.0% 0 0 0.0% 0 0 0.0% 14 11 78.6% 7 7 100.0%
5 Posyandu Mawar Motung 0 0 0.0% 0 0 0.0% 0 0 0.0% 30 28 93.3% 17 12 70.6%
6 Posyandu Simarata 0 0 0.0% 0 0 0.0% 0 0 0.0% 32 23 71.9% 23 13 56.5%
7 Pardamean Sibisa (Sweaping 0 0 0.0% 0 0 0.0% 0 0 0.0% 0 18 0.0% 0 10 0.0%

Total 0 0 0.0% 0.0% 0.0% 0.0% 0.0%

ASIONAL
Periode 2
Nama petugas Eni lase

dan cakupan imunisasi campak rubela

Usia 12 -<15 thn
Usia 7-<12 thn (bagi 5 Prov.) Total Total
Campak Rubela Campak Rubela Sasaran dimunisasi Total
Campak Campak Cakupan
Jumlah Jumlah Jumlah Jumlah Rubella Rubella
% %
sasaran diimunisasi sasaran diimunisasi
r s t u v w x = l+o+r / yl+o+r+u
= m+p+s / m+p+s+v
14 14 100.0% 7 5 71.4% 22 19 86.4%
0 0 0.0% 0 1 0.0% 0 10 0.0%
0 1 0.0% 0 4 0.0% 38 30 78.9%
0 1 0.0% 0 0 0.0% 20 17 85.0%
0 3 0.0% 0 2 0.0% 47 45 95.7%
0 3 0.0% 0 0 0.0% 57 39 68.4%
0 3 0.0% 0 2 0.0% 0 33 0.0%

0.0% 0.0% 184 193 95.3%

Nama Provinsi : Sumatera Utara

Nama Kabupaten : Toba

Nama Puskesmas : Ajibata

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

a b c d e
1 SDN 173672 HORSIK 0 0 #DIV/0!
2 Parsaoran Sibisa 0 0 #DIV/0!
3 Posyandu Dos Roha I 0 0 #DIV/0!
4 Posyandu Dos Roha II 0 0 #DIV/0!
5 Posyandu Mawar Motung 0 0 #DIV/0!
6 Posyandu Simarata 0 0 #DIV/0!
7 Pardamean Sibisa 0 0 #DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
TOTAL 0 0 #DIV/0!

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

Isilah Kolom yang berwarna!

IPV DPT-HB-Hib

Indeks
Jumlah Vial Jumlah Jumlah Vial
Jumlah diimunisasi Pemakaian IP
digunakan diimunisasi digunakan
Vaksin
f g h i j k
0 0 #DIV/0! 0 0 #DIV/0!
0 0 #DIV/0! 0 0 #DIV/0!
0 0 #DIV/0! 0 0 #DIV/0!
0 0 #DIV/0! 0 0 #DIV/0!
0 0 #DIV/0! 0 0 #DIV/0!
0 0 #DIV/0! 0 0 #DIV/0!
0 0 #DIV/0! 0 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!
0 0 #DIV/0! 0 0 #DIV/0!
SMAS

Campak Rubela Jumlah Logistik yang digunakan

Jumlah diimunisasi Jumlah Vial IP Pelarut Dropper ADS 0,5 ML ADS 5 ML

l m n o p q r
19 2 10 1 0 19 2
10 1 10 1 0 10 1
30 3 10 3 0 30 3
17 2 9 2 0 17 2
45 5 9 5 0 45 5
39 4 8 4 0 49 4
33 3 8 3 0 33 3

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
193 20 9.65 19 0 203 20
ang digunakan

Safety Box Pen Marker

s t
1 1
1 1
1 1
0 0
1 1
0 0
0 0

4 4