1.

Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 2 V 4 5 6
3 2 0 3 4 6 2 Bulan : 2023
NAMA FASKES/ PUSKESMAS NARINGGUL 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN SUMBER ALOKON

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
STATUS PESERTA KB

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN
ISTRI

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN
PENCABUTAN

PENCABUTAN

KEGAGALAN
PEMBERIAN/

KOMPLIKASI
NAMA SUAMI

OPERATIF/

LAINNYA
TANGGAL

MANDIRI
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

BERAT
LAHIR

(Kode)

TIDAK

APBN

APBD
DAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 13-March-2023 DEDEN SYAPARI 3 2 1 7 0 8 4 4 0 6 8 3 0 0 2 2 EVA MARLINA 04-June-1983 KP.MITRA BAKTI 2 1 0 0 2 0 0 1 1 0 0 0

ASEP SAEPUL 02-January-1998

2 13-March-2023 3 2 0 3 2 4 4 2 0 1 8 8 0 0 0 9 ALIT SUSANTI KP.HEGARMANAH 1 1 1 0 8 0 0 1 1 0 0 0
ANWAR
20-December-
3 13-March-2023 CACANG 3 2 0 3 2 4 6 0 1 2 9 2 0 0 0 2 AI KARYATI KP.TEGALBUNGUR 3 1 0 0 8 0 0 1 1 0 0 0
1992
16-November-
4 13-March-2023 DADIN 3 2 0 3 2 4 5 6 1 1 8 7 0 0 0 2 WIDAYANTI KP.CIAWI TALI 2 1 0 0 8 0 0 1 1 0 0 0
1987

5 13-March-2023 DARYANA 3 2 0 3 2 4 5 2 0 6 7 8 0 0 0 3 NANI 12-June-1978 KP. CITEREP 2 1 0 0 8 0 0 1 1 0 0 0

03-September-
6 13-March-2023 DASE 3 2 0 3 2 4 6 0 0 6 9 6 0 0 0 4 NURAENI KP. CIHALIMUN 2 1 0 0 8 0 0 1 1 0 0 0
1994
06-January-1993
7 13-March-2023 DEDI ROSIDIN 3 2 0 3 2 3 4 6 0 1 9 3 0 0 1 5 TASRIAH KP.SUKAJADI 1 1 0 0 8 0 0 1 1 0 0 0

01-January-1995
8 13-March-2023 DIAN KARYANTO 3 2 7 3 3 0 4 1 0 1 9 5 0 0 0 9 DERA JANWAR KP. DATARKUBANG 1 1 1 0 8 0 0 1 1 0 0 0

01-January-1999
9 13-March-2023 DIKI ABDULAH 3 2 0 4 4 0 4 1 0 1 9 9 0 0 7 4 SANTI KP. JALAN PANGKALAN 2 1 0 0 8 0 0 1 1 0 0 0

10 13-March-2023 DUDUH 3 2 0 3 2 4 4 5 0 7 7 6 0 0 0 7 IIS 05-June-1976 KP. CIALENGKA 2 1 0 0 8 0 0 1 1 0 0 0

06-February-
11 13-March-2023 ERUS 3 2 0 3 2 4 4 6 0 2 7 9 0 0 0 2 NONIH KP.PUNCAKJAYA 2 1 0 0 8 0 0 1 1 0 0 0
1979
09-January-1982
12 13-March-2023 HAMIDUN 3 2 0 3 2 4 4 9 0 1 8 2 0 0 0 4 EMAY KP.KANCAH NANGKUB 2 1 0 0 8 0 0 1 1 0 0 0

13 13-March-2023 HENDAR PERMANA 3 2 0 3 2 4 4 4 0 7 7 6 0 0 0 2 TITIN KARTINI 06-July-1976 KP. MEKARLAKSANA 1 1 1 0 8 0 0 1 1 0 0 0

14 13-March-2023 HENDRI IRAWAN 3 2 0 3 2 4 4 9 0 8 0 0 0 0 0 3 TARWITI 09-June-2000 KP. PASIR IPIS 1 1 1 0 8 0 0 1 1 0 0 0

08-February-
15 13-March-2023 HERWAN 3 2 0 3 2 4 4 8 0 2 8 7 0 0 0 4 SITI NURHAYATI KP. SITURANDU 1 1 1 0 8 0 0 1 1 0 0 0
1987

16 13-March-2023 HILMAN IKSANUDIN 3 2 0 3 2 4 5 3 0 5 9 1 0 0 0 1 AI ROHANAH 15-May-1991 KP. CIBOGO 2 1 0 0 8 0 0 1 1 0 0 0

21-November-
17 13-March-2023 IMAN 3 2 0 3 2 4 6 1 1 1 8 5 0 0 0 4 TATIN KP.PASAGI TUNGGUL 1 1 1 0 8 0 0 1 1 0 0 0
1985

18 13-March-2023 JAJAT 3 2 0 3 2 4 4 1 0 7 9 2 0 0 5 1 SANTI 01-July-1992 KP. GIRIJAYA 1 1 1 0 8 0 0 1 1 0 0 0

29-February-
19 13-March-2023 JONI 3 2 0 3 2 4 6 9 0 2 9 6 0 0 0 4 INTAN LESTARI KP. CISINTOK 2 1 0 0 8 0 0 1 1 0 0 0
1996

20 13-March-2023 MUSTOPA 3 2 0 3 2 4 6 7 0 7 7 5 0 0 0 3 WARYATI 21-July-1975 KP.PASIR IPIS 2 1 0 0 8 0 0 1 1 0 0 0

21 13-March-2023 NUNUNG KURNIA 3 2 0 3 2 4 4 1 0 3 7 8 0 0 2 1 YUNINGSIH 01-March-1978 KP. CIAWITALI 2 1 0 0 8 0 0 1 1 0 0 0

22 13-March-2023 ODI 3 2 0 3 2 4 4 1 0 7 0 0 0 0 6 3 NINA 01-July-2000 KP. GIRIJAYA 2 1 0 0 8 0 0 1 1 0 0 0

21-February-
23 13-March-2023 OJA 3 2 0 3 2 4 6 1 0 2 8 1 0 0 0 5 WASIKAH KP.UJUNG JAYA 2 1 0 0 8 0 0 1 1 0 0 0
1981

24 13-March-2023 RAHMA 3 2 0 3 2 4 6 5 0 4 8 9 0 0 0 1 KRISNA JUARNI 25-April-1989 KP. CICUKANG 2 1 0 0 8 0 0 1 1 0 0 0

25 13-March-2023 RAHMAWAN 3 2 0 3 2 4 6 7 0 4 9 8 0 0 0 2 RANENGSIH 27-April-1998 KP. CITEUREUP 3 1 0 0 8 0 0 1 1 0 0 0

13-August-1989
26 13-March-2023 RUSTADIN 3 2 0 3 2 4 5 3 0 8 8 9 0 0 0 2 RISMAYANTI KP. DATARMALA 2 1 0 0 8 0 0 1 1 0 0 0

31-October-1991
27 13-March-2023 SAHMUDIN 3 2 0 3 2 4 7 1 1 0 9 1 0 0 0 1 SUMINAR KP. KANCAH NANGKUB 1 1 0 0 8 0 0 1 1 0 0 0
 04-August-1998
28 13-March-2023 SAMSUDIN 3 2 0 3 2 4 4 4 0 8 9 8 0 0 0 2 ARYU WINDARI KP. CIHALIMUN 1 1 1 0 8 0 0 1 1 0 0 0

29 13-March-2023 SARIP 3 2 0 3 2 4 5 0 0 4 9 0 0 0 1 2 LIA 10-April-1990 KP. SIMPANGSARI 2 1 0 0 8 0 0 1 1 0 0 0

30 13-March-2023 TARYANA 3 2 0 3 2 4 4 5 0 3 9 1 0 0 1 2 DARLIMAH 05-March-1991 KP. BABAKAN 2 1 0 0 8 0 0 1 1 0 0 0

01-January-1989
31 13-March-2023 TATANG 3 2 0 3 2 4 5 0 0 1 8 9 0 0 0 7 CICIN NURYANI KP. CISINTOK 2 1 0 0 8 0 0 1 1 0 0 0

10-August-1991
32 13-March-2023 UGAN HERMAWAN 3 2 0 3 2 4 5 0 0 8 9 1 0 0 0 3 TUTI NURSAMSI KP. CIBOGO 1 1 1 0 8 0 0 1 1 0 0 0

33 17-March-2023 ADE SUARNO 3 2 0 3 2 4 5 4 0 4 9 6 0 0 0 2 RITA PURNAMASARI 07-May-1997 KP PASIR BARU 1 1 1 0 8 0 0 1 1 0 0 0

34 17-March-2023 AGUS SUGANDA 3 2 0 4 3 8 4 3 0 7 8 1 0 0 1 5 YATI 03-July-1981 KP. BUNISARI 3 1 0 0 8 0 0 1 1 0 0 0

35 17-March-2023 AHMAD SOLEHUDIN 3 2 0 3 2 4 4 8 0 3 0 5 0 0 0 1 NURCALIH 08-March-2005 KP. BUNISARI 1 1 1 0 8 0 0 1 1 0 0 0

36 17-March-2023 APIN 3 2 0 3 2 4 4 6 0 3 7 7 0 0 0 7 HALIMAH 06-March-1977 KP BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0

08-August-1981
37 17-March-2023 A.SAEPUDIN 3 2 0 3 2 4 4 2 0 8 8 1 0 0 0 2 IIS RUSMINI KP. BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0

ASEP SURYA
38 17-March-2023 3 6 0 2 2 1 5 0 0 6 8 7 0 0 0 5 RIMAYA 10-June-1987 KP. BUNISARI 2 1 0 0 8 0 0 1 1 0 0 0
SOMANTRI
14-January-1998
39 17-March-2023 ASEP SUTIANA 3 2 0 3 2 4 5 4 0 1 9 8 0 0 0 9 SUSI SUSILAWATI KP. BUNISARI 2 1 0 0 8 0 0 1 1 0 0 0

12-October-1982
40 17-March-2023 BASIR 3 2 0 3 2 4 5 2 1 0 8 2 0 0 0 3 ROKAYAH KP PASIR KIAMIS 2 1 0 0 8 0 0 1 1 0 0 0

14-February-
41 17-March-2023 DAMA 3 2 0 3 2 4 5 4 0 2 8 1 0 0 0 1 ELIS KP BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0
1981

42 17-March-2023 DARMIN 3 2 0 3 2 4 5 3 0 5 8 7 0 0 0 1 ATIK 13-May-1987 KP BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0

43 17-March-2023 DEDEN GUNAWAN 3 2 0 3 2 4 6 1 0 7 8 5 0 0 0 1 NENG HERAWATI 21-July-1986 KP. TARENGTONG 2 1 0 0 8 0 0 1 1 0 0 0

44 17-March-2023 DEDE R 3 2 0 3 2 4 5 6 0 7 7 6 0 0 0 5 RATIMAH 16-July-1976 KP. DATARKUPA 3 1 0 0 8 0 0 1 1 0 0 0

20-January-1981
45 17-March-2023 DEDI 3 2 0 3 2 4 6 0 0 1 8 1 0 0 0 4 HOTIMAH KP. PS KIAMIS 1 1 1 0 8 0 0 1 1 0 0 0

29-January-1991
46 17-March-2023 DENI 3 2 0 3 2 4 6 9 0 1 9 1 0 0 0 1 CINDY KP SINDANG KASIH 2 1 0 0 8 0 0 1 1 0 0 0

47 17-March-2023 HENDI 3 2 0 4 3 8 4 1 0 7 0 1 0 0 1 8 AI SANTI 01-July-1998 KP. BUNISARI 2 1 0 0 8 0 0 1 1 0 0 0

48 17-March-2023 IDAN 3 2 0 3 2 4 4 8 0 6 9 6 0 0 0 4 AI RIRA HAYATI 08-June-1996 KP. BUNISARI 1 1 1 0 8 0 0 1 1 0 0 0

49 17-March-2023 IDEN NURJAMAN 3 2 0 3 2 4 6 7 0 7 8 7 0 0 0 1 SARYANI 27-July-1987 KP. MIDUANA 1 1 1 0 8 0 0 1 1 0 0 0

50 17-March-2023 IDEN NURJAMAN 3 2 0 3 2 4 6 7 0 7 8 7 0 0 0 1 SARYANI 27-July-1987 KP. MIDUANA 2 1 0 0 8 0 0 1 1 0 0 0

51 17-March-2023 II ABDULLAH 3 2 0 3 2 4 4 3 0 6 9 5 0 0 0 6 RESKI YUNI NUR SOLIH 03-June-1995 KP PASIR BARU 2 1 0 0 8 0 0 1 1 0 0 1

17-October-1978
52 17-March-2023 IJA 3 2 0 3 2 4 5 7 1 0 7 8 0 0 0 2 WATI KP. LEMBUR LAMPING 2 1 0 0 8 0 0 1 1 0 0 0

25-September-
53 17-March-2023 INA 3 2 0 3 2 4 6 5 0 9 7 5 0 0 0 2 HAERANI KP. BALEGEDE 1 1 1 0 8 0 0 1 1 0 0 0
1975

54 17-March-2023 ISAD 3 2 0 3 2 4 4 6 0 7 8 4 0 0 0 1 TATIN 06-July-1984 KP BABAKAN 1 1 1 0 8 0 0 1 1 0 0 0

10-August-1992
55 17-March-2023 IWAN 3 2 0 3 2 4 5 0 0 8 9 2 0 0 0 7 LINA HERLINA KP PASIRBARU 2 1 0 0 8 0 0 1 1 0 0 0

56 17-March-2023 KADIN 3 2 0 3 2 4 4 6 0 4 7 9 0 0 0 1 ROHAENI 06-April-1979 KP. BALEGEDE 3 1 0 0 8 0 0 1 1 0 0 0

01-January-1982
57 17-March-2023 KOSWARA 3 2 0 3 2 4 4 1 0 1 8 2 0 0 1 1 AMINAH KP. SINDANG KASIH 1 1 1 0 8 0 0 1 1 0 0 1

01-February-
58 17-March-2023 NENDI 3 2 0 3 2 4 4 1 0 2 7 9 0 0 1 9 JAMILAH KP BABAKAN 2 1 0 0 8 0 0 1 1 0 0 0
1979
12-September-
59 17-March-2023 NURIYANTI 3 2 0 3 2 4 5 2 0 9 9 4 0 0 0 1 ABDUL LATIF KP. PASIR KIAMIS 2 1 0 0 8 0 0 1 1 0 0 0
1994
15-February-
60 17-March-2023 ODI HIDAYAT 3 2 0 3 2 4 5 5 0 2 9 0 0 0 0 8 ENI KP. AWI SEWU TONGOH 2 1 0 0 8 0 0 1 1 0 0 0
1990
17-August-1976
61 17-March-2023 ODIM 3 2 0 3 2 4 5 7 0 8 7 6 0 0 0 5 BETI HAYATI KP. BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0

24-November-
62 17-March-2023 OHIM 3 2 0 3 2 4 6 4 1 1 8 9 0 0 0 4 NINA KP. MIDUANA 1 1 1 0 8 0 0 1 1 0 0 0
1989

63 17-March-2023 OPIK MUSTOPA 3 2 0 3 2 4 5 3 0 3 8 3 0 0 0 5 NIA 13-March-1983 KP. BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0

64 17-March-2023 PADIL 3 2 0 3 2 4 4 1 0 3 9 3 0 0 1 8 IWIN WINENGSIH 01-March-1993 KP.MIDUANA 1 1 1 0 8 0 0 1 1 0 0 0

12-January-1980
65 17-March-2023 RAHMAN 3 2 0 3 2 4 5 2 0 1 8 0 0 0 0 5 DINAH KP BABAKAN 1 1 1 0 8 0 0 1 1 0 0 0
66 17-March-2023 RAHYA 3 2 0 3 2 4 4 6 1 0 3 9 0 0 0 1 NARTI 21-March-1990 KP BABKAN 1 1 1 0 8 0 0 1 1 0 0 0

67 17-March-2023 RAPIK 3 2 0 3 2 4 4 6 0 7 8 7 0 0 0 5 TUTI 06-July-1987 KP CIAWITALI 2 1 0 0 8 0 0 1 1 0 0 0

68 17-March-2023 RUDI HERMAWAN 3 2 0 3 2 4 5 1 0 3 9 7 0 0 0 6 LENI HENDRAYANTI 11-March-1997 KP. PASIR KIAMIS 3 1 0 0 8 0 0 1 1 0 0 0

21-November-
69 17-March-2023 SAEP 3 2 0 3 2 4 6 1 1 1 8 1 0 0 0 2 CINI ROHAENI KP. BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0
1981

70 17-March-2023 SAHNA 3 2 0 3 2 4 2 5 0 4 8 2 0 0 0 8 POPON 12-April-1982 KP LEMBUR LAMPING 2 1 0 0 8 0 0 1 1 0 0 0

10-January-1974
71 17-March-2023 SARDI 3 2 0 3 2 4 5 0 0 1 7 4 0 0 0 5 WANIH KP BABAKAN 2 1 0 0 8 0 0 1 1 0 0 0

17-December-
72 17-March-2023 SARIPUDIN 3 2 0 3 2 4 5 7 1 2 8 9 0 0 0 1 NURHAYATI KP. BABAKAN 2 1 0 0 8 1 0 0 1 0 0 0
1989
29-November-
73 17-March-2023 SOBARI 3 2 0 3 2 4 6 9 1 1 8 5 0 0 0 1 NENG ASIH KP BALEGEDE 1 1 1 0 8 0 0 1 1 0 0 0
1985
18-January-1988
74 17-March-2023 SOLIHIN 3 2 0 3 2 4 5 8 0 1 8 6 0 0 0 1 SITI KP. BALEGEDE 3 1 0 0 8 0 0 1 1 0 0 0

08-September-
75 17-March-2023 SOPIAN 3 2 0 3 2 4 4 8 0 9 8 8 0 0 0 5 LENI KP. BUNISARI 2 1 0 0 8 0 0 1 1 0 0 0
1988

76 17-March-2023 SUGANDA 3 2 0 4 3 8 4 3 0 7 8 1 0 0 1 5 YATI 03-July-1981 KP. BUNISARI 3 1 0 0 8 0 0 1 1 0 0 0

02-August-1988
77 17-March-2023 SUKARMIN 3 2 0 3 2 4 4 2 0 8 8 8 0 0 0 7 WINAGSIH KP. PASIR KIAMIS 3 1 0 0 8 0 0 1 1 0 0 0

78 17-March-2023 SUPRIADI 3 2 0 3 2 4 5 1 0 7 8 0 0 0 0 4 SARINA 11-July-1980 KP PASIRBARU 2 1 0 0 8 0 0 1 1 0 0 0

07-August-1974
79 17-March-2023 SUTIAWAN 3 2 0 3 2 4 5 2 0 5 7 3 0 0 0 6 CARYATI KP PASIR KIAMIS 2 1 0 0 8 0 0 1 1 0 0 0

80 17-March-2023 TARNA 3 2 0 3 2 4 5 1 0 4 8 3 0 0 0 7 NETI SUMYATI 11-April-1983 KP. PASIRBARU 2 1 0 0 8 0 0 1 1 0 0 0

03-February-
81 17-March-2023 TARWIN AENUDIN 3 2 0 3 2 4 4 3 0 2 9 2 0 0 1 9 NENI KP. PASIR BARU 2 1 0 0 8 0 0 1 1 0 0 0
1992

82 17-March-2023 TARYANA 3 2 0 3 2 4 6 3 0 5 8 6 0 0 0 3 ENOH 23-May-1986 KP. SINDANGKASIH 1 1 1 0 8 0 0 1 1 0 0 0

29-October-1991
83 17-March-2023 WAHYU 3 2 0 3 2 4 6 9 1 0 9 1 0 0 0 1 DEWI NURHAYATI KP TARENGTONG 3 1 0 0 8 0 0 1 1 0 0 0

05-September-
84 17-March-2023 WAWA 3 2 0 3 2 4 4 5 0 9 9 1 0 0 1 0 RIKA KP. BABAKAN 2 1 0 0 8 0 0 1 1 0 0 0
1991

85 17-March-2023 YANA 3 2 0 3 2 4 6 1 0 6 9 0 0 0 0 1 TATI 21-June-1990 KP CIAWITALI MIDUANA 2 1 0 0 8 0 0 1 1 0 0 0

17-February-
86 17-March-2023 YOKA 3 2 0 3 2 4 5 7 0 2 8 1 0 0 0 3 HINDUN KP PASIR BARU 2 1 0 0 8 0 0 1 1 0 0 0
1981

87 17-March-2023 ZENI HIDAYAT 3 2 0 3 2 4 4 7 0 7 8 4 0 0 0 1 TITING SURYANI 07-July-1984 KP LEMBUR TENGAH 2 1 0 0 8 0 0 1 1 0 0 0

MELISKAH WINLIH
88 20-March-2023 ABIH NUGRAHA 3 2 0 3 2 4 5 7 0 6 9 2 0 0 0 3 17-June-1992 KP.SINDANG KASIH 1 1 1 0 8 0 0 1 1 0 0 0
LAURA

89 20-March-2023 ADAS ADI 3 2 0 3 2 4 4 6 0 6 7 6 0 0 1 2 ISAH 06-June-1976 KP.BABAKAN 2 1 0 0 8 0 0 1 1 0 0 0

90 20-March-2023 ADE ABUY 3 2 0 3 2 4 5 2 0 5 7 8 0 0 0 5 RINI PARLINA 12-May-1978 KP.LEMBUR LAMPING 2 1 0 0 8 0 0 1 1 0 0 0

91 20-March-2023 AEP SAEPUDIN 3 2 0 3 2 0 4 5 0 2 8 2 0 0 0 1 NENGSIH 02-May-1982 KP.SINDANGKASIH 2 1 0 0 8 0 0 1 1 0 0 0

92 20-March-2023 AHMAD SOPANDI 3 2 0 3 2 4 6 3 0 7 7 7 0 0 0 2 IIS 23-July-1977 KP.BALE GEDE 2 1 0 0 8 0 0 1 1 0 0 0

93 20-March-2023 AHMIN 3 2 0 3 2 4 4 1 0 2 8 0 0 0 0 8 SARIAH 01-April-1980 KP.SUKAWENING 2 1 0 0 8 0 0 1 1 0 0 0

94 20-March-2023 AJAT 3 2 0 3 2 4 5 0 0 5 8 7 0 0 0 6 SANTI 10-June-1987 KP.PASIR LOJI 2 1 0 0 8 0 0 1 1 0 0 0

95 20-March-2023 AMAR SOPANDI 3 2 0 3 2 4 4 1 0 3 9 1 0 0 1 4 NEMI 12-May-1991 KP.BALE GEDE 1 1 1 0 8 0 0 1 1 0 0 0

12-August-1990
96 20-March-2023 AWAN 3 2 0 3 2 4 4 2 0 6 9 0 0 0 0 9 LISNAWATI KP.PATROL KOLOT 1 1 1 0 8 0 0 1 1 0 0 0

97 20-March-2023 DAIN 3 2 0 3 2 4 4 1 0 7 7 6 0 0 1 9 JUBAEDAH 01-July-1976 KP.BABAKAN 2 1 0 0 8 0 0 1 1 0 0 0

98 20-March-2023 DAIN 3 2 0 3 2 4 5 8 0 4 6 9 0 0 0 3 INING 18-April-1969 KP. TARENGTONG 1 1 1 0 8 0 0 1 1 0 0 0

27-February-
99 20-March-2023 DAMIN 3 2 0 3 2 4 6 7 0 2 8 3 0 0 0 6 IIS SUMINAR KP.PATROL KOLOT 2 1 0 0 8 0 0 1 1 0 0 0
1983
01-October-1980
100 20-March-2023 DDIDN SAEPULOH 3 2 0 3 2 4 4 1 1 0 8 0 0 0 0 3 IWIN KP.TARENGTONG 2 1 0 0 8 0 0 1 1 0 0 0

12-December-
101 20-March-2023 DEDE 3 2 0 3 2 4 5 2 1 2 8 6 0 0 0 6 AI ROSMIATI KP.TARENGTONG 2 1 0 0 8 0 0 1 1 0 0 0
1986
16-February-
102 20-March-2023 DEDE B 3 2 0 3 2 4 4 5 0 2 7 5 0 0 0 9 EUTIK KP.SINDANGKASIH 2 1 0 0 8 0 0 1 1 0 0 0
1975
06-December-
103 20-March-2023 DIAN 3 2 0 3 2 4 4 6 1 2 8 9 0 0 0 7 TINA MARLINA KP.PASIRBARU 2 1 0 0 8 0 0 1 1 0 0 0
1989
 17-October-1995
104 20-March-2023 D.RISWANTO 3 2 7 3 1 0 7 5 1 0 9 5 0 0 0 2 SHINTIA OKTAVIANI KP.SINDANG KASIH 1 1 1 0 8 0 0 1 1 0 0 0

105 20-March-2023 GUGUN GUNAWAN 3 2 0 3 2 4 5 7 0 7 8 6 0 0 0 5 IDA LAELAWATI 17-July-1986 KP.KUBANG JAMBU 2 1 0 0 8 0 0 1 1 0 0 0

27-August-1977
106 20-March-2023 HIDAYAT 3 2 0 3 2 4 6 7 0 8 7 7 0 0 0 4 IKAH KP.BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0

107 20-March-2023 JAJA 3 2 0 3 2 4 4 3 0 3 7 8 0 0 0 4 WINIH 03-March-1978 KP.BABAKAN 2 1 0 0 8 0 0 1 1 0 0 0

108 20-March-2023 KIOH CANOTO 3 2 0 3 2 4 5 5 0 4 8 1 0 0 0 1 IIS SUMYATI 15-April-1981 KP.PATROL KOLOT 2 1 0 0 8 0 0 1 1 0 0 0

01-January-1977
109 20-March-2023 MAMUR MULYANA 3 2 0 3 2 4 4 1 0 1 7 7 0 0 0 6 AI KARMINI KP.PATROL KOLOT 2 1 0 0 8 0 0 1 1 0 0 0

110 20-March-2023 NANDANG 3 2 0 3 2 4 5 6 0 7 7 5 0 0 1 0 EROS 10-July-1975 KP.BALE GEDE 2 1 0 0 8 0 0 1 1 0 0 0

111 20-March-2023 NANDANG 3 2 0 3 2 4 5 7 0 3 9 5 0 0 0 5 ROCIMAH 17-May-1995 KP.BABAKAN 1 1 1 0 8 0 0 1 1 0 0 0

17-December-
112 20-March-2023 PIANDI 3 2 0 3 2 4 5 7 1 2 7 2 0 0 0 2 SANAH KP.LEMBUR LAMPING 2 1 0 0 8 0 0 1 1 0 0 0
1972
16-October-1993
113 20-March-2023 SAHMA 3 2 0 3 2 4 5 6 1 0 9 3 0 0 0 7 DEA NURINTAN KP.BABAKAN 1 1 1 0 8 0 0 1 1 0 0 0

07-January-1970
114 20-March-2023 SARNA 3 2 0 3 2 4 4 7 0 1 7 0 0 0 1 2 EEN KP.BALE GEDE 2 1 0 0 8 0 0 1 1 0 0 0

115 20-March-2023 SOMANTRI 3 2 0 3 2 4 4 5 0 4 8 3 0 0 0 3 YANI NOVIANTI 05-April-1983 KP.BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0

116 20-March-2023 SOPANDI 3 2 0 3 2 4 4 8 0 5 9 0 0 0 0 9 ANICAHYANI 08-May-1990 KP.BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0

22-December-
117 20-March-2023 SOPANDI 3 2 0 3 2 4 6 2 1 2 8 2 0 0 0 2 SITI AISAH KP.PASIRLOJI 2 1 0 0 8 0 0 1 1 0 0 0
1982
14-October-1990
118 20-March-2023 SULAEMAN 3 2 0 3 2 4 5 4 1 0 9 0 0 0 0 6 IDAR KP.TARENGTONG 2 1 0 0 8 0 0 1 1 0 0 0

17-November-
119 20-March-2023 SUPIANDI 3 2 0 3 2 4 5 7 1 1 8 1 0 0 0 7 ANING KP.TARENGTONG 2 1 0 0 8 0 0 1 1 0 0 0
1981
14-November-
120 20-March-2023 YANDI 3 2 0 3 2 4 6 4 1 1 7 6 0 0 0 2 SATRI KP.BALEGEDE 2 1 0 0 8 0 0 1 1 0 0 0
1976
07-January-1997
121 13-March-2023 AEP SUTISNA 3 2 0 3 2 4 4 7 0 1 9 7 0 0 0 6 MERI LISNAWATI KP. GIRIJAYA 1 1 1 0 9 0 0 1 1 0 0 0

04-February-
122 13-March-2023 ASEP SETIAWAN 3 2 0 3 2 4 4 4 0 2 8 8 0 0 0 1 IKEU KOMALASARI KP. GIRIJAYA 1 1 1 0 9 0 0 1 1 0 0 0
1988
DADANG 30-September-
123 13-March-2023 3 2 0 3 2 4 4 9 0 3 8 3 0 0 0 4 RINA YULIANA WATI KP. CISUREN 2 1 0 0 9 0 0 1 1 0 0 0
HERMAWAN 1983
08-September-
124 13-March-2023 DEDE JENAL 3 2 0 3 2 4 4 8 0 9 8 5 0 0 0 1 LELA KP. DATAR KUBANG 1 1 1 0 9 0 0 1 1 0 0 0
1985
06-September-
125 13-March-2023 DIMAN 3 2 0 3 2 4 4 6 0 9 8 2 0 0 0 1 ESIH KP. HEGARMANAH 1 1 1 0 9 0 0 1 1 0 0 0
1982
04-November-
126 13-March-2023 ENGKUS 3 2 0 3 2 4 4 4 1 1 8 8 0 0 0 5 YANI KP. HEGARMANAH 2 1 0 0 9 0 0 1 1 0 0 0
1988
18-February-
127 13-March-2023 IDAM HELI 3 2 0 3 2 4 5 8 0 2 8 8 0 0 0 5 MAE NUR LAELA KP. DATARKUBANG 1 1 1 0 9 0 0 1 1 0 0 0
1988
04-December-
128 13-March-2023 IWAN 3 2 0 3 2 4 4 4 1 2 7 6 0 0 0 3 ROROS KP. HEGARMANAH 1 1 1 0 9 0 0 1 1 0 0 0
1976
08-January-1976
129 13-March-2023 KAHRIMAN 3 2 0 3 2 4 4 8 0 1 7 6 0 0 0 4 RAHWATI KP. KANCAH NANGKUB 1 1 0 0 9 0 0 1 1 0 0 0

130 13-March-2023 KOMARUDIN 3 2 0 3 2 4 4 6 0 7 8 2 0 0 1 7 LENI MARLINA 06-July-1982 KP. SITURANDU 1 1 1 0 9 0 0 1 1 0 0 0

131 13-March-2023 NANA TARYANA 3 2 0 3 2 4 5 6 0 3 7 9 0 0 0 3 ELA KOMALASARI 16-March-1979 KP. PATROL KOLOT 1 1 1 0 9 0 0 1 1 0 0 0

24-November-
132 13-March-2023 RAKIM 3 2 0 3 2 4 6 4 1 1 0 0 0 0 0 2 DILAWATI KP. KANCAH NANGKUB 1 1 1 0 9 0 0 1 1 0 0 0
2000
05-February-
133 13-March-2023 RUSMAN 3 2 0 3 2 4 4 5 0 2 8 2 0 0 0 8 ERAT KP. CITEURREUP 1 1 1 0 9 0 0 1 1 0 0 0
1982
01-February-
134 13-March-2023 SADIN 3 2 0 3 2 4 4 1 0 2 7 8 0 0 1 3 SURYANI KP. SUKAJADI 1 1 1 0 9 0 0 1 1 0 0 0
1978

135 13-March-2023 TORI 3 2 0 3 2 4 4 7 0 9 9 0 0 0 0 5 LILIS ALIMA 01-July-1993 KP. SINDAMGKASIH 1 1 1 0 9 0 0 1 1 0 0 0

136 13-March-2023 WAHYU 3 2 0 3 2 4 4 1 0 7 8 9 0 0 5 1 SURYATIN 01-July-1989 KP.KERTASARI 2 1 0 0 9 0 0 1 1 0 0 0

1) Keterangan Kode

STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi

2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA CENTANG (V)
1. Petugas Entri Lamp.R/I/KB/20
Data LAMPIRAN R/I/KB/20 Lembar 5

1 2 V 4 5 6
3 2 0 3 4 6 2 Bulan : 2023
NAMA FASKES/ PUSKESMAS NARINGGUL 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

RINGKASAN HASIL PELAYANAN KB

PESERTA KB BARU (PB) PESERTA KB ULANGAN PELAYANAN KASUS

PEMBERIAN
PEMBERIAN INFORMED PB DAN KESERTAAN JKN INFORMED CONSENT
METODE
NO. CONSENT (Untuk Peserta KB
KONTRASEPSI
(Untuk PB) PB PASCA PB PASCA Ulangan) PELAYANAN ULANG KOMPLIKASI BERAT
GANTI CARA PENCABUTAN KEGAGALAN
PERSALINAN KEGUGURAN
PB JKN PB NON JKN TOTAL PB

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
2 IMPLAN 1 0 0 0 0 0 0 0 0 0 0
3 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
4 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
5 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
6 IUD 1 0 0 0 1 0 0 0 0 0 0
7 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
8 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
9 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
10 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
11 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
12 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
13 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
14 IUD 0 0 0 0 0 0 1 1 0 0 0
15 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
16 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
17 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
18 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
19 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
20 IMPLAN 0 0 0 0 0 0 1 0 1 0 0
21 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
22 IMPLAN 0 0 0 0 0 0 1 1 0 0 0

JUMLAH 45 0 0 0 42 0 91 81 10 0 0 0

Cianjur , 17-March-2023
Pimpinan Faskes KB/Jaringan/Jejaring*

dr. YOGESWARA SOEHARTO

( .................................................................................................)

NIP/NRP
* Coret yang tidak perlu