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FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Gamasi 1,2


Kabupaten/Kota : Kotabaru Bulan : Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Tanjung lalak Selatan

IMD Vitamin A
Kepemilik ASI Eksklusif Vitamin A
Februari
an Buku 1 = Ya Agustus
Panjang Cara Ukur
Berat KIA/KMS
Badan /
No Anak Ke Tanggal Lahir Jenis No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Badan Panjang Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Tanggal BB (Kg) 2 =Tidak
Tinggi 1= 1
Kelamin Lahir Lahir 1 = Ya Pengukuran 1 =Ya
Badan(cm Telentang =Ya
(gram)
1 =Ya ) 2 =berdiri
2=
2 2
Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 2 =Tidak
= Tidak =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 3 2/2/2018 P 6302181911070044 630204303180001 Nadila Ariana 2,3 49 1 1 Amiruddin 6302180101710001 - TLS 1 1 9/8/2021 13 92 2 1 1 1 1 1 1 1 1

2 3 2/7/2019 P - 630220420719000 Fatimah Azzahra 2,8 47 1 1 Ahmad Jaelani 6302182209880001 - TLS 1 1 9/8/2021 9,5 82 1 1 1 1 1 1 1 1 1

3 6 3/11/2020 L 63021830091200004 - Muhammad Uwais 3,7 52 1 1 Sulaiman 6302181504770001 085156095462 TLS 1 1 9/8/2021 9 78 2 1 1 1 1 1 1 1 1

4 4 20/01/2017 L 63020330010130001 6302182101170001 Muhammad Hafiz Ansari 3,3 46 1 1 Abdul Jawad 63021712003800002 085245366286 TLS 1 1 9/8/2021 13 97 2 1 1 1 1 1 1 1 1

5 6 4/4/2018 P 6302180802170001 - Anisa Rahma 3,5 50 1 1 Ahmad Supiannor 63020612066720005 - TLS 1 1 9/8/2021 14 98 2 1 1 1 1 1 1 1 1

6 3 27/08/2019 P 6302206708190001 6302206708190001 Nindi Alia Azizah 2,3 49 1 1 Nasaruddin 6302173112760002 085348932687 TLS 1 1 9/8/2021 11 88 1 1 1 1 1 1 1 1 1

7 3 27/12/2017 P 6302201207190001 6302206712170001 Aira Nyr Zahira 3,2 49 1 1 Syahrani 6302060808940011 - TLS 1 1 9/8/2021 13 100 2 1 1 1 1 1 1 1 1

8 1 28/04/2020 P 6302202401200003 - Quraini Ramadhani 3,2 49 1 1 Muhammad Irsyad 6302181008950001 - TLS 1 1 9/8/2021 8,5 76 2 1 1 1 1 1 1 1 1

9 2 8/8/2017 P 6302181003170001 6302206808170001 Fikra Hanisa 2,2 45 1 1 Mulki 6302180706900002 - TLS 1 1 9/8/2021 12 88 2 1 1 1 1 1 1 1 1

10 2 10/11/2016 P 6302181910150001 6302205011160001 Siti Nur Athira 3,1 50 1 1 Husaini (Alm) - - TLS 1 1 9/8/2021 14,5 103 2 1 1 1 1 1 1 1 1

11 4 3/11/2019 P 6302181502120003 - Nurul Raisyah 2,5 48 1 1 Rahmansyah 6302180203810001 - TLS 1 1 9/8/2021 8,5 79 2 1 1 1 1 1 1 1 1

12 2 18/11/2020 L 6302180701160001 - Muhammad Zaini 3,8 50 1 1 Tajuddin 5329250611820001 082251121644 TLS 1 1 9/8/2021 8 73 2 1 1 1 1 1 1 1 1

13 1 1/4/2017 L - 63020301044170001 Bahrul Ilmi 3,2 49 1 1 Tajuddin 3029250511820001 082251121644 TLS 1 1 9/8/2021 12 98 2 1 1 1 1 1 1 1 1

14 5 28/02/2018 P 6302182011070011 6302186802180002 Noor AsySifa 3,6 48 1 1 Hasriadi 63021806830001 - TLS 1 1 9/8/2021 13 100 2 1 1 1 1 1 1 1 1

15 1 6/4/2017 P 63021807051200004 6302184804170001 Aqifa Naila 3,2 50 1 1 Wahyudi 6302180608840001 085348648992 TLS 1 1 9/8/2021 18 112 2 1 1 1 1 1 1 1 1

16 4 5/9/2018 L 6302181012080002 6302200509180001 M, Mirza 2.9 47 1 1 Sukri 6302180303770003 082354168122 TLS 1 1 9/8/2021 11,8 89 2 1 1 1 1 1 1 1 1

17 10 9/11/2018 L 6302181009080012 - M. Mirza Ukail 3,5 50 1 1 Anton 6302183112760006 - TLS 1 1 9/8/2021 12,5 90 2 1 1 1 1 1 1 1 1

18 1 1/5/2019 L 6302183001160001 6302200105190001 ArshakhaVirendra Shafwan 3`3 49 1 1 Wahyudi 7605020503900001 081335630852 TLS 1 1 9/8/2021 12 91 2 1 1 1 1 1 1 1 1

19 4 8/12/2019 L 6302171202080018 630220081290001 Riski Pranata 3,2 48 1 1 Ruslan 630217110776002 - TLS 1 1 9/8/2021 10,5 78 2 1 1 1 1 1 1 1 1

20 6 7/4/2020 P 6302180408080003 - Faisyah 3,4 48 1 1 Rudi 6302180107780002 - TLS 1 1 9/8/2021 10,5 80 1 1 1 1 1 1 1 1 1

21 2 16/09/2020 P - - Adiba Azzahra 2,7 45 1 1 Irwanto 6302171205890002 - TLS 1 1 9/8/2021 8 73 2 1 1 1 1 1 1 1 1

22 1 4/1/2018 P 6302201002200002 6302205401180002 KHAIRA Nursafia 3,8 50 1 1 Baharuddin 6302181907930003 - TLS 1 1 9/8/2021 13,5 97 2 1 1 1 1 1 1 1 1

23 3 21/4/2020 L 6302180504180002 - Ahmad Fauzan 3,1 46 1 1 Rifa'i 6302182011840001 - TLS 1 1 9/8/2021 9,5 78 1 1 1 1 1 1 1 1 1

24 2 13/11/2018 P 6302031911150002 - Arika Fatimah 2,8 50 1 1 Nasrullah 6302170603900002 - TLS 1 1 9/8/2021 11,5 100 1 1 1 1 1 1 1 1

25 2 26\4/2019 P - - Silmi 3,2 48 1 1 Ma Arif - 082351923939 TLS 3 2 9/8/2021 9,5 96 2 1 1 1 1 1 1 1 1

26 1 5/5/2018 L - - Dafa Mu'affak 2,8 47 1 1 Burhan 6302184810940001 081346359435 TLS 3 2 9/8/2021 10'5 84 1 1 1 1 1 1 1 1 1

27 2 7/9/2019 L - - Dafin Maleakhi 4 50 1 1 Burhan 6302184810940001 081346359435 TLS 3 2 9/8/2021 9,5 79 2 1 1 1 1 1 1 1 1

28 3 4/12/2020 P - - Olivia Keisya 3,2 51 1 1 Burhan 6302184810940001 081346359435 TLS 3 2 9/8/2021 9 70 2 1 1 1 1 1 1 1 1

29 2 18/03/2018 P - - Riska Aulia 2,7 48 1 1 Rusliadi - - TLS 3 2 9/8/2021 11,5 92 1 1 1 1 1 1 1 1

30 2 6/6/2018 P - - Anisa Bahadi 3,2 48 1 1 Bahadi 6302180107810636 - TLS 3 2 9/8/2021 11 91 1 1 1 1 1 1 1 1 1

31 1 14/12/2016 P - - Siti Aisyah 3,4 50 1 1 Bahadi 6302180107810636 - TLS 3 2 9/8/2021 12 99 2 1 1 1 1 1 1 1 1

32 3 29/11/2019 L - - Muhammad 3,5 50 1 1 Bahadi 6302180107810636 - TLS 3 2 9/8/2021 9 78 1 1 1 1 1 1 1 1 1

33 3 4/5/2017 L 6302182909120008 6302206712180001 Nur Aisya 3,6 50 1 1 Rahmat 630218016920001 085349703974 TLS 3 2 9/8/2021 10 90 1 1 1 1 1 1 1 1 1

34 2 4/5/2017 L 6302182909120008 6302180405170001 M Yahya 2,8 49 1 1 Rahmat 630218016920001 085349703974 TLS 3 2 9/8/2021 12 98 2 1 1 1 1 1 1 1 1

35 4 10/12/2020 L 6302182909120008 - Muhliani 4,6 52 1 1 Rahmat 630218016920001 085349703974 TLS 3 2 9/8/2021 8,5 75 2 1 1 1 1 1 1 1 1

36 5 11/12/2018 P 6302182412080015 - Sindi Ainun Nisa 3,2 50 1 1 Rusdiansyah 6302182010830001 08530273749 TLS 3 2 9/8/2021 11 82 2 1 1 1 1 1 1 1 1
37 4 17/7/2017 P 6302182412080015 6302185708170001 Sindi Sarni Agustina - - 1 1 Rusdiansyah 6302182010830001 08530273749 TLS 3 2 9/8/2021 12 91 2 1 1 1 1 1 1 1 1

38 6 - P 6302182412080015 - Keisya 2,8 50 1 1 Rusdiansyah 6302182010830001 08530273749 TLS 3 2 9/8/2021 8,5 68 2 1 1 1 1 1 1 1 1

39 4 28/11/2020 P 6302182502080007 - Alifia Faisya Muliadi 3,1 49 1 1 Mus Muliadi 6302180508780002 085252511316 TLS 3 2 9/8/2021 7,1 65 2 1 1 1 1 1 1 1 1

40 3 7/6/2020 L 6302181507110001 - Arsha Rahman 3,6 48 1 1 Rahman 6302182305850002 082256204964 TLS 3 2 9/8/2021 8 75 2 1 1 1 1 1 1 1 1

41 1 26/8/2018 P 6302182712180002 - Zahra Sakila 3,3 47 1 1 Noor Dian 6302182909970002 085388240759 TLS 3 2 9/8/2021 9 83 2 1 1 1 1 1 1 1 1

42 1 26/12/2016 L 630218111160001 6302182612160001 Achmad Rafli 3,3 49 1 1 Ahmad Badawi 6302180608920001 081235764602 TLS 3 2 9/8/2021 12,5 95 2 1 1 1 1 1 1 1 1

43 2 5/5/2020 P 630218111160001 - Vania Ramadhani 3,4 50 1 1 Ahmad Badawi 6302180608920001 081235764602 TLS 3 2 9/8/2021 7,5 72 2 1 1 1 1 1 1 1 1

44 4 22/02/2016 L 6302181112080037 - Muhammad Ridho 3,2 51 1 1 Hasanuddin - 081351396176 TLS 3 1 9/8/2021 13,5 103 2 1 1 1 1 1 1 1 1

45 2 4/5/2017 L 6302182909120008 6302206712180001 Nur Aisya 3,6 50 1 1 Rahmat 630218016920001 085349703974 TLS 3 2 9/8/2021 8,5 74 2 1 1 1 1 1 1 1 1

46 2 30/04/2019 L 6302201302200002 - Fauzan 3,5 51 1 1 Jamlis 6302181606020001 - TLS 3 2 9/8/2021 10,5 80 2 1 1 1 1 1 1 1 1

47 3 6/8/2020 L 6302201302200002 - Muhammad Faul 2,8 50 1 1 Jamlis 6302181606020001 - TLS 3 2 9/8/2021 7,5 72 2 1 1 1 1 1 1 1 1

48 3 22/7/2019 L 6302182511080007 `- Khaerullah 3,3, 49 1 1 Subaer 6302182010760001 - TLS 3 2 9/8/2021 10,5 82 2 1 1 1 1 1 1 1 1

49 4 31/1/-2018 L 6302200904190002 6302203112180002 M. Abil Rafif Zidqi 3,6 50 1 1 Herizon 1806011501900004 - TLS 3 2 9/8/2021 12 91 2 1 1 1 1 1 1 1 1

50 5 2/1/2020 P 6302200904190002 - Almaira tunnisa 3,8 51 1 1 Herizon 1806011501900004 - TLS 3 2 9/8/2021 9,5 87 2 1 1 1 1 1 1 1 1

51 4 12/5/2020 P - - Atila Nur Suci R 3,2 49 1 1 Jupri 6302180912720001 - TLS 3 2 9/8/2021 7,7 78 1 1 1 1 1 1 1 1 1

52 2 5/11/2016 P 63021827120800042 6302184511160001 Tylas Ramazhany 4 52 1 1 Mahfud 6302182108810001 082247077619 TLS 3 2 9/8/2021 12 96 2 1 1 1 1 1 1 1 1

53 5 13/5/2018 P 630218511070068 - Meilan Indah 3,2 48 1 1 Busman 6302182107730001 - TLS 3 2 9/8/2021 10 96 2 1 1 1 1 1 1 1 1

54 3 7/1/2018 P 6302171202080008 6302184701180001 Atika 3,6 49 1 1 Herianto 630272304790002 - TLS 3 2 9/8/2021 11,5 82 2 1 1 1 1 1 1 1 1

55 1 1/1/2018 L 6302181812180002 6302180101180001 Hafis Athala Faqih 3,6 52 1 1 Ramadhan 6302181004880001 082157589736 TLS 3 2 9/8/2021 14 100 2 1 1 1 1 1 1 1 1

56 2 1/-10/2017 L 6302171202080011 6302181410160001 Akmal Fauzan 3,6 50 1 1 Ahmad Jaunuddin 6302172704850002 081316614222 TLS 3 2 9/8/2021 14,5 102 2 1 1 1 1 1 1 1 1

57 1 29/5/2018 L 6302031764180003 630218905180002 Abizar Maulana 2,6 47 1 1 Faizal 63020607041900003 081240837700 TLS 3 2 9/8/2021 11,5 84 2 1 1 1 1 1 1 1 1

58 1 6/9/2017 L 6302181112180002 6302180609170001 Miftahul Hidayat 3,3 52 1 1 Hafsul Riadi 6302180608920001 082149561813 TLS 3 2 9/8/2021 12,5 90 2 1 1 1 1 1 1 1 1

59 1 27/5/2016 P 6302182503100002 - Andi Rahmaniatal 3,5 50 1 1 Andi Azwar 6302181905820001 082357842664 TLS 3 2 9/8/2021 13 102 2 1 1 1 1 1 1 1 1

60 2 29/12/2017 P 6302182503100002 - Andi Rahmaniatal 3,4 50 1 1 Andi Azwar 6302181905820001 082357842664 TLS 3 2 9/8/2021 10 92 2 1 1 1 1 1 1 1 1

61 1 8/1/2017 P 6302180702170001 6302186801170001 Helwatin Najwa 3,3 50 1 1 Juwaeni ,6302172409890002 081254156592 TLS 3 2 9/8/2021 12,5 96 2 1 1 1 1 1 1 1 1

62 2 8/11/2020 P 6302180702170001 - Humaira Madina 3,4 51 1 1 Juwaeni ,6302172409890002 081254156592 TLS 3 2 9/8/2021 7 69 2 1 1 1 1 1 1 1 1

63 1 2/10/2020 P 6302181311180001 - Yufita 2,7 49 1 1 Febri 6302182011960001 085248735820 TLS 3 2 9/8/2021 7 70 2 1 1 1 1 1 1 1 1

64 3 19/5/2018 P 6302180811140001 - Windi Ramadhani 4 51 1 1 Syamsuddin 6302181109890001 - TLS 4 2 9/8/2021 10,5 93 2 1 1 1 1 1 1 1 1

65 5 15/6/2020 L 63021828050001 - Ahmad Sany 3,3 50 1 1 Sahamma 6302182503830001 - TLS 4 2 9/8/2021 10 76 2 1 1 1 1 1 1 1 1

66 2 18/10/2018 P 6302200409200006 - Mutmainnah 3,3 49 1 1 Rahmadi 6302030708920002 - TLS 4 2 9/8/2021 10 92 2 1 1 1 1 1 1 1 1

67 1 9/8/2020 P 6302201410200002 6302204909200001 Herliani 2,5 47 1 1 Haril 6302180503010003 - TLS 4 2 9/8/2021 9 68 1 1 1 1 1 1 1 1 1

68 1 21-/8/2016 P 6302201410200001 6302206108160001 Miati 3,2 4,9 1 1 M, Darwis 6302182210990001 - TLS 4 2 9/8/2021 13 95 2 1 1 1 1 1 1 1 1

69 2 21/07/2017 L 6302201410200001 - Wawawn Saputra 3,1 48 1 1 M, Darwis 6302182210990001 - TLS 4 2 9/8/2021 11 86 2 1 1 1 1 1 1 1 1

70 2 27/08/2019 L 63021812180001 - Adrian 3,7 50 1 1 Supliansyah 6302180308950001 - TLS 4 2 9/8/2021 9 75 1 1 1 1 1 1 1 1 1

71 1 16/04/2018 P 63021812180001 - Ayuni Soraya 3,7 50 1 1 Supliansyah 6302180308950001 - TLS 4 2 9/8/2021 10 84 1 1 1 1 1 1 1 1 1

72 4 20/06/2019 L 6302180811140001 - Bayu Saputra 3,5 51 1 1 Syamsuddin 6302181109890001 - TLS 4 2 9/8/2021 9 82 2 1 1 1 1 1 1 1 1

73 3 4/6/2018 P 6302030110120002 - Kadija 2,8 52 1 1 Hasanuddin 63020309840001 - TLS 4 2 9/8/2021 9 84 2 1 1 1 1 1 1 1 1

74 4 20/09/2020 P 6302030110120002 - Sabrina 3,6 51 1 1 Hasanuddin 63020309840001 - TLS 4 2 9/8/2021 7 68 2 1 1 1 1 1 1 1 1

75 6 9/9/2016 P 6302183112080004 6302170107360002 Siti Syarah 2,7 47 1 1 Najamuddin 6302181609750001 081347936738 TLS 4 2 9/8/2021 13 96 2 1 1 1 1 1 1 1 1

76 2 14/02/2017 L 6302182812090010 6302181402170001 Heriansyah 3,4 50 1 1 Suriadi 6302180412760001 - TLS 4 2 9/8/2021 11 95 2 1 1 1 1 1 1 1 1

77 1 27/07/2017 P 6302182612180003 6302185707170001 Malia Fatmayani 3,9 51 1 1 Wawan Suki 6302181303850001 - TLS 4 2 9/8/2021 14 97 2 1 1 1 1 1 1 1 1

78 1 22/09/2016 P 6302041507100003 630220620916001 Putri Amelia 4 51 1 1 Robi Darwis 6302042808900001 - TLS 4 2 9/8/2021 12 101 2 1 1 1 1 1 1 1 1

79 2 26/08/2020 P 6302041507100003 6302206608200001 Putri Dian Irawati 3,2 50 1 1 Robi Darwis 6302042808900001 - TLS 4 2 9/8/2021 7 65 2 1 1 1 1 1 1 1 1
80 2 19/07/2018 P 6302181508180001 6302185907170001 Wulandari 2,2 47 1 1 M. Daud 6302180308940001 - TLS 4 2 9/8/2021 14 96 2 1 1 1 1 1 1 1 1

81 2 5/1/2019 P 6302180210120005 - Miyura Salsabila 3,5 50 1 1 Baharuddin 6302181003900001 - TLS 4 2 9/8/2021 13 90 2 1 1 1 1 1 1 1 1

82 5 28/12/2020 L 6302181501090012 - Ahmad Mujiono 3,5 51 1 1 Mukhlis 6302180207810002 - TLS 4 2 9/8/2021 6 64 2 1 1 1 1 1 1 1 1

83 1 25/05/2018 L 6302180310130001 6302182905180001 Riski Ramadani 4 51 1 1 Asmar 6302182902720001 - TLS 4 2 9/8/2021 11,5 94 2 1 1 1 1 1 1 1 1

84 7 18/09/2018 P 6302180301090018 6302202905170001 Vera 3,1 49 1 1 Asis 6302180511610001 - TLS 4 2 9/8/2021 10 86 2 1 1 1 1 1 1 1 1

85 6 7/11/2020 P 6302170502080018 - Naira Sheiyra 3,9 50 1 1 Sirajuddin 6302180208820002 - TLS 4 2 9/8/2021 11 84 2 1 1 1 1 1 1 1 1

86 4 19/05/2020 P 6302183012080023 630220590520001 Azzahra Ramadhani 3,3 48 1 1 Sudarman 6302181509750001 - TLS 4 2 9/8/2021 9 69 2 1 1 1 1 1 1 1 1

87 2 14/03/2020 L 6302182504170001 _ Ahmad Robi 3,3 50 1 1 Suriansyah 6302180107960007 - TLS 4 2 9/8/2021 9 89 2 1 1 1 1 1 1 1 1

88 3 17/06/2020 L 6302062106070027 - M. Alif 2,7 47 1 1 H. Sa,dani 6302060603560001 081344086879 TLS 4 2 9/8/2021 11 76 2 1 1 1 1 1 1 1 1

89 1 3/3/2020 P 6302201007200001 630220430200001 Naila Salsabila 3,4 50 1 1 Mansa 6302181701980001 082351037207 TLS 4 2 9/8/2021 9 70 2 1 1 1 1 1 1 1 1

90 2 1/6/2020 L 6302180901140003 - Rendy Alfiansyah 4,2 52 1 1 Sunardi 63021806033910001 085249500971 TLS 4 2 9/8/2021 11,5 75 2 1 1 1 1 1 1 1 1

91 1 6/9/2018 L - - Abdul Rahman 3,6 50 1 1 Ahmad Jaelani - - TLS 4 2 9/8/2021 12 88 2 1 1 1 1 1 1 1 1

92 3 26/04/2020 P 630218220780013 - Mykaila Ramadani 3,2 48 1 1 Hamlis 630218100780001 081349460278 TLS 4 2 9/8/2021 9 74 2 1 1 1 1 1 1 1 1

93 1 13/02/2020 P 6302200406200002 6302205303300001 Akila Naila Putri 3,9 50 1 1 Irpan Ramadan 6302020912000002 081351378761 TLS 4 2 9/8/2021 9 78 2 1 1 1 1 1 1 1 1

94 2 19/07/2018 P 630220128190002 6302205907180001 Debi Arsila 3,3 51 1 1 Sulis Yono 6302212003850001 - TLS 4 2 9/8/2021 13 92 2 1 1 1 1 1 1 1 1

95 1 30/07/2019 P 6302201004190003 6302207007190001 Salsabila 3,4 48 1 1 Hasdi 630218005980002 081258075380 TLS 4 2 9/8/2021 12 92 1 1 1 1 1 1 1 1 1

96 5 9/1/2017 L 6302182011070034 6302180901170001 M. Rilo Dirga 3,2 49 1 1 Rusdi 6302180710860001 082251133088 TLS 4 2 9/8/2021 12 92 2 1 1 1 1 1 1 1 1

97 1 18/10/2019 P 6302202204190002 - Kaila Adreena 2,9 49 1 1 Masyadi 6302010610910003 085347238533 TLS 2 1 9/8/2021 10,5 88 2 1 1 1 1 1 1 1 1

98 3 29/012021 P 6302180103190006 - Rahel 2,5 49 1 1 Syaiful 6302180509890003 - TLS 2 1 9/8/2021 6,2 65 1 1 1 1 1 1 1 1 1

99 2 29/08/2017 L 6302180103190006 - Rohan 2,8 48 1 1 Syaiful 6302180509890003 - TLS 2 1 9/8/2021 11,5 90 2 1 1 1 1 1 1 1 1

100 1 27/03/2018 P 6302182803180002 6302186703180001 Nur Arsila Irfan 4 51 1 1 Irfan Aswin 6302171412930001 - TLS 2 1 9/8/2021 13 89 2 1 1 1 1 1 1 1 1

101 3 30/09/2019 P 6302200912190001 6302207009180001 Nuraulia Rahmah 3 49 1 1 Anton 630220107760027 - TLS 2 1 9/8/2021 11,7 90 2 1 1 1 1 1 1 1 1

102 4 23/01/2018 P 6302171202080028 630212206301180001 Nazwa Azzahra 2,1 48 1 1 Sahalang 6302171207730002 - TLS 2 1 9/8/2021 12 93 2 1 1 1 1 1 1 1 1

103 2 11/7/2019 L 6302182909120021 6302201107190001 Nizam Awais Al Asri 3,4 50 1 1 Asriansyah 6302180911850001 - TLS 2 1 9/8/2021 11 89 2 1 1 1 1 1 1 1 1

104 1 27/05/2018 P 6302182811180007 6302186705180001 Nabila Ishak 3,2 50 1 1 Ishak S.pd 6302181204940001 - TLS 2 1 9/8/2021 14 87 2 1 1 1 1 1 1 1 1

105 2 18/02/2020 L 6302182401170001 - Muhammad Gibran 3,4 50 1 1 Zulfa 6302180807940002 - TLS 2 1 9/8/2021 9 78 2 1 1 1 1 1 1 1 1

106 2 12/10/2019 L 6302181312110001 6302201210190002 M. Alfarizi 3,3 50 1 1 Safaruddin 5302182410850004 - TLS 2 1 9/8/2021 9,1 83 2 1 1 1 1 1 1 1 1

107 4 27/03/2020 L 630218102080006 - Ali M Zaki 3,5 50 1 1 Harianto 630218010860001 - TLS 2 1 9/8/2021 9,5 85 2 1 1 1 1 1 1 1 1

108 2 23/10/2020 P 6302182312080009 - Maulida Khumaira Khalik 2,5 47 1 1 Idham Khalik 6302190504870003 - TLS 2 1 9/8/2021 7,5 76 2 1 1 1 1 1 1 1 1

109 4 26/04/2018 P 6302182812090015 - Muslimah 2,9 49 1 1 Sahuddin 6302182106770001 - TLS 2 1 9/8/2021 14 98 2 1 1 1 1 1 1 1 1

110 6 5/9/2018 P 6302180508080156 - Hazika Kaila 2,1 48 1 1 Ilham 6302180107780828 - TLS 2 1 9/8/2021 10 81 2 1 1 1 1 1 1 1 1

111 7 18/03/2019 L 630218212090012 - Ferdi 3,9 51 1 1 Repi 6302180309810002 - TLS 2 1 9/8/2021 10 83 2 1 1 1 1 1 1 1 1

112 8 29/10/2017 L 630218212090012 - Rafli 3,5 49 1 1 Repi 6302180309810002 - TLS 2 1 9/8/2021 10,5 88 2 1 1 1 1 1 1 1 1

113 1 3/5/2018 P 630218020480003 6302184305180001 Khusnul Khotimah 3,3 48 1 1 Nuranfin 63020210960001 - TLS 2 1 9/8/2021 12 80 2 1 1 1 1 1 1 1 1

114 1 23/03/2020 p 6302202905200009 6302206003200001 Fania Nurliana 2.8 47 1 1 Fadliansyah 630218281200002 - TLS 2 1 9/8/2021 11 73 2 1 1 1 1 1 1 1 1

115 2 6/2/2019 P 630218080720002 6302205102190001 Debi Auren 2,8 47 1 1 Jasman 630211150690001 - TLS 2 1 9/8/2021 10,5 85 2 1 1 1 1 1 1 1 1

116 3 18/10/2018 L 6302171202080024 630218181080001 Ahmad Farel 3,3 50 1 1 Johardi 6302172309730002 - TLS 2 1 9/8/2021 12 93 2 1 1 1 1 1 1 1 1

117 3 27/01/2020 P 630218260110003 - Azzahra Chintya Fariza 3,2 51 1 1 Hendra 6302180303910001 082388128191 TLS 2 1 9/8/2021 8.8 78 2 1 1 1 1 1 1 1 1

10 107
Perkembangan

Tindak
KPSP Buku Lanjut
Ds/Dm KIA SL/SU/
/Dp S/TS R
(30) (31) (32)
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FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Bandeng


Kabupaten/Kota : Kotabaru Bulan :Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Tanjung Lalak Utara

IMD Vitamin A
Kepemilik ASI Eksklusif Vitamin A
Februari
an Buku 1 = Ya Agustus
Panjang Cara Ukur
Berat KIA/KMS
Badan /
No Anak Ke Tanggal Lahir Jenis No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Badan Panjang Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Tanggal BB (Kg) 2 =Tidak
Tinggi 1= 1
Kelamin Lahir Lahir 1 = Ya Pengukuran 1 =Ya
Badan(cm Telentang =Ya
(gram)
1 =Ya ) 2 =berdiri
2=
2 2
Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 2 =Tidak
= Tidak =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 6 22/02/2016 P 6302171902080002 6302186203160001 Ishana 3,4 49 1 1 Punding 6302171202670002 - TLU 3 2 10/8/2021 13,6 96 2 1 1 1 1 1 1 1 1

2 3 9/8/2018 L 63021807010900012 6302180908180001 M. Agus Riansyah 3,2 49 1 1 Sumang 630210060269001 - TLU 3 2 10/8/2021 11,2 90 2 1 1 1 1 1 1 1 1

3 2 17/07/2018 L - - Idrus 3 48 1 2 Nurdin - - TLU 1 1 10/8/2021 8,2 74 2 1 1 1 1 1 1 1 1

4 - 1/6/2019 L - - Muhlis 2,8 48 1 2 Muhlis - - TLU 1 1 10/8/2021 6,4 62 2 1 1 1 1 1 1 1 1

5 2 1/3/2018 L - - Erfan Hidayat 3,2 48 2 2 Hadasri - - TLU 1 1 10/8/2021 94 82 2 1 1 1 1 1 1 1 1

6 - 4/8/2017 L - - M.Harun 3,8 47 2 2 Suaeb - - TLU 1 1 10/8/2021 12 91 2 1 1 1 1 1 1 1 1

7 3 14/05/2020 P - - Aisya Mikaila 3,2 47 1 1 Muhtazar - - TLU 4 2 10/8/2021 8,6 72 1 1 1 1 1 1 1 1 1

8 2 18/03/2017 P 6302182003130001 6302185803170001 Jihan Talita 2,8 47 1 1 Sugiadi 6302182012820002 - TLU 1 1 10/8/2021 11,2 72 2 1 1 1 1 1 1 1 1

9 2 23/10/2016 P 6302181912150001 6302186310160001 Dewi Hastuti 3,2 48 1 1 Sarjan 6302180406850001 - TLU 1 1 10/8/2021 12 97 2 1 1 1 1 1 1 1 1

10 3 6/2/2018 L 6302180301090029 6302180602180001 Ahmad Sulfikar 3,5 47 1 1 Musran 6302031505840001 - TLU 1 1 10/8/2021 12,4 98 2 1 1 1 1 1 1 1 1

11 3 30/08/2018 L 6302181401090026 6302183008180001 Nur Anggara 3,2 49 1 1 Hambali 6302180105850501 - TLU 1 1 10/8/2021 11,6 86 2 1 1 1 1 1 1 1 1

12 2 20/01/2016 P 6302182607130001 6302186201160001 Anindita 3,2 48 1 1 Abu Likman 6302181111940001 - TLU 1 1 10/8/2021 13,6 88 2 1 1 1 1 1 1 1 1

13 1 11/2/2017 P 6302181711170003 6302185162170001 Kanza 3,6 48 1 1 Hendri 6302020506970001 - TLU 1 1 10/8/2021 10,6 99 2 1 1 1 1 1 1 1 1

14 6 1/7/2018 P 6302181304090023 6302184107180001 Akila F 3 49 1 1 Rinto 6302181106800001 - TLU 1 1 10/8/2021 11,2 92 2 1 1 1 1 1 1 1 1

15 3 28/11/2017 P 7310100806100001 7310106811170001 Akila Fansa 3,2 48 1 1 Agus 7310103107790001 - TLU 1 1 10/8/2021 8,2 90 2 1 1 1 1 1 1 1 1

16 5 1/7/2019 P 6302181009150001 6302184107190001 Nur Asfafiah 3 48 1 1 Asran 6302062412880007 - TLU 1 1 10/8/2021 13,6 92 2 1 1 1 1 1 1 1 1

17 9 20/10/2016 P 6302180306080001 6302186310150001 Kasya Aynayya 3,2 48 1 1 Hermansya 6302180708780001 - TLU 1 1 10/8/2021 9,2 74 2 1 1 1 1 1 1 1 1

18 2 15/11/2019 L 6302182407120003 6302181511190001 M. Yadhi 3,2 48 1 1 Busman 6302180702920003 - TLU 1 1 10/8/2021 7,2 92 2 1 1 1 1 1 1 1 1

19 1 23/12/2019 P 6302031503190001 6302036312190001 Hanifa Aulia 3,2 47 1 1 Habiruddin 6302030902940002 - TLU 5 2 10/8/2021 10,2 84 2 1 1 1 1 1 1 1 1

20 1 5/5/2018 L 6302201106200002 6302200505180001 Dafa 3 47 2 2 Hasiati 6302184810940001 - TLU 1 1 10/8/2021 11,2 96 2 1 1 1 1 1 1 1 1

21 2 7/9/2019 L 6302201106200002 6302200709190001 Dafin 2,8 48 2 2 Hasiati 6302184810940001 - TLU 1 1 10/8/2021 9,3 88 2 1 1 1 1 1 1 1 1

22 3 20/08/2019 P 6302180603140002 6302186008190001 Akifa Naila 3,2 48 1 1 Sugianto 63021808002930001 - TLU 3 10/8/2021 11,4 88 2 1 1 1 1 1 1 1 1

23 2 24/03/2018 L 6302033012150001 6302032403180001 Alfan 3 47 2 2 Alfiannor 6302030107830201 - TLU 1 1 10/8/2021 9,2 88 2 1 1 1 1 1 1 1 1

24 7 5/8/2017 P 6302180307120002 6302204508170001 Qamta Sajida 3,2 48 2 2 Syamsul 6302180107730843 - TLU 1 1 10/8/2021 14,2 106 2 1 1 1 1 1 1 1 1

25 8 6/1/2019 P 6302180307120002 6302204601190001 Aulia Sasmita 3,7 48 2 2 Syamsul 6302180107730843 - TLU 1 1 10/8/2021 12,6 100 2 1 1 1 1 1 1 1 1

26 6 20/06/2017 L 6302181408090016 6302182006170001 Dahrul Hilman 3 49 1 1 Suparman 6302181303750001 - TLU 2 1 10/8/2021 9,2 84 2 1 1 1 1 1 1 1 1

27 6 20/10/2019 L 6302180408090016 6302186910190001 Dev Hariasyah 2,8 47 1 2 Asriansyah 6302181807800001 - TLU 2 1 10/8/2021 12,6 92 2 1 1 1 1 1 1 1 1

28 6 20/11/2019 P 6302180709170001 6302183009170003 Riska Ayu A 3 47 1 1 Miskar 6302182012820002 - TLU 1 1 10/8/2021 7,4 62 2 1 1 1 1 1 1 1 1

29 4 22/06/2017 L - - Ahmad Nur A 3,2 48 1 1 Mansur 6302182208720001 - TLU 5 2 10/8/2021 12,2 92 2 1 1 1 1 1 1 1 1

30 4 13/07/2018 L 6302180869140002 6302181307180001 M Akmal 3 47 1 1 Marhudding 6302170107790003 - TLU 5 2 10/8/2021 13,4 90 2 1 1 1 1 1 1 1 1

31 3 7/10/2018 L 63021807010900017 6302180401180001 Andika Pra. U 3,5 49 1 1 Ridwansyah 630218007360827 - TLU 3 10/8/2021 12,6 90 2 1 1 1 1 1 1 1 1

32 4 20/11/2017 P 6302182412080001 6302186011170001 Sarina Putri 3 48 1 1 Hasriadi 6302180506890001 - TLU 3 10/8/2021 11,2 92 2 1 1 1 1 1 1 1 1

33 4 21/05/2020 P - - Sinta Aisya 2,8 47 1 2 Salinah - - TLU 2 1 10/8/2021 7,4 70 1 1 1 1 1 1 1 1 1

34 3 26/07/2020 L - - Dimas Saputra 3 47 1 1 Basri - - TLU 2 1 10/8/2021 8,6 74 1 1 1 1 1 1 1 1 1

35 3 28/04/2020 P - - Zahra Ramadani 3,2 48 1 1 Wahriansyah - - TLU 4 2 10/8/2021 8,1 74 1 1 1 1 1 1 1 1 1

36 5 20/03/2020 L - - Abdullah Fatih 3,6 47 1 1 Naharuddin - - TLU 2 1 10/8/2021 8,6 74 1 1 1 1 1 1 1 1 1


37 1 13/04/2020 L - - M.Rafifi 3,2 48 1 1 Syayuti - - TLU 4 2 10/8/2021 9,2 84 1 1 1 1 1 1 1 1 1

38 2 2/1/2020 P - - Afidah Salsabila 3,2 47 2 2 Baharuddin - - TLU 2 1 10/8/2021 8,2 74 1 1 1 1 1 1 1 1 1

39 2 20/09/2018 L - - M Noval 3 48 1 2 Yutto - - TLU 2 1 10/8/2021 9,4 82 2 1 1 1 1 1 1 1 1

40 3 6/12/2019 P - - Jumrah 3,4 48 1 1 Hamsah - - TLU 3 2 10/8/2021 8,4 64 1 1 1 1 1 1 1 1 1

41 2 24/04/2018 P - - Hasrianti 3,6 48 1 1 Hamsah - - TLU 3 2 10/8/2021 10,4 86 2 1 1 1 1 1 1 1 1

42 5 30/12/2019 P 6302181703100009 - Athalia 3 48 1 2 Satinong 6302181602750001 - TLU 2 1 10/8/2021 10,4 82 2 1 1 1 1 1 1 1 1

43 1 4/6/2020 L - - M Irsyat Al Fatih 3,2 47 1 1 Andri - - TLU 4 2 10/8/2021 6,8 68 1 1 1 1 1 1 1 1 1

44 5 9/11/2018 P 63020228100800038 6302184911180001 Afifa Aulia 2,5 48 1 1 Hariadi 6302021205770003 - TLU 4 2 10/8/2021 12,6 86 2 1 1 1 1 1 1 1 1

45 1 19/08/2017 L 6302181104180004 6302181908170001 Arif Nauval 3,5 48 1 1 Fardiansyah 6302181207950001 - TLU 3 10/8/2021 13,6 90 2 1 1 1 1 1 1 1 1

46 3 14/03/2018 L 6302182303150002 6302201403180001 Hurdian Argani 32 48 1 1 Herman Halim 76050705088400004 - TLU 5 2 10/8/2021 11,2 90 2 1 1 1 1 1 1 1 1

47 3 17/09/2018 L 6302182012180001 630281709180001 M. Alif 3,6 48 1 1 Syamsul 6302180204940001 - TLU 2 1 10/8/2021 11,1 82 2 1 1 1 1 1 1 1 1

48 1 14/06/2016 L 6302180612170001 630218166160001 M. Afif Ali 3,2 49 1 1 Mukhfazar 630203280586000 - TLU 4 2 10/8/2021 13,6 102 2 1 1 1 1 1 1 1 1

49 4 15/05/2018 P 6302181612080003 6302185505180001 Siska Bela 2,7 48 1 1 Salman 6302182312840001 - TLU 2 1 10/8/2021 10,6 90 2 1 1 1 1 1 1 1 1

50 2 19/08/2018 P 63048284180609 630220590818001 Syahrini 2,7 48 1 1 Masryadi 6302181301870004 - TLU 1 1 10/8/2021 10,2 90 2 1 1 1 1 1 1 1 1

51 10 27/01/2017 L 630482108080616 6302182101170001 M. Fathar 3 48 1 1 Kamah 6302170107680017 - TLU 2 1 10/8/2021 12,4 96 2 1 1 1 1 1 1 1 1

52 3 30/07/2017 L 6302152409080005 6302183060170001 Al Gazali 3,6 49 1 1 Tajuddin S 630215590582001 - TLU 2 1 10/8/2021 14,4 96 2 1 1 1 1 1 1 1 1

53 2 19/09/2019 L 6302180601160003 6302185809190001 M. Rafif 3 48 1 1 Syamsul 6302180204940001 - TLU 2 1 10/8/2021 11,1 82 2 1 1 1 1 1 1 1 1

54 5 7/9/2013 L 6302181507080001 630218070915002 M. Alfikrul 3,2 49 1 1 Naharuddin 630210107760825 - TLU 2 1 10/8/2021 13,4 96 2 1 1 1 1 1 1 1 1

55 4 118/4/2017 P 6302181401090031 630218580417001 Nur Tauzia S 2 48 1 1 Darwis 6302181712880001 - TLU 2 1 10/8/2021 12,2 92 2 1 1 1 1 1 1 1 1

56 6 31/102018 P 6302180301090003 6302187110180001 Zakia 3 49 1 1 Budiansyah 6302182305840004 - TLU 1 1 10/8/2021 11,2 86 2 1 1 1 1 1 1 1 1

57 1 21/08/2018 P 6302180501170001 6302186108180001 Naura Rania 2,9 48 1 1 Badriansyah 6302180602910001 - TLU 4 2 10/8/2021 11,2 90 2 1 1 1 1 1 1 1 1

58 5 14/02/2018 P 6302182605080003 6302181402180001 Rupiah 3,2 48 1 1 Rusli 6302180506820001 - TLU 2 1 10/8/2021 11,6 88 2 1 1 1 1 1 1 1 1

59 6 13/03/2019 P 6302182108080020 6302205303190001 Nur Aisya 2,8 47 1 1 Abidin 6302180202750001 - TLU 2 1 10/8/2021 9,2 82 2 1 1 1 1 1 1 1 1

60 1 30/09/2017 L 6302180709170001 6302183009170003 Syamsul Mubarak 3,2 48 1 1 Husni Mubarak 6302181007910001 - TLU 1 1 10/8/2021 10,6 88 2 1 1 1 1 1 1 1 1

61 2 5/4/2018 L 6302182804120002 6302180504180002 Ahmad Afandi 3 47 2 2 Mardiansyah 6302181705880001 - TLU 5 2 10/8/2021 10,2 82 2 1 1 1 1 1 1 1 1

62 1 23/05/2017 P 6302181111130001 6302186305170001 Marwa Nurizza 3,2 49 1 1 Aminuddin 6302181004880002 - TLU 5 2 10/8/2021 12,6 92 2 1 1 1 1 1 1 1 1

63 3 3/1/2019 L 63021815120003 6302180301190001 M. Bilal Zabir 2,3 47 1 1 Agusriadi 6302182110830002 - TLU 4 2 10/8/2021 9,2 86 2 1 1 1 1 1 1 1 1

64 1 28/02/2018 P - - Safira Oktavia 3,2 48 2 2 Firman - - TLU 1 1 10/8/2021 8,2 74 2 1 1 1 1 1 1 1 1

65 3 4/6/2017 L - - M Riski Ramadan 3 48 2 2 Sahabuddin - - TLU 1 1 10/8/2021 11,8 82 2 1 1 1 1 1 1 1 1

66 4 22/12/2019 P 63021815120003 6302206212190001 Abida Nurul J 2,7 49 1 1 Agusriadi 6302182110830002 - TLU 4 2 10/8/2021 7,2 62 2 1 1 1 1 1 1 1 1

67 3 25/09/2018 L 6302180403080003 6302202509180001 M Ryzki A 2,9 49 1 1 M Arsyad 6302182609690001 - TLU 4 2 10/8/2021 9,2 84 2 1 1 1 1 1 1 1 1

68 1 4/10/2019 L 6302182011180001 630220041019001 M. Demis 3,2 49 1 1 Misbahuddin 6302181302900001 - TLU 4 2 10/8/2021 8,4 70 2 1 1 1 1 1 1 1 1

69 1 25/09/2017 L 6302182009170002 6302182509170007 Ahmad Ikhsanul 3 49 1 1 Jasnuddin 6302180603860001 - TLU 4 2 10/8/2021 11,4 92 2 1 1 1 1 1 1 1 1

70 5 12/1/2018 P 6302181610100001 6302185201180001 Aisyah Sania 3 49 1 1 Efendi 6302180804790002 - TLU 4 2 10/8/2021 11,2 90 2 1 1 1 1 1 1 1 1

71 5 11/2/2017 L 6302183010080001 6302185102170001 M. Muzzammil 3,2 49 1 1 Syamsurif 6302181506700001 - TLU 4 2 10/8/2021 12,6 106 2 1 1 1 1 1 1 1 1

72 5 9/11/2018 P 6302022810080038 6302184911180001 Napisa Aulia 2,5 48 1 1 Hariadi 6302021205770003 - TLU 4 2 10/8/2021 12,2 84 2 1 1 1 1 1 1 1 1

73 5 7/5/2017 L 6302181703100009 63002180705170002 M Ashar 2,8 47 2 2 Syahnong 6302181602750001 - TLU 2 1 10/8/2021 10,2 88 1 1 1 1 1 1 1 1 1

74 1 11/7/2018 P - 6302185107180001 Adelis Claudia 2,8 48 2 2 Ayupdianyah 6302172903890001 - TLU 1 1 10/8/2021 10,4 92 2 1 1 1 1 1 1 1 1

75 6 30/01/2018 P - 6302187001180001 Adiba Aidah 2,8 47 2 2 Musmuliadi - - TLU 1 1 10/8/2021 8,6 88 2 1 1 1 1 1 1 1 1

76 4 8/2/2017 P 6302170112070003 6302184812170001 Nur Intan 3,8 48 1 1 Ibrahim 6302172503730002 - TLU 4 2 10/8/2021 10,2 90 2 1 1 1 1 1 1 1 1

77 1 30/08/2017 P 6302160407190002 6302187008170001 Adinda Amalia 3 48 1 1 Ikhsan 6302171011970001 - TLU 1 1 10/8/2021 10,2 92 2 1 1 1 1 1 1 1 1

78 5 4/2/2018 L 6302180408090016 6302180408100001 Wildan Febriansyah 4 48 1 1 Asriansya 6302181807800001 - TLU 2 1 10/8/2021 12,2 102 2 1 1 1 1 1 1 1 1

79 3 21/08/2019 L 630205062180001 6302202108190081 M Deva Agriady 3,8 50 1 1 Andi Siardi 6302051612870001 - TLU 3 1 10/8/2021 8,2 77 2 1 1 1 1 1 1 1 1
80 2 2/11/2015 L 6302050602180001 630220021150001 Dafa Agriady 4 50 1 1 Andi Siardi 6302051612870001 - TLU 3 1 10/8/2021 12,6 102 2 1 1 1 1 1 1 1 1

81 3 24/06/2019 L 6302181609120003 6302202406190001 Syabil Ahmad N 3,5 50 1 1 Masbur 6302010501830001 - TLU 5 2 10/8/2021 10,6 82 2 1 1 1 1 1 1 1 1

82 2 19/12/2019 L - - M Sabil 3,2 49 1 1 Suriadi - - TLU 2 1 10/8/2021 7,2 67 1 1 1 1 1 1 1 1 1


83 3 28/7/2017 L 6302180301090014 - M Rafa 2,8 49 1 1 Haeruddin 6302181508810001 - TLU 5 2 10/8/2021 11,5 95 2 1 1 1 1 1 1 1 1

84 4 20/10/2017 P 630217300108007 5302206010170001 Khafiza Khumairah 3,8 49 1 1 Yahya 6302170706680002 - TLU 5 2 10/8/2021 12,4 84 2 1 1 1 1 1 1 1 1

0 84

Mengetahui, Tanjung Lalak, 10 Agustus 2021


Plt. Kepala Puskesmas Tanjung Lalak
Kec. Pulau Laut Kepulauan Pembuat Laporan,

Muhammad Nur, AMG


Hasbullah, SKM Nip. 19910909 201403 1 001
Nip. 19700403 199101 1 003

Ayu Istiqomah, A.Md.Gz


NRPTT. 11.7.2017.3.4.06
FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Cumi-cumi


Kabupaten/Kota : Kotabaru Bulan : Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Oka-oka

IMD Vitamin A
Kepemilik ASI Eksklusif Vitamin A
Februari
an Buku 1 = Ya Agustus
Panjang Cara Ukur
Berat KIA/KMS
Badan /
No Anak Ke Tanggal Lahir Jenis No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Badan Panjang Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Tanggal BB (Kg) 2 =Tidak
Tinggi 1= 1
Kelamin Lahir Lahir 1 = Ya Pengukuran 1 =Ya
Badan(cm Telentang =Ya
(gram)
1 =Ya ) 2 =berdiri
2=
2 2
Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 2 =Tidak
= Tidak =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 2 22/2/2018 P 6302182009120001 6302206102180001 Najliah 3,3 50 1 1 Abdul Wahab 6302181905930001 - Oka-Oka 1 1 12/8/2021 15 104 2 1 1 1 1 1 1 1 1

2 3 20/1/2018 P 6302180712090004 6302186781180001 Nibra Hergiana 3,2 50 1 1 Hermansyah 6302171402820003 82132962433 Oka-Oka 3 2 12/8/2021 11 95 2 1 1 1 1 1 1 1 1

3 1 1/11/2017 P 6302182507180001 6302184111170001 Fahmida Shaisha 3 49 1 1 Sapar 7604151411920003 - Oka-Oka 2 1 12/8/2021 11 96 2 2 2 2 2 2 2 1 1

4 1 10/3/2019 L 6302200404190010 6302201003190001 M.Naufal Zikri A 2,8 50 1 1 M. Ali Akbar 6302628028080004 85251102329 Oka-Oka 1 1 12/8/2021 10 96 2 2 2 2 2 2 2 1
1
5 1 4/4/2018 L - - Adam Pranata 2,2 47 1 1 Rahliansyah 6302180101960003 - Oka-Oka 3 2 12/8/2021 13 92 2 1 1 1 1 1 1 1 1

6 3 14/62019 L 6302182701110021 6302201406190001 Muhammad Riski 3,8 48 1 1 Rusdiansyah 6302180305920001 - Oka-Oka 1 1 12/8/2021 10 82 2 1 1 1 1 1 1 1 1

7 3 16/09/2017 P 6302030708080040 6302185609170001 Inayah Azmi A 3,1 49 1 1 Idris 6302031007840003 - Oka-Oka 3 2 12/8/2021 11,5 98,5 2 1 1 1 1 1 1 1 1

8 6 5/6/2018 L 6302180712090001 ,6302180506180001 Abdul Rahim 3 50 1 1 Baharnor 6302181203800001 - Oka-Oka 2 1 12/8/2021 11 93 2 1 1 1 1 1 1 1 1

9 5 16/4/2017 L 6302180712090001 6302181604170001 Revan 3,2 49 1 1 Baharnor 6302181203800001 - Oka-Oka 2 1 12/8/2021 11,5 97 2 1 2 2 2 2 2 1 1

10 2 5/10/2018 L 6302182206990010 6302180510180001 Ahmad Dihya 3,5 48 1 1 Agus 6301180706030002 85249089192 Oka-Oka 1 1 12/8/2021 12,5 95 2 2 2 2 2 2 2 1 1

11 3 3/1/2018 L 6302181907160001 6302180301180001 Azka Rafasya 2,5 49 1 1 M.Ikhsan 6302020408910001 82351885402 Oka-Oka 1 1 12/8/2021 11 96 2 1 1 2 2 2 2 1 1

12 3 7/9/2018 P 630218280409002 6302204709180002 Kaila Maritsa 3.1 49 1 1 Saparuddin 6302180207840001 - Oka-Oka 3 2 12/8/2021 9 89 2 1 1 1 1 1 1 1 1

13 7 27/07/2018 P 6302182701110016 6302206707180001 Ina Yulfaidah 2,9 49 1 1 Baharuddin 6302180503790001 - Oka-Oka 3 2 12/8/2021 10 90 2 1 1 2 2 2 2 1 1

14 6 31/12/2018 L 6302182212180003 630220312180003 Muhammad Kaisan 3 50 1 1 Budiansyah 6302180506650005 - Oka-Oka 4 2 12/8/2021 10 90 2 2 1 1 1 1 1 1 1

15 4 13/08/2019 L 6302183009120014 6302201308190001 Muhammad Ilham 3,3 50 1 1 Jufriadi 6302180711830001 - Oka-Oka 4 2 12/8/2021 10 84 1 1 1 1 1 1 1 1 1

16 7 19/07/2016 P 6302182108080022 6302185907160001 Nurhidayah 3,4 49 1 1 Muliadi 6302180107780013 - Oka-Oka 1 1 12/8/2021 12 98 2 1 1 1 1 1 1 1 1

17 8 12/10/2018 L 6302182108080022 6302201210180001 M.Adzan 3 50 1 1 Muliadi 6302180107780013 - Oka-Oka 1 1 12/8/2021 10 92 2 1 1 1 1 1 1 1 1

18 4 16/04/2018 L 6302182510100002 6302181904180001 Mardiannor 3 48 1 1 Masdar 6302180511830001 - Oka-Oka 1 1 12/8/2021 11 91 2 1 1 1 1 1 1 1 1

19 1 12/6/2017 P 6302182310170001 6302185206170001 Annisa Faena 3,8 50 1 1 Ramdani 6302030402950001 - Oka-Oka 1 1 12/8/2021 11 99 2 1 1 1 1 1 1 1 1

20 2 26/06/2017 P 6302181312140001 6302186906170001 Yuyun Anggita 3 49 1 1 Tajuddin 6302180203950001 - Oka-Oka 1 1 12/8/2021 12 100 2 1 1 1 1 1 1 1 1

21 3 23/08/2018 L 6302183009120014 6302202308180001 Muh Fahmi 3 49 1 1 Jufriadi 6302180711870001 - Oka-Oka 4 2 12/8/2021 13 105 2 1 1 1 1 1 1 1 1

22 3 26/08/2018 L 6302180712090007 6302200608180001 Al Habsi Maulana 3,1 49 1 1 Masdar 6302181506720001 - Oka-Oka 1 1 12/8/2021 12 90 2 1 2 2 2 2 2 1 1

23 2 22/08/2018 P 6302182109120027 6302206208180001 Kayla Azzahra 2,6 48 1 1 Rudiansyah - 085349521994 Oka-Oka 2 1 12/8/2021 11 85 2 1 1 1 1 1 1 1 1

24 2 8/1/2018 P 6302183009120023 63021848001180001 Erika Fatinah 3,1 48 1 1 Nasruddin 6302181504880001 - Oka-Oka 4 2 12/8/2021 11,7 84 2 1 1 1 1 1 1 1 1

25 2 8/5/2017 P 6302183009120015 6302204805170001 Nina Ritriani 2,8 49 1 1 Aliansyah 6302181503940002 81257816526 Oka-Oka 3 2 12/8/2021 10 85 2 1 1 1 1 1 1 1 1

26 3 22/08/2018 L 6302183009120015 Muh Alfah 3 49 1 1 Aliansyah 6302181503940002 81257816526 Oka-Oka 3 2 12/8/2021 10 91 2 1 1 2 2 2 2 1 1

27 1 30/01/2019 P 6302200607200004 6302207001190001 Sitnah Hilmah 2,8 49 1 1 Edy 6302181509770001 81348795192 Oka-Oka 4 2 12/8/2021 13 102 2 1 1 1 1 1 1 1 1

28 2 9/8/2017 L 6302183009120013 6302180908170001 Fatir Anwar 3,5 50 1 1 Heliansyah 6302032607910001 Oka-Oka 3 2 12/8/2021 13 105 2 1 1 1 1 2 2 1 1

29 2 16/06/2017 P 6302183009120020 6302185605170001 Salsabila 3 49 1 1 Hasruddin 6302181009950001 - Oka-Oka 4 2 12/8/2021 12 103 2 1 1 1 1 1 1 1 1

30 1 18/06/2019 p 6302202907200007 6302205806190001 Nur Azani 1 1 Gusti Randa 6302181304930001 - Oka-Oka 1 1 12/8/2021 11 84 2 1 2 2 2 2 2 1 1

31 6 7/9/2019 L 6302180908170001 - Abdul Somad 3,3 50 1 1 Jaharuddin 6302181509770001 81348795192 Oka-Oka 3 2 12/8/2021 9 82 1 1 1 1 1 1 1 1 1
32 2 3/4/2020 P 6302202905190001 - Fani Afnan Jannah 3,6 50 1 1 Haeruddin 6302061208850009 85348072960 Oka-Oka 2 1 12/8/2021 8 72,5 1 1 1 1 1 1 1 1 1

33 1 30/05/2020 P 6302200809200002 6302207005200002 Adiva Umaiza 3,2 49 1 1 Sunardi 6302180301880001 82195446187 Oka-Oka 3 2 12/8/2021 8,3 72,5 1 2 2 1 1 1 1 1 1

34 3 6/6/2020 P ,- ,- Aulia Hadijah 3,4 50 1 1 Lunding - - Oka-Oka 2 1 12/8/2021 7 67 2 1 1 1 1 1 1 1 1

35 3 7/6/2020 L 6302180710120083 - Ahmad Hidayat 2,8 50 1 1 Abdul Rahman 6302180306910001 82256038054 Oka-Oka 1 1 12/8/2021 8,5 75 2 2 2 2 2 2 2 1 1

36 4 5/1/2020 L 6302021606090001 6302200501200001 Muhammad Riswan 3,3 49 1 1 Haerol 6302020101650004 - Oka-Oka 4 2 12/8/2021 9 83 1 1 1 1 1 1 1 1 1

37 2 8/11/2019 P ,6302182206090002 6302284811190001 Sri Herlina 3,8 49 1 1 Askar 6302051912870001 82210171259 Oka-Oka 2 1 12/8/2021 9,5 76 1 2 2 2 2 2 2 1 1

38 2 7/2/2020 L 6302051610140004 - Ahmad Hafizah 2,7 48 1 1 Ahmad Fauzan 6302051912870001 - Oka-Oka 2 1 12/8/2021 8 75 1 1 1 1 1 1 1 1 1

39 2 14/07/2017 L 6302182310170001 - M.Noor Amin 3,9 50 1 1 Ramdani 6302030402950001 - Oka-Oka 1 1 12/8/2021 9 73 1 1 1 2 2 2 2 1 1

40 14 27/07/2019 P 6302182701110016 - Ina Deliana 3,5 51 1 1 Baharuddin 6302180503790001 - Oka-Oka 3 2 12/8/2021 6,4 65 2 1 1 1 1 1 1 1 1

41 2 10/1/2020 P 6302182310170001 630220500120001 Marwah Nur Asyifa 3,2 48 1 1 Suriadi 7601081018800001 82241529066 Oka-Oka 1 1 12/8/2021 8,2 73 1 1 1 1 1 1 1 1 1

42 2 30/06/2016 L 6302181312140001 6302183006170002 Muh Fauzan 3 50 1 1 Nursuki 6302181203800001 - Oka-Oka 3 2 12/8/2021 15 99 2 2 1 1 1 1 1 1 1

43 1 - L - - Muhammad Aji Nuh - - - - - - - Oka-Oka - 1 12/8/2021 - - 1 1 2 2 2 2 2 2 1

44 1 26/02/2020 L 630204250509170001 6302202608200001 Ahmad Rohim 2,8 47 1 1 Ahmad M 7310021408830003 081254648034 Oka-Oka 4 2 12/8/2021 7,9 70 2 1 2 2 2 2 2 2 1

45 - 27/08/2019 P - - Eli - - 1 1 - - - Oka-Oka 4 2 12/8/2021 - - 2 2 2 2 2 2 2 2 1

46 4 15/1-/2021 L 6302182804100002 6302201501210001 Rahman Maulana 3,2 49 1 1 Massuddin 6302180107750838 - Oka-Oka 1 1 12/8/2021 7 68 1 1 1 1 1 1 1 2 1

47 1 2/1/2021 L - - M.Ibrahim - - - - - - - Oka-Oka 2 1 12/8/2021 7,4 67 1 1 1 1 1 1 1 2 1

48 2 2/3/2015 L - - M. Fahri 3 48 1 1 Nuraedi - - Oka-Oka 1 1 12/8/2021 - - - - - - - - - - 1


3 45

Mengetahui,
Plt. Kepala Puskesmas Tanjung Lalak
Tanjung Lalak, 12 Agustus 2021
Kec. Pulau Laut Kepulauan Pembuat Laporan,

Muhammad Nur, AMG


Hasbullah, SKM
Nip. 19910909 201403 1 001
Nip. 19700403 199101 1 003

Ayu Istiqomah, A.Md.Gz


NRPTT. 11.7.2017.3.4.06
FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Udang Tiger


Kabupaten/Kota : Kotabaru Bulan : Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Teluk Aru

IMD Vitamin A
Kepemilik ASI Eksklusif Vitamin A
Februari
an Buku 1 = Ya Agustus
Panjang Cara Ukur
Berat KIA/KMS
Badan /
No Anak Ke Tanggal Lahir Jenis No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Badan Panjang Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Tanggal BB (Kg) 2 =Tidak
Tinggi 1= 1
Kelamin Lahir Lahir 1 = Ya Pengukuran 1 =Ya
Badan(cm Telentang =Ya
(gram)
1 =Ya ) 2 =berdiri
2=
2 2
Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 2 =Tidak
= Tidak =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 2 10/06/2018 L 6302180308090001 6302181006180001 Alhabsy Zuki Ramadani 3,2 50 1 1 Mukhtar 6302181502860002 - Teluk Aru 2 1 13/08/2021 10 85 2 1 1 1 1 1 1 1 1

2 7 10/04/2019 P 6302181709080003 6302205004190001 Arsy Putri Samsul 2,7 50 1 1 Samsul 6302180506750001 - Teluk Aru 2 1 13/08/2021 9 82 2 1 1 1 1 1 1 1 1

3 2 22/05/2019 P 6302182305180001 6302206205190001 Nayla rossaRamadani 3,5 51 1 1 Robby ,6302180799800002 - Teluk Aru 2 1 13/08/2021 10 79 2 1 1 1 1 1 1 1 1

4 5 19/12/2019 L 6302181709080008 6302202912190001 Ahmad Abu Alsahab 3,6 50 1 1 Budi 6302181709080008 - Teluk Aru 2 1 13/08/2021 9 79 2 1 1 1 1 1 1 1 1

5 1 17/03/2018 P 6302181905170001 6302185703180001 Annasya Nuril Adreena 2,9 49 1 1 Edy Suryadi 63020303041290 - Teluk Aru 3 2 13/08/2021 18 93 2 1 1 1 1 1 1 1 1

6 1 5/7/2019 L 6310020803190002 6310020507190002 Nabil 2,6 50 1 1 Sahrul 6310021204950003 - Teluk Aru 3 2 13/08/2021 12 81 2 1 1 1 1 1 1 1 1

7 5 8/10/2017 P 6302182401090018 6302184810170001 Irseylina 2,9 49 1 1 Tamrin 6302182907720001 - Teluk Aru 3 2 13/08/2021 13 92 2 1 1 1 1 1 1 1 1

8 4 15/06/2019 P 6302180110180001 6302205506190001 Nurul Afifah 2,5 50 1 1 Sugianto 6302182706890001 - Teluk Aru 3 2 13/08/2021 11 77 2 1 1 1 1 1 1 1 1

9 4 21/06/2018 L - - Alby 2,7 49 1 1 Hamdi 6302182201860001 - Teluk Aru 3 2 13/08/2021 9 77 2 1 1 1 1 1 1 1 1

10 5 7/4/2020 P - - Amaira Ayuni 4,2 51 1 1 Hamdi 6302182201860001 - Teluk Aru 13/08/2021 10 78 2 1 1 1 1 1 1 1 1

11 4 29/04/2020 L 6302181510080002 6302202904200001 M.Riad Mahrez Alfarizky 2,7 49 1 1 Sulaeman 6302180107760008 - Teluk Aru 3 2 13/08/2021 9 77 2 1 1 1 1 1 1 1 1

12 4 15/5/2021 P 6302181703100008 - Rahma dani 3,5 50 1 1 Hami 6302180408890001 - Teluk Aru 3 2 13/08/2021 13 85 2 1 1 1 1 1 1 1 1

13 6 15/1/2021 P 6302181410080006 6301205501200001 Jumiati 25 49 1 1 Burahima 6302182008650001 - Teluk Aru 3 2 13/08/2021 8 72 2 1 1 1 1 1 1 1 1

14 3 14/10/2019 L 6302181001090004 6302181407840001 Riski Maulana 2,7 50 1 1 Ameluddin 6302181407840001 - Teluk Aru 3 2 13/08/2021 10 77 2 1 1 1 1 1 1 1 1

15 3 17/8/2019 L 6302180804100001 - Muhammad Zanil Agustin 2,5 48 1 1 Hermansyah 6302180401720001 - Teluk Aru 2 1 13/08/2021 10 82 2 1 1 1 1 1 1 1 1

16 2 17/03/2018 L 63022212120004 6302211703180001 Muhammad Ali 3,3 51 1 1 Mihiddin 6302020107860829 - Teluk Aru 2 1 13/08/2021 12 74 2 1 1 1 1 1 1 1 1

17 2 24/04/2019 L 6302181601160002 6302202404190002 Risal 2,7 49 1 1 Joni 6302181211950001 - Teluk Aru 2 1 13/08/2021 10 82 2 1 1 1 1 1 1 1 1

18 2 3/10/2017 L 6302181920900004 6302100310170001 Daffa Saputra 3,2 49 1 1 Safruddin 6302182912730001 - Teluk Aru 5 2 13/08/2021 12 92 2 1 1 1 1 1 1 1 1

19 8 6/6/2018 P 6302181703100002 6302204606180001 Hasnah 3,3 48 1 1 Hasdi 6302181404840001 - Teluk Aru 4 2 13/08/2021 11 84 2 1 1 1 1 1 1 1 1

20 3 19/06/2019 L 6302181906190001 6302201906190003 Aril Wijaya 2,6 50 1 1 Safruddin 6302182912730001 - Teluk Aru 5 2 13/08/2021 9 81 2 1 1 1 1 1 1 1 1

21 2 31/10/2017 L 6302030612190001 6302183110170001 Muhammad Zaki Anwar 3,2 49 1 1 Abdul Wahid 6302031209880001 - Teluk Aru 4 2 13/08/2021 14 94 2 1 1 1 1 1 1 1 1

22 5 15/05/2019 L 6302181601090007 - M. Ramadani 3,9 51 1 1 Zaenal Abidin 6302181609790001 - Teluk Aru 4 2 13/08/2021 10 81 2 1 1 1 1 1 1 1 1

23 3 13/03/2017 P 6302181905100002 6302185303170001 Siti Gusma 3,3 50 1 1 Sarupuddin 6302181110730001 - Teluk Aru 5 2 13/08/2021 18 97 2 1 1 1 1 1 1 1 1

24 1 2/4/2017 P - - Hawadia 3,1 50 1 1 Misran - - Teluk Aru 5 2 13/08/2021 15 98 2 1 1 1 1 1 1 1 1

25 8 10/3/2017 L 6302181410080005 6302181003170001 Rian Hidayat 4,2 52 1 1 Yanni 6302182609670001 - Teluk Aru 2 1 13/08/2021 13 89 2 1 1 1 1 1 1 1 1

26 1 - L - - Ahmad Alim 3,1 49 1 1 Muhammad Kammi - - Teluk Aru 2 1 13/08/2021 10 79 1 1 1 1 1 1 1 1 1

27 1 - L - - Muhammad Rehan 3 48 1 1 Mahayuddin - - Teluk Aru 2 1 13/08/2021 14 94 2 1 1 1 1 1 1 1 1

28 3 13/09/2017 L 6302182703090078 6302201409170001 Fiqriansyah 2,7 49 1 1 Rudiansyah 6302180808900003 - Teluk Aru 1 1 13/08/2021 14 87 2 1 1 1 1 1 1 1 1

29 5 12/5/2020 P 6302180511730001 - Aisya Khumairah 2,7 50 1 1 Pandi 6302180511730001 - Teluk Aru 1 1 13/08/2021 10 80 1 1 1 1 1 1 1 1 1

30 1 14/05/2018 L 6302200708190002 6302201405180001 Muhammad Fadil 3 49 1 1 Baharuddin 6302200708190002 - Teluk Aru 3 2 13/08/2021 13 84 2 1 1 1 1 1 1 1 1

31 1 14/04/2020 P - - Tasya Khumairah 2,5 49 1 1 Abdul Wahid 6302021505000003 - Teluk Aru 3 2 13/08/2021 10 80 2 1 1 1 1 1 1 1 1

32 1 15/04/2018 P - - Rahayu 2,6 50 1 1 jasluddin - - Teluk Aru 1 1 13/08/2021 13 87 2 1 1 1 1 1 1 1 1

33 1 24/03/2019 P 6302280280920002 6302204003190001 Hasni 3,2 50 1 1 Hasan 6302180203860001 - Teluk Aru 5 2 13/08/2021 9 72 2 1 1 1 1 1 1 1 1

34 3 1/2/2018 P ,6302182611500001 63022041102180001 Kesya Nurjannah 3,3 50 1 1 Musdar 6302182701820001 - Teluk Aru 5 2 13/08/2021 12 86 2 1 1 1 1 1 1 1 1

35 4 25/03/2020 P 6302182611150001 6302206503200001 Bilqis 3 50 1 1 Masdar 6302182701820001 - Teluk Aru 5 2 13/08/2021 10 89 1 1 1 1 1 1 1 1 1

36 2 6/9/2018 P 6302180610150003 6302184609180001 Naura Anindira 2,5 48 1 1 Nurdin ,6302020109870001 - Teluk Aru 2 1 13/08/2021 12 86 2 1 1 1 1 1 1 1 1
37 1 17/01/2019 L 63021202309200003 6302201701190001 Herlina 3 48 1 1 Ardiansyah ,6302170107010013 - Teluk Aru 5 2 13/08/2021 10 78 2 1 1 1 1 1 1 1 1

38 3 - P - - Mirna 3 50 1 1 Hamma Nur - - Teluk Aru 2 1 13/08/2021 10 75 1 1 1 1 1 1 1 1 1

39 4 19/08/2018 L 6302181410080027 6302201900180001 Benni Adrian 2'5 48 1 1 Badawi 6302181011880001 - Teluk Aru 2 1 13/08/2021 13 89 2 1 1 1 1 1 1 1 1

40 1 2103/2017 L 6302183011170001 6302182103170001 Fatan Agni Zero 3.1 49 1 1 Haeruddin 6302181806950001 - Teluk Aru 4 2 13/08/2021 12 90 2 1 1 1 1 1 1 1 1

41 2 22/10/2018 L 6302118301170001 6302182009160001 Fahmi Agni Maffa 3,3 50 1 1 Haeruddin 6302181806950001 - Teluk Aru 4 2 13/08/2021 11 86 2 1 1 1 1 1 1 1 1

42 3 10/6/2019 P - 6302204204190001 Aisyah 2,6 49 1 1 Haeruddin 6302185612950001 - Teluk Aru 4 2 13/08/2021 10 73 2 1 1 1 1 1 1 1 1

43 8 15-6-2019 L 6302182100104008 - Muksin 2,8 49 1 1 Sulaiman 6302181405610001 - Teluk Aru 5 2 13/08/2021 10 79 2 1 1 1 1 1 1 1 1

44 5 5/6/2020 L 6302180911070006 - Khairan Delvin Assalam 2,9 50 1 1 Abdul Salam 6302180104830001 - Teluk Aru 3 2 13/08/2021 7,8 73 2 1 1 1 1 1 1 1 1

45 8/10/2018 P 6302183101090049 - Hesti Amelia 2,7 49 1 1 Baharuddin 6302181206770003 - Teluk Aru 5 2 13/08/2021 10 75 2 1 1 1 1 1 1 1 1

46 4 7/6/2016 L 6202180201090001 6302180706180001 Rahid Mumtazh 3,5 50 1 1 Hariadi 6302182108830002 - Teluk Aru 2 1 13/08/2021 12 89 2 1 1 1 1 1 1 1 1

47 1 - P - - Livia 3.1 49 1 1 Muhammad Wahyu - - Teluk Aru 2 1 13/08/2021 10 84 2 1 1 1 1 1 1 1 1

48 2 - L - - Akbar 3 50 1 1 Misran - - Teluk Aru 5 2 13/08/2021 5,5 66 1 1 1 1 1 1 1 1 1

49 1 - L - - Muhammad Alim Rafiski 3 49 1 1 Ahmadullah - - Teluk Aru 3 2 13/08/2021 8 68 1 1 1 1 1 1 1 1 1

50 2 - P 6302180608160002 - Debi Aulia 2,9 49 1 1 Kamaruddin 6302182611860002 - Teluk Aru 1 1 13/08/2021 7,1 68 1 1 1 1 1 1 1 1 1

51 5 23-8-2020 P 6302182703090078 - Yopita Riandini 3 50 1 1 Hartono 6302181102810001 - Teluk Aru 1 1 13/08/2021 8,2 73 1 1 1 1 1 1 1 1 1

52 3 21-4-2020 P 6302182701090003 6302206104200001 Sadrina 2,5 49 1 1 Saripuddin 6302180303740001 - Teluk Aru 1 1 13/08/2021 9,6 74 1 1 1 1 1 1 1 1 1

53 2 - L 6302280280920002 - Hasdi 2,7 48 1 1 Hasan 6302180203860001 - Teluk Aru 5 2 13/08/2021 6,4 72 1 1 1 1 1 1 1 1 1

54 4 - L - - Aska 2,8 49 1 1 Kaswin - - Teluk Aru 4 2 13/08/2021 7,2 64 1 1 1 1 1 1 1 1 1

55 - L - - Muhammad Akbar Ramadhan 3 49 1 1 Malik - - Teluk Aru 2 1 13/08/2021 9 64 1 1 1 1 1 1 1 1 1

56 - L - - Mahdan 3,1 50 1 1 Mahayuddin - - Teluk Aru 2 1 13/08/2021 10 75 1 1 1 1 1 1 1 1 1

57 - L - - Muhammad Repan Aska 3,2 51 1 1 Saenuddin - - Teluk Aru 1 1 13/08/2021 10 75 1 1 1 1 1 1 1 1 1

58 2 27-07-2021 L - - Muhammad Fatlian Noor - - 1 1 Muhammad Wahyu - - Teluk Aru 2 1 13/08/2021 5,8 63 1 1 1 1 1 1 1 1 1

59 1 - P 6302201706120001 6302204601210001 Naila 3 50 1 1 Darmansyah - - Teluk Aru 1 1 13/08/2021 7,5 65 1 1 1 1 1 1 1 1 1

60 2 - P - - Najwa - - 1 1 Riduan - - Teluk Aru 1 1 13/08/2021 8,1 67 1 1 1 1 1 1 1 1 1

61 1 - P - - Kaysa - - 1 1 Margani - - Teluk Aru 2 1 13/08/2021 6,7 6 6 1 1 1 1 1 1 1 1

62 3 9-12-1019 P 6302181711120002 6302242121900002 Fadela 3,3 51 1 1 Fardiansyah 6302181208920001 - Teluk Aru 5 2 13/08/2021 10 78 1 1 1 1 1 1 1 1 1

63 8 - P 6302181410080014 - Pia 3 50 1 1 Hasanuddin 6302182102640002 - Teluk Aru 4 2 13/08/2021 7,5 75 1 1 1 1 1 1 1 1 1

64 3 - L - - Aqliannor 3,5 49 1 1 Zulkifli - - Teluk Aru 1 1 13/08/2021 10 61 2 1 1 1 1 1 1 1 1

65 4 - L - - Guntur 3,5 50 1 1 Zulkifli - Teluk Aru 1 1 13/08/2021 78 70 1 1 1 1 1 1 1 1 1

66 2 9/6/2020 L - - Ameruddin 2,5 49 1 1 Jasluddin - - Teluk Aru 1 1 13/08/2021 8 70 1 1 1 1 1 1 1 1 1

67 4 26-2-2018 L 630218080410001 - Alif Akbar 2,7 49 1 1 Sahril 6302181007760001 - Teluk Aru 2 1 13/08/2021 12 93 2 1 1 1 1 1 1 1 1

68 3 17-7-2018 L 6302181703100008 6302181707180001 Ahmad Dani 3,7 50 1 1 Hami 6302180408890001 - Teluk Aru 3 2 13/08/2021 12 90 2 1 1 1 1 1 1 1 1

69 2 10/9/2017 L ,63021820501090002 6302201009170001 Noor Ifansyah 4 51 1 1 Jufriansyah 6302180501860002 - Teluk Aru 2 1 13/08/2021 13 90 2 1 1 1 1 1 1 1 1

70 2 8/10/2017 L 6302030308120003 6302038810170001 M.Afik Rahman 2,9 50 1 1 Kaharuddin 6302180107890008 - Teluk Aru 2 1 13/08/2021 13 94 2 1 1 1 1 1 1 1 1

71 2 5/6/2018 P 6302180210120007 6302184506180001 Nindy Aulia 2,5 49 1 1 Hermansyah 6302181010900002 - Teluk Aru 3 2 13/08/2021 12 89 2 1 1 1 1 1 1 1 1

72 2 25-12-2018 P 630218603090004 - Imel 3,1 50 1 1 Rinto Harahap 6302181712930001 - Teluk Aru 1 1 13/08/2021 12 83 2 1 1 1 1 1 1 1 1

73 2 25-12-2018 P 630218603090004 - Amel 3,2 50 1 1 Rinto Harahap 6302181712930001 - Teluk Aru 1 1 13/08/2021 12 84 2 1 1 1 1 1 1 1 1

74 1 21-6-2018 P 6302183105180001 - Aqila 3,2 50 1 1 Suandi 6302182106920002 - Teluk Aru 1 1 13/08/2021 12 89 2 1 1 1 1 1 1 1 1

75 3 26-5-2019 L 6302182406080062 6302202605190001 Faul Ramadani 4 51 1 1 Basri 630218300164002 - Teluk Aru 5 2 13/08/2021 11 87 2 1 1 1 1 1 1 1 1

76 1 18-5-2017 L 6302181302190001 6302201805170001 Abrilan Rafif Azhari 3,2 50 1 1 Subhan ,7310020506890002 - Teluk Aru 2 1 13/08/2021 13 99 2 1 1 1 1 1 1 1 1

77 2 6/6/2018 L 6302181302190001 6302200606180011 Irzan Reynaldi 3 50 1 1 Subhan ,7310020506890002 - Teluk Aru 2 1 13/08/2021 13 97 1 1 1 1 1 1 1 1

78 1 26-8-2019 P - - Ivit Sapitri 2,5 49 1 1 Irwandi 6302181111990004 - Teluk Aru 1 1 13/08/2021 11 78 2 1 1 1 1 1 1 1 1

79 2 27-4-2017 L 6302180812090002 6302202704170001 M.Ma,ruf Alfatih 3,7 50 1 1 Zulkifli 6302180811640001 - Teluk Aru 2 1 13/08/2021 12 87 2 1 1 1 1 1 1 1 1
80 2 - L - - Muhammad Miran Aditia 2,9 49 1 1 Busman - - Teluk Aru 3 2 13/08/2021 7 85 1 1 1 1 1 1 1 1 1

81 4 25-7-2017 L - - Surya Ahmad Risaldi 2,9 49 1 1 Bahmad - - Teluk Aru 4 2 13/08/2021 12 93 2 1 1 1 1 1 1 1 1

82 3 6/10/2016 L 6302180803140001 6302180610160001 Izan Norman 3,2 50 1 1 Jalamin 7605012801280877 - Teluk Aru 4 2 13/08/2021 13 96 2 1 1 1 1 1 1 1 1
83 10 18-4-2020 L 6302182201110834 - Daffa Gizal 3,1 50 1 1 Mahmur 6302182305790001 - Teluk Aru 4 2 13/08/2021 8 86 2 1 1 1 1 1 1 1 1

84 9 20-9-2016 L 6302182201110834 6302182009160001 M.Akmal Nasrollah 3,3 50 1 1 Mahmur 6302182305790001 - Teluk Aru 4 2 13/08/2021 13 90 2 1 1 1 1 1 1 1 1

85 3 19-12-2019 P - - Cinta Pasda 3,3 51 1 1 Fardiansyah 6302181208920001 - Teluk Aru 5 2 13/08/2021 11 87 1 1 1 1 1 1 1 1

86 8 11/7/2018 L 6302182201110834 - Arief 2,7 49 1 1 Mahmur 6302182305790001 - Teluk Aru 4 2 13/08/2021 13 91 2 1 1 1 1 1 1 1 1

87 3 8/5/2017 P ,6302182506130001 6302184805170001 Ilma Tiara 3,2 50 1 1 Budi Doto 6302181003820001 - Teluk Aru 4 2 13/08/2021 15 96 2 1 1 1 1 1 1 1 1

4 83

Mengetahui,
Plt. Kepala Puskesmas Tanjung Lalak Tanjung Lalak, 13 Agustus 2021
Kec. Pulau Laut Kepulauan Pembuat Laporan,

Muhammad Nur, AMG


Hasbullah, SKM Nip. 19910909 201403 1 001
Nip. 19700403 199101 1 003

Ayu Istiqomah, A.Md.Gz

NRPTT. 11.7.2017.3.4.06
FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Tembang 1,2,3


Kabupaten/Kota : Kotabaru Bulan : Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Teluk Kemuning

IMD Vitamin A
Kepemilik ASI Eksklusif Februari Vitamin A
an Buku Panjang Cara Ukur 1 = Ya Agustus
Berat KIA/KMS Badan /
Jenis Badan Panjang Tanggal Tinggi 1= 2 =Tidak 1
No Anak Ke Tanggal Lahir Kelamin No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Lahir Lahir 1 = Ya Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Pengukuran BB (Kg) 1 =Ya
(gram) Badan(cm Telentang =Ya
1 =Ya ) 2 =berdiri
2= 2 2
Tidak = Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 =Tidak 2 =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 1 11/10/2019 L - - Muhammad Gunawan 3,6 51 1 1 Masnur 6302021203960829 - Teluk Kemuning 1 1 16/08/2021 9,8 90 2 1 1 1 1 1 1 1 1

2 1 6/11/2019 L - - M Sandy 3 46 1 1 Samsul Irpai 6302181782980001 - Teluk Kemuning 1 1 16/08/2021 8,5 80 1 1 1 1 1 1 1 1 1

3 8 25-12-2019 P 6302182801090006 - Rabani 4,5 52 1 1 Hasan 6302181008760001 - Teluk Kemuning 1 1 16/08/2021 8,8 74 2 1 1 1 1 1 1 1 1

4 5 1/1/2020 P 6302021110120058 - Tania 2,8 48 1 1 Hasanuddin 6302021500740002 - Teluk Kemuning 1 1 16/08/2021 8,7 75 1 1 1 1 1 1 1 1 1

5 3 1/2/2018 P 6302182503130001 - Juhan Amela 4,2 51 1 1 Nasril 6302070107820056 - Teluk Kemuning 1 1 16/08/2021 14 98 2 1 1 1 1 1 1 1 1

6 2 13-5-2019 L 6302182202170001 - Zabir Safran 3,5 51 1 1 Tri Budi Setiawan ,6302181003950002 085350272969 Teluk Kemuning 1 1 16/08/2021 9,2 81 1 1 1 1 1 1 1 1 1

7 1 21-4-2017 L 6302182202170001 - Azka RafasyaSetiawan 3,6 49 1 1 Tri Budi Setiawan ,6302181003950002 085350272969 Teluk Kemuning 1 1 16/08/2021 13'5 102,5 2 1 1 1 1 1 1 1 1

8 16/08/2021 1 1 1 1 1 1 1 1

9 4 27-10-2016 L 620218110070002 6302182710160001 Muhammad Hafiz 3,8 52 1 1 Sabri 63021808806770001 0812500762279 Teluk Kemuning 1 1 16/08/2021 15,6 109 2 1 1 1 1 1 1 1 1

10 1 9/7/2017 L 6302182905170001 6302180907170001 Rasyid Alwi Ramadhan 2,8 48 1 1 Ramadhansyah 6302010501940001 - Teluk Kemuning 1 1 16/08/2021 12,8 100 2 1 1 1 1 1 1 1 1

11 3 10/5/2017 L 6302180710120016 6302181005170001 Muhammad Arfi 3,4 51 1 1 Arman Riadi ,6302181103760001 085252809239 Teluk Kemuning 1 1 16/08/2021 14,5 107 2 1 1 1 1 1 1 1 1

12 4 21-04-2019 L 6302180710120009 6302202104190001 Alzam Rayyan 4,2 51 1 1 M Ali 6302181206780005 081356845806 Teluk Kemuning 1 1 16/08/2021 10 84 1 1 1 1 1 1 1 1 1

13 7 29-04-2018 P 63021800310003 - Adila Putri 3,1 48 1 1 Baharuddin 6302182003710001 - Teluk Kemuning 1 1 16/08/2021 10,5 94 2 1 1 1 1 1 1 1 1

14 9 16-10-2019 P 63021800310003 - Dina Putri 3 49 1 1 Baharuddin 6302182003710001 - Teluk Kemuning 1 1 16/08/2021 8 54,5 2 1 1 1 1 1 1 1 1

15 5 11/5/2019 P 6302181103100002 6302205105190001 Narsita Ramashan 3,3 48 1 1 Juniansyah 6302181010770001 - Teluk Kemuning 1 1 16/08/2021 9,5 82 2 1 1 1 1 1 1 1 1

16 4 2/4/2018 L 630217310101090009 6302200204180001 Abdul Rasaq 4,5 53 1 1 Abdul Rajab 6302182107700001 - Teluk Kemuning 1 1 16/08/2021 14 98 2 1 1 1 1 1 1 1 1

17 2 30-5-2019 L 6302182801090009 6302203005190001 Naufal Hasyim Ramadhani 2,8 50 1 1 Hasanuddin 6302180107850829 - Teluk Kemuning 1 1 16/08/2021 11,5 84 2 1 1 1 1 1 1 1 1

18 7 15-08-2017 P 6302180406080003 6302185508170001 Kayla Luthfia Putri 2,8 45 1 1 Harianto ,6302182505820001 - Teluk Kemuning 1 1 16/08/2021 13 102 2 1 1 1 1 1 1 1 1

19 8 24-4-2019 L 6302180406080003 6302202104190001 Nizam Arfan Nafif 3,3 48 1 1 Harianto ,6302182505820001 - Teluk Kemuning 1 1 16/08/2021 8,6 78 1 1 1 1 1 1 1 1 1

20 2 28-08-2018 L - - M. Arif 2,8 49 1 1 Hamdi 6302021006820001 - Teluk Kemuning 2 1 16/08/2021 11,5 92 1 1 1 1 1 1 1 1 1

21 3 29-2-2019 L 6302180803170001 - Bima Saputra 3,2 47 1 1 Syahruddin 6302181207930001 - Teluk Kemuning 1 1 16/08/2021 9,5 82 2 1 1 1 1 1 1 1 1

22 8 7/11/2016 L 6302182801090002 6302180711160001 Wahyu Pradana 3,8 50 1 1 Mahmuda 6302180103740001 - Teluk Kemuning 1 1 16/08/2021 14 108 2 1 1 1 1 1 1 1 1

23 1 20-07-2020 P 6302202406000007 6302026001200001 Jihan Firdeani 3,2 48 1 1 Ardiansyah ,6302180909990002 0852499502514 Teluk Kemuning 1 1 16/08/2021 8 77 1 1 1 1 1 1 1 1 1

24 2 24-7-2018 P 6302202406000007 6302026407180001 Ardeani Azizah 3,4 48 1 1 Ardiansyah ,6302180909990002 0852499502514 Teluk Kemuning 1 1 16/08/2021 11 90 2 1 1 1 1 1 1 1 1

25 5 21-02-2019 P 6302062807110001 - Afifah Zahura 3,4 49 1 1 Saparuddin 6302021509870006 - Teluk Kemuning 1 1 16/08/2021 8,4 79 2 1 1 1 1 1 1 1 1

26 3 28-02-2018 P 6302182704010001 - Sukma 2,8 48 1 1 Mail 6302182508780001 - Teluk Kemuning 1 1 16/08/2021 12,2 96 2 1 1 1 1 1 1 1 1

27 2 26-08-2017 L - - Muhammad Zahir 3,5 51 1 1 Sappe 6302190205490001 - Teluk Kemuning 1 1 16/08/2021 14,8 105 2 1 1 1 1 1 1 1 1

28 3 10/8/2018 L 6302182004100002 - Arjuna 3,3 50 1 1 Radiansyah 6302182107870002 - Teluk Kemuning 1 1 16/08/2021 11,5 92 2 1 1 1 1 1 1 1 1

29 6 29-09-2018 P 6302173101080076 - Sofia Salsabila 3,6 50 1 1 Sameruddin 6302170107820010 - Teluk Kemuning 1 1 16/08/2021 12 93 2 1 1 1 1 1 1 1 1

30 1 4/4/2019 L 6302180710120073 - Rfif Nur Rahman 3.3 52 1 1 Rahman 6302180304930001 082224101617 Teluk Kemuning 6 2 16/08/2021 12 86 2 1 1 1 1 1 1 1 1

31 1 5/5/2019 P - - Nuraini Ramadhan 3,1 47 1 1 Sallawangi `6302022508890002 - Teluk Kemuning 1 1 16/08/2021 9 86 1 1 1 1 1 1 1 1 1

32 4 17-7-2019 L 6302180813100001 6302201707190001 Dhafin Algifari 3,5 52 1 1 Idrus 6302170107830015 - Teluk Kemuning 1 2 16/08/2021 9,8 86 1 1 1 1 1 1 1 1 1

33 5 7/5/2017 L 6302180705120001 `- Ramadhani 3,8 51 1 1 M Tahir 6302182106860001 - Teluk Kemuning 2 1 16/08/2021 14,4 102 2 1 1 1 1 1 1 1 1

34 6 22-09-2018 P 6302180705120001 - Melani 3,6 51 1 1 M Tahir 6302182106860001 - Teluk Kemuning 2 1 16/08/2021 11 90 2 1 1 1 1 1 1 1 1

35 2 2/6/2019 L 6302181403170001 - M Fadlian Ramadhan 3 50 1 1 Bidan Sari 6302180304970001 - Teluk Kemuning 2 1 16/08/2021 10 88 2 1 1 1 1 1 1 1 1

36 4 7/4/2018 L 6302180710120019 - M. Fadli 4,5 53 1 1 Saharul 6302180107890002 - Teluk Kemuning 2 1 16/08/2021 11,5 93 2 1 1 1 1 1 1 1 1

37 6 2/11/2017 P 6302180910080003 63021842111170002 Dhafita Luthfia Ismi 3,7 51 1 1 Samang 6302180309700001 - Teluk Kemuning 2 1 16/08/2021 12,5 96 2 1 1 1 1 1 1 1 1

38 5 21-3-2018 P 6302180406080004 6302206103180001 Afifah 3,5 50 1 1 Muhiding 6302181003730001 - Teluk Kemuning 2 1 16/08/2021 12,5 96 2 1 1 1 1 1 1 1 1

39 3 2/4/2018 L 6302182107080002 6302180204180001 Ahmad MuzammulAlfath 3,2 49 1 1 Ahmad Tepu 6302181204850001 - Teluk Kemuning 2 1 16/08/2021 12 95 2 1 1 1 1 1 1 1 1

40 1 14-01-2017 L 630218080802190001 6302185401170002 Nur Asyifa Awalia 2,9 48 1 1 Muhammad Ali 6302181307880003 - Teluk Kemuning 2 1 16/08/2021 13.5 98 2 1 1 1 1 1 1 1 1

41 9 14-04-2018 L 6302170502080118 - Zaikullah Azhari 3,1 48 1 1 Ramli 6302170905720002 - Teluk Kemuning 2 1 16/08/2021 12,2 93 2 1 1 1 1 1 1 1 1

42 2 20-12=2017 L 6302182807170003 - Muhammad Ulul Azmi 2,3 45 1 1 Haeruddin 6302183008980001 - Teluk Kemuning 2 1 16/08/2021 135 98 2 1 1 1 1 1 1 1 1

43 1 21-09-2017 P 6302210806200001 6302221609170001 Zahira Amani 3 49 1 1 Busman 6302180301990002 085248719384 Teluk Kemuning 2 1 16/08/2021 14,5 96 2 1 1 1 1 1 1 1 1

44 2 9/7/2017 P 6302180710120053 6302185007170001 Jelita 3,5 50 1 1 Zaenal Abidin 6302181607900001 - Teluk Kemuning 2 1 16/08/2021 13,5 96 2 1 1 1 1 1 1 1 1

45 2 19-11-2016 L 6302182303150001 6302182711170001 Adinda Ratu 3,1 51 1 1 Randi Wirandi Nata 6302180110950001 - Teluk Kemuning 2 1 16/08/2021 13,5 101 2 1 1 1 1 1 1 1 1

46 2 27-11-2017 L 6302182303150001 6302182711170001 Muhammad Fahri 3,6 51 1 1 Hairul Aspar 6302181207900001 - Teluk Kemuning 2 1 16/08/2021 14 98 2 1 1 1 1 1 1 1 1

47 1 5/4/2019 P 6302182407180001 6302204504190001 Ayesha Nadine 3,1 49 1 1 Sadikinnor 6302021508850002 - Teluk Kemuning 6 2 16/08/2021 11,5 78 2 1 1 1 1 1 1 1 1

48 3 1/5/2019 P 6302170502080140 6302204105190001 Asyifa Azzahra 3,2 49 1 1 Rusdianyah 6302172107850002 - Teluk Kemuning 2 1 16/08/2021 10 82 2 1 1 1 1 1 1 1 1

49 2 2/10/2018 L 6302180710120023 6302200210180001 Muhammad Reihan 3,7 50 1 1 Wahyudin 6302170506870002 - Teluk Kemuning 2 1 16/08/2021 10 91 2 1 1 1 1 1 1 1 1

50 3 16-11-2018 L 630218062507120002 - Andika Pratama 3,2 48 1 1 Japaruddin 6302180107890021 - Teluk Kemuning 2 1 16/08/2021 9,3 90 2 1 1 1 1 1 1 1 1

51 1 17-12-2017 L - - Riansyah 3,2 50 1 1 Romansyah 6302021207000001 081299624047 Teluk Kemuning 2 1 16/08/2021 7,8 72,5 2 1 1 1 1 1 1 1 1

52 4 25-2-2020 P 6302182508150001 6302182508150001 Tisa Alisa 3,5 50 1 1 Muliadi 6302061312860001 - Teluk Kemuning 2 1 16/08/2021 7 70,5 1 1 1 1 1 1 1 1 1

53 7 18-8-2018 P 6302170402080090 - Aqila Salsabila 3,3 49 1 1 Abdul Wahid 6302180401780002 - Teluk Kemuning 3 1 16/08/2021 10 92 2 1 1 1 1 1 1 1 1

54 1 19-09-2016 L - - Muhammad Ftir 3,5 51 1 1 Zulfikar 6302022509960001 - Teluk Kemuning 3 1 16/08/2021 15,8 10 2 1 1 1 1 1 1 1 1

55 3 17-07-2019 L 6302181106150001 - Al Mubarak 3,2 48 1 1 Marwan 6302172403820002 - Teluk Kemuning 3 1 16/08/2021 13 96,5 2 1 1 1 1 1 1 1 1

56 4 9/7/2019 L 6302181106150001 - Al Farizi 3,7 50 1 1 Marwan 6302172403820002 - Teluk Kemuning 3 1 16/08/2021 87 80 2 1 1 1 1 1 1 1 1

57 1 15-10-2019 P 6302182201160001 6302185610160001 Khalizah Naura 3,8 51 1 1 Hamsyah 6302031007840004 - Teluk Kemuning 3 1 16/08/2021 16,8 100 2 1 1 1 1 1 1 1 1

58 2 10/8/2018 L 6302182201160001 6302201008180001 Muhammad Nasran Rohid 4,3 53 1 1 Hamsyah 6302031007840004 - Teluk Kemuning 3 1 16/08/2021 13 95 2 1 1 1 1 1 1 1 1
59 1 18-09-2017 L - - Arkani 3,2 51 1 1 Andra Wijaya 6302180808980001 - Teluk Kemuning 3 1 16/08/2021 13,8 97 2 1 1 1 1 1 1 1 1

60 2 19-12-2017 L 6302182202130001 6302182202130001 Farez Adnan 3,5 50 1 1 Abdul Rahman 6302031409930002 - Teluk Kemuning 3 1 16/08/2021 13 96 2 1 1 1 1 1 1 1 1

61 1 7/5/2017 L 6302180404170001 6302180705170001 Muhammad Raja Firdaus 2,8 46 1 1 Muhmmad Rafi'i 6302051802880002 - Teluk Kemuning 3 1 16/08/2021 15 96 2 1 1 1 1 1 1 1 1

62 4 20-10-2016 P - - Zakia Prajati 3,1 51 1 1 Zulfikar 6302181004880002 - Teluk Kemuning 3 1 16/08/2021 17 113 2 1 1 1 1 1 1 1 1

63 1 31-10-2017 P 6302181801170001 6302187110170001 Agista Salsabila 3,5 57 1 1 Narto Saputra 6302181302920001 - Teluk Kemuning 3 1 16/08/2021 14 103 2 1 1 1 1 1 1 1 1

64 5 18-8-2018 L 6302182819020001 6302201808180001 Hafiz Dzikri 3,3 51 1 1 Kamaruddin 6302181505820001 - Teluk Kemuning 3 1 16/08/2021 11,5 87 2 1 1 1 1 1 1 1 1

65 1 25-09-2018 L 6392180712160002 6392182509180001 Ahmad Rafasta Aditia 3,2 49 1 1 Harianto 6302181706930001 - Teluk Kemuning 3 1 16/08/2021 12 90.5 2 1 1 1 1 1 1 1 1

66 3 27-01-2019 L 6307181711170002 - Apriani Wulandari 4 50 1 1 Muhammad Rizal 6402171704840001 - Teluk Kemuning 3 1 16/08/2021 9,7 76 2 1 1 1 1 1 1 1 1

67 1 11-12-1018 P 6302181311180002 - Atika Zahra 3,8 48 1 1 Irfan Riadi 6302182606980001 - Teluk Kemuning 3 1 16/08/2021 10 86 2 1 1 1 1 1 1 1 1

68 1 28-10-2017 P 6302180103170001 6302186810170001 Aisyah Tari Saputri 3 48 1 1 Taufik 6302180304930002 - Teluk Kemuning 3 1 16/08/2021 13 96 2 1 1 1 1 1 1 1 1

69 2 26-10-2019 L - - Afid Rama Al 4,2 52 1 1 Mariadi - - Teluk Kemuning 3 1 16/08/2021 11,5 83 2 1 1 1 1 1 1 1 1

70 2 26-10-2019 P - - Fika Alya Fikar 3 50 1 1 Zulfikar 6302022509960001 - Teluk Kemuning 3 1 16/08/2021 9,8 81 1 1 1 1 1 1 1 1 1

71 3 3/1/2020 P 6302181806120001 63022043001200001 Aiswah Nahla 3,8 51 1 1 Jabbar 6302182104880002 082354168554 Teluk Kemuning 2 1 16/08/2021 9,8 80 1 1 1 1 1 1 1 1 1

72 7 17-11-2019 L 63021812011000005 - Marlis Maulio 3,5 50 1 1 Rahmadi 6302182604700001 - Teluk Kemuning 4 2 16/08/2021 9,6 78 2 1 1 1 1 1 1 1 1

73 5 29-10-2019 L 63021808061000002 - Muhammad Azhar 3,5 51 1 1 Karman 6302182310780001 - Teluk Kemuning 4 1 16/08/2021 10,2 79 2 1 1 1 1 1 1 1 1

74 1 11/10/2019 L - - Hairil Anwar 2,9 50 1 1 Hariansyah 64080910005770007 - Teluk Kemuning 4 2 16/08/2021 10 78 2 1 1 1 1 1 1 1 1

75 1 1/12/2019 L - - Muhammad Rifki 2,9 49 1 1 Hendri Mulyomo 630218171009500001 - Teluk Kemuning 4 2 16/08/2021 98 77,5 2 1 1 1 1 1 1 1 1

76 1 5/2/2018 P - - Adelia 3 49 1 1 Ardiansyah - - Teluk Kemuning 4 2 16/08/2021 13 96 2 1 1 1 1 1 1 1 1

77 1 29-01-2020 L - - Muhammad Rifaldi 3 47 1 1 Muhammad Rafli - - Teluk Kemuning 4 2 16/08/2021 7,8 75 2 1 1 1 1 1 1 1 1

78 3 10/5/2018 P 6302180710120082 - Humaerah 3,1 48 1 1 Jamiluddin 6302172106800002 - Teluk Kemuning 4 2 16/08/2021 12 92 2 1 1 1 1 1 1 1 1

79 4 11/10/2019 P 6302180710120082 - Humaeni 3,6 50 1 1 Jamiluddin 6302172106800002 - Teluk Kemuning 4 2 16/08/2021 9,6 80 2 1 1 1 1 1 1 1 1

80 2 11/2/2019 L 6302183006140001 - Muhammad Rayyan 4 51 1 1 Rahmadi 6302180902930001 - Teluk Kemuning 4 2 16/08/2021 18 83 2 1 1 1 1 1 1 1 1

81 3 2/8/2018 P 6302183003100001 - Nur Fadila Sofia 4,2 50 1 1 Hamma Onang 630218175730001 - Teluk Kemuning 4 2 16/08/2021 13 93 2 1 1 1 1 1 1 1 1

82 3 24-5-2018 L 6302170202080023 6302204505180002 Muhammad Adli 4 51 1 1 M Idrus 6302181408800003 - Teluk Kemuning 4 2 16/08/2021 13,5 95 2 1 1 1 1 1 1 1 1

83 1 30-1-2017 P 6302022801100003 6302027001170001 Alika Naila Putri 3,8 51 1 1 Rusdiansyah 6302020309920001 - Teluk Kemuning 4 2 16/08/2021 14 104 2 1 1 1 1 1 1 1 1

84 6 10/10/2016 L 6302171102080059 - Muhammad Zaki 3,5 51 1 1 Abdul Karim 630217130260002 - Teluk Kemuning 4 2 16/08/2021 14,5 107 2 1 1 1 1 1 1 1 1

85 7 6/5/2018 P 6302171102080059 - Nur Saqna 3,5 50 1 1 Abdul Karim 630217130260002 - Teluk Kemuning 4 2 16/08/2021 11,6 92,5 2 1 1 1 1 1 1 1 1

86 1 18-04-2017 L - - M. Said 3 51 1 1 Jais 6302182202880001 - Teluk Kemuning 4 2 16/08/2021 15 105,5 2 1 1 1 1 1 1 1 1

87 2 30-09-2018 L - - Fathur Alghifari 3,6 50 1 1 Jais 6302182202880001 - Teluk Kemuning 4 2 16/08/2021 12,5 91 2 1 1 1 1 1 1 1 1

88 1 12/10/2018 P 6302200108190001 630220520180001 Nur Zani 4,1 51 1 1 Sahadi 6302031605930001 - Teluk Kemuning 4 2 16/08/2021 12 78,5 2 1 1 1 1 1 1 1 1

89 2 3/1/2017 P 6302170402080104 - Salma 3,2 51 1 1 Salihu 6302170306780002 - Teluk Kemuning 5 2 16/08/2021 14,8 104 2 1 1 1 1 1 1 1 1

90 1 8/12/2016 L - - Rafiansyah 3 51 1 1 Hendra 6302031403950002 - Teluk Kemuning 5 2 16/08/2021 15 108 2 1 1 1 1 1 1 1 1

91 3 18-10-2017 P 6302180604090009 - Diani 3 50 1 1 Suadi 6302190210860002 - Teluk Kemuning 5 2 16/08/2021 14 104 2 1 1 1 1 1 1 1 1

92 4 7/5/2019 L 6302180604090009 Akbar Ramadhani 3,2 50 1 1 Suadi 6302180210860002 - Teluk Kemuning 5 2 16/08/2021 10 80 2 1 1 1 1 1 1 1 1

93 6 27-05-2019 P 630202050199001 - Putri Aulia 2,6 48 1 1 Hasanuddin 6302020206820003 - Teluk Kemuning 5 2 16/08/2021 10,6 79,5 2 1 1 1 1 1 1 1 1

94 4 10/1/2017 L - - Arfan Irawan Putra 2,9 50 1 1 Bono - - Teluk Kemuning 5 2 16/08/2021 13,5 103,5 2 1 1 1 1 1 1 1 1

95 5 9/5/2017 L 6302180910080005 - Alman 3,5 51 1 1 Usman 6302181712790001 - Teluk Kemuning 5 2 16/08/2021 15 106 2 1 1 1 1 1 1 1 1

96 3 20-09-2017 P 6302182801090004 - Aulia 3,2 50 1 1 Alimuddin 6302180107830827 - Teluk Kemuning 5 2 16/08/2021 15 101 2 1 1 1 1 1 1 1 1

97 2 29-11-2016 L - - Stevan William 2,7 50 1 1 Faisal Anwar - - Teluk Kemuning 5 2 16/08/2021 14,8 106 2 1 1 1 1 1 1 1 1

98 3 24-09-2016 L - - M Arka Pratama 3,7 51 1 1 Irfan - `- Teluk Kemuning 5 2 16/08/2021 17,5 109 2 1 1 1 1 1 1 1 1

99 2 10/2/2018 L - - Muhammad Alfin G. 3,2 51 1 1 Ipin 6302030410830001 - Teluk Kemuning 5 2 16/08/2021 13,5 94,5 2 1 1 1 1 1 1 1 1

100 1 13-10-2018 L - - Imran 1 1 Udin 6302170705830001 - Teluk Kemuning 5 2 16/08/2021 12,4 88 2 1 1 1 1 1 1 1 1

101 4 23-10-2018 P 6302180910080011 - Salsabila 3,6 50 1 1 Kamiluddin 6302180705830001 - Teluk Kemuning 5 2 16/08/2021 13,5 90 2 1 1 1 1 1 1 1 1

102 3 30-06-2019 L 630218411090001 Muhammad Irsyad 3,2 50 1 1 Maradona 6302182005870001 - Teluk Kemuning 5 2 16/08/2021 8,5 79 1 1 1 1 1 1 1 1 1

103 1 2/7/2019 P 6302180604090020 - Dira 3 48 1 1 Salama 6302180302900003 - Teluk Kemuning 5 2 16/08/2021 9 79 1 1 1 1 1 1 1 1 1

104 2 11/9/2019 P 6302180912110002 - Rika Rahim 4 52 1 1 Sudarmin 6302180306800002 - Teluk Kemuning 4 2 16/08/2021 9,2 79,5 1 1 1 1 1 1 1 1 1

105 3 7/8/2019 L 6302180703150002 - Adnan Ramadhan 3,8 53 1 1 Rini 630203171707749991 - Teluk Kemuning 5 2 16/08/2021 11,3 81,5 1 1 1 1 1 1 1 1 1

106 4 21-02-2017 P - - Siti Aulia 3.1 50 1 1 Abu Yasid - - Teluk Kemuning 5 2 16/08/2021 14 100 2 1 1 1 1 1 1 1 1

107 2 4/11/2019 L 6302022212120001 - Farel 4 51 1 1 Rudi Hartono 6302180205940001 - Teluk Kemuning 5 2 16/08/2021 10,2 74,5 1 1 1 1 1 1 1 1 1

108 5 31-3-2019 P 6302180710120074 - Selina 3,1 48 1 1 Hendra 6302180203900001 - Teluk Kemuning 6 2 16/08/2021 12 80 1 1 1 1 1 1 1 1 1

109 2 8/11/2016 P 6302180710120038 6302184811160001 Anindi Fauziah 4 52 1 1 Mustar 630218030880001 - Teluk Kemuning 6 2 16/08/2021 15 106,5 2 1 1 1 1 1 1 1 1

110 2 9/10/2016 L 6302181311070065 6302180910160001 Firsan 3 50 1 1 Murdin 6302181509700001 - Teluk Kemuning 6 2 16/08/2021 15 106 2 1 1 1 1 1 1 1 1

111 3 27-10-2018 L 6302181311070065 - Farhan 3,2 49 1 1 Murdin 6302181509700001 - Teluk Kemuning 6 2 16/08/2021 10,5 84,5 2 1 1 1 1 1 1 1 1

112 6 20-07-2017 P 6302182406140001 6302186007170001 Safna 3 48 1 1 Abd Ahmad 6302032511780001 - Teluk Kemuning 6 2 16/08/2021 14 95,5 2 1 1 1 1 1 1 1 1

113 1 18-06-2017 L 6302180404170002 6302180206170001 Rama Dani 2,8 47 1 1 Zainal 6302181305930001 - Teluk Kemuning 6 2 16/08/2021 14,5 95,5 2 1 1 1 1 1 1 1 1

114 1 18-7-2019 P 6302180301190003 6302205807190001 Alona Meisyah 3,3 50 1 1 Husnan Ariadi 6302020303940001 - Teluk Kemuning 6 2 16/08/2021 9 75 1 1 1 1 1 1 1 1 1

115 4 9/8/2019 L 6302180710120077 6302200908190001 Abdul Aziz 2,8 45 1 1 Samsuddin 6302180906780001 - Teluk Kemuning 6 2 16/08/2021 9 75 1 1 1 1 1 1 1 1 1

116 1 21-11-2018 L 6302180510170002 - Muhammad Hafis 3,2 49 1 1 Rahmat 6302182706820002 - Teluk Kemuning 6 2 16/08/2021 10,5 86 1 1 1 1 1 1 1 1 1

117 2 26-01-2017 L 6302180710120067 6302182601170001 Firman 4,1 53 1 1 Hamsyah 6302181212830001 - Teluk Kemuning 6 2 16/08/2021 16 105 2 1 1 1 1 1 1 1 1

118 2 23-10-2016 L 6302189005140003 6302182310160001 Aditia Rifki A 3,2 51 1 1 Rudiansyah 6302180609930001 - Teluk Kemuning 6 2 16/08/2021 15,5 106,5 2 1 1 1 1 1 1 1 1

119 2 11/3/2018 L 6302182101170001 - Saputra 3 50 1 1 Muslim 6202170603950002 - Teluk Kemuning 6 2 16/08/2021 13 92,5 2 1 1 1 1 1 1 1 1

120 3 19-09-2018 P 6302180905140003 - Halula Farzina 4 49 1 1 Rudiansyah 6302180609930001 - Teluk Kemuning 6 2 16/08/2021 14,5 87,5 2 1 1 1 1 1 1 1 1

121 8 30-6-2019 P 630218230908000 - Raya Sapralia 4,9 53 1 1 Juliansyah 6302180607760002 - Teluk Kemuning 6 2 16/08/2021 11,5 87,5 2 1 1 1 1 1 1 1 1

122 2 18-8-2017 P 6302180111130001 6302185808170001 Aisya Aliani Arka 4,6 52 1 1 Ilham m 6302182502870001 - Teluk Kemuning 6 2 16/08/2021 14,5 87,5 2 1 1 1 1 1 1 1 1

123 5 9/9/2018 P 630218183100002 - Nelsa Sagita 3,9 50 1 1 Bahtiar - - Teluk Kemuning 6 2 16/08/2021 12 108 2 1 1 1 1 1 1 1 1
124 3 25-10-2016 L 6302180210180003 6302182510160002 Boy Sandii 3 51 1 1 Yahya 6302180107840833 - Teluk Kemuning 6 2 16/08/2021 14 104 2 1 1 1 1 1 1 1 1

125 2 2/4/2018 L 6302030610080142 - Ahmad Arlan 3 48 1 1 Kamaruddin 6302030810680001 - Teluk Kemuning 6 2 16/08/2021 14 96 2 1 1 1 1 1 1 1 1

126 3 22-12-2016 L 6302182801090005 6302182212160001 Fadliansyah 3,2 51 1 1 Jasanuddin 6302182404790001 - Teluk Kemuning 6 2 16/08/2021 12,5 107,5 2 1 1 1 1 1 1 1 1

127 5 23-04-2017 P 6302182302090043 - Safira 2,8 46 1 1 Abdul Hamid ,6302182011040003 - Teluk Kemuning 6 2 16/08/2021 15,2 100 2 1 1 1 1 1 1 1 1

128 1 8/9/2017 L 6302180204180001 6302180809170002 Rafaska 3,5 52 1 1 Karman 6302181212970001 - Teluk Kemuning 6 2 16/08/2021 16 103 2 1 1 1 1 1 1 1 1

129 2 28-5-2019 L 6302180204180001 - Nuh Rifki 3 50 1 1 Karman 6302181212970001 - Teluk Kemuning 6 2 16/08/2021 9,4 80 2 1 1 1 1 1 1 1 1

130 6 30-04-10`9 L - - Muhammad Arif 41 52 1 1 Heru Sentosa 6302022807790001 - Teluk Kemuning 6 2 16/08/2021 12 82 2 1 1 1 1 1 1 1 1

131 1 9/10/2017 P 6302185608980001 - Sarisa Musifa 3,5 51 1 1 Sahril - - Teluk Kemuning 6 2 16/08/2021 13 95,5 2 1 1 1 1 1 1 1 1

132 2 2/9/2018 L 6302185608980001 - Azril Muammar 3,5 52 1 1 Sahril - - Teluk Kemuning 6 2 16/08/2021 14 84 2 1 1 1 1 1 1 1 1

133 1 16-1-2017 P - - Naila Devina 3,2 50 1 1 Rusdianyah - - Teluk Kemuning 6 2 16/08/2021 14,4 97 2 1 1 1 1 1 1 1 1

134 4 4/4/2018 P - 6302024404180002 Anita 3,3 50 1 1 Saripuddin 6302022602830001 - Teluk Kemuning 6 2 16/08/2021 12 88 2 1 1 1 1 1 1 1 1

135 1 6/11/2018 P 6302180806180001 - Nur Luthfia Sofia 4,2 52 1 1 Baldi Syaifullah 6302091901930002 - Teluk Kemuning 6 2 16/08/2021 11,5 85 2 1 1 1 1 1 1 1 1

136 7 3/12/2019 P 6302180703150007 - Naila Putri 3,5 52 1 1 Burhan 6302041608780001 - Teluk Kemuning 6 2 16/08/2021 11,2 84 2 1 1 1 1 1 1 1 1

137 2 8/2/2019 P - - Adila Nisa 3,8 50 1 1 Syardani 6302182306930001 - Teluk Kemuning 6 2 16/08/2021 10 80,5 2 1 1 1 1 1 1 1 1

138 1 28-03-2019 L - - Muhammad Aqil Aryan 2,8 48 1 1 Ependam 5304241809970002 - Teluk Kemuning 6 2 16/08/2021 11,5 85 2 1 1 1 1 1 1 1 1

139 2 24-3-2018 l 6302181904160001 6302202403180001 M Ummar Alfarizi 3 50 1 1 Zainal 6302182402960001 - Teluk Kemuning 6 2 16/08/2021 11,2 84 2 1 1 1 1 1 1 1 1

140 1 24-03-2018 P - - Almira Tisa 2,8 45 1 1 Ahmad Bakri 6302020609960001 - Teluk Kemuning 6 2 16/08/2021 9,8 80 2 1 1 1 1 1 1 1 1

141 3 1/9/2019 P 6302110202080036 - Raina Syakila 4 50 1 1 Naharudin 6302180203800003 - Teluk Kemuning 6 2 16/08/2021 10,6 80 2 1 1 1 1 1 1 1 1
142 6 25-10-2016 P 6302180704090004 6302186510160001 Nur Isani 3,2 51 1 1 Alimuddin 6302182706820002 - Teluk Kemuning 6 2 16/08/2021 14,8 108,5 2 1 1 1 1 1 1 1 1

143 6 19-3-2018 L 6302180707120001 - Muhammas arya 4,5 53 1 1 Kaco 6302182002800001 - Teluk Kemuning 6 2 16/08/2021 13,6 94 2 1 1 1 1 1 1 1 1

144 2 9/12/2017 L 63021822021300001 6302181912170001 FarezAdnan 3,3 50 1 1 Abdul Rahman 6302031409930003 085348141361 Teluk Kemuning 3 1 16/08/2021 13 96 2 1 1 1 1 1 1 1 1

145 4 23-03-2020 L 6302181711170002 - Muhammad Rizaldi 3,4 50 1 1 M Rizal 6402171704840001 082152996999 Teluk Kemuning 3 1 16/08/2021 10,5 74,5 1 1 1 1 1 1 1 1 1

146 1 31-03-2020 L - - Jasman 3,2 52 1 1 Dardiansyah ,6302182810010002 - Teluk Kemuning 1 1 16/08/2021 9,8 78 1 1 1 1 1 1 1 1 1

147 8 4/4/2020 L - - Azka Erlan Tahir 4 51 1 1 Abdul Wahid 6302180401780001 - Teluk Kemuning 3 1 16/08/2021 8,6 75 1 1 1 1 1 1 1 1 1

148 4 6/4/2020 P 6302182509130001 - Nadira Herdianti 3,4 50 1 1 Harianto 6302181912840001 - Teluk Kemuning 2 1 16/08/2021 9,4 73 1 1 1 1 1 1 1 1 1

149 1 12/4/2020 L - - Muhammad Hafiz Ansari 3,6 50 1 1 Nasrullah 6302182212980002 - Teluk Kemuning 3 1 16/08/2021 9,3 80 1 1 1 1 1 1 1 1 1

150 6 6/5/2020 P 6302170502080078 6302204605200001 Hesti 3,5 50 1 1 Nurdiansyah 6302170107820031 - Teluk Kemuning 2 1 16/08/2021 8,3 77 1 1 1 1 1 1 1 1 1

151 7 14-04-2020 L 63021806604090026 - M. Ramadan 3 50 1 1 Hanis 6302180207760001 - Teluk Kemuning 4 2 16/08/2021 7,5 70 1 1 1 1 1 1 1 1 1

152 1 22-5-2020 P 6302170202080020 - Sujasmin 2,8 49 1 1 Suriansyah 6302172606810000 - Teluk Kemuning 6 2 16/08/2021 9,4 74,5 1 1 1 1 1 1 1 1 1

153 3 30-5-2020 P 6302181503130001 63022070050001 Nurmiati Putri 3,1 47 1 1 Samsuddin 6302181104920002 - Teluk Kemuning 1 1 16/08/2021 8,7 75 1 1 1 1 1 1 1 1 1

154 4 2/6/2020 P 630218261200002 - Aisya Humairah 3,8 51 1 1 Ahmad Riadi 6302180709910001 - Teluk Kemuning 3 1 16/08/2021 8,3 76 1 1 1 1 1 1 1 1 1

155 3 6/6/2020 P 6302180209140002 - Fatimah Zahro 3,7 51 1 1 Roniansyah 6302020803830002 - Teluk Kemuning 6 2 16/08/2021 7,8 78 1 1 1 1 1 1 1 1 1

156 1 25-06-2020 L - - M Rival Jaelani 3 49 1 1 rizal Tanjung 6302181010000003 - Teluk Kemuning 1 1 16/08/2021 9,7 76 1 1 1 1 1 1 1 1 1

157 2 11/3/2018 L 6302182101170001 - Saputra 3 50 1 1 Muslim 6202170603950002 - Teluk Kemuning 6 2 16/08/2021 7,6 75 1 1 1 1 1 1 1 1 1

158 1 29-06-2020 L - - Abdul Rahim 3,5 50 1 1 Erwin 630218406020002 - Teluk Kemuning 2 1 16/08/2021 7,2 74 1 1 1 1 1 1 1 1 1

159 4 9/7/2020 P 63021822080800001 - Aqila Humairah 2,4 46 1 1 Sudarman 6302180510740004 - Teluk Kemuning 3 1 16/08/2021 9 75,5 1 1 1 1 1 1 1 1 1

160 4 27-7-2020 P 6302182604140001 - Aulia Khusnul Khotimah 3,9 51 1 1 Hanari 6302182007820003 - Teluk Kemuning 1 1 16/08/2021 8,5 75 1 1 1 1 1 1 1 1 1

161 2 18-7-2020 L - - M Ammar 3,8 51 1 1 Sallawangi `6302022508890002 - Teluk Kemuning 1 1 16/08/2021 9,8 76 1 1 1 1 1 1 1 1 1

162 1 7/8/2020 P - - Maimunah 3,8 50 1 1 Rizal 6302024101010827 - Teluk Kemuning 4 2 16/08/2021 8,6 74 1 1 1 1 1 1 1 1 1

163 5 10/8/2020 L 6302180710120070 - Markani 2,7 48 1 1 Samsuddin 6302180906780000 - Teluk Kemuning 1 1 16/08/2021 8 74 1 1 1 1 1 1 1 1 1

164 5 12/8/2020 P 6302173101080050 - Mirsa Amelia 2,5 46 1 1 Bahtiar 6302170107100010 - Teluk Kemuning 6 2 16/08/2021 7,3 68,5 1 1 1 1 1 1 1 1 1

165 5 12/8/2020 P 6302182303150001 - Muhammad rafa 3,1 50 1 1 Muslimin 6302031302930001 - Teluk Kemuning 4 2 16/08/2021 9 75 1 1 1 1 1 1 1 1 1

166 3 12/9/2020 P 6302182303150001 - Nairah 3,5 50 1 1 Hairul Aspar 6302181207900001 - Teluk Kemuning 2 1 16/08/2021 8,8 74,5 1 1 1 1 1 1 1 1 1

167 2 14-09-2020 P 6302180103170001 - Muhammad Rayyan 2,8 48 1 1 Taufik 6302180304930002 - Teluk Kemuning 1 1 16/08/2021 8,8 72,5 1 1 1 1 1 1 1 1 1
168 1 4/10/2020 P 6302200209190000 - Mutmainnah 3 50 1 1 Jamaluddin 6302021302930001 - Teluk Kemuning 4 2 16/08/2021 8,4 71 1 1 1 1 1 1 1 1 1

169 2 23-10-2020 L 6302182611140000 - Muhammad Afnan 4 50 1 1 Agus Safari 6302181607920001 - Teluk Kemuning 6 2 16/08/2021 9,5 74 1 1 1 1 1 1 1 1 1

170 1 22-11-2020 L - - Muhammad Revan 3 48 1 1 Sembara 630218060990001 - Teluk Kemuning 4 2 16/08/2021 8,2 70 1 1 1 1 1 1 1 1 1

171 1 30-11-2020 L - - Muhammad Akmal 2,8 48 1 1 Erwiansyah 3529230807970002 - Teluk Kemuning 3 1 16/08/2021 8,2 75 1 1 1 1 1 1 1 1 1

172 3 8/12/2020 P 6302180710120053 - Ghina Kolbu Rafifa 2,9 48 1 1 Zainal Abidin 6302181607900001 - Teluk Kemuning 3 1 16/08/2021 8,8 73 1 1 1 1 1 1 1 1 1

173 3 15-12-2020 L 6302180203150005 - Satria Sadriannor 3,9 51 1 1 Sadaruddin ,6302181404930002 - Teluk Kemuning 5 2 16/08/2021 7,6 70 1 1 1 1 1 1 1 1 1

174 5 18-12-2020 P 6302203012190001 - Nadira Putri 4,2 51 1 1 Abdul Rajab 6302182102760001 - Teluk Kemuning 1 1 16/08/2021 7,8 70 1 1 1 1 1 1 1 1 1

175 3 25-12-2020 L - - Azzam Aulian Putra 3,8 51 1 1 Rudiansyah 6302020309920001 - Teluk Kemuning 4 2 16/08/2021 5,4 63 1 1 1 1 1 1 1 1 1

176 3 26-12-2020 L 6302180810120001 - Andres 3,8 51 1 1 Kasman 6302182805920001 - Teluk Kemuning 5 2 16/08/2021 7,8 68 1 1 1 1 1 1 1 1 1

177 5 12/1/2021 P 630218180810120003 - Wulan 3,8 50 1 1 Burhanuddin 6302170805920002 - Teluk Kemuning 5 2 16/08/2021 7,4 67,5 1 1 1 1 1 1 1 1 1

178 3 17-1-2021 P 6302180111130001 - Cici Thalia 4,9 51 1 1 Kham 6302180504850001 - Teluk Kemuning 6 2 16/08/2021 8,3 68 1 1 1 1 1 1 1 1 1

179 3 26-01-2021 P 6302180304930001 - Anasya Aufa Rahman 3,7 53 1 1 Abdul Rahman 6302180710120073 - Teluk Kemuning 6 2 16/08/2021 7,7 74 1 1 1 1 1 1 1 1 1

180 1 6/2/2021 P - - Meisya Salsabila 3,7 51 1 1 Muhammad Wahid 63021825040000001 - Teluk Kemuning 4 2 16/08/2021 7,5 71 1 1 1 1 1 1 1 1 1

181 3 22-02-2021 P P '6302181904160001 - Muhammad Kholil 3,5 51 1 1 Sainal 6302182402960001 - Teluk Kemuning 6 2 16/08/2021 8,2 71 1 1 1 1 1 1 1 1 1

19 162

Mengetahui,
Plt. Kepala Puskesmas Tanjung Lalak Tanjung Lalak, 16 Agustus 2021
Kec. Pulau Laut Kepulauan Pembuat Laporan,

Muhammad Nur, AMG


Hasbullah, SKM Nip. 19910909 201403 1 001
Nip. 19700403 199101 1 003

Ayu Istiqomah, A.Md.Gz

NRPTT. 11.7.2017.3.4.06
FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Manrewasa


Kabupaten/Kota : Kotabaru Bulan : Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Pulau Kerasian

IMD Vitamin A
Kepemilik ASI Eksklusif Vitamin A
Februari
an Buku 1 = Ya Agustus
Panjang Cara Ukur
Berat KIA/KMS
Badan /
No Anak Ke Tanggal Lahir Jenis No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Badan Panjang Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Tanggal BB (Kg) 2 =Tidak
Tinggi 1= 1
Kelamin Lahir Lahir 1 = Ya Pengukuran 1 =Ya
Badan(cm Telentang =Ya
(gram)
1 =Ya ) 2 =berdiri
2=
2 2
Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 2 =Tidak
= Tidak =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 3 - L 6302181312130002 - Muhammad Refan 2,5 47 1 1 Wahyuddin 6403022711790002 - Pulau Karasian 1 1 18/08/2021 7 78 2 1 1 1 1 1 1 1 1

2 4 17-6-2019 P 6302182603090024 6302205706190001 Ainun Alfisah 3,1 49 1 1 Darhan 6302170107780010 - Pulau Karasian 1 1 18/08/2021 12 80 2 1 1 1 1 1 1 1 1

3 1 3/12/2017 P 6302182603090024 6.302188431217E+016 Fatihyl Hidatah 2,7 47 1 1 Ikal Ratno 6302180505870002 - Pulau Karasian 1 1 18/08/2021 13 96 2 1 1 1 1 1 1 1 1

4 2 24-5-2016 L 6302181611130001 - Muhammad Algibran 2,6 47 1 1 Rendi Pranata 6302172611910003 - Pulau Karasian 1 1 18/08/2021 10 82 2 1 1 1 1 1 1 1 1

5 5 12/6/2017 L 6302180304090010 6302181205170001 Muhammad reyhan 2,7 47 1 1 Kunding 6302180107600841 - Pulau Karasian 1 1 18/08/2021 14 100 2 1 1 1 1 1 1 1 1

6 2 7/4/2016 P 6302180608140001 6302184704160001 Ranita 3 49 1 1 Patno 6302181109870001 - Pulau Karasian 1 1 18/08/2021 15 102 2 1 1 1 1 1 1 1 1

7 3 26-3-2020 P 6302180608140001 6302206603200001 Nursyifa 2,7 46 1 1 Patno 6302181109870001 - Pulau Karasian 1 1 18/08/2021 8,5 80 2 1 1 1 1 1 1 1 1

8 3 19-6-2017 L 6302182701110014 6302181906170001 Rendra Ramadani 3 48 1 1 Umar 6302181907800002 - Pulau Karasian 1 1 18/08/2021 12 91 2 1 1 1 1 1 1 1 1

9 3 29-4-2016 P 6302181303090002 63021869041600001 Najwa Khairunnisa 2,9 46 1 1 Robbi 6302180503850001 - Pulau Karasian 1 1 18/08/2021 12 95 2 1 1 1 1 1 1 1 1

10 3 26-3-2020 L 6302182206130001 - Rafi Aflan 3 48 1 1 Wahyuddin 6302170807830002 - Pulau Karasian 1 1 18/08/2021 9 81 1 1 1 1 1 1 1 1 1

11 1 1/1/2016 P 6302180408170001 6302184101160001 Anindia Adiba Sakila 3 48 1 1 Aldi 6302171009960002 - Pulau Karasian 1 1 18/08/2021 13 95 2 1 1 1 1 1 1 1 1

12 3 15-4-2018 L 6302183012080001 6302201504180001 Farid Yusran 3 49 1 1 Farhan 6302180212850002 - Pulau Karasian 1 1 18/08/2021 10 97 2 1 1 1 1 1 1 1 1

13 1 1/1/2016 P 6302182102180001 6302184101160002 Asila Yumna 2,9 47 1 1 Irfandi N Hama 7605031412940001 - Pulau Karasian 1 1 18/08/2021 13 96 2 1 1 1 1 1 1 1 1

14 1 7/9/2018 P 6302181209150003 6302204709180001 Servi Intan Maulani 2,7 46 1 1 Rizal Fauzi 6302180402900001 - Pulau Karasian 1 1 18/08/2021 12 89 2 1 1 1 1 1 1 1 1

15 2 7/5/2017 P 6302181112080078 6302184705170001 Jitni Lufita 3,1 49 1 1 Riki Hamdani 6302182812780002 - Pulau Karasian 1 1 18/08/2021 13 100 2 1 1 1 1 1 1 1 1

16 1 23-10-2017 P 6302181610170002 6302206310170001 Naura Alvira 2,9 48 1 1 Nuaris 6302181508890002 - Pulau Karasian 1 1 18/08/2021 13 96 2 1 1 1 1 1 1 1 1

17 2 2/8/2020 L 6302181610170002 - Iman Ramadhan 3 47 1 1 Nuaris 6302181508890002 - Pulau Karasian 1 1 18/08/2021 9,2 80 2 1 1 1 1 1 1 1 1

18 1 16-02-2017 P 6302182007080001 6302015602170001 Naila Alpisah Liani 3 49 1 1 Rahim 6302182007540001 - Pulau Karasian 1 1 18/08/2021 13 95 2 1 1 1 1 1 1 1 1

19 - 1/5/2021 P - - Kayla Ramadani 2,9 47 1 1 Sapruddin - - Pulau Karasian 1 1 18/08/2021 6 52 1 1 1 1 1 1 1 1 1

20 1 24-04-2021 P - - Aprilia Laili Ramadani 3 46 1 1 Hamdani - - Pulau Karasian 1 1 18/08/2021 6,1 64 1 1 1 1 1 1 - - 2

21 - 11/1/2021 P - - Afrah Nairah 2,7 46 1 1 Muslimin - - Pulau Karasian 1 1 18/08/2021 7,5 70 1 1 1 1 1 1 1 1 1

22 3 25-03-2020 P 6302182603090030 - Aira Saiwa 2,8 46 1 1 Irfan Suandi 6302181301870003 - Pulau Karasian 1 1 18/08/2021 8 80 2 1 1 1 1 1 1 1 1

23 2 2/3/2021 L - - Muhammad Dzikrah Rafsanjani 3 47 1 1 Ali Akbar Rafsanjani - - Pulau Karasian 1 1 18/08/2021 8,8 69 1 1 1 1 1 1 1 1 1

24 - 29-02-2020 P - - Ailen SahiraAfrani 2,8 47 1 1 Samanuddin - - Pulau Karasian 1 1 18/08/2021 6.4 87 1 1 1 1 1 1 1 1 1

25 2 30-6-2017 L 6302182301130001 6302183006170001 Muhammad Rifal Al Kahfi 3,2 49 1 1 Hamdani Amd 6302182207840001 - Pulau Karasian 2 1 18/08/2021 14 96 1 1 1 1 1 1 1 1 1

26 3 1/8/2017 L 6302181209080015 6302200108170001 Ilham 2,9 48 1 1 Ramli 6302180101810004 - Pulau Karasian 2 1 18/08/2021 11 89 1 1 1 1 1 1 1 1 1

27 2 23-9-2017 L 6302180411140002 6302182309170001 Ahmad Zidan Algibran 3 48 1 1 Madwan 6302180101840004 - Pulau Karasian 2 1 18/08/2021 13 97 1 1 1 1 1 1 1 1 1

28 1 21-04-2018 P - - Syafiatul Aini 3 48 1 1 Asmar marro - - Pulau Karasian 2 1 18/08/2021 10 87 1 1 1 1 1 1 1 1 1

29 2 24-12-16 P 6302180908170003 6302186412160001 Shakila Aulia Amri 3 49 1 1 Hermansyah 6302181506870001 - Pulau Karasian 2 1 18/08/2021 13 99 1 1 1 1 1 1 1 1 1

30 3 10/11/2017 L 6302180309140002 6302181011170001 Alam Dimas 3 49 1 1 Saddam 6302181005920002 - Pulau Karasian 2 1 18/08/2021 12 108 1 1 1 1 1 1 1 1 1

31 4 11/5/2019 P 6302181108080003 6302205105190002 Silmi Kamadani 3 47 1 1 Ismail 6302182004760001 - Pulau Karasian 2 1 18/08/2021 12 85 1 1 1 1 1 1 1 1 1

32 2 11/6/2019 P 6302182710160001 6302205106190001 Putri Safirah 3,1 49 1 1 Lukman 6302180107710836 - Pulau Karasian 2 1 18/08/2021 12 87 1 1 1 1 1 1 1 1 1

33 6 7/8/2016 P 6302171102080044 6302184708160001 Salsabila 3 49 1 1 M.Saleh 6302170102740002 - Pulau Karasian 2 1 18/08/2021 14 98 1 1 1 1 1 1 1 1 1

34 4 21-2-2018 L 6302180301090025 6302202102180001 Ahmad Zaki 2,9 48 1 1 Suhardi 6302180301770001 - Pulau Karasian 2 1 18/08/2021 13 97 1 1 1 1 1 1 1 1 1

35 4 17-04-2019 P - - Nur Elina 2,6 46 1 1 Saharoni - - Pulau Karasian 2 1 18/08/2021 10 82 1 1 1 1 1 1 1 1 1

36 3 9/4/2019 P 6302031901110021 6302204904190001 Azizah Azzahra 3 48 1 1 Mismaruddin 6302032612860001 - Pulau Karasian 2 1 18/08/2021 10 83 1 1 1 1 1 1 1 1 1
37 4 - P 6302180601100008 - Nurfatimah azzahra - - 1 1 Ramsisi 6302181707820002 - Pulau Karasian 2 1 18/08/2021 9 83 1 1 1 1 1 1 1 1 1

38 2 5/10/2018 P 6302181202160002 - Wafika Hapria 3 49 1 1 Amril 6302181711170001 - Pulau Karasian 2 1 18/08/2021 12 90 1 1 1 1 1 1 1 1 1

39 3 25-10-2018 P 6302182604120001 6302186510180001 Sabria Fathia Afrah 2,8 46 1 1 Albar Kurniawan 6302031203860002 - Pulau Karasian 2 1 18/08/2021 13 89 1 1 1 1 1 1 1 1 1

40 2 22-07-2021 L 6302201908190001 - Ahmad siddik 3 49 1 1 Maksum 6302010606880001 - Pulau Karasian 2 1 18/08/2021 4,4 50 1 1 1 - - - - - 2

41 2 11/9/2017 P 6302181405130001 6302185109710001 Naira Alfadila 3 48 1 1 Nasrullah 6302182706900003 - Pulau Karasian 2 1 18/08/2021 13 95 2 1 1 1 1 1 1 1 1

42 1 17-2-2019 P - - Nur Afifah 2,7 46 1 1 Nasruddin - - Pulau Karasian 2 1 18/08/2021 11 90 2 1 1 1 1 1 1 1 1

43 2 9/4/2017 L - - Muhammad Altan Yasif 3 48 1 1 Saldi Mansyah - - Pulau Karasian 2 1 18/08/2021 16 97 2 1 1 1 1 1 1 1 1

44 3 14-05-2019 P - - Nur Aisya Ramadani 3,1 49 1 1 Saldi Mansyah - - Pulau Karasian 2 1 18/08/2021 9,8 89 2 1 1 1 1 1 1 1 1

45 3 29-1-2017 L 6302181806160001 6302182901170001 Aldo Saputra 3 46 1 1 Rijal 6302105006890001 - Pulau Karasian 3 1 18/08/2021 10 98 2 1 1 1 1 1 1 1 1

46 2 26-4-2018 L 6302170502080059 6302182609180001 M. Nur Wahid 3 47 1 1 Saharuddin 6302170107760011 - Pulau Karasian 3 1 18/08/2021 9,7 90 2 1 1 1 1 1 1 1 1

47 2 3/4/2019 L 6302180504170001 6302200104190001 Muhammad Adnan 2,9 47 1 1 Saepullah 6302171301930002 - Pulau Karasian 3 1 18/08/2021 10 91 2 1 1 1 1 1 1 1 1

48 2 8/11/2017 L 6302180309150001 6302200209180001 Deo Setiawan 2,8 49 1 1 Aan Setiawan 6302182008920001 - Pulau Karasian 3 1 18/08/2021 10,5 92 2 1 1 1 1 1 1 1 1

49 3 2/9/2018 L 6302200203190001 6302200209180001 Muhammad Naufal Hakim 2,7 46 1 1 Samsuddin 7310022309800001 - Pulau Karasian 3 1 18/08/2021 11 90 2 1 1 1 1 1 1 1 1

50 2 13-2-2019 L 6302180910120002 6302201303190001 Mudhalol Asrar 3 48 1 1 Habliansyah 6302170506860002 - Pulau Karasian 3 1 18/08/2021 11 90 2 1 1 1 1 1 1 1 1

51 1 24-10-2017 L 6302180704170002 6302182410170001 Rifki Pratama 3,1 47 1 1 Safriansyah 6302182705920001 - Pulau Karasian 3 1 18/08/2021 12 91 2 1 1 1 1 1 1 1 1

52 2 10/6/2021 L - - Zaidan 3 49 1 1 Safriansyah 6302182705920001 - Pulau Karasian 3 1 18/08/2021 6 60 1 1 1 1 - - - - 2

53 4 27-11-2017 L 6302182907110001 - M. Alfatih 2,9 46 1 1 Agus Harianto 6302180208820002 - Pulau Karasian 3 1 18/08/2021 13 93 2 1 1 1 1 1 1 1 1

54 5 31-10-2016 L 6302170502080018 6302183110150001 Ahmad Khairat 2,7 47 1 1 Sirajuddin 6302180208820002 - Pulau Karasian 3 1 18/08/2021 14 100 2 1 1 1 1 1 1 1 1

55 1 30-03-2021 L - - M. Atha Raihan Syakiel 2,6 47 1 1 Refki Riskullah - - Pulau Karasian 3 1 18/08/2021 5,7 60 1 1 1 1 1 1 1 1 1

56 1 4/7/2020 L - - Ahmad Rasyid Riswan 2,6 46 1 1 Riswan - - Pulau Karasian 3 1 18/08/2021 9 87 1 1 1 1 1 1 1 1 1

57 1 15-04-2021 - - Qiana Putri Allura 2,7 48 1 1 Hasrullah - - Pulau Karasian 3 1 18/08/2021 5,4 64 1 1 1 1 1 - - - 2

58 3 25-5-2017 P 6302182703090049 6302186505170001 Nur Asila 3 46 1 1 Samsul 6302180107630839 - Pulau Karasian 4 2 18/08/2021 12 90 2 1 1 1 1 1 1 1 1

59 1 13-6-2-18 L 6302180712170001 6302181306180001 Ramadan 2,9 49 1 1 Hermansyah 6302172611930002 - Pulau Karasian 4 2 18/08/2021 10 90 2 1 1 1 1 1 1 1 1

60 3 16-7-2018 L - - Muh Ahsan Fauzi 3 47 1 1 Jumarlis - - Pulau Karasian 4 2 18/08/2021 10,7 90 2 1 1 1 1 1 1 1 1

61 3 25-4-2019 P 6302180801100001 6302206504190001 Nurul Nufidah 2,7 46 1 1 Syamsuddin 6302181808720001 - Pulau Karasian 4 2 18/08/2021 12 92 2 1 1 1 1 1 1 1 1

62 2 13-6-2017 P 6310060103170008 6310065306170002 Alif Ramadani 3.1 49 1 1 Suriansyah 6310090112840005 - Pulau Karasian 4 2 18/08/2021 13 95 2 1 1 1 1 1 1 1 1

63 4 11/9/2017 P 7605021712130002 - Nuril Anjani 3,1 49 1 1 Ibrahim 7605020505790002 - Pulau Karasian 4 2 18/08/2021 12 90 2 1 1 1 1 1 1 1 1

64 6 14-4-2019 L 6302202907200009 6302201404190001 Khairul Al Ibnu 2,8 47 1 1 Ibrahim H 7605020505790002 - Pulau Karasian 4 2 18/08/2021 10 83 2 1 1 1 1 1 1 1 1

65 1 4/1/2020 L - - Muhammad Muzaky 3 47 1 1 Bambang Ali Akbar - - Pulau Karasian 4 2 18/08/2021 9 80 2 1 1 1 1 1 1 1 1

66 5 3/9/2018 P 6302170802080065 - Rahma Dani 2,7 46 1 1 Sumarjo 6302170301640002 - Pulau Karasian 4 2 18/08/2021 10,7 89 2 1 1 1 1 1 1 1 1

67 3 22-05-2019 L ,6302182703090080 - M. Risky 2,6 47 1 1 Bohari 6302181807810001 - Pulau Karasian 4 2 18/08/2021 10,8 90 2 1 1 1 1 1 1 1 1

68 3 28-4-2020 P 6302180410120002 6302206804200001 Humairah Ramadani 2,8 46 1 1 Lukman 6302180512720001 - Pulau Karasian 4 2 18/08/2021 9,2 89 2 1 1 1 1 1 1 1 1

69 4 -2026 L - - Abid Pranaja 3 47 1 1 Eliyanto - - Pulau Karasian 4 2 18/08/2021 9,6 87 2 1 1 1 1 1 1 1 1

70 1 11/10/2019 L 6302180110180003 6302201103190001 M. Fadil 2,6 45 1 1 Andriadi 6302180709900003 - Pulau Karasian 4 2 18/08/2021 9 89 2 1 1 1 1 1 1 1 1

71 5 28-3-2020 P 6302181209080009 6302206803200001 Vania azzahra 2,7 46 1 1 Riswan 6302180204820001 - Pulau Karasian 4 2 18/08/2021 7,8 76 2 1 1 1 1 1 1 1 1

72 2 23-3-2017 L 6302180104170001 6302202303170001 Sabri - - 1 1 Sudirman 6302180210870001 - Pulau Karasian 4 2 18/08/2021 13 96 2 1 1 1 1 1 1 1 1

73 3 9/10/2019 L 6302180104170001 6302200910190001 Andri - - 1 1 Sudirman 6302180210870001 - Pulau Karasian 4 2 18/08/2021 12 80 2 1 1 1 1 1 1 1 1

74 20-08-2020 L - - Abdul Sahran 2,8 47 1 1 M. Hadi - - Pulau Karasian 4 2 18/08/2021 11 75 2 1 1 1 1 1 1 1 1

75 3 23-05-2021 L - - Irsyad 2,5 45 1 1 Sudarman - - Pulau Karasian 4 2 18/08/2021 4,3 50 1 1 1 1 1 1 1 1 2

76 8/3/2021 L - - Rafardan Athala 1 1 Sumanto - - Pulau Karasian 4 2 18/08/2021 6,8 68 1 1 1 1 1 1 1 1 2

77 1 6/5/2021 P - - Hilya Elina Almira 1 1 Heriansyah - - Pulau Karasian 4 2 18/08/2021 5,2 60 1 1 1 1 1 1 1 1 2

78 3 14-05-2021 P - - Raisa Sapitri 2,7 48 1 1 Baharuddin - - Pulau Karasian 4 2 18/08/2021 6,4 87 1 1 1 1 1 1 1 1 2

79 3 2/6/2020 P 6302182511080004 - Gina Ulya Syarifah 2,8 47 1 1 Asmar 6302181002830001 - Pulau Karasian 4 2 18/08/2021 8 69 1 1 1 1 1 1 1 1 1
80 1 12/6/2019 L 630220181119001 6302201206190001 Muh Fatan Khalifah Atar 3 49 1 1 Fahrul 6302181501970001 - Pulau Karasian 5 2 18/08/2021 9,5 87 2 1 1 1 1 1 1 1 1

81 3 3/9/2016 P 6302170602080160 63021843091600001 Badriah Nursuha 3,2 49 1 1 Hamsa Jaya 6302171508830002 - Pulau Karasian 5 2 18/08/2021 15 102 2 1 1 1 1 1 1 1 1

82 4 28-06-2017 P 6302182406080007 - Mikayla Ramadani 3,1 48 1 1 Hasbullah R. Saputra 6302180304700002 - Pulau Karasian 5 2 18/08/2021 14 96 2 1 1 1 1 1 1 1 1

83 3 9/8/2019 P 6302180705120002 6302204908180001 Meydina Kurniawan 3 49 1 1 Edy Kurniawan 6302180111860001 - Pulau Karasian 5 2 18/08/2021 11 91 2 1 1 1 1 1 1 1 1

84 8 21-9-2016 P 6302183103090017 6302186109160001 Febrianti 2,7 48 1 1 Mansur 6302180107680842 - Pulau Karasian 5 2 18/08/2021 15 100 2 1 1 1 1 1 1 1 1

85 9 12/10/2019 L 6302183103090017 6302201210190001 Muh Ikbal 3,1 49 1 1 Mansur 6302180107680842 - Pulau Karasian 5 2 18/08/2021 10,5 89 2 1 1 1 1 1 1 1 1

86 2 3/7/2017 P 6302173001080003 6302184307170001 Nur Fitriani 2,7 46 1 1 Darmin 6302170610740002 - Pulau Karasian 5 2 18/08/2021 13 95 2 1 1 1 1 1 1 1 1

87 3 23-02-2021 L 6302173001080003 - Muh Febri 3 48 1 1 Darmin 6302170610740002 - Pulau Karasian 5 2 18/08/2021 9 76 1 1 1 1 1 1 1 1 1

88 3 6/3/2019 L 6302180508160001 - M. Alif Akbar 3,1 49 1 1 Naharuddin 6302182009880001 - Pulau Karasian 5 2 18/08/2021 10 90 2 1 1 1 1 1 1 1 1

89 2 27-11-2016 L 6302181106140002 6302182711160002 Khafid Ikram 2,7 46 1 1 Hariadi 6102182208870003 - Pulau Karasian 5 2 18/08/2021 14 95 2 1 1 1 1 1 1 1 1

90 1 17-7-2019 P 6302203107190001 6302205707190001 Ika Purnama Sari 2,6 47 1 1 Abdaluddin 6302181212950001 - Pulau Karasian 5 2 18/08/2021 12 92 2 1 1 1 1 1 1 1 1

91 8/7/2017 P 6302181104160001 6302181807170001 Selya Putri 3,2 49 1 1 Hasman 6302180401950001 - Pulau Karasian 5 2 18/08/2021 13,2 93 2 1 1 1 1 1 1 1 1

92 3 10/4/2018 L 6302180403090010 6302201004180001 Baihaki 2,8 46 1 1 Abdul Gafur 6302182808680001 - Pulau Karasian 5 2 18/08/2021 12 93 2 1 1 1 1 1 1 1 1

93 4 23-7-2019 L 6302182703090005 6302202307190001 Muh Putra Liandra 2,5 46 1 1 Apul 6302180906800001 - Pulau Karasian 5 2 18/08/2021 10,2 85 2 1 1 1 1 1 1 1 1

94 2 10/5/2019 P 6302180810160002 - Annisa Safitri 3 49 1 1 Rudi 6302181101840001 - Pulau Karasian 5 2 18/08/2021 10 84 2 1 1 1 1 1 1 1 1

95 1 22-08-2018 P - - Gina Inayah - - - - Imran - - Pulau Karasian 5 2 18/08/2021 15 97 2 1 1 1 1 1 1 1 1

96 1 17-4-2018 P 6302200501210001 3529235704180001 Kayla Efendi 2,8 47 1 1 Rahmat Efendi 3402120504800004 - Pulau Karasian 5 2 18/08/2021 10 84 2 1 1 1 1 1 1 1 1

97 22-11-2019 P 6302181509080025 - Mawar Liana 3,1 49 1 1 Rahmadi 6302173005770002 - Pulau Karasian 5 2 18/08/2021 9,3 82 2 1 1 1 1 1 1 1 1

98 3 23-09-2017 L 6302180410120001 6302182309170002 Deni Irawan 3,1 49 1 1 Gusno 6302171005910002 - Pulau Karasian 6 2 18/08/2021 14 96 2 1 1 1 1 1 1 1 1

99 4 3/2/2017 L 6302171502080003 6302180302170001 Royyan Iqmal 3 47 1 1 B0bi 6302181002780001 - Pulau Karasian 6 2 18/08/2021 15 98 2 1 1 1 1 1 1 1 1

100 4 19-09-2016 L 6302060809110005 6302061909160003 M. Arsya Alhairi 3,1 48 1 1 Sarjono Fatah 6302062004820004 - Pulau Karasian 6 2 18/08/2021 16 103 2 1 1 1 1 1 1 1 1

101 2 7/11/2018 L 6302180905140002 - Rizzam Muazzam 3,2 49 1 1 M. Asri 6302181203900001 - Pulau Karasian 6 2 18/08/2021 14 96 2 1 1 1 1 1 1 1 1

102 1 6/5/2019 L 6302200406200003 6302200605190001 Muh Ramadani 3 47 1 1 Abdul Wahab 6302181010980002 - Pulau Karasian 6 2 18/08/2021 11 86 2 1 1 1 1 1 1 1 1

103 1 5/7/2016 L 6302180602170001 6302180507160001 Luthfie sakhi Zaidan 3 49 1 1 Jadil 6302020312930001 - Pulau Karasian 6 2 18/08/2021 15 103 2 1 1 1 1 1 1 1 1

104 2 3/1/2020 P 6302180602170001 6302207001200001 Quensha Debby Aqila 2,8 46 1 1 Jadil 6302020312930001 - Pulau Karasian 6 2 18/08/2021 11,6 86 2 1 1 1 1 1 1 1 1

105 4 16-06-2020 P 6302181605130001 - Bilkis Salsabila 2,7 46 1 1 Firman 6302180107900022 - Pulau Karasian 6 2 18/08/2021 9,5 84 1 1 1 1 1 1 1 1 1

106 3 20-10-2018 L 6302183012080015 6302182010160001 M. Hanif 3 48 1 1 M. Idris 6302182510770001 - Pulau Karasian 6 2 18/08/2021 12 89 2 1 1 1 1 1 1 1 1

107 1 27-3-2020 P 6302031808170001 6302206703200001 Khaira Nadifa 2,8 46 1 1 Amirullah 6302032010930003 - Pulau Karasian 6 2 18/08/2021 9 85 1 1 1 1 1 1 1 1 1

108 3 27-8-2019 P 6302180806110001 6302206708190001 Nur Anisa 2,6 45 1 1 Sunardi 6302181308890001 - Pulau Karasian 6 2 18/08/2021 11,5 87 2 1 1 1 1 1 1 1 2

109 - 6/3/2021 P - - Mutmainah 2,7 46 1 1 Suardi - - Pulau Karasian 6 2 18/08/2021 3,8 51 1 1 1 1 1 1 1 1 1

110 - 16-10-2020 P - - Nur Aeni 3,2 49 1 1 Sahril - - Pulau Karasian 6 2 18/08/2021 9 76 1 1 1 1 1 1 1 1 1

111 2 22-4-2020 L 6302182307150001 - Ahmad Zaidan 2,8 49 1 1 Adnan 53021808028400001 - Pulau Karasian 6 2 18/08/2021 9 76 1 1 1 1 1 1 1 1 1

112 - 15-02-2020 P - - Akifah 3 49 1 1 Fajarudin - - Pulau Karasian 6 2 18/08/2021 7,5 68 1 1 1 1 1 1 1 1 1

113 1 10/5/2020 P - - Munti Hana 3,2 49 1 1 Darmawi - - Pulau Karasian 6 2 18/08/2021 9,5 78 1 1 1 1 1 1 1 1 1

114 - 10/11/2016 L - - Jumaidil 3 49 1 1 Hasludin - - Pulau Karasian 6 2 18/08/2021 16 102 1 1 1 1 1 1 1 1 2

115 - 7/4/2021 P - - Maria Ulfa 2,7 46 1 1 Darwis - - Pulau Karasian 6 2 18/08/2021 5,5 60 1 1 1 1 1 1 1 1 2

116 1 18-03-2021 P - - Khafiza Khaira Lubna 3,2 49 1 1 Muntazirillah - - Pulau Karasian 6 2 18/08/2021 6,6 67 1 1 1 1 1 1 1 1 2
117 1 2/3/2021 L - - Alif Riansu 3 47 1 1 Suaib - - Pulau Karasian 6 2 18/08/2021 6,4 67 1 1 1 1 1 1 1 1 1

118 3 17-3-12018 P 6302181203080003 6302184703480001 Afifah Azzahra 3,1 49 1 1 Muh Yunus B - - Pulau Karasian 6 2 18/08/2021 11 89 2 1 1 1 1 1 1 1 1

119 2 20-03-2021 L - - Raif Raihan 3,1 47 1 1 Ruslan - - Pulau Karasian 6 2 18/08/2021 7 67 1 1 1 1 1 1 1 1 2

120 - 2/6/2021 L - - Muh. Afnan 2,8 46 1 1 Pansyah - - Pulau Karasian 6 2 18/08/2021 5,4 62 1 1 1 1 1 1 1 1 2

12 108

Mengetahui,
Plt. Kepala Puskesmas Tanjung Lalak Tanjung Lalak, 18 Agustus 2021
Kec. Pulau Laut Kepulauan Pembuat Laporan,

Muhammad Nur, AMG


Hasbullah, SKM
Nip. 19910909 201403 1 001
Nip. 19700403 199101 1 003

Ayu Istiqomah, A.Md.Gz

NRPTT. 11.7.2017.3.4.06
FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Kerapu


Kabupaten/Kota : Kotabaru Bulan : Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Pulau Kerumputan

IMD Vitamin A
Kepemilik ASI Eksklusif Vitamin A
Februari
an Buku 1 = Ya Agustus
Panjang Cara Ukur
Berat KIA/KMS
Badan /
No Anak Ke Tanggal Lahir Jenis No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Badan Panjang Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Tanggal BB (Kg) 2 =Tidak
Tinggi 1= 1
Kelamin Lahir Lahir 1 = Ya Pengukuran 1 =Ya
Badan(cm Telentang =Ya
(gram)
1 =Ya ) 2 =berdiri
2=
2 2
Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 2 =Tidak
= Tidak =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 2 22-8-2018 P 6302182408160001 6302206208160001 Rani Ayu Ulfita 2,9 49 1 1 M.Alwi 6302185601830001 - Pulau Kerumputan 3 2 19/08/2021 14 96 2 1 1 1 1 1 1 1 1

2 3 2/9/2016 L 6302183112180003 6302182208160001 Ahmad Agus R 3,1 50 1 1 Samsuddin 6302180105700001 - Pulau Kerumputan 3 2 19/08/2021 17 103 2 1 1 1 1 1 1 1 1

3 4 20-11-2016 L 6302182912080001 - Ahmad Masjudin 2,7 48 1 1 Sirajuddin 6302181205760003 - Pulau Kerumputan 1 1 19/08/2021 14 95 2 1 1 1 1 1 1 1 1

4 2 20-11-2016 L 6302180709120001 63021813011160001 M.Fauzan 3,1 50 1 1 M` Rizal 6302182011890002 - Pulau Kerumputan 1 1 19/08/2021 14 104 2 1 1 1 1 1 1 1 1

5 2 15-1-2018 P 6302182509120004 6302185501080001 Syafikah Luthfiah 3,4 50 1 1 Lukman 63021841180001 - Pulau Kerumputan 5 1 19/08/2021 15 103 2 1 1 1 1 1 1 1 1

6 1 26-1-2017 P 6302180910180002 6302186601170001 Mutmainnah 3,1 50 1 1 Rafansyah 6302180601390001 - Pulau Kerumputan 3 2 19/08/2021 13 101 2 1 1 1 1 1 1 1 1

7 1 31-01-2017 P 6302181507160001 6302187101170001 Normalianti 2,7 49 1 1 Burhanuddin 6302061011790015 - Pulau Kerumputan 3 2 19/08/2021 13 98 2 1 1 1 1 1 1 1 1

8 1 19-2-1017 P 6302200404190009 6302205902170001 Saspina 2,9 49 1 1 Samsir 63022001950006 - Pulau Kerumputan 2 1 19/08/2021 12 99 2 1 1 1 1 1 1 1 1

9 4 24-4-2017 L 6302180612080001 6302202404170001 Farid Asraf 3,5 51 1 1 Abdul Rauf 6302182106800001 - Pulau Kerumputan 5 1 19/08/2021 13 101 2 1 1 1 1 1 1 1 1

10 1 6/5/2017 L 6302182111160002 6302180605170001 Hisyam Nizam 3 50 1 1 Darmansyah 6302181307880001 - Pulau Kerumputan 5 1 19/08/2021 14 102 2 1 1 1 1 1 1 1 1

11 1 4/6/2017 L 6302181005160001 6302180108170001 Daavi 3 50 1 1 Sahrul 63021877038800002 - Pulau Kerumputan 2 1 19/08/2021 13 101 2 1 1 1 1 1 1 1 1

12 2 9/6/2017 L 6302182509120010 6302180906170001 Zaki Fajrullah 2,9 49 1 1 Rusding 63021806840001 - Pulau Kerumputan 5 1 19/08/2021 14 100 2 1 1 1 1 1 1 1 1

13 1 5/6/2017 P 6302181606160008 6302205207170001 Yutasyah 3 49 1 1 Sakir 6302180309890003 - Pulau Kerumputan 4 2 19/08/2021 14 103 2 1 1 1 1 1 1 1 1

14 5 6/2/2017 P 630218061210001 6302204602170001 Anindia Nur Fadia 3 50 1 1 M`Saleh 630218506750001 - Pulau Kerumputan 2 1 19/08/2021 12 98 2 1 1 1 1 1 1 1 1

15 1 18-07-2017 P 6302180806170002 6302184806170001 Safaras Alfiani 2,9 49 1 1 Ahmad Efendi 6302181007900001 - Pulau Kerumputan 2 1 19/08/2021 13 100 2 1 1 1 1 1 1 1 1

16 1 29-9-2017 L 6302200708190001 630220299170001 Desya Fijratullah 2,7 49 1 1 Dedi Rusadi 6302170408900002 - Pulau Kerumputan 3 2 19/08/2021 12 94 2 1 1 1 1 1 1 1 1

17 4 5/10/2017 L 6302180612080016 630218050170001 Fadil Gani 2,8 49 1 1 Saenal 6302182505790001 - Pulau Kerumputan 4 2 19/08/2021 14 93 2 1 1 1 1 1 1 1 1

18 1 12/10/2017 P 6302181807180001 6302185210170001 Amairah 2,8 49 1 1 Zaenuddin '630218250590001 - Pulau Kerumputan 2 1 19/08/2021 12 88 2 1 1 1 1 1 1 1 1

19 6 12/10/2017 P 6302182912080001 - Siti Baitul Arafah 2,9 49 1 1 Sirajuddin 630218105760003 Pulau Kerumputan 1 1 19/08/2021 12 90 2 1 1 1 1 1 1 1 1

20 4 19-10-2017 P 6302182207080015 6302185910170001 Iska Paula 2,8 48 1 1 Muhammad Suaib 6302180306770001 - Pulau Kerumputan 3 2 19/08/2021 14 94 2 1 1 1 1 1 1 1 1

21 1 25-11-2017 L 6302182408160001 6302206511170001 Dindra Maharani 3,1 50 1 1 M.Alwi 6302185601830001 - Pulau Kerumputan 3 2 19/08/2021 13 94 2 1 1 1 1 1 1 1 1

22 2 17-2-2018 L 6302183112180003 6302181702180001 Ahmad Faris R 2,9 50 1 1 Samsuddin 6302180105700001 - Pulau Kerumputan 3 2 19/08/2021 12 93 2 1 1 1 1 1 1 1 1

23 2 3/3/2018 L 6302180602150002 6302200304180001 Sapril 2,7 49 1 1 Usman 6302181509950003 - Pulau Kerumputan 3 2 19/08/2021 12 94 2 1 1 1 1 1 1 1 1

24 1 18-3-2018 P 6302181011170002 6302205803180002 Naura Nadiva 2,8 50 1 1 Jalaluddin 6302181405880001 - Pulau Kerumputan 4 2 19/08/2021 11 93 2 1 1 1 1 1 1 1 1

25 4 5/4/2018 P 6302182002090006 6302180504180001 Restu Sihab 3,2 50 1 1 Burhanuddin 6302182106790001 - Pulau Kerumputan 4 2 19/08/2021 13 95 2 1 1 1 1 1 1 1 1

26 2 24-2-2018 P 6202200404100009 6302206402180001 Saspita 2,7 49 1 1 Samsir 63022001950006 - Pulau Kerumputan 2 1 19/08/2021 13 98 2 1 1 1 1 1 1 1 1

27 3 16-5-2018 L 6302180608080020 6302181805180001 Muhammad Abid 3,2 50 1 1 Suadi 6302182401840001 - Pulau Kerumputan 2 1 19/08/2021 12 89 2 1 1 1 1 1 1 1 1

28 3 20-5-2018 L 6302182705100001 630218200510001 M.Aldi 3,1 49 1 1 Halipuddin 630218030180001 - Pulau Kerumputan 2 1 19/08/2021 14 95 2 1 1 1 1 1 1 1 1

29 1 7/6/2018 P 6302181606160009 6302184706180001 Nur Aqufa Zahwa 2,7 49 1 1 Samsuri 6302031588660001 - Pulau Kerumputan 2 1 19/08/2021 11,3 84 2 1 1 1 1 1 1 1 1

30 4 14-8-2018 L 6302172811070027 6302181406180001 Abiyan 2,9 49 1 1 Supriadi 6302170503810002 - Pulau Kerumputan 2 1 19/08/2021 11 90 2 1 1 1 1 1 1 1 1

31 1 15-8-2018 L 6302202506200002 6302201508180001 M. Akmal 2,9 49 1 1 Arman 6302170107000006 - Pulau Kerumputan 3 2 19/08/2021 10,5 92 2 1 1 1 1 1 1 1 1

32 2 28-9-2018 P 6302200404190001 6302185307150001 Hapisah 3 50 1 1 Sayuti 6302200310930001 - Pulau Kerumputan 2 1 19/08/2021 14 98 2 1 1 1 1 1 1 1 1

33 3 24-10-2018 L 6302172611070047 6302202410180001 Adnan Said/Aconan 2,9 49 1 1 Hamsu 6302171568820002 - Pulau Kerumputan 3 2 19/08/2021 12 88 2 1 1 1 1 1 1 1 1

34 4 2/11/2018 P 6302180501090021 6302104211180002 Putri Kaila 2,9 49 1 1 Samsuri 63021807990001 - Pulau Kerumputan 4 2 19/08/2021 11 87 2 1 1 1 1 1 1 1 1

35 5 11/8/2018 P 6302180912080014 - Raina 3,2 49 1 1 Abdul Hamid 6302181502690001 - Pulau Kerumputan 2 1 19/08/2021 11 87 2 1 1 1 1 1 1 1 1

36 1 8/12/2018 L 6302181011170001 6302200812180001 Raffasnya 2,7 49 1 1 Bahriansyah 6302182203830001 - Pulau Kerumputan 2 1 19/08/2021 12 87 2 1 1 1 1 1 1 1 1
37 2 14-12-18 P 6302182603090048 - Ayudia Inara 3,2 50 1 1 Sahar 6302181010880005 - Pulau Kerumputan 3 2 19/08/2021 11,4 86 2 1 1 1 1 1 1 1 1

38 2 21-1-2019 P 6302181507160001 6302206101190001 Nur Laeli 2,9 50 1 1 Burhanuddin 6302011011790015 - Pulau Kerumputan 3 2 19/08/2021 10,6 85 2 1 1 1 1 1 1 1 1

39 1 23-01-2019 L 6302180712160001 - Ahmad Antar 3,1 50 1 1 Indra 6302180910930001 - Pulau Kerumputan 4 2 19/08/2021 12 93 2 1 1 1 1 1 1 1 1

40 2 1/4/2019 P 63021807180001 - Amira 2,8 50 1 1 Zainuddin 630218250590001 - Pulau Kerumputan 2 1 19/08/2021 10,6 81 2 1 1 1 1 1 1 1 1

41 4 5/9/2019 P 6302182207080010 6302204905190001 Lailatul Nur Ramadan 3,3 49 1 1 Supriadi 630218178500001 - Pulau Kerumputan 2 1 19/08/2021 10,5 92 2 1 1 1 1 1 1 1 1

42 4 27-2-2016 P 6302183012080005 - Putri Ramadani 3,4 50 1 1 M.Arif 6302180206740001 - Pulau Kerumputan 1 1 19/08/2021 10,3 89 2 1 1 1 1 1 1 1 1

43 2 15-06-2019 P 6302182902080001 6302205506190003 Afrin Annisa 3,1 49 1 1 Jumadiansyah 6302180207820001 - Pulau Kerumputan 2 1 19/08/2021 10 87 2 1 1 1 1 1 1 1 1

44 3 3/8/2019 P 6302180709120001 6302204308190001 Isa Asisa 2,7 48 1 1 Muhammad Rizal 6302180111880001 - Pulau Kerumputan 1 1 19/08/2021 10,7 94 2 1 1 1 1 1 1 1 1

45 5 4/8/2019 P 6302172811070057 6302204408190001 Difa Azzahra 2,7 48 1 1 Zainal Abidin 6302170308730002 - Pulau Kerumputan 2 1 19/08/2021 10,3 82 2 1 1 1 1 1 1 1 1

46 1 23-6-2019 P 6302202702200001 6302206308190001 Afrin Agustian 2,8 48 1 1 Saenuddin 6302182508890002 - Pulau Kerumputan 2 1 19/08/2021 8,9 86 2 1 1 1 1 1 1 1 1

47 1 23-6-2019 P 6302182002090002 6302201110190002 Muhammad Kaustar 2,9 49 1 1 Rudiansyah 6302180600730001 - Pulau Kerumputan 4 1 19/08/2021 10,3 86 2 1 1 1 1 1 1 1 1

48 5 5/11/2019 P 630218061210001 6302205212190001 Jihan Aulia 2,9 49 1 1 Sunardi 6302020203880001 - Pulau Kerumputan 1 1 19/08/2021 8,2 82 2 1 1 1 1 1 1 1 1

49 2 23-12-2019 P 0302183112180004 6302202312190001 Aisya Putri Rifa'i 3 50 1 1 Husni Rifa'i 6302181111830001 - Pulau Kerumputan 2 1 19/08/2021 8,4 79 2 1 1 1 1 1 1 1 1

50 3 11/3/2020 L 6302182603090048 - Azril Al Fauzan 2,9 49 1 1 Sahar 6302181010880005 - Pulau Kerumputan 3 2 19/08/2021 9,9 82 2 1 1 1 1 1 1 1 1

51 2 11/3/2020 L 6302181011170002 6302202203200001 Asril Rafi Alfarisi 2,8 50 1 1 Jalaluddin 6302181405880001 - Pulau Kerumputan 4 2 19/08/2021 9,8 83 2 1 1 1 1 1 1 1 1

52 3 12/6/2020 L 6302182509120037 6302201206200001 M. Yasid Luthfi 3,2 51 1 1 Rasdi 6302182906750001 - Pulau Kerumputan 3 2 19/08/2021 11 77 2 1 1 1 1 1 1 1 1

53 1 10/7/2020 P 630220050520001 - Aurora Azzahra 3,2 49 1 1 Rahmat 6302182010990002 - Pulau Kerumputan 2 1 19/08/2021 7,7 74 2 1 1 1 1 1 1 1 1

54 1 26-08-2020 P 6302201706200001 - Mikaila Humaira 3,1 48 1 1 Arifin 6302170100890002 - Pulau Kerumputan 3 2 19/08/2021 7,1 72 2 1 1 1 1 1 1 1 1

55 3 2/8/2016 L 6302180912080009 6302181712050001 Pajar 2,7 49 1 1 Tayuddin 6302181798840002 - Pulau Kerumputan 2 1 19/08/2021 12 99 2 1 1 1 1 1 1 1 1

56 3 11/9/2020 P 6302181612090006 6302205209200001 Afifa Tania M 3,3 50 1 1 Awaluddin 6302182005820002 - Pulau Kerumputan 2 1 19/08/2021 7.8 73 2 1 1 1 1 1 1 1 1

57 1 29-2-2019 P 6302066502190003 Naila Zahra 3 50 1 1 Jamaluddin 63021811690001 - Pulau Kerumputan 4 2 19/08/2021 9,1 80 2 1 1 1 1 1 1 1 1

58 1 29-10-2020 P 6302202406200002 - Afiqa 3 49 1 1 Hermansyah 6302032004930001 - Pulau Kerumputan 4 2 19/08/2021 7,3 71 2 1 1 1 1 1 1 1 1

59 1 23-9-2019 L 63022012062000004 6302202309190001 Akbar Caesar 2,9 49 1 1 yadi 6302210211050001 - Pulau Kerumputan 3 2 19/08/2021 10 86 2 1 1 1 1 1 1 1 1

60 3 4/9/2020 P 6302201206200007 - Nur Asyifa 3,1 48 1 1 Oki Agustin Hayati 31740702089220003 - Pulau Kerumputan 3 2 19/08/2021 7,6 74 2 1 1 1 1 1 1 1 1

61 1 29-01-2018 L 6302201206200007 6302202901180001 M Yusuf Aldani 2,7 49 1 1 Oki Agustin Hayati 31740702089220003 - Pulau Kerumputan 3 2 19/08/2021 13 102 2 1 1 1 1 1 1 1 1

62 2 2/11/2019 L 6302201206200007 - Ahmad Maulana 3 49 1 1 Oki Agustin Hayati 31740702089220003 - Pulau Kerumputan 3 2 19/08/2021 8,8 81 82 1 1 1 1 1 1 1 1

63 5 17--1-2017 L 6302183001090015 - Rehan Riadi 3,1 50 1 1 Tarman 6302180402600001 - Pulau Kerumputan 3 2 19/08/2021 11,6 90 2 1 1 1 1 1 1 1 1

64 2 28-12-2019 L 6302021703080001 6302022812190001 M.Azzan Nabil 3,7 50 1 1 Fahruddin 6302021905880001 - Pulau Kerumputan 3 2 19/08/2021 14 82 2 1 1 1 1 1 1 1 1

65 1 24-1-2019 P 6302202406200004 - Naila Muzahra 3,1 49 1 1 Risno trisno 6302184104970002 - Pulau Kerumputan 3 2 19/08/2021 10 89 2 1 1 1 1 1 1 1 1
66 5 7/12/2020 P 6302180612080011 - Siti Asheqa Nahla 3,4 50 1 1 Muhammad Husen 6302180207740001 - Pulau Kerumputan 2 1 19/08/2021 7,3 69 1 1 1 1 1 1 1 1 1

67 4 31-12-2018 L 63002200404190007 63020203112180001 Muhammad Ardilan 2,9 50 1 1 Jumain 7604151405870001 - Pulau Kerumputan 1 1 19/08/2021 15 102 2 1 1 1 1 1 1 1 1

68 2 13-9-2017 P 6302180602150001 6302185309170001 Azzahra Cintia Fariza 2,6 48 1 1 Rusandi 6302105707980001 - Pulau Kerumputan 1 1 19/08/2021 14 98 2 1 1 1 1 1 1 1 1

69 1 7/6/2017 P 6302202801200010 6302204706170001 Nur Diniya 3,1 49 1 1 Baharuddin 6302181101950001 - Pulau Kerumputan 1 1 19/08/2021 13 99 2 1 1 1 1 1 1 1 1

70 5 28-05-2018 L 6302183101090026 - M Adrian 3,7 50 1 1 Amiruddin 6302180108700002 - Pulau Kerumputan 3 2 19/08/2021 11,3 96 2 1 1 1 1 1 1 1 1

71 2 10/8/2019 P 6302181801130001 - Sahida 3,2 51 1 1 Jani 6302180210610001 - Pulau Kerumputan 3 2 19/08/2021 10 89 2 1 1 1 1 1 1 1 1

72 1 4/1/2020 P 6302202111190001 - Alesya Alifa 3,1 50 1 1 Sopian 6302181707930001 - Pulau Kerumputan 4 2 19/08/2021 10 89 2 1 1 1 1 1 1 1 1

73 4 9/11/2016 P 6302180608080030 630218570610001 Aulia Rahmah 3 50 1 1 Suriadi 6302182301790001 - Pulau Kerumputan 2 1 19/08/2021 15 100 2 1 1 1 1 1 1 1 1

74 3 4/4/2018 P - 6302185104180001 Safrani 2,7 48 1 1 Safaruddin 6302060307840004 - Pulau Kerumputan 2 1 19/08/2021 11,2 89 2 1 1 1 1 1 1 1 1

75 1 13-12-1010 P - - Desi Ratna Sari 3.1 49 1 1 Edi 6302174707970002 - Pulau Kerumputan 1 1 19/08/2021 7,1 63 1 1 1 1 1 1 1 1 1

76 1 5/11/2020 L - - Muhammad hafi 3,2 50 1 1 Anwar 6302171405000002 Pulau Kerumputan 1 1 19/08/2021 8,2 66 1 1 1 1 1 1 1 1 1

7 69

Mengetahui,
Plt. Kepala Puskesmas Tanjung Lalak Tanjung Lalak, 19 Agustus 2021
Kec. Pulau Laut Kepulauan Pembuat Laporan,

Muhammad Nur, AMG


Hasbullah, SKM Nip. 19910909 201403 1 001

Nip. 19700403 199101 1 003

Ayu Istiqomah, A.Md.Gz

NRPTT. 11.7.2017.3.4.06
FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Serisih


Kabupaten/Kota : Kotabaru Bulan : Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Pulau Kerayaan

IMD Vitamin A
Kepemilik ASI Eksklusif Vitamin A
Februari
an Buku 1 = Ya Agustus
Panjang Cara Ukur
Berat KIA/KMS
Badan /
No Anak Ke Tanggal Lahir Jenis No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Badan Panjang Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Tanggal BB (Kg) 2 =Tidak
Tinggi 1= 1
Kelamin Lahir Lahir 1 = Ya Pengukuran 1 =Ya
Badan(cm Telentang =Ya
(gram)
1 =Ya ) 2 =berdiri
2=
2 2
Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 2 =Tidak
= Tidak =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 3 8/3/2021 P 6302182703090002 - Salsa Bila 3,2 47 1 1 Ahmad 6302180608860003 - Pulau Kerayaan 3 1 20/08/2021 6 63 1 1 1 1 1 1 1 1 1

2 4 5/4/2019 L 6302181909080001 - Sabriansyah 3,2 50 1 1 Arifin 6302180307760002 - Pulau Kerayaan 6 2 20/08/2021 11 91 2 1 1 1 1 1 1 1 1

3 4 27-3-2020 L 6302180304090005 - Jumadi 3,2 4 1 1 Raman 6302180107890019 - Pulau Kerayaan 3 1 20/08/2021 9 72 2 1 1 1 1 1 1 1 1

4 3 28-5-2017 P 6302180304090005 6302186805170001 Wulan Suci 3,3 4 1 1 Rahman 6302180107890019 - Pulau Kerayaan 3 1 20/08/2021 15 100 2 1 1 1 1 1 1 1 1

5 3 2/5/2018 P 6302181202090021 6302184205180001 Nurliana 4 50 1 1 Heri 6302180107900019 081254648778 Pulau Kerayaan 2 1 20/08/2021 13 90,1 2 1 1 1 1 1 1 1 1

6 1 24-1-2017 P - - Zalfazia Almairah 3,6 49 1 1 Alwir - - Pulau Kerayaan 2 1 20/08/2021 68 66 1 1 1 1 1 1 1 1 1

7 3 12/10/2020 P 6302180503120001 6302205210200001 Azka Afzin 3,3 49 1 1 Nasrullah 6302170401870002 - Pulau Kerayaan 4 2 20/08/2021 7,3 70 2 1 1 1 1 1 1 1 1

8 3 15-11-2019 P 63021811302168005 - Naila 3,2 5 1 1 Jasluddin 630203200186660001 - Pulau Kerayaan 2 1 20/08/2021 7,8 97 1 1 1 1 1 1 1 1 1

9 2 27-10-2020 L - - Ahmad Gandi 3,2 49 1 1 Jumansyah - - Pulau Kerayaan 2 1 20/08/2021 8,8 68 2 1 1 1 1 1 1 1 1

10 2 2/5/2018 P 6302181511140001 6302204205180002 Berlian 2,4 48 1 1 Herman 6302170107930006 082255885537 Pulau Kerayaan 3 1 20/08/2021 11,3 89,5 2 1 1 1 1 1 1 1 1

11 2 2/5/2018 P 6302181511140001 6302204205180001 Intan 2,7 47 1 1 Herman 6302170107930006 082255885537 Pulau Kerayaan 3 1 20/08/2021 106 95 2 1 1 1 1 1 1 1 1

12 1 23-3-2019 P 6302181112180001 63022006303190001 Aldarisma Annisa 3,7 47 1 1 Hidayat Norwahid 6302170101990003 - Pulau Kerayaan 2 1 20/08/2021 11,2 99 2 1 1 1 1 1 1 1 1

13 4 18-2-2020 P 6302182105100001 - Lydya Ayunda 3,6 49 1 1 Ilhamsyah 6302181304810002 - Pulau Kerayaan 1 1 20/08/2021 10,3 86 1 1 1 1 1 1 1 1 1

14 1 24-03-2021 L 6302200312200001 - Hafidz Qurratanain 3,6 49 1 1 Sulaiman 7205075208970001 - Pulau Kerayaan 1 1 20/08/2021 12 92 2 1 1 1 1 1 1 1 1

15 2 1/9/2020 L 6302200312200001 - Aiman Zafran 3,2 50 1 1 Sulaiman 7205075208970001 - Pulau Kerayaan 1 1 20/08/2021 7,5 72 2 1 1 1 1 1 1 1 1

16 4 15-1-2018 L 630180404080002 6302261501180001 Rijal 3,6 49 1 1 Jamhuri 6302181005740001 - Pulau Kerayaan 2 1 20/08/2021 9 85 2 1 1 1 1 1 1 1 1

17 1 8/11/2020 L 6302182805080002 - Arkam Maulana 4 49 1 1 Syaripuddin 63021700090100002 - Pulau Kerayaan 6 2 20/08/2021 7,5 67 2 1 1 1 1 1 1 1 1

18 2 31-09-2020 P 6302182712180006 - Nur Aisyah 3,3 49 1 1 Zainal 6302182087900002 - Pulau Kerayaan 6 2 20/08/2021 7,7 73 2 1 1 1 1 1 1 1 1

19 1 3/12/2020 L 6302182302090025 - Yusril Mahendra 3,3 50 1 1 Nursang 6302186010990001 081380082201 Pulau Kerayaan 3 1 20/08/2021 10 80 2 1 1 1 1 1 1 1 1

20 1 3/12/2018 P 6302201001200001 6302204312180001 Ratifha Mutia 3,9 49 1 1 Jumaansyah 6302186010990001 - Pulau Kerayaan 1 1 20/08/2021 12 91 2 1 1 1 1 1 1 1 1

21 2 10/10/2020 P 6302181412180003 - Nur Afifah 4 49 1 1 Irvan 6302180808800001 - Pulau Kerayaan 3 1 20/08/2021 8,5 70 2 1 1 1 1 1 1 1 1

22 6 31-2-2018 P 6302181909080009 6302207112180002 Nurul Putri Naswa 3 49 1 1 Makmur 630218207770001 `- Pulau Kerayaan 6 2 20/08/2021 11,5 99 2 1 1 1 1 1 1 1 1

23 6 15-12-2018 L 6302181909080001 6302201512180001 Suriansyah 3,2 47 1 1 Bahriansyah 6302180107780014 - Pulau Kerayaan 6 2 20/08/2021 12,6 101 2 1 1 1 1 1 1 1 1

24 3 26-09-2019 P 6302181106120001 6302206609190001 Zulfahira 3 47 1 1 Alaswar 6302181102870001 08525251855327 Pulau Kerayaan 6 2 20/08/2021 10,1 89 2 1 1 1 1 1 1 1 1

25 2 29-7-2017 L 6302183103120001 6302183103120001 M.Riskullah 3,7 42 1 1 Syamsul Bahri 6302181206820001 085389637440 Pulau Kerayaan 6 2 20/08/2021 11,2 97 2 1 1 1 1 1 1 1 1

26 1 15-6-2020 L 6302011504690010 - M. Syawal Rahmatullah 3,9 50 1 1 Rahmatullah 6302011303010001 082354270859 Pulau Kerayaan 6 2 20/08/2021 10,1 91 2 1 1 1 1 1 1 1 1

27 1 24-11-2017 L 6302181008170002 6302182411170001 Muhammad Alif 3,9 50 1 1 Indra Aditia 630203310190001 085251422058 Pulau Kerayaan 6 2 20/08/2021 11,5 101 2 1 1 1 1 1 1 1 1

28 4 31-1-2018 L 6302180810080002 630218311011800001 Ahmad Rafli 3,2 47 1 1 Abdul Haris 6302182304860001 082324317923 Pulau Kerayaan 6 2 20/08/2021 9,8 81 2 1 1 1 1 1 1 1 1

29 4 27-2-2018 L 6302180612080015 6302182702180001 M.Akbar 3,9 42 1 1 Anwar 6302180507750001 - Pulau Kerayaan 6 2 20/08/2021 11,2 101 2 1 1 1 1 1 1 1 1

30 1 10/7/2019 P 630220120620002 6302205067190001 Rahmaida 3,2 48 1 1 Muh Tading 6302201101920005 - Pulau Kerayaan 6 2 20/08/2021 12,1 98 2 1 1 1 1 1 1 1 1

31 11 10/11/2016 P 6302180612080021 6302185011160001 Saprina 3,1 45 1 1 Mas Ud 6302180107660827 085332043367 Pulau Kerayaan 6 2 20/08/2021 11,1 100 2 1 1 1 1 1 1 1 1

32 12 22-8-2019 L 6302180612080021 6302202268190001 Masriansyah 3,8 47 1 1 Mas Ud 6302180107660827 085332043367 Pulau Kerayaan 6 2 20/08/2021 9,8 97 2 1 1 1 1 1 1 1 1

33 1 12/4/2017 L 630218280400001 6302201264170001 Saipul Anwar 3,2 49 1 1 Rahmat 6302182004940001 081254616756 Pulau Kerayaan 6 2 20/08/2021 11,8 100 2 1 1 1 1 1 1 1 1

34 3 10/5/2018 L 6302182207110001 6302181006180002 M Syepong Ramadan 2,7 47 1 1 Ali Akbar Syah 6302030865780001 - Pulau Kerayaan 1 1 20/08/2021 10 99 2 1 1 1 1 1 1 1 1

35 1 17-01-2018 L 6302031166190001 6302031701880001 M Altab Abrizam 3,5 49 1 1 Fatnullah ;63020308910001 - Pulau Kerayaan 1 1 20/08/2021 14,6 97 2 1 1 1 1 1 1 1 1

36 2 27-12-2018 L 6302031166190001 630207121180001 Atalla Musyafa 3,7 50 1 1 Fatnullah ;63020308910001 - Pulau Kerayaan 1 1 20/08/2021 12,1 95 2 1 1 1 1 1 1 1 1
37 2 16-06-2017 P 6302181302160009 6302262212190001 Adiba Isatunnisa 4,2 49 1 1 Hartono 6302080512700006 - Pulau Kerayaan 1 1 20/08/2021 21 110 2 1 1 1 1 1 1 1 1

38 3 22-12-2019 L 6302181302160009 6302262212190001 Azka Daippsa Setya 3,9 49 1 1 Hartono 6302080512700006 - Pulau Kerayaan 1 1 20/08/2021 11 88 2 1 1 1 1 1 1 1 1

39 3 13-04-2017 L 6302182209080001 6302161364110001 Ahmad Abid Aqila 3,5 50 1 1 Yusran 6302180207810001 - Pulau Kerayaan 1 1 20/08/2021 16 100 2 1 1 1 1 1 1 1 1

40 4 14-1-2018 P 6302182302090030 6302185401180001 Alfa Delita 3,2 47 1 1 Unding 6302181507860001 - Pulau Kerayaan 1 1 20/08/2021 11,2 99 2 1 1 1 1 1 1 1 1

41 2 31-12-2018 L 6302181312120001 6302183112160001 Abdul Ravif 4 48 1 1 Syaripuddin 6302181507860001 - Pulau Kerayaan 1 1 20/08/2021 13,5 100 2 1 1 1 1 1 1 1 1

42 3 10/7/2018 L 6302182304090035 63021810007180001 Adam 3,9 37 1 1 Saenuddin 6302180705830002 - Pulau Kerayaan 1 1 20/08/2021 12,5 97 2 1 1 1 1 1 1 1 1

43 4 23-04-2016 P 630218030490022 6302186304160001 Afrilia Putri 4 50 1 1 Ahmad 6302181006880001 - Pulau Kerayaan 1 1 20/08/2021 16,2 101 2 1 1 1 1 1 1 1 1

44 3 27-08-2020 P 6302181302160004 6302186701170001 Riani Mahani 3,2 47 1 1 Aco 6302180611910001 Pulau Kerayaan 1 1 20/08/2021 13,2 100 2 1 1 1 1 1 1 1 1

45 1 12/3/2017 L 6302208119000003 6302201203170001 M Syarwedi 4 50 1 1 Mustar 63021816011910001 - Pulau Kerayaan 1 1 20/08/2021 11,5 95 2 1 1 1 1 1 1 1 1

46 1 16-6-2017 L 6202200201210002 6302201606170001 Muhkis Ramadan 3,2 47 1 1 Muhdar 6302182465920001 - Pulau Kerayaan 1 1 20/08/2021 12,9 103 2 1 1 1 1 1 1 1 1

47 1 4/12/2018 P 6302201988200005 6302204412180001 Hasnawati 3,9 50 1 1 Hasmadi 6302181906940001 - Pulau Kerayaan 1 1 20/08/2021 11,2 99 2 1 1 1 1 1 1 1 1

48 4 22-6-2019 L 6302201908200005 6302202206190001 M Bilal Fauzan 4 47 1 1 Muhlis 6302180704780001 - Pulau Kerayaan 1 1 20/08/2021 11 96 2 1 1 1 1 1 1 1 1

49 1 1/8/2017 L 6302180208170001 6302180108170001 Azril Aqila Hafis 3,9 50 1 1 Muhammad David 6302182212900001 - Pulau Kerayaan 1 1 20/08/2021 17 100 2 1 1 1 1 1 1 1 1

50 3 9/16/2017 P 6302180601090012 - Fika Lestari 3,8 50 1 1 M. Idris 6302180701860001 085250480074 Pulau Kerayaan 2 1 20/08/2021 13,5 110 2 1 1 1 1 1 1 1 1

51 2 8/11/2018 L 630218311090001 630281811180001 Mahmud 3,1 45 1 1 M. Agus 6302180207950001 085248025413 Pulau Kerayaan 2 1 20/08/2021 11,5 92 2 1 1 1 1 1 1 1 1

52 7 15-6-2019 P 6302183181090021 6302200206190001 Risma Aliyah 29 49 1 1 Abd Rahim ,6302180105950001 085248025413 Pulau Kerayaan 2 1 20/08/2021 13 100 2 1 1 1 1 1 1 1 1

53 1 28-5-2017 L 630228011200013 6302202815170001 Ramadan 3,3 50 1 1 Haerul 73750817058700011 - Pulau Kerayaan 2 1 20/08/2021 12 112 2 1 1 1 1 1 1 1 1

54 2 22-6-2019 P 63022028011200013 6302206206190001 Sulastri 2,3 49 1 1 Haerul 73750817058700011 - Pulau Kerayaan 2 1 20/08/2021 11 92 2 1 1 1 1 1 1 1 1

55 1 25-6-2019 P 6301071209180007 631076506180003 Permata 3,2 50 1 1 Saepul 6301071812960001 081254234423 Pulau Kerayaan 2 1 20/08/2021 13 100 2 1 1 1 1 1 1 1 1

56 7 17-1-2017 L 6302181202090001 - Fahri 3,8 50 1 1 Bustang 6302180107680836 - Pulau Kerayaan 2 1 20/08/2021 14 99,9 2 1 1 1 1 1 1 1 1

57 4 15-11-2019 P'- - - Naya 3,3 49 1 1 Jalal - - Pulau Kerayaan 2 1 20/08/2021 11 91 2 1 1 1 1 1 1 1 1

58 3 2/11/2018 P 6302181811080003 6302184211160001 Ainnun Salsabila 3,8 49 1 1 Nur Wahyu 630218190480001 - Pulau Kerayaan 1 1 20/08/2021 11 92 2 1 1 1 1 1 1 1 1

59 4 3/1/2020 P 6302181811080003 Ummi Umaira 3,8 50 1 1 Nur Wahyu 630218190480001 - Pulau Kerayaan 1 1 20/08/2021 10,9 81 2 1 1 1 1 1 1 1 1

60 4 5/9/2018 L 6302181102090012 Fathin Fahira 3,5 50 1 1 Burhan 6302180207780003 - Pulau Kerayaan 1 1 20/08/2021 15 98 2 1 1 1 1 1 1 1 1

61 2 23-11-2019 L 6302180803160006 Afzal Atalla 4 50 1 1 Herman 6302181907880001 - Pulau Kerayaan 1 1 20/08/2021 10,2 89 2 1 1 1 1 1 1 1 1

62 4 10/7/2017 L 6302180362090002 Ervin Arianto 3,5 47 1 1 Herni Johan 6302180804690001 - Pulau Kerayaan 1 1 20/08/2021 11 100 2 1 1 1 1 1 1 1 1

63 2 22-10-2017 L 6302180810140001 Arfan Aqila 3,2 45 1 1 Sahlan 6302182211870001 - Pulau Kerayaan 1 1 20/08/2021 14,2 98 2 1 1 1 1 1 1 1 1

64 1 25-11-2019 P 6302200509190002 Jasmin Mufidah 3,3 47 1 1 Jamaluddin 7604010512890002 - Pulau Kerayaan 1 1 20/08/2021 11,5 100 2 1 1 1 1 1 1 1 1

65 2 21-04-2019 P 6302181202210002 Mutiara Madina 3,5 50 1 1 Mukhdar 6302182405920001 - Pulau Kerayaan 1 1 20/08/2021 12 95 2 1 1 1 1 1 1 1 1

66 3 20-04-2017 L 6302181202090012 Muhammad Dafa 3,2 49 1 1 Sukiman 6302180107900016 - Pulau Kerayaan 1 1 20/08/2021 14 100 2 1 1 1 1 1 1 1 1

67 4 7/5/2020 P 6302182712080004 Sabrina 3,5 48 1 1 Hasriadi 6302181601870002 - Pulau Kerayaan 1 1 20/08/2021 10 89 2 1 1 1 1 1 1 1 1

68 5 4/2/2020 L 6302180304090022 Fausi 4 50 1 1 Akhmadi 6302181006880001 - Pulau Kerayaan 1 1 20/08/2021 11 91 2 1 1 1 1 1 1 1 1

69 3 27-08-2020 P 6302181302160004 6302186701170001 Riani Mahani 3,2 47 1 1 Aco 6302180611910001 - Pulau Kerayaan 1 1 20/08/2021 9,5 85 2 1 1 1 1 1 1 1 1

70 1 16-07-2020 L 630220176120002 M. Alkuri Nor 3,7 48 1 1 Nalansyah `6302182706930001 - Pulau Kerayaan 1 1 20/08/2021 10 100 2 1 1 1 1 1 1 1 1

71 1 20-05-2019 P 6302180112180001 63022060805190001 Akifah Ramadani 3,5 49 1 1 Akbar Achmad - Pulau Kerayaan 1 1 20/08/2021 12,7 110 2 1 1 1 1 1 1 1 1

72 1 P 6302181112180001 - Aldarisma Annisa 3,7 47 1 1 Hidayat Norwahid 6302170101990003 - Pulau Kerayaan 2 1 20/08/2021 13 101 2 1 1 1 1 1 1 1 1

73 4 15-09-2017 P 6302180412080002 6302185569170001 Sayla Nadzifa 4 49 1 1 Ahmad Burhanuddin 6302180107850826 085391515704 Pulau Kerayaan 2 1 20/08/2021 15,2 100 2 1 1 1 1 1 1 1 1

74 2 11/1/2020 L 6302182804160001 6302201101200001 M Syahdan 3,8 47 1 1 Rahmat 6302182004940001 - Pulau Kerayaan 6 2 20/08/2021 9,8 78 2 1 1 1 1 1 1 1 1

75 4 28-8-2017 L 6302181106150002 - Regino 3,9 49 1 1 Ikbal 630218171147900001 - Pulau Kerayaan 6 2 20/08/2021 8 78 2 1 1 1 1 1 1 1 1

76 1 4/4/2018 P 6302202901200008 6302204404180001 Nur Adira 3,8 45 1 1 Rajiansyah 63021800270001 082115903417 Pulau Kerayaan 6 2 20/08/2021 12,5 87 2 1 1 1 1 1 1 1 1

77 2 10/5/2020 L 6302202461200008 - Reski Ramadan 3,7 47 1 1 Rajiansyah 63021800270001 082115903417 Pulau Kerayaan 6 2 20/08/2021 9,1 79 2 1 1 1 1 1 1 1 1

78 3 17-08-2016 L 6302183101090040 6302181708160001 Ainul Fikri 3 48 1 1 Dedi 6302181506800001 - Pulau Kerayaan 6 2 20/08/2021 11,1 100 2 1 1 1 1 1 1 1 1

79 4 23-05-2019 L 6302183101090040 6302202305190001 Muhammad Rafi 4 47 1 1 Dedi 6302181506800001 - Pulau Kerayaan 6 2 20/08/2021 9,8 82 2 1 1 1 1 1 1 1 1
80 4 10/5/2017 L 6302181005610002 6302201005070001 Azhar Munajib 3,9 50 1 1 Sabri 6302181012810002 - Pulau Kerayaan 5 2 20/08/2021 11,9 82 2 1 1 1 1 1 1 1 1

81 2 24-8-2018 P 6302180805150001 6302186408180001 Nur Hidaya 3,5 47 1 1 Fadlullah 9101010906860006 082398304123 Pulau Kerayaan 5 2 20/08/2021 13,5 81 2 1 1 1 1 1 1 1 1

82 3 14-03-2021 P 6302180805150001 63021808051500001 Aisyah Sitanun 4 50 1 1 Fadlullah 9101010906860006 082398304123 Pulau Kerayaan 5 2 20/08/2021 8,2 67 2 1 1 1 1 1 1 1 1
83 2 08-01=2018 L 6302180710120043 6302180801180001 Alif Alfino 3,2 46 1 1 Sudirman 63021801079000014 082353130680 Pulau Kerayaan 5 2 20/08/2021 11,2 98 2 1 1 1 1 1 1 1 1

84 1 19-10-2017 L - 6302181910170001 M Ismufa ky Alfiannor 4 48 1 1 Ansyar Lubis 6302182411920001 - Pulau Kerayaan 4 2 20/08/2021 14,8 100 2 1 1 1 1 1 1 1 1

85 4 24-8-2017 P 6302182002090012 6302186408170002 Hapnia 4,3 49 1 1 Ibrahim 6302180212750001 08539303989 Pulau Kerayaan 3 1 20/08/2021 14 101 2 1 1 1 1 1 1 1 1

86 2 23-2-2018 P 6302181501160001 6302206305180003 Arfina Sahrah 4 42 1 1 Muhriadi 630218010794813 - Pulau Kerayaan 3 1 20/08/2021 10,2 89 2 1 1 1 1 1 1 1 1

87 3 15-6-2020 P 6302180612080030 - Sabila Afda 3,2 45 1 1 As Ari 6302181501820001 - Pulau Kerayaan 6 2 20/08/2021 7,8 72 2 1 1 1 1 1 1 1 1

88 3 13-7-20199 L 6302180304090020 6302201307190001 M Rahul 2,7 3 1 1 Rano Karno 63021801077890019 - Pulau Kerayaan 3 1 20/08/2021 8,7 82 2 1 1 1 1 1 1 1 1

89 5 23-07-2018 P 6302181202090029 6302206307180001 Damini 4 49 1 1 M Amin 6302180107730839 - Pulau Kerayaan 3 1 20/08/2021 9,9 100 2 1 1 1 1 1 1 1 1

90 1 27-02-2018 L 6302201908200003 - Muhammad Kavi 3,2 48 1 1 Burhanuddin 630211017840003 - Pulau Kerayaan 6 2 20/08/2021 10,2 89 2 1 1 1 1 1 1 1 1

91 3 3/1/2018 P 6302011310100005 63022004301180001 Elsa Monica 3,2 50 1 1 Syamsuddin 6302010811840001 - Pulau Kerayaan 6 2 20/08/2021 11,3 92 2 1 1 1 1 1 1 1 1

92 2 25-05-2019 P 6302181411070069 - Kailatul Nizfia 2,9 49 1 1 Sukian 6302180107750006 - Pulau Kerayaan 1 1 20/08/2021 10,1 97 2 1 1 1 1 1 1 1 1

93 2 8/11/2018 L 630218311090001 630281811180001 Mahmud 3,1 45 1 1 M. Agus 6302180207950001 085248025413 Pulau Kerayaan 2 1 20/08/2021 11,1 99 2 1 1 1 1 1 1 1 1

94 2 22-12-2017 L 6302182809130001 6302182212170001 M Julianto 2,9 46 1 1 Asluddin 6302183103850007 - Pulau Kerayaan 5 2 20/08/2021 12,2 9,7 2 1 1 1 1 1 1 1 1

95 6 15-12-2018 L 6302181909080001 6302201512180001 Suriansyah 3,2 47 1 1 Bahriansyah 6302180107780014 - Pulau Kerayaan 6 2 20/08/2021 9,8 78 2 1 1 1 1 1 1 1 1

96 3 10/10/2020 P 6302205010200001 6302205010200001 Hafiza Ainun Nazia 3 42 1 1 M Said Alwi 6302061312880004 - Pulau Kerayaan 6 2 20/08/2021 9,2 69 2 1 1 1 1 1 1 1 1

97 2 10/7/2019 L 6302182909140001 6302201071900001 Rifky Adg Faturrahman 4 49 1 1 Abdul Rahman 6302181407490001 - Pulau Kerayaan 1 1 20/08/2021 11,1 92 1 1 1 1 1 1 1 1 1

8 89
Mengetahui,
Plt. Kepala Puskesmas Tanjung Lalak Tanjung Lalak, 20 Agustus 2021
Kec. Pulau Laut Kepulauan Pembuat Laporan,

Muhammad Nur, AMG


Hasbullah, SKM Nip. 19910909 201403 1 001

Nip. 19700403 199101 1 003

Ayu Istiqomah, A.Md.Gz

NRPTT. 11.7.2017.3.4.06
FORMULIR PEMBERIAN VITAMIN A

Provinsi : Kalimantan Selatan Nama Posyandu : Tengiri


Kabupaten/Kota : Kotabaru Bulan : Agustus
Puskesmas/Kecamatan : Tanjung Lalak / Pulau Laut Kepulauan Tahun : 2021
Desa/Kelurahan : Kerayaan Utara

IMD Vitamin A
Kepemilik ASI Eksklusif Vitamin A
Februari
an Buku 1 = Ya Agustus
Panjang Cara Ukur
Berat KIA/KMS
Badan /
No Anak Ke Tanggal Lahir Jenis No Kartu Keluarga (KK) NIK Balita (0-59bln) Nama Anak Badan Panjang Nama Ayah NIK Ayah No Telp/Hp Ayah Alamat RT RW Tanggal BB (Kg) 2 =Tidak
Tinggi 1= 1
Kelamin Lahir Lahir 1 = Ya Pengukuran 1 =Ya
Badan(cm Telentang =Ya
(gram)
1 =Ya ) 2 =berdiri
2=
2 2
Tidak Umur 0 Umur 1 Umur 2 Umur 3 Umur 4 Umur 5 2 =Tidak
= Tidak =Tidak
bln bln bln bln bln bln
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29)
1 3 27-08-2017 P 6302062001110024 6302066708170001 Kiran Khairina 2.8 48 1 1 Wahyuddin 6302060501760006 85386975777 Kerayaan Utara 2 1 23/08/2021 13 95 2 1 1 1 1 1 1 1 1
Wahyo

2 1 19-05-2019 P 6302181101190001 6302205905190001 Arumi Kesya 3.3 50 1 1 Mujahid 9101012405860002 81248499534 Kerayaan Utara 2 1 23/08/2021 10 81 2 1 1 1 1 1 1 1 1
Ramadani

3 6 25-04-2016 L 6302180505090002 6302182504160001 Ma'rifat 2,5 49 2 1 Jupri 6302180107790837 85350409050 Kerayaan Utara 7 2 23/08/2021 14 104 2 1 1 1 1 1 1 1 1

4 7 31-10-2018 P 6302180505090002 6302207110180001 Alina 2,5 49 2 1 Jupri 6302180107790837 85350409050 Kerayaan Utara 7 2 23/08/2021 12 84 2 1 1 1 1 1 1 1 1

5 4 28-12-2018 L 6302181603090001 630220282180002 Muhammad Ilham 2'8 50 1 1 Muhammad Ali 6302180107760830 - Kerayaan Utara 7 2 23/08/2021 10 86 2 1 1 1 1 1 1 1 1

6 5 06-05-2019 P 630218108150001 6302204805190001 Meilan Putri 3,1 50 1 1 Ahmad Patoni 6302180805790002 82351272877 Kerayaan Utara 5 1 23/08/2021 13 100 2 1 1 1 1 1 1 1 1
Ramadhan

7 2 02-03-2017 P 630220020720001 6302184203170001 Naurah Amaliah 3'1 50 1 1 Nadirah 6302184706970002 82158247427 Kerayaan Utara 6 2 23/08/2021 13 98 2 1 1 1 1 1 1 1 1

8 4 17-06-2016 P 6302180707100003 6302185706160001 Ira Ramadani 2,8 48 2 1 Iyan Putra 6302180107860833 85331193140 Kerayaan Utara 6 2 23/08/2021 18 111 2 1 1 1 1 1 1 1 1

9 5 18-06-2018 L 63022016021800003 6302181806180001 Nafiz Syafi'i 3,5 50 1 1 Iyan Putra 6302180107860833 85331193140 Kerayaan Utara 6 2 23/08/2021 13 93 2 1 1 1 1 1 1 1 1

10 3 24-05-2019 L 6302181811140002 630220240519000 Muhammad Ismail 3'6 49 1 1 Maskur 6302170107820040 81350386797 Kerayaan Utara 7 2 23/08/2021 15 105 2 1 1 1 1 1 1 1 1

11 1 19-07-2018 P 6302182106180002 6302185907180001 Raihanita Qolbio 3 49 1 1 Hamdi 9101010306810001 8125061558 Kerayaan Utara 6 2 23/08/2021 13 91 2 1 1 1 1 1 1 1 1

12 3 20-01-2017 P 6302180710120002 6302186001170001 Ismi Adliana 3 50 2 1 Basriadi 6302180407880002 81330205728 Kerayaan Utara 6 2 23/08/2021 15 104 2 1 1 1 1 1 1 1 1

13 4 13-04-2019 P 6302180710120002 6302205304190001 Mirna Indriani 3,8 50 1 1 Basriadi 6302180407880002 81330205728 Kerayaan Utara 6 2 23/08/2021 11 87 2 1 1 1 1 1 1 1 1

14 1 18-03-2021 P 6302180212080008 6302205803210003 Anggit Aqila 2,8 49 1 1 Hartono 6302180207820002 - Kerayaan Utara 1 1 23/08/2021 5,3 62 2 1 1 1 1 1 1 1 1

15 3 8/2/2021 L 6302182303130001 - Muhammad Alfin 2,7 49 1 1 Erwin L 6408121110760003 - Kerayaan Utara 1 1 23/08/2021 8 66,3 2 1 1 1 1 1 1 1 1

16 7 02-08-2016 P 6302183112080005 6302184208160001 Lilis Mastika 3,8 50 1 1 Sayadi 6302180207730000 6302180207730000 Kerayaan Utara 4 1 23/08/2021 14 98 2 1 1 1 1 1 1 1 1

17 8 04-03-2018 L 6302183112080005 6302180403180001 Muhammad Asraf 3,1 48 1 1 Sayadi 6302180207730000 6302180207730000 Kerayaan Utara 4 1 23/08/2021 11 90 2 1 1 1 1 1 1 1 1

18 9 24-11-2019 P 6302183112080005 6302206411190001 Nur Akifa 3,5 50 1 1 Sayadi 6302180207730000 6302180207730000 Kerayaan Utara 4 1 23/08/2021 10 80 2 1 1 1 1 1 1 1 1

19 3 14-05-2019 L 6302182910140001 6302201405190001 Muhammad Reza 2,6 49 1 1 Marliansyah 6302180909870001 - Kerayaan Utara 7 1 23/08/2021 10 83 2 1 1 1 1 1 1 1 1

20 8 22-04-2020 L 6302183012090003 630220220420001 Muhammad Fahmi Arif 3 50 1 1 Masnur 63021807680843 - Kerayaan Utara 3 1 23/08/2021 8 7,4 2 1 1 1 1 1 1 1 1

21 7 12-11-2018 L 6302180212080023 630220121180002 Muhammad Zikri Alif 2,8 49 1 1 Ridwan 6302180107670828 82352124524 Kerayaan Utara 6 2 23/08/2021 11 83,3 2 1 1 1 1 1 1 1 1

22 6 20-10-2017 L 63021820001090012 6302182010170001 Hauzan Irhab 2,6 50 1 1 Ahmad Efendi 6302182507750001 - Kerayaan Utara 1 1 23/08/2021 11 96,5 1 1 1 1 1 1 1 1

23 3 27-12-2016 L 6302030210120015 6302032712160001 Yusran 3'5 48 1 1 Muhammad Ali Mustofha 6302031112850002 85251859149 Kerayaan Utara 6 2 23/08/2021 14 100 2 1 1 1 1 1 1 1 1

24 1 22-12-2017 L 6302182609160006 6302182212170002 Ahmad Rifaldi 2'5 48 1 1 Sukriadi 6302180307850001 82151509677 Kerayaan Utara 7 2 23/08/2021 15 104 2 1 1 1 1 1 1 1 1

25 7 20-06-2016 L 6302180206120001 6302182006150001 Ahmad Ramadhan 2,6 49 1 1 Rusdiansyah 6302182707740002 - Kerayaan Utara 7 2 23/08/2021 13 100 2 1 1 1 1 1 1 1 1

26 - 29-08-2020 L - - Denis 2,7 51 1 1 Suriansyah - - Kerayaan Utara 7 2 23/08/2021 8,5 7,2 2 1 1 1 1 1 1 1 1

27 1 7/2/2021 L - - Jibran 3 51 1 1 Sapriansyah - - Kerayaan Utara 7 2 23/08/2021 7,2 68 2 1 1 1 1 1 1 1 1

28 3 26-04-2021 P 6302180810120022 - Purnama Sari 3 52 1 1 Herliansyah 6302181010870001 - Kerayaan Utara 7 2 23/08/2021 6,6 61 2 1 1 1 1 1 1 1 1

29 1 5/4/2018 L - - Faqih 2,6 52 1 1 Fadlan - - Kerayaan Utara 1 1 23/08/2021 10 92 2 1 1 1 1 1 1 1 1

30 2 27-09-2019 L - - A Izzam A 2,6 50 1 1 Fadlan - - Kerayaan Utara 1 1 23/08/2021 11 82 2 1 1 1 1 1 1 1 1

31 4 - P 6302182101090006 6302204710190001 Nurfadilah 3,5 48 1 1 Nuryadin 630218218210380001 82152549784 Kerayaan Utara 6 1 23/08/2021 9 77 2 1 1 1 1 1 1 1 1
32 2 10-05-2020 L 6302182106180002 - Gibran 2,7 50 1 1 Hamdi 9101010306810001 8125061558 Kerayaan Utara 6 2 23/08/2021 8,5 73 2 1 1 1 1 1 1 1 1

33 5 22-04-2019 L 6302182101100002 6302202204190001 Elman Fauzan 3'5 49 1 1 Nur Ifansyah 6302182701870001 82323278682 Kerayaan Utara 5 2 23/08/2021 7,3 70 2 1 1 1 1 1 1 1 1

34 5 22-04-2019 L 6302182101100002 - Elin Falia 2,5 52 1 1 Nur Ifansyah 6302182701870001 82323278682 Kerayaan Utara 5 2 23/08/2021 5,8 62 2 1 1 1 1 1 1 1 1

35 - 30-08-2018 L - - Muhammad Rifki 2,7 50 1 1 Salihin - - Kerayaan Utara 5 2 23/08/2021 12 70 2 1 1 1 1 1 1 1 1

36 - 6/10/2020 L - - Muhammad Alfalah 2,5 50 1 1 Randi - - Kerayaan Utara 7 2 23/08/2021 8,5 74 2 1 1 1 1 1 1 1 1

37 1 25-04-2020 P - - Ghina Ulyh s 2,6 49 1 1 Muslim - - Kerayaan Utara 6 2 23/08/2021 7 72 2 1 1 1 1 1 1 1 1

38 1 29-05-2020 L - - Aska Alsyi 2,7 52 1 1 Syamsir Alam - - Kerayaan Utara 6 2 23/08/2021 9 76 2 1 1 1 1 1 1 1 1

0 38

Mengetahui,
Plt. Kepala Puskesmas Tanjung Lalak Tanjung Lalak, 23 Agustus 2021
Kec. Pulau Laut Kepulauan Pembuat Laporan,

Muhammad Nur, AMG


Hasbullah, SKM Nip. 19910909 201403 1 001
Nip. 19700403 199101 1 003

Ayu Istiqomah, A.Md.Gz


NRPTT. 11.7.2017.3.4.06

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