FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVI

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Nama Puskesmas/Fasyankes/Pos : TANJUNG LALAK

Kabupaten/Kota : KOTABARU
Provinsi : KALIMANTAN SELATAN
Tanggal Pelaksanaan 1/Nov/23

Dosis I
Merek
Kelompok
No No. Registrasi NAMA NIK JK Pekerjaan* Tanggal Lahir Umur Alamat No. Hp Vaksin
Umur
(***) Tanggal
Pemberian No. Batch
Vaksinasi

1 ABDUL KADIR 6302182811780001 L 28/Nov/78 45 18-59 TELUK ARU,RT02/RW01 085346231377 A

SITTI FARWAH, A.md.
2 Keb
6302185608920001 P 16/Aug/92 31 18-59 P KERAYAAN,RT05/RW02 081380430105 A
3 MUJI IRAWAN 6302181512830001 L 15/Dec/83 40 18-59 TELUK ARU,RT03/RW01 082256389935 A
4 M. HUSNI 6302181505000004 L 15/May/00 23 18-59 TELUK KEMUNING,RT02/RW01 082358563117 A
5 MUHAMMAD IKHSAN 6302020408910001 L 4/Aug/91 32 18-59 OKA OKA,RT01/RW01 085348487092 A
6 JUHAENI 6302186804910001 L D 28/Apr/91 33 18-59 P KERAYAAN,RT01/RW01 082217793805 A
7 HASPAR NURLILI 6302181207790001 L F 12/Jul/79 44 18-59 OROBATU TAPALANG, 082353158505 A
8 LUKMAN 6302180111800001 L F 1/Nov/80 43 18-59 P KERUMPUTAN,RT05/RW01 082262313231 A
9 LULU MUSAYYANA 6302174909990002 P F 9/Sep/99 24 18-59 P KERAYAAN,RT05/RW00 082237397091 A
10 HERMAWAN 6302181204000001 L F 12/Apr/00 24 18-59 TELUK ARU,RT01/RW01 082217214375 A
11 SRI RUSDAYANI 6302184205890002 P D 2/May/89 35 18-59 P KERASIAN,RT02/RW01 082350865589 A
12 BERLIAN 6302186106770002 P D 21/Jun/77 46 18-59 P KERASIAN,RT01/RW01 081247216463 A
13 IRMAWATI 6302184210840002 P F 2/Oct/84 39 18-59 TELUK ARU,RT03/RW02 081223162936 A
14 HASRIANI 6302176401960002 P F 24/Jan/96 28 18-59 P KERAYAAN,RT04/RW00 085342866069 A
15 JIMMI, A.Md. AK 6302180410950001 L F 4/Oct/95 28 18-59 P KERAYAAN,RT05/RW02 082155839726 A
16 NUR AZIZAH 6302186810020001 P F 28/Oct/02 21 18-59 P KERAYAAN,RT02/RW01 082385728891 A
17 ABDUL RAHMAN 6302180509000001 L F 5/Sep/00 23 18-59 KERAYAAN UTARA,RT02/RW01 081390465043 A
18 MUDAWIL 6302182307000001 L F 23/Jul/00 23 18-59 KERAYAAN UTARA,RT05/RW02 082339295180 A
19 KASPUL 6302182402000002 L F 24/Feb/02 22 18-59 TELUK ARU,RT01/RW01 085368286527 A
20 JAMALUDIN 6302183101970001 L F 31/Jan/97 27 18-59 TG LALAK UTARA,RT04/RW02 082352844716 A
21 MUHAMMAD YUSUF 6302180506770003 L F 5/Jun/77 46 18-59 KERAYAAN UTARA,RT01/RW01 082254610165 A
22 MUHAMMAD SYARIF 6302181802980001 L F 18/Feb/98 26 18-59 P KERASIAN,RT06/RW02 085391433888 A
23 SUKMAN 6302183112800001 L F 31/Dec/80 43 18-59 P KERAYAAN,RT01/RW01 081250070789 A
24 JAKA 6302180503030001 L F 5/Mar/03 21 18-59 TELUK ARU,RT02/RW01 085251539839 A
25 MIRNAWATI.S 6302184712940001 P F 7/Dec/94 29 18-59 TG LALAK SELATAN,RT01/RW01 085231693457 A
26 SUBONO 6302021601800001 L F 16/Jan/80 44 18-59 TANUNG PELAYAR,RT04/ 082253028217 A
27 MUSMULIADI 6302180602880001 L F 6/Feb/88 36 18-59 OKA OKA,RT03/RW02 081247700252 A
28 SANDI SAPUTRA 6302171609000002 L F 16/Sep/00 23 18-59 TG LALAK UTARA,RT03/RW02 082348459562 A
29 MALUDDIN 6302180711930001 L F 7/Nov/93 30 18-59 TG LALAK UTARA,RT03/RW01 081351953081 A
30 NUR KHOLILAH 6302186105840001 P F 21/May/84 39 18-59 P KERASIAN,RT05/RW02 082132461417 A
31 ABDUL RAHIM 6302181812980002 L F 18/Dec/98 25 18-59 P KERASIAN,RT06/RW02 082217777946 A
32 HERY HERMAWAN 6302170807030002 L F 8/Jul/03 20 18-59 TG LALAK SELATAN,RT01/RW01 082357658120 A
33 AINATUL SAFITRI 6302185006960002 P F 10/Jun/96 27 18-59 P KERASIAN,RT04/RW02 085252285521 A
34 CHANDRA WHULAND 6302185111030002 P F 11/Nov/03 20 18-59 TG LALAK SELATAN,RT02/RW01 081351926742 A
35 NURHASANAH 6302184510950001 P F 5/Oct/95 28 18-59 P KERASIAN,RT04/RW02 082158164258 A
36 HARSAH 6302180209930002 F 2/Sep/93 30 18-59 TELUK ARU,RT02/RW01 082287900203 A
37 RACHMAT SAYUTHI 6302010804960004 L 8/Apr/96 28 18-59 TG LALAK UTARA,RT04/RW02 082286996969 A
38 HARIANTO 6302180508000002 L F 1/Jun/00 23 18-59 TELUK KEMUNING,RT01/RW01 082141935297 A
39 LILIS PURWANDA 6302186302020003 P F 23/Feb/02 22 18-59 TELUK KEMUNING,RT03/RW01 085299764085 A
40 TOMI DEFISA 6302182403030001 L F 24/Mar/03 21 18-59 TELUK KEMUNING,RT01/RW01 081348525011 A
41 M. SURYAN 6302021101030002 L F 11/Jan/03 21 18-59 TG PELAYAR,RT04/RW02 085348656331 A
42 MELA OKTAVIA 6302184507990001 P F 5/Jul/99 24 18-59 TELUK KEMUNING,RT03/RW01 082358823081 A
43 ABDUL WARIS 6302182009620001 L D 20/Sep/62 61 60-100 TELUK ARU,RT03/RW02 081345176532 A
44 DESI SALFIANI 6302185808010001 P F 18/Aug/01 22 18-59 TELUK KEMUNING,RT01/RW01 085299839535 A
45 AGUS 6302180706830002 L F 7/Jun/83 40 18-59 OKA OKA,RT01/RW01 085249089192 A
46 BADRUL AINI 6302182505940001 L F 25/May/94 29 18-59 KERAYAAN UTARA,RT02/RW01 081254165181 A
47 SUCI RAHMADANI 6302180303940001 L F 3/Mar/94 30 18-59 TG LALAK UTARA,RT05/RW02 081349597576 A
48 RINTO HARAHAP 6302181007880002 L F 10/Jul/88 35 18-59 TG LALAK UTARA,RT05/RW02 085251136330 A
49 HASFIANA 6302184101800010 P F 1/Jan/80 44 18-59 TG LALAK UTARA,RT04/RW02 082250916308 A
50 ZARKASI NOOR 6302181502990001 P F 15/Feb/99 25 18-59 BARU TENGAH,RT05/RW00 082350917663 A
51 SITI RUHMANIAH 6302185101910001 P 11/Jan/91 33 18-59 P KERASIAN, 085332255388 A
52 SISWO PRAYITNO 6302062512650001 L F 25/Dec/65 58 18-59 SEMAYAP, 081250301783 A
53 AHMAD RIADI 6302180702910001 L F 7/Feb/91 33 18-59 TELUK KEMUNING,RT03/RW01 082157735685 A
54 HENDI ALFYAN 6302180201010001 L F 2/Jan/01 23 18-59 TG LALAK UTARA,RT03/RW02 082358174143 A
55 EKA DAMAYANTI 6302177006980002 P F 30/Jun/98 25 18-59 TELUK KEMUNING,RT03/RW01 082351872783 A
56 LUKMANSYAH 6302181403900001 L F 14/Mar/90 34 18-59 TELUK ARU,RT03/RW02 085348313295 A
57 ANISA DZAKIRA 6302176802990002 P F 28/Feb/99 25 18-59 P KERASIAN,RT01/RW01 085204999279 A
58 POPY 6302184507000001 F 5/Jul/03 20 18-59 TG LALAK UTARA,RT02/RW01 081257498405 A
59 ARMAN RIADI 6302181103760001 L F 11/Mar/76 48 18-59 TELUK KEMUNING,RT01/RW01 085252809239 A
60 ABDUL SALAM 6302182007880002 L F 20/Jul/88 35 18-59 OKA OKA,RT03/RW02 085251518050 A
INDRIKA SAFITRI
61 UTAMA
6302184811990001 P F 8/Nov/99 24 18-59 TG LALAK UTARA,RT03/RW02 082150297290 A
62 SUSIADI 6302181905780001 L F 19/May/78 45 18-59 KERAYAAN UTARA,RT06/RW02 085332184976 A
AHMAD SYAHDAN
63 NOOR
6302022507950004 L F 25/Jul/95 28 18-59 LONTAR UTARA, 082155102328 A
64 AFDALUDDIN 6302182307020001 L F 23/Jul/02 21 18-59 P KERUMPUTAN,RT02/RW01 082352205014 A
65 RIDUAN 6302180708840001 L F 7/Aug/84 39 18-59 TELUK ARU,RT01/RW01 082153240389 A
66 LATIF.S.TP 6302040903910002 L F 9/Mar/91 33 18-59 TG LALAK UTARA, 082354438003 A
67 YUSUF EFENDI 7324034107720001 L F 11/Jul/86 37 18-59 TG LALAK SELATAN,RT01/RW01 082172260694 A
68 SAMSIR WAHYUDI 6302020104770825 L F 1/Apr/77 47 18-59 TANJUNG TENGAH, 085349749967 A
69 DARLIANI 6302184504010001 P F 5/Apr/01 23 18-59 P KERASIAN,RT04/RW02 081239602804 A
70 RAMLI 6302180510820002 L F 5/Oct/82 41 18-59 TG LALAK SELATAN,RT01/RW01 081351008706 A
71 SIDDIK SARIPUDDIN 6302180309740002 L F 3/Sep/74 49 18-59 P. KERAYAAN,RT01/RW01 081357881740 A
72 DWI SAFITRI 6302186404000001 P F 24/Apr/00 24 18-59 TG LALAK UTARA,RT04/RW02 081256568786 A
73 124 FALSE A
74 124 FALSE A
75 124 FALSE A
76 124 FALSE A
77 124 FALSE A
78 124 FALSE A
79 124 FALSE A
80 124 FALSE A
81 124 FALSE A
82 124 FALSE A
83 124 FALSE A
84 124 FALSE A
85 124 FALSE A
86 124 FALSE A
ATATAN PELAKSANAAN VAKSINASI COVID-19
PUSKESMAS/FASYANKES/POS VAKSINASI

Dosis 2 Keterangan
(Ditunda/
Tidak
Tanggal Diberikan/
Pemberian No. Batch Lanjut)
Vaksinasi
 87 124 FALSE A
88 124 FALSE A
89 124 FALSE A
90 124 FALSE A
91 124 FALSE A
92 124 FALSE A
93 124 FALSE A
94 124 FALSE A
95 124 FALSE A
96 124 FALSE A
97 124 FALSE A
98 124 FALSE A
99 124 FALSE A
100 124 FALSE A
101 124 FALSE A
102 124 FALSE A
103 124 FALSE A
104 124 FALSE A
105 124 FALSE A
106 124 FALSE A
107 124 FALSE A
108 124 FALSE A
109 124 FALSE A
110 124 FALSE A
111 124 FALSE A
112 124 FALSE A
113 124 FALSE A
114 124 FALSE A
115 124 FALSE A
116 124 FALSE A
117 124 FALSE A
118 124 FALSE A
119 124 FALSE A
120 124 FALSE A
121 124 FALSE A
122 124 FALSE A
123 124 FALSE A
124 124 FALSE A
125 124 FALSE A
126 124 FALSE A
127 124 FALSE A
128 124 FALSE A
129 124 A
130 124 A
131 124 A
132 124 A
133 124 A
134 124 A
135 124 A
136 124 A
137 124 A
138 124 A
139 124 A
140 124 A
141 124 A
142 124 A
143 124 A
144 124 A
145 124 A
146 124 A
147 124 A
148 124 A
149 124 A
150 124 A
151
152
153
154
155
156
157
158
159
160

Keterangan ***Merek Vaksin Kelompok Umur: Pemberian Dosis Pekerjaa

* Pekerjaan dikelompokkan menjadi: A = Sinovac 12 s/d 17 0 Dosis 1 0 A
A = Tenaga Medis B = V-19 BIOFARMA 18 s/d 59 0 Dosis 2 0 B
B = Lansia C = MODERNA 60 s/d 100 0 Total 0 C
C = Petugas / Pelayan Publik Total 0 D
D = Tenaga Pendidik Jenis Vaksin: E
E = Masyarakat Rentan A 150 F
F = Masyarakat Umum B 0 G
G = Remaja (12-17) C 0 Total
Total 150
Pekerjaan
0
0
0
4
0
61
0
65
Nama Puskesmas/Fasyankes/Pos : TANJUNG LALAK
Kabupaten/Kota : KOTABARU
Provinsi : KALIMANTAN SELATAN

Umur
No. Registrasi No. Registrasi Kelompok
No NIK Nama Penerima Vaksin JK Pekerjaan* (18-59
I II Umur
tahun)

1 N - 34017B7C W-36DAFBBB 6302180304700001 Hasbullah, SKM L A 51 46-59

2 N - F82497BA W-AE437E70 6302066008820010 dr. Liana P A 38 31-45
3 N-15AE472B W-6BE5AC84 6302012005770001 Irwan, .A.Md.,Kep L A 44 31-45
4 N-221701D1 W-0105796F 6302060408900009 Faridl Hamzah, AMK L A 31 31-45
5 N-45838FED W-F7B58410 6304054210750001 Umi Mamah, Amd. Keb P A 45 31-45
6 N-F49C8E4A W-18981EC0 6302174706780002 ST Aisyah, S.S.T.Keb P A 43 31-45
7 N-E1096FBE W-DC19F410 6302177003900002 Siti Rahmah, Amd. Keb P A 31 31-45
8 N-348A33CE W-B82407FA 6302176511880002 Novianti, Amd. Keb P A 33 31-45
9 N-23BA7A07 W-3CDAA19F 7605015904820001 Hikmah, S.Si., Apt P A 39 31-45
10 N-11ACBE49 W-7A1F903D 6371010404760015 Muhammad Fahruddin Azmi, AMd L A 45 31-45
11 N-C4A136B9 W-EB0B47D4 6302170909910002 Muhammad Nur, A.M.G L A 29 18-30
12 N-B6463393 W-E6076403 6302045407930002 Syarifah Erniwahyuni, A. Md. KG P A 28 18-30
13 N-B66F5793 W-2DD30E8E 6302185104710002 Widi Astutik P A 50 46-59
14 N-910458EC W-5539FDDD 6302065110770004 Syamsiah A.Md.,Keb P A 43 31-45
15 N-B30C5156 W-C798DD6F 6302061503940003 Batholo Cahya Kusuma, SKM L A 27 18-30
16 N-2917AC09 W-9280F822 6302174511910002 Nur Aida, SE P A 29 18-30
17 N-F5A19F02 W-939FBF08 6302180306770003 Sukri L A 44 31-45
18 N-796C1B5F W-FEE2B297 6302186406940001 Puji AstutiI, Amd,Kep P A 27 18-30
19 N-3FC93359 W-C997DAAE 3311025509890001 Dwi Hastuti, Amd. Keb P A 31 31-45
20 N-72E377FA W-95EF9461 6302185912900003 Desy Silviana Rasyid, A. Md. Keb P A 30 18-30
21 N-F8E3A630 W-12763469 6302184711900001 Siti Damsiah, A.Md.Keb P A 31 31-45
22 N-B86901E0 W-CF465A0B 6302035210960002 Novi Herlina Samin Amd.,Farm P A 24 18-30
23 N - 5B7AB006 W-1BE1FC4D 6302185110940001 Rahmatan, SKM P A 26 18-30
24 N - F8D330A3 W-D3F669AA 6302181311940002 Ahmad Gunawan. R. SE L A 26 18-30
25 N-F6461C37 W-A6B9020C 6302186604960001 Kiky Naillah, S.Tr.Kes P A 25 18-30
26 N-2957870C W-4A92D46F 6302172907930002 Qamarullah, Amd L A 28 18-30
27 N-CC8A6177 W-EA2536E5 6302186408950002 Ryan Nurul Hasanah P A 25 18-30
28 N-7657A7C3 W-EAB40A19 6302180406910001 Hermansyah, Amk L A 30 18-30
29 P-1XDSI1OC P-67BD22C9 6302186095880001 Musdariah., Amd.Keb P A 33 31-45
30 P-1XDJVQPH P-F74853AF 6302024907950001 Imroatul Mufidah, Amd.Keb P A 26 18-30
31 P-57R3E7AK Q-55612B58 6302186204910001 Lis Indrayani, Amd. Keb P A 30 18-30
32 P-57RNKJ9R Q-55612B58 6302174609920002 Nirwana, Amd Keb P A 28 18-30
33 P-1XFHDQ3K Q-54C97341 6302064503940004 Ayu Istiqomah A.Md Gz P A 27 18-30
34 N-FE679CAB 6302174609740002 Sri Wahyuni, A.M.Keb P A 46 46-59
35 N-CC598596 6302186310830001 Mardia, A.Md.Kep P A 37 31-45
36 S-0A9A6404 6302185009830001 Nursaidah, AMK p A 37 31-45
37 S-0F7F8795 6301036607910002 Widiawati Astuti, A. Md. AK P A 30 18-30
38 N-EB985121 6302181706860001 Ahmad L A 35 31-45
39 6302185511880003 Nur Alam S., A. Md. Kep P A 32 31-45
40 7310025507921001 Rosalia, SKM P A 29 18-30
41 6302176309940002 Devi Syamsiah, SKM P A 26 18-30
42 6302185206900004 Sunarti, Amd.Keb P A 31 31-45
43 6302185409920001 Erdawati, A.Md, Keb P A 28 18-30

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diter
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya'

Dosis I
pada kolom yang sesuai)
Merek
Tanggal
Alamat No. Hp Vaksin
Screening
(***) Tanggal
BPJS BPJS Non
Pemberian No. Batch
PBI Non PBI Anggota
Vaksinasi

Tanjung Lalak Utara 081251293567 YA A 2/3/2021 2/3/2021 202011044

Jln. Panorama No.34 Rt09 Rw.02 081382708650 YA A 2/3/2021 2/3/2021 202011044
P. Kerayaan 081242438453 YA A 2/3/2021 2/3/2021 202011044
Jln. Perumnas Batu Silira 085245372010 YA A 2/3/2021 2/3/2021 202011044
T. Aru 081253874609 YA A 2/3/2021 2/3/2021 202011044
Tanjung Lalak Utara 085350071778 YA A 2/3/2021 2/3/2021 202011044
Oka-Oka 082220053092 YA A 2/3/2021 2/3/2021 202011044
P. Kerasian 085331327223 YA A 2/3/2021 2/3/2021 202011044
Tanjung Lalak Utara 085233082882 YA A 2/3/2021 2/3/2021 202011044
Banjarmasin 085350071717 YA A 2/3/2021 2/3/2021 202011044
P. Kerayaan 081257876554 YA A 2/3/2021 2/3/2021 202011044
Berangas 082352845036 YA A 2/3/2021 2/3/2021 202011044
P. Kerumputan 085386708893 YA A 2/3/2021 2/3/2021 202011044
T. Kemuning 081348372777 YA A 2/3/2021 2/3/2021 202011044
Jln. Campa Jawa Desa Sigam Ktb 082250106464 YA A 2/3/2021 2/3/2021 202011044
P. Kerayaan 081251325456 YA A 2/3/2021 2/3/2021 202011044
Tanjung Lalak Selatan 082354168122 YA A 2/3/2021 2/3/2021 202011044
Tanjung Lalak Selatan 082352666016 A 2/3/2021 2/3/2021 202011044
Kerayaa Utara 082254810005 A 2/3/2021 2/3/2021 202011044
P. Kerayaan 082136725893 YA A 2/3/2021 2/3/2021 202011044
P. Kerumputan 085349537816 A 2/3/2021 2/3/2021 202011044
Tanjug Seloka 081352513343 A 2/3/2021 2/17/2021 202011044
Tanjung Lalak Selatan 081254007728 A 2/3/2021 2/3/2021 202011044
Tanjung Lalak Selatan 082154026045 A 2/3/2021 2/3/2021 202011044
Tanjung Lalak Utara 081346476385 YA A 2/3/2021 2/17/2021 202011044
Tanjung Lalak Selatan 082152013369 YA A 2/3/2021 2/17/2021 202011044
Teluk Aru 081223162936 YA A 2/3/2021 2/3/2021 202011044
P. Kerumputan 085245662308 A 3/4/2021 3/4/2021 202011044
P. Kerayaan 085340620329 A 2/3/2021 2/3/2021 202011044
Desa Bangun Rejo PLTS 085754165740 YA A 2/3/2021 2/3/2021 202011044
Teluk Kemuing 082256021550 YA A 3/4/2021 3/4/2021 202011044
Tanjung Lalak Utara 085349966609 YA A 3/4/2021 3/4/2021 202011044
Kotabaru 081254919339 YA A 3/4/2021 3/4/2021 202011044
P. Kerasian 081346219093 YA 3/4/2021
Kerayaan Utara 082152718627 2/3/2021
P. Kerasian 082151354736 YA 2/3/2021
Kotabaru 085386016857 YA 2/3/2021
Tanjung Lalak Utara 085388818252
Tanjung Lalak Selatan 081351693462
Tanjung Lalak Utara 082292456820 YA
Tanjung Lalak Utara 085388825253 YA
P. Kerayaan 082252973003 YA
Teluk Kemuning 082224101617 YA

Kelompok Umur: Kepesertaan BPJS

18-30 21 BPJS PBI 4
ksin yang diterima Puskesmas/Faskes) 31-45 19 BPJS Non PBI 28
SI COVID-19
NASI

Dosis 2
Keterangan
(Ditunda/ Tidak Efek
Hasil Pemeriksaan KIPI
Diberikan/ Sampig
Tanggal
Lanjut)
Pemberian No. Batch
Vaksinasi

2/17/2021 202011044 Lanjut

2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
3/4/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
3/4/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
3/22/2021 202011044 Lanjut
3/4/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
3/23/2021 202011044 Lanjut HT
2/17/2021 202011044 Lanjut
2/17/2021 202011044 Lanjut
3/22/2021 202011044 Lanjut Menyusui
3/22/2021 202011044 Lanjut Menyusui
3/22/2021 202011044 Lanjut Menyusui
Tunda DM
Tunda Konfirm C-19 (PCR)
Tunda Menyusui
Tunda Konfirm C-19 (PCR)
Belum Screening
Tunda Hamil
Tunda Hamil
Tunda Konfirm C-19 (PCR)
Belum Screening
Tunda Menyusui

Pekerjaan KETERANGAN
A 43 Lanjut 33
B 0 Tunda 8
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
46-59 3 Non Anggota 0
Total 43 Total 32
Jenis Vaksin: Pemberian Dosis
A 33 Dosis 1 33
B 0 Dosis 2 33
C 0 Total 66
Total 33
 C 0 Tidak diberikan 0
D 0 Belum Screening 2
E 0 TOTAL 43
Total 43
 FORMAT PENCATATAN PELAKSANAAN VAKSINAS
TINGKAT PUSKESMAS/FASYANKES/POS VAKSI

Nama Puskesmas/Fasyankes/Pos : TANJUNG LALAK

Kabupaten/Kota : KOTABARU
Provinsi : KALIMANTAN SELATAN

Kepesertaan BPJS (tulis 'Ya'

pada kolom yang sesuai)
Umur Merek
No. Registrasi No. Registrasi Kelompok Tanggal
No NIK Nama Penerima Vaksin JK Pekerjaan* (18-59 Alamat No. Hp Vaksin
I II Umur Screening
tahun) (***)
BPJS BPJS Non
PBI Non PBI Anggota

1 N - 34017B7C W-36DAFBBB 6302180304700001 Hasbullah, SKM L A 51 46-59 Tanjung Lalak Utara 081251293567 YA A 2/3/2021
2 N - F82497BA W-AE437E70 6302066008820010 dr. Liana P A 38 31-45 Jln. Panorama No.34 Rt09 Rw.02 081382708650 YA A 2/3/2021
3 N-15AE472B W-6BE5AC84 6302012005770001 Irwan, .A.Md.,Kep L A 44 31-45 P. Kerayaan 081242438453 YA A 2/3/2021
4 N-221701D1 W-0105796F 6302060408900009 Faridl Hamzah, AMK L A 31 31-45 Jln. Perumnas Batu Silira 085245372010 YA A 2/3/2021
5 N-45838FED W-F7B58410 6304054210750001 Umi Mamah, Amd. Keb P A 45 31-45 T. Aru 081253874609 YA A 2/3/2021
6 N-F49C8E4A W-18981EC0 6302174706780002 ST Aisyah, S.S.T.Keb P A 43 31-45 Tanjung Lalak Utara 085350071778 YA A 2/3/2021
7 N-E1096FBE W-DC19F410 6302177003900002 Siti Rahmah, Amd. Keb P A 31 31-45 Oka-Oka 082220053092 YA A 2/3/2021
8 N-348A33CE W-B82407FA 6302176511880002 Novianti, Amd. Keb P A 33 31-45 P. Kerasian 085331327223 YA A 2/3/2021
9 N-23BA7A07 W-3CDAA19F 7605015904820001 Hikmah, S.Si., Apt P A 39 31-45 Tanjung Lalak Utara 085233082882 YA A 2/3/2021
10 N-11ACBE49 W-7A1F903D 6371010404760015 Muhammad Fahruddin Azmi, AMd L A 45 31-45 Banjarmasin 085350071717 YA A 2/3/2021
11 N-C4A136B9 W-EB0B47D4 6302170909910002 Muhammad Nur, A.M.G L A 29 18-30 P. Kerayaan 081257876554 YA A 2/3/2021
12 N-B6463393 W-E6076403 6302045407930002 Syarifah Erniwahyuni, A. Md. KG P A 28 18-30 Berangas 082352845036 YA A 2/3/2021
13 N-B66F5793 W-2DD30E8E 6302185104710002 Widi Astutik P A 50 46-59 P. Kerumputan 085386708893 YA A 2/3/2021
14 N-910458EC W-5539FDDD 6302065110770004 Syamsiah A.Md.,Keb P A 43 31-45 T. Kemuning 081348372777 YA A 2/3/2021
15 N-B30C5156 W-C798DD6F 6302061503940003 Batholo Cahya Kusuma, SKM L A 27 18-30 Jln. Campa Jawa Desa Sigam Ktb 082250106464 YA A 2/3/2021
16 N-2917AC09 W-9280F822 6302174511910002 Nur Aida, SE P A 29 18-30 P. Kerayaan 081251325456 YA A 2/3/2021
17 N-F5A19F02 W-939FBF08 6302180306770003 Sukri L A 44 31-45 Tanjung Lalak Selatan 082354168122 YA A 2/3/2021
18 N-796C1B5F W-FEE2B297 6302186406940001 Puji AstutiI, Amd,Kep P A 27 18-30 Tanjung Lalak Selatan 082352666016 A 2/3/2021
19 N-3FC93359 W-C997DAAE 3311025509890001 Dwi Hastuti, Amd. Keb P A 31 31-45 Kerayaa Utara 082254810005 A 2/3/2021
20 N-72E377FA W-95EF9461 6302185912900003 Desy Silviana Rasyid, A. Md. Keb P A 30 18-30 P. Kerayaan 082136725893 YA A 2/3/2021
21 N-F8E3A630 W-12763469 6302184711900001 Siti Damsiah, A.Md.Keb P A 31 31-45 P. Kerumputan 085349537816 A 2/3/2021
22 N-B86901E0 W-CF465A0B 6302035210960002 Novi Herlina Samin Amd.,Farm P A 24 18-30 Tanjug Seloka 081352513343 A 2/3/2021
23 N - 5B7AB006 W-1BE1FC4D 6302185110940001 Rahmatan, SKM P A 26 18-30 Tanjung Lalak Selatan 081254007728 A 2/3/2021
24 N - F8D330A3 W-D3F669AA 6302181311940002 Ahmad Gunawan. R. SE L A 26 18-30 Tanjung Lalak Selatan 082154026045 A 2/3/2021
25 N-F6461C37 W-A6B9020C 6302186604960001 Kiky Naillah, S.Tr.Kes P A 25 18-30 Tanjung Lalak Utara 081346476385 YA A 2/3/2021
26 N-2957870C W-4A92D46F 6302172907930002 Qamarullah, Amd L A 28 18-30 Tanjung Lalak Selatan 082152013369 YA A 2/3/2021
27 N-CC8A6177 W-EA2536E5 6302186408950002 Ryan Nurul Hasanah P A 25 18-30 Teluk Aru 081223162936 YA A 2/3/2021
28 N-7657A7C3 W-EAB40A19 6302180406910001 Hermansyah, Amk L A 30 18-30 P. Kerumputan 085245662308 A 3/4/2021
29 P-1XDSI1OC P-67BD22C9 6302186095880001 Musdariah., Amd.Keb P A 33 31-45 P. Kerayaan 085340620329 A 2/3/2021
30 P-1XDJVQPH P-F74853AF 6302024907950001 Imroatul Mufidah, Amd.Keb P A 26 18-30 Desa Bangun Rejo PLTS 085754165740 YA A 2/3/2021
31 P-57R3E7AK Q-55612B58 6302186204910001 Lis Indrayani, Amd. Keb P A 30 18-30 Teluk Kemuing 082256021550 YA A 3/4/2021
32 P-57RNKJ9R Q-55612B58 6302174609920002 Nirwana, Amd Keb P A 28 18-30 Tanjung Lalak Utara 085349966609 YA A 3/4/2021
33 P-1XFHDQ3K Q-54C97341 6302064503940004 Ayu Istiqomah A.Md Gz P A 27 18-30 Kotabaru 081254919339 YA A 3/4/2021
34 N-FE679CAB 6302174609740002 Sri Wahyuni, A.M.Keb P A 46 46-59 P. Kerasian 081346219093 YA 3/4/2021
35 N-CC598596 6302186310830001 Mardia, A.Md.Kep P A 37 31-45 Kerayaan Utara 082152718627 2/3/2021
36 S-0A9A6404 6302185009830001 Nursaidah, AMK p A 37 31-45 P. Kerasian 082151354736 YA 2/3/2021
37 S-0F7F8795 6301036607910002 Widiawati Astuti, A. Md. AK P A 30 18-30 Kotabaru 085386016857 YA 2/3/2021
38 N-EB985121 6302181706860001 Ahmad L A 35 31-45 Tanjung Lalak Utara 085388818252
39 6302185511880003 Nur Alam S., A. Md. Kep P A 32 31-45 Tanjung Lalak Selatan 081351693462
40 7310025507921001 Rosalia, SKM P A 29 18-30 Tanjung Lalak Utara 082292456820 YA
41 6302176309940002 Devi Syamsiah, SKM P A 26 18-30 Tanjung Lalak Utara 085388825253 YA
42 6302185206900004 Sunarti, Amd.Keb P A 31 31-45 P. Kerayaan 082252973003 YA
43 6302185409920001 Erdawati, A.Md, Keb P A 28 18-30 Teluk Kemuning 082224101617 YA

Keterangan ***Merek Vaksin Kelompok Umur:

* Pekerjaan dikelompokkan menjadi: A = Sinovac 18-30 21
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes) 31-45 19
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat 46-59 3
C = Administrator Pemerintahan Total 43
D = Lainnya Jenis Vaksin:
E = Tidak Bekerja A 33
B 0
C 0
Total 33
ENCATATAN PELAKSANAAN VAKSINASI COVID-19
KAT PUSKESMAS/FASYANKES/POS VAKSINASI

Dosis I Dosis 2
Keterangan
(Ditunda/ Tidak Efek
Hasil Pemeriksaan KIPI
Diberikan/ Sampig
Tanggal Tanggal
Lanjut)
Pemberian No. Batch Pemberian No. Batch
Vaksinasi Vaksinasi

2/3/2021 202011044 2/17/2021 202011044 Lanjut

2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 3/4/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/17/2021 202011044 3/4/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/17/2021 202011044 3/22/2021 202011044 Lanjut
2/17/2021 202011044 3/4/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
3/4/2021 202011044 3/23/2021 202011044 Lanjut HT
2/3/2021 202011044 2/17/2021 202011044 Lanjut
2/3/2021 202011044 2/17/2021 202011044 Lanjut
3/4/2021 202011044 3/22/2021 202011044 Lanjut Menyusui
3/4/2021 202011044 3/22/2021 202011044 Lanjut Menyusui
3/4/2021 202011044 3/22/2021 202011044 Lanjut Menyusui
Menolak DM
Tunda Konfirm C-19 (PCR)
Tunda Menyusui
Tunda Konfirm C-19 (PCR)
Menolak
Hamil
Tunda Hamil
Tunda Konfirm C-19 (PCR)
Belum Screening
Tunda Menyusui

Kepesertaan BPJS Pekerjaan KETERANGAN

BPJS PBI 4 A 43 Lanjut 33
BPJS Non PBI 28 B 0 Tunda 6
Non Anggota 0 C 0 Tidak diberikan 0
Total 32 D 0 Belum Screening 1
Pemberian Dosis E 0 TOTAL 40
Dosis 1 33 Total 43
Dosis 2 33
Total 66