FORMAT PENCATATAN PELAKSANAAN VAKSINASI COV

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 PANDI 6302180511730001 L 5/Nov/73 50 18-59 TELUKARU,RT 01/RW 01 081341929355 A

MUHAMMAD
2 WAHYUDINNOR
6302170308940002 L 3/Aug/94 29 18-59 TG LALAK UTARA, RT 03/RW 02 081258048499 A
3 DARMUNG 6302181003630001 L 10/Mar/63 61 60-100 TELUK ARU, RT01/RW01 082293485620 A
4 BASRI 6302180306810001 L 3/Jun/81 42 18-59 OKA OKA, RT03/RW02 082152013012 A
5 BUSRANG 7605061010850004 L 10/Oct/85 38 18-59 TAMMERODO 083195833309 A
6 SUMADIONO 6302180508780003 L 5/Aug/78 45 18-59 TELUK KEMUNING,RT01/RW01 085249497222 A
7 IRWAN 6302180102740001 L 1/Feb/74 50 18-59 P KERASIAN,RT04/RW02 082149384190 A
8 FIRMAN TAUFIK 6302180207020003 L 2/Jul/02 21 18-59 P KERASIAN,RT04/ 082149384190 A
9 HASARUDDIN 6302181212780003 L 12/Dec/78 45 18-59 P KERUMPUTAN,RT02/RW01 085390625919 A
10 KURMIATI 6302184503950003 P 5/Mar/95 29 18-59 TELUK KEMUNING,RT01/RW01 085225880678 A
11 SUSIANA 6302184812960001 P 8/Dec/96 27 18-59 TELUK KEMUNING,RT01/RW01 085388670558 A
12 MUSLIMIN 7605021304910001 L 13/Apr/91 33 18-59 TELUK KEMUNING,RT06/RW02 081287920770 A
13 NOOR RAHMAN 6302182706030003 L 27/Jun/03 20 18-59 TELUK KEMUNING,RT02/RW01 082247050521 A
14 DA'ALI 6302201011870002 L 10/Nov/87 36 18-59 TELUK ARU,RT02/RW01 081257710744 A
15 HARDIANA YANTI 6302184804890001 P 8/Apr/89 35 18-59 TELUK KEMUNING,RT01/RW01 085294177170 A
16 ALDIAN 6302181204010001 L 12/Apr/01 23 18-59 TELUK ARU,RT03/RW02 082151055931 A
17 CICI ELDIANA 6310094504910008 P 5/Apr/91 33 18-59 KERAYAANUTARA,RT05/RW02 082157213725 A
18 SAHRUL GUNAWAN 6302182608000001 L 26/Aug/00 23 18-59 TELUK ARU,RT03/RW00 085397200385 A
19 RAMA 6302180303940002 L 3/Mar/00 24 18-59 TELUK ARU,RT01/RW01 081295362551 A
20 ABDILLAH 6302181707010001 L 17/Jul/01 22 18-59 TELUK ARU,RT02/RW01 081256339568 A
21 SAPRUDDIN 6302182810940001 L 28/Oct/94 29 18-59 P KERASIAN,RT05/RW02 085388767295 A
22 UJANG PRIANTO 6302180808930001 L 8/Jun/93 30 18-59 TG LALAK SELATAN,RT03/RW02 081258357989 A
23 BAHRIANSYAH 6302182203830001 L 22/Mar/83 41 18-59 P KERUMPUTAN,RT02/RW01 085345662959 A
24 TALIPUDDIN 6302181304820001 L 13/Apr/82 42 18-59 P KERUMPUTAN,RT05/RW01 085161055708 A
25 FAHRIANI 6302185107000002 P 11/Jul/00 23 18-59 KERAYAANUTARA,RT02/RW01 081347641680 A
26 HENDRIK EKO PRASETYO 6302182903980001 L 29/Mar/98 26 18-59 TELUK ARU,RT03/RW02 085387518046 A
27 AMRAN 6302181206030001 L 12/Jun/03 20 18-59 TG LALAK SELATAN,RT03/RW02 082350520531 A
28 ABDUL HAMID 6302181502690001 L 15/Feb/69 55 18-59 P KERUMPUTAN,RT02/RW01 085249991893 A
29 JALIL 7310020107910003 L 1/Jul/91 32 18-59 PL DEWAKANG,RT03/RW01 085251941658 A
30 HESTI NURAIDA 6302185507020001 P 15/Jul/02 21 18-59 KERAYAANUTARA,RT01/RW01 085240142909 A
31 YANNI 6302182609970001 L 26/Sep/67 56 18-59 TELUK ARU,RT02/RW01 085252309685 A
32 SUKUR 6302180107700844 L 1/Jul/70 53 18-59 TELUK ARU,RT01/RW01 082217214375 A
33 ROSMIATI 6302185804770001 P 18/Apr/77 47 18-59 P KERUMPUTAN,RT02/RW01 085393148772 A
34 RISA AINUN NAJIB 6302186312930001 P 23/Dec/93 30 18-59 P KERUMPUTAN,RT02/RW01 081332019675 A
35 ZULFA 6302186203010001 P 22/Mar/01 23 18-59 KERAYAANUTARA,RT02/RW01 082149819258 A
TANJUNG ORANATA
36 LAINONG
6302181008970001 L 10/Aug/97 26 18-59 TANJUNGLALAKUTARA,RT01/RW01 081287630124 A
37 SELDINA 6302186104030002 P 21/Apr/03 21 18-59 TELUK KEMUNING,RT02/RW01 082350220939 A
38 BURHANUDDIN 6302182106790001 L 21/Jun/79 44 18-59 P KERUMPUTAN,RT04/RW02 081386290166 A
39 ZAINAL ABIDIN 6302170306730002 L 1/Jun/73 50 18-59 P KERUMPUTAN,RT02/RW01 082150478634 A
40 MUH.JAFRI 6302180305740001 L 3/May/74 50 18-59 P KERUMPUTAN,RT02/RW01 085246469160 A
41 MUKMIN 6302180607880003 L 6/Jul/88 35 18-59 P KERUMPUTAN,RT04/RW01 085348126397 A
42 JAMBERI 6302180506740001 L 5/Jun/74 49 18-59 P KERUMPUTAN,RT02/RW01 085386052367 A
43 MURDIANA 6302186102760001 P 21/Feb/76 48 18-59 P KERUMPUTAN,RT02/RW01 085246469160 A
44 HESTINAPURA 6302184903010002 P 9/Mar/01 23 18-59 P KERUMPUTAN,RT02/RW01 085246469160 A
45 SATRIANA 6302184702900001 P 7/Feb/90 34 18-59 P KERUMPUTAN,RT01/RW01 081336672571 A
46 MIRSYAD PRIBADI 6302182211020003 L 22/Nov/02 21 18-59 P KERAYAAN,RT02/RW01 082347526602 A
47 ST.NURCHALISA 6302174703000002 P 7/Mar/00 24 18-59 P KERAYAAN,RT05/RW02 082158914702 A
48 M.SYAIFUL ANWAR 6302171805990002 L 18/May/99 24 18-59 OKA OKA, RT01/RW01 082331277804 A
49 DIKI HIMAWAN 6302182007020001 L 20/Jul/02 21 18-59 P KERUMPUTAN,RT02/RW01 082250113937 A
50 SITTI PATIMAH 6302177010780002 P 30/Oct/78 45 18-59 PULAU KERASIAN 082292879873 A
51 DIMAS RIFALDI 6302181404030002 L 14/Apr/03 21 18-59 TELUK KEMUNING,RT02/RW01 082149040841 A
52 AHMAD FAJRUL ALIM 6302182405000002 L 24/May/00 23 18-59 TANJUNG LALAK SELATAN RT05/RW03 082155632194 A
53 RINTO 6302180512020001 L 5/Dec/02 21 18-59 P KERUMPUTAN,RT02/RW01 082197247648 A
FATHIAH MUFIDAH
54 SALSABILA
6302187110020001 P 31/Oct/02 21 18-59 TANJUNG LALAK SELATAN RT01/RW01 082250518400 A
55 HELDA RUKMANA SARI 6302186410960001 P 24/Oct/96 27 18-59 P KERAYAAN,RT01/RW01 085245413646 A
56 RAMLIA 6302184212820001 P 2/Dec/82 41 18-59 TELUK ARU,RT01/RW03 082154642824 A
57 MASDAR ALIANSYAH 6302020304980004 L 3/Apr/98 26 18-59 P KERAYAAN,RT05/RW02 085331361616 A
58 NURUL FAHMI 6302184208030002 P 2/Aug/03 20 18-59 KERAYAANUTARA,RT05/RW02 082251636598 A
59 SAMSUDDIN 6302182006680001 L 20/Jun/68 55 18-59 TELUK ARU,RT02/RW01 085157319985 A
60 MERI MARLINDA 6302184908010001 P 9/Aug/01 22 18-59 TELUK KEMUNING RT01/RW02 081315329645 A
61 AISYA 6302184810020001 P 8/Oct/02 21 18-59 P KERAYAAN UTARA RT 01/RW01 082253028289 A
62 FERDIANSYAH 6302181005960003 L 10/May/96 27 18-59 PULAU KERASIAN RT04/RW02 082229389901 A
63 SANDI WAHYUNI 6302181606980001 P 16/Jun/98 25 18-59 TELUK ARU RT03/RW02 082210162053 A
64 VERI ARDIAN 6302181411030001 L 14/Nov/03 20 18-59 TELUK KEMUNING RT01/RW01 081250450938 A
65 M. ILHAM 6302180407980001 L 4/Jul/98 25 18-59 PULAU KERASIAN RT04/RW02 082137286051 A
66 AHMADI A. 6302181003930003 L 10/Mar/93 31 18-59 PULAU KERAYAAN RT003/RW001 082223507025 A
MUHAMMAD KURNIA
67 NUGRAHA
6302182106960001 L 21/Jun/96 27 18-59 PULAU KERAYAAN RT001/RW002 081255179949 A
68 SYAMSUL 6302180110730001 L 1/Oct/73 50 18-59 TANJUNG LALAK UTARA RT05/RW02 081256333305 A
69 SUPYAN 6302180104990001 L 1/Apr/99 25 18-59 KERAYAAN UTARA RT03/RW01 085236450154 A
70 HARIADI 6302021205770003 L 12/May/77 47 18-59 TANJUNG LALAK UTARA RT04/RW02 085251573889 A
71 AHMAD 6302181204760001 L 12/Apr/76 48 18-59 TANJUNG LALAK UTARA RT04/RW02 082353382529 A
72 SUCI ADELIA 6302174811040002 P 8/Nov/04 19 18-59 TANJUNG LALAK SELATAN RT01/RW01 081253956056 A
73 HAMDI 9101010306810001 L 11/Sep/86 37 18-59 KERAYAAN UTARA RT06/RW02 082287091828 A
74 RINTO 6302180512020000 L 9/Dec/02 21 18-59 PULAU KERAYAAN UTARA RT02/RWO1 082197247648 A
MUHAMMAD FAJRIAN
75 NUR
6302171305030000 L 13/Jun/03 20 18-59 TANJUNG LALAK UTARA RT04/RW.02 082149926305 A
76 HARDIANSYAH 6302171007970002 L 10/Jul/97 26 18-59 PULAU KERASIAN RT.005/RW.002 082352767564 A
77 PEDLI 6302182703010001 L 27/Mar/93 31 18-59 TELUK ARU RT.002/RW.001 085348073110 A
78 ERIN SASMITAH 6302184209030002 P 2/Sep/03 20 18-59 TANJUNG LALAK UTARA RT.003.RW.002 082154643112 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
TATAN PELAKSANAAN VAKSINASI COVID-19
USKESMAS/FASYANKES/POS VAKSINASI

Dosis 2 Keterangan
(Ditunda/
Tidak
Tanggal Diberikan/
Pemberian No. Batch Lanjut)
Vaksinasi
 85 124 FALSE A
86 124 FALSE A
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 FALSE A
130 124 FALSE A
131 124 FALSE A
132 124 FALSE A
133 124 FALSE A
134 124 FALSE A
135 124 FALSE A
136 124 FALSE A
137 124 FALSE A
138 124 FALSE A
139 124 FALSE A
140 124 FALSE A
141 124 FALSE A
142 124 FALSE A
143 124 FALSE A
144 124 FALSE A
145 124 FALSE A
146 124 FALSE 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 Peke

* 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
0
0
0
0
0
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