FORM PELAPOR FASKES

DAFTAR PENGIRIM SAMPEL COVID 19

FASKES PENGIRIM : RSU ADHYAKSA

JL. HANKAM RAYA NO.60, CEGER, JAK-TIM

NO NAMA PASIEN NIK TGL LAHIR ALAMAT TGL KIRIM SAMPEL JAM KET CITO

BIASA

319 BAYU ASIDO 3175102602770002 10/26/1977 JL. PONDOK RANGGON RT 001/004 11/10/2020 16.00 Pasien

320 DARKOM 3175101306770007 6/13/1977 JL. GIRI KENCANA NO. 13 11/10/2020 16.00 Pasien

321 WILLVERIN SHERLY 3171086503720001 3/25/1977 JL. PERCETAKAN NEGARA RT 001/003 11/10/2020 16.00 Pasien

322 SITI MUAMALAH 3329106903930002 3/29/1993 JL RAYA CIPAYUNG NO. 67 11/10/2020 16.00 Pasien

323 MULIANAH 3175095508500001 8/15/1950 JL. RAYA PONCOL RT 001/007 CIRACAS 11/10/2020 16.00 Pasien

324 LIANATASHA 3175056907890002 7/29/1989 JL. BARET BIRU III NO. 11 KALISARU 11/10/2020 16.00 Pasien

325 B RENI NAPITUPULU 3175106609710003 11/26/1971 JL. DAMAI III NO 34 11/10/2020 16.00 Pasien

326 ASEP SETIADI 3210201505940021 4/15/1994 BLOK RAKSADIPA RT 002/005 11/10/2020 16.00 Pasien

327 NI MADE ROHMAH 3275125709960001 8/17/1996 KP PONDOK RANGGON RT 06/03 11/10/2020 16.00 Pasien

328 S EDISON MARPAUNG 3175102601430001 1/26/1943 JL. GLADIUL KAV DKI BLOK G1 11/10/2020 16.00 Pasien

329 HJ. SOENARSIH 3276105011450006 11/10/1945 JL. DALANG SEMAR NO. 1A RT 010/005 11/10/2020 16.00 Pasien

330 NOVITASARI 3175106311840004 11/23/1984 JL. DALANG NO.65 RT 003/005 11/10/2020 16.00 Pasien

331 ABDUL LATIF 3175101708480005 8/17/1948 JALAN MABES ABRI GG GOTONG ROYONG 11/10/2020 16.00 Pasien

332 NOVITA ANGGRAINI 3175106711840001 11/27/1984 JL. SMP 160 RT 004/005 11/10/2020 16.00 Pasien

333 CAHYANTI KUSUMA A 3175094408971001 8/4/1997 JL. TANJUNG RT 008/002 11/10/2020 16.00 Pasien

334 EDUARD P SIANIPAR 0'3172041411830010 11/14/1983 JL. TENGKI RT 04/03 NO. 97 11/10/2020 16.00 Pasien
335 ELLY KOMARIAH 3174064209560001 9/2/1956 JL. CIPETE V NO.20 11/10/2020 16.00 Pasien
 FORM PELAPOR FASKES
DAFTAR PENGIRIM SAMPEL COVID 19

FASKES PENGIRIM : RSU ADHYAKSA

JL. HANKAM RAYA NO.60, CEGER, JAK-TIM
NO NAMA PASIEN NIK TGL LAHIR ALAMAT TGL KIRIM SAMPEL JAM KET CITO
CITO

336 DJOKO SETIO ADJI 3175091703560004 3/17/1956 JL. NANGKA GROWONG RT 004/001 11/10/2020 16.00 Pasien

337 MEHDI SAPUTRA 3171083003880008 3/30/1988 JL. SAIBUN RT 05/04 11/10/2020 16.00 Pasien

338 MAULIDYA HAIFA 3275126909900003 9/29/1990 JL. GEBRAS SUSUKAN CIRACAS 11/10/2020 16.00 Pasien

339 FATHULLOH 3175090206600009 6/2/1960 GANG GALUR NO.41 RT 004/009 11/10/2020 16.00 Pasien

340 MUHIDI 3175102512710003 12/25/1971 JL. ANGKASA RT 004/002 CEGER 11/10/2020 16.00 Pasien

341 DRS BAMBANG 3172022007670009 7/20/1967 JL. SWASEMBADA BRT XVIII NO. 29 11/10/2020 16.00 Pasien

342 CATUR NUR ZAQIAN 3327010709970003 9/7/1997 JL. KOTA BAMBU UTARA RT 006/004 11/10/2020 16.00 NAKES

343 SUCI AJENG NINGTYAS 3175095902920005 2/19/1992 JL. MASJID NURUL HIDAYAH RT 001/009 11/10/2020 16.00 Pasien