FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Nama Puskesmas/Fasyankes/Pos : Banjar 3

Kabupaten/Kota : Banjar
Provinsi : Jawa Barat
Tanggal : 02-02-2021 : 07/7/2021

Kepesertaan BPJS (tulis 'Ya'

pada kolom yang sesuai)
Jenis Umur Kelompok
No No. Registrasi NIK Nama Penerima Vaksin Pekerjaan* Alamat No. Hp
Kelamin (18-59 tahun) Umur
BPJS
BPJS PBI
Non PBI

1 W-61368EB7 3279042004790001 DEDI HARYANTO L A 42 085223852444 1

2 U-00008P67 3279015702870001 LIA HERLIANI P A 34 085223174534 1

3 U-00008N27 3279010505810005 AYI NURROHMAN L A 40 085321885994 1

4 Q-AEC6A7AB 1572025412910001 MONICA AFRINDA P A 29 082258555799 1

5 U-0000XHEG 3279010506890001 YUNIAR NURYANA L A 32 085352400453 1

6 FI 3207181509890004 KUSNADI L A 32 085962301231 1

7 U-0000XQLC 3206141604860001 IMAN ROHOIMAN L A 35 082117279528 1

8 W-E515C41F 3207182405930002 AGUNG WIGUNA L A 28 082126935020 1

9 U-00004L4V 3207194901930001 UTIANI KHOIRUNISA P A 28 082318444865 1

10 P-87E64EE8 3207190602950001 SURYADI L A 26 082320672726 1

11 U-0000XH93 3279024801920002 NURMALASARI P A 29 085286566922 1

12 U-0000XPT2 3207172212890001 JAKARIA ALI ROSIDI L A 32 082240166188 1

13 U-00002350 3279014101960003 HANAYASMIN NURDIANI P A 25 082124024805 1

14 W-2352D9AC 3279022504820001 DANI PURNA IRAWAN L A 39 089608128022 1

15 W-4F61D08E 3207192310970003 DEDE KARDIMAN L A 23 085722485890 1

16 U-0000475T 3207034401840003 YANI ROSMALA DEWI P A 37 085353353217 1

17 P-D544B632 3279022110950002 PREDY FIRMANSYAH L A 25 085861886321 1

18 U-000041RH 3207202204960001 REZA ZAKARIA L A 25 088707855551 1

19 Y-000094HY 1171044304870005 dr. ROSITA P A 34 08560067275 1

20 U-0000XPTY 3207172404920005 ELFIN PRATAMA L A 29 085718394518 1

21 Q-FE918AA0 3279026811900002 NOVIANTI P A 31 082115277139 1

22 W-8486B0D0 3279012109810001 YAYAT WAHIDIYAT L A 40 0813121488646 1

23 W-22F8594 3279046508900003 DEWI GUSTININGSIH P A 25 087826705005 1

24 U-00008RCT 3279026104800004 RINA KARTINA P A 41 082127692621 1

25 U-00004905 3207054512900001 DENA AFRIANTI P A 30 085283571515 1

26 W-0BB32984 3279022406870001 RUDI IRAWAN L A 34 081460904944 1

27 P-211FB36C 3279010706910002 JOHANSYAH L A 30 08979930599 1

28 U-00008028 3279013001980001 IRWAN NUR AKBAR L A 23 08560358760 1

29 P-43E55646 3279012207890001 IRVAN HILMI A L A 32 082122462356 1

30 U-00011SYP 3279035108760001 NENENG HENDRIANI P A 45 087826775656 1

31 W-501BB0BC 3279044812910004 NUR ENDANG SUSILOWATI P A 29 085222947981 1

32 W-5B1A15A5 3279026903920001 EKA NURSABRINA P A 29 08112476422 1

33 W-10739CE1 3279015806890003 ELYA HASANAH P A 31 081322031303 1

34 W-4620450 3279011010960001 AZIZ AMRULLOH L A 25 0882000205339 1

35 W-237946FC 3207174705810004 YANI MARYANI P A 40 081383212198 1

36 U-00004138 3207171806880001 YUNISTIO GINANJAR L A 33 081214189512 1

37 U-0000YPM6 3207300209870001 ANDRI SUSANTO L A 34 081386086186 1

38 U-00004J24 3207180208890003 AGUS SIDIK GUMELAR L A 32 085975369013 1

39 W-3110D9AC 3279010505970002 ARIEP HIDAYAT L A 24 082116947162 1

 40 W-2D54094E 3279034107960002 ELSA SUKMALIANI P A 25 082218143048 1

41 U-00004HDM 3207156408930002 dr. ADE NURLINA P A 28 085320291838 1

42 Q-35AEDB97 3279011208880001 ABDUL PRIAT L A 33 0895621002920 1

43 FI 3279010107480009 dr. DJADJA KOESNENDAR Sp.OG L A 73 08122347287 1

44 W-41F8CD4 3279026306810001 dr. RINA ROBERTHA P A 40 082129774998 1

45 1

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
B = Lainnya (Mohon disebutkan jenis vaksin yang diterima
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan
Puskesmas/Faskes)
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja

Kepesertaan
Kelompok Umur: Pekerjaan
BPJS
18-30 0 BPJS PBI 0 A 0
31-45 0 BPJS Non PBI 0 B 0
46-59 0 Non Anggota 0 C 0
Total 0 Total 0 D 0
Pekerjaan: Pemberian Dosis E 0
A 0 Dosis 1 45 Total 0
B 0 Dosis 2 0
C 0 Total
D 0
E 0
Total 0
ATAN PELAKSANAAN VAKSINASI COVID-19
KESMAS/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya'

Dosis I Moderna Dosis 2
pada kolom yang sesuai) Keterangan
Merek Vaksin*** Tanggal Screening (Ditunda/Tidak
Tanggal Diberikan/Lanjut)
Non Tanggal Pemberian
No. Batch Pemberian No. Batch
Anggota Vaksinasi
Vaksinasi

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

B 9/24/2021 9/24/2021 012D21A

 Absensi Vaksin Moderna (Fix Data)
Sesi Ke-2 (44 Doses)
Tanggal 24-September-2021

No Nama Karyawan Unit Kerja TTD Keterangan

1 Lia Herliani Billing
2 Ayi Nurohman CSSD & Laundry
3 Yuniar Nuryana Customer Service
4 dr. Djadja Kosnendar, Sp.OG Dokter Spesialis
5 Kusnadi Inst. Bedah Sentral
6 Monica Afrinda Inst. Farmasi
7 Iman Rohiman Inst. Farmasi
8 Agung Wiguna Inst. Farmasi
9 UTIANI KHOIRUNNISA Inst. Farmasi
10 Suryadi Inst. Gawat Darurat
11 Nurmalasari Inst. Gawat Darurat
12 Jakaria Ali Rosidi Inst. Gawat Darurat
13 Hanayasimin Nurdiani Inst. Gizi
14 Dani Purna Irawan Inst. Gizi
15 Dede Kardiman Inst. Gizi
16 Yani Rosmala Dewi Kamar Bersalin
17 Predy Firmansyah Kasir
18 Neneng Hendriani Kasir
19 dr. Rina Robertha Klinik dr. Rina
20 Reza Zakaria Ananda Laboratorium
21 Elfin Pratama Mahoni-HCU
22 Novianti Mahoni-HCU
23 Dewi Gustiningsih Meranti
24 Rina Kartina Meranti
25 Yayat Wahidiyat Pelaksana Umum
26 Rudi Irawan Pelaksana Umum
27 Johansyah Pelaksana Umum
28 Irwan Nur Akbar Pelaksana Umum
29 dr. Rosita Pelayanan
30 Irvan Hilmi Pendaftaran
31 Nur Endang Susilowati Perinatal
32 Eka Nursabrina Perinatal
33 Elya Hasanah Perinatal
34 Aziz Amrulloh Petugas Limbah
35 Dena Afriyanti RasCen
36 Yani Maryani RasCen
No Nama Karyawan Unit Kerja TTD Keterangan
37 Yunistio Ginanjar RasCen
38 Andri Susanto RasCen
39 Agus Sidik Gumelar Rawat Jalan
40 Elsa Sukmaliani Rawat Jalan
41 dr. Ade Nurlina Rawat Jalan
42 Dedi Haryanto Security
43 Abdul Priat Security
44 Ariep Hidayat Teknisi

Banjar, 24 September 2021

Koodinator Vaksinator

dr. Dwi Haryoko