Propinsi : Sumatera Utara

Kabupaten : Deli Serdang

Puskesmas/Kecamatan : Kenangan/ Percut Sei Tuan
Desa/Kelurahan : Kenangan/ Percut Sei Tuan

Jenis NIK (Nomor Induk

No Anak ke Tanggal Lahir No Kartu Keluarga
Kelamin Kependudukan)

(1) (2) (3) (4) (5) (6)

1 2 3/2/2019 Pr 1207261209180042
2 2 10/10/2019 Lk 1207262302160024 0
3 1 10/12/2018 Lk 1207261409092585 1207261012180002
4 4 11/10/2019 Pr 1207261505130004 0
5 1 13-7-2019 Lk 1207261409093242 0
6 2 12/7/2019 Pr 1207261511160034 0
7 1 20-6-2019 Lk - 0
8 1 19-9-2019 Lk - 0
9 2 19-10-2019 Pr 1207263001150032 1207265910190001
10 4 23-7-2017 Pr 1207261807130001 0
11 3 2/10/2019 lk 1207261202130008 0
12 1 25-10-2019 Lk 0
13 2 16-1-2018 Pr 0
14 1 27-3-2019 Pr 0
15 3 12/5/2018 Lk 1207262005110015 1207262906160009
16 2 3/3/2016 Pr 1207261409098922 1207265510030017
17 1 10/8/2018 Lk 1207261509090793 1207261811000003
18 1 12/12/2017 Lk 1207022411150007 1207021712150003
19 3 10/7/2016 Pr 1207260409120001 1207265007160001
20 1 8/4/2019 Pr 1207260906170004
21 1 12/3/2019 Pr 1207261307180033 1207265203190005
22 2 12/18/2024 Pr 1207262712130026 999999999999999
23 1 7/8/2019 Lk 1271062610160019 1271060708190002
24 2 2/15/2018 Pr 1271040802180010 10000000000000000
25 11/23/2019 Pr 1207261909090609
26 1 10/6/2019 Lk 1207261402190035 1207261006190005
27 1 21-11-2019 Pr 9999999999999999 9999999999999999
28 2 28-10-2019 Lk 1207261402170019 9999999999999999
29 1 4/11/2017 Lk 1207261402170019 1207260411170002
30 2 19-9-2019 Pr 1207261311170006 9999999999999999
31 2 28-6-2019 Pr 1207261703160041 9999999999999999
32 2 21-11-2019 Pr 9999999999999999 9999999999999999
33 1 28-6-2018 Pr 1207261311170006 9999999999999999
34 1 1/6/2019 Pr 1207262009160037 1207264106190005
35 3 20-8-2019 Pr 1271182009130004 9999999999999999
36 3 1/12/2018 Lk 1207261509093988 9999999999999999
37 1 9/2/2019 Pr 1207260503180025 1207264902190001
38 3 29-7-2019 Lk 1207260102110025 1207262907190003
39 2 5/5/2018 Pr 1207262112120020 1207264505180002
40 1 27-7-2019 Pr 1207260107190012 1207266707190006
41 2 19-1-2019 Pr 1271040708170002 9999999999999999
42 3 30-9-2019 Pr 1207261104140031 9999999999999999
43 2 19-9-2019 Pr 1207261311170006 9999999999999999
44 2 7/8/2016 Lk 1207262007180047 1027260708160004
45 1 4/5/2018 Pr 1207262103180018 1207267105960016
46 3 9/9/2016 Pr 1207260903150028 1207260909150011
47 2 26-3-2017 Lk 120726200801430 1207026603130001
48 2 11/9/2016 Lk Muhammad Fikri 120726200801438
49 1 24-4-2017 Lk 120726200801833 1271042404140003
50 1 30-1-2017 Pr 120726200800018 1207267001140001
51 1 17-1-2016 Lk 120726200800022 1207261701141010
52 3 30-9-2015 pr 1207262901140016 1207267009150010
53 4 12/6/2018 Lk 1207262901140016 1207261206180001
54 1 9/4/2015 Pr 1207262707170038 1207264904140006
55 2 13-11-2017 Pr 1207262707170038 1207265311150007
56 4 29-12-2017 Lk 1207260910180025 1207262912170006
57 5 28-8-2016 Pr 1207261509093785 1207266808160003
58 6 10/3/2018 Pr 1207261509093785 -
59 6 5/12/2015 Pr 1207261509093043 1207264512100007
60 7 2/3/2018 Pr 1207261509093043 1207264203130007
61 1 5/1/2018 Lk 1207260512170080 1207260504180001
Lk
62 1 22-5-2016 120726200800028 1207262203140001
63 1 8/12/2017 Pr 1207260808180042 1207264812170005
64 1 15-11-2018 Lk 1207271611170006 1207271511180001
65 1 20-11-2019 Pr 1207262509180011 -
66 1 13-08-2019 Pr 1207262008180047 -
67 1 31-10-2019 Lk 1213112702190001 -
68 1 7/5/2015 Pr 1207262407150012 1207264705150003
69 2 4/8/2019 Pr 1207262407150012 -
70 3 15-10-2019 Lk 1207261605140008 -
71 3 14-07-2018 Lk 1207262504140006 -
72 3 14-05-2016 Pr 1207262203160012 1207265405160004
73 2 20-08-2017 Pr 1207272407180002 1205076008170003
74 4 14-06-2019 Pr 1207262204130022 -
75 1 30-01-2018 Pr 1207262011170034 1207267001180005
76 3 29-09-2018 Pr 1207262806190017 1207266909180008
77 1 16-05-2018 Pr 1207260702170017 1207265605180005
 78 4 28-1-2016 Lk 1207261409099567 1207262801150008
79 1 13-10-2015 Lk 1207262202170028 1207261308150006
80 2 29-8-2019 Pr 1207262202170028 9999999999999999
81 1 7/1/2016 Pr 1207020410170023 1207024701130008
82 2 11/1/2020 Pr 1207020410170023 9999999999999999
83 1 13-2-2019 Lk 1207261509091542 9999999999999999
84 1 23-1-2016 Pr 1207261509090665 1207266301160012
85 2 3/2/2016 Pr 1207263107120016
86 4 9/9/2017 Lk 1271103105110002 9999999999999999
87 1 15-1-2017 Lk 1207260205170023 1207261501170002
89 1 7/11/2017 Lk 1207261707170020 1207260711170004
90 2 2/12/2019 Lk 1207261707170020 1207260212190001
91 1 18/09/2019 Lk 1207262402150011 1207261809190001
92 1 7/6/2019 Lk 1207262005190021 1207260706190001
93 1 29/10/2019 Lk 1207261709190039
94 1 24/10/2016 Lk 1207261409097822
95 2 30/08/2019 Pr 1207261409097822
96 1 30/01/2015 Pr 1207261202160018 1207267001150005
97 2 29/06/2018 Lk 1207261202160018 1207262906180004
98 1 21/06/2016 Lk 1207261610170029 1207262106160008
99 3 14-10-2014 Lk 1207261410140019 1207260911120009
100 1 4/14/2015 Lk 1207261805150010 1207261404140004
101 1 10/27/2015 Lk 1207261811150012 1207262710940004
102 2 12/23/2016 Pr 1207261709093652 1207266312130002
103 4 5/25/2015 Pr 1207260903110032 1207266606440002
104 1 5/5/2016 Lk 1207261303120048 1207260805120003
105 1 1/28/2018 Lk 1207260410170043 1271042801160008
106 4 9/17/2015 Lk 1207262609140005 1207261709070010
107 3 8/8/2018 Pr 1207263101110003 9999999999999999
108 1 7/9/2019 Pr 1207260402190011
109 2 28-10-2019 Lk 1207261402170019
110 2 27-09-2019 Lk 1207261409098245
111 4 2/10/2019 Lk 1207261202130008
112 3 17-10-2019 Pr 1207261409096286
113 2 8/10/2019 Pr 1207261310160067
114 3 26-5-2015 Lk 1207261911120020 9999999999999999
115 3 3/2/2014 Pr 1207260103110042 9999999999999999
116 4 9/5/2014 Lk 1207261709091485 9999999999999999
117 2 6/3/2015 Pr 1206063101085275 9999999999999999
118 2 27/2/2014 Pr 1207261911120020 9999999999999999
119 2 5/5/2015 Pr 1207260203120052 1207264505150003
120 3 24/5/2018 Pr 1207260203120052 1207266405180003
121 1 10/1/2015 Lk 1207260207180020 1207261001150011
122 1 20/3/2018 Pr 1207262407180032 1207266003180003
123 1 23/11/2015 Pr 1207260706180025 1207266311150007
124 1 16/7/2018 Lk 1305132607180001 1305131607180001
125 1 16/11/2018 Pr 1207261105180033 120726581118009
126 1 31/10/2015 Pr 1271040305180009 1271047110150005
127 2 20-4-2017 Pr 1207261405140041 -
128 3 24-10-2019 LK 1207261405140041 --
129 2 22-12-2017 Lk 1207261203180019 1207262212170004
130 3 23-09-2019 LK 1207261203180019 -
131 6 16-04-2019 Pr 1207261409094934 1207265604190006
132 1 8/9/2019 LK 1207260702190032 -
133 5 4/4/2019 Pr 1207264404190001 1207260409120021
134 1 12/8/2018 LK 1207222404190007 1207221208030001
135 2 1/8/2015 Lk 1207260205130027 1207260108150004
136 3 13-07-2018 Lk 1207260205130027 1207261307180001
137 1 3/7/2016 Lk 1207260103170030 1207260307160006
138 2 13-01-2016 Pr 1207262212110049 1207265301160002
139 3 4/12/2017 Lk 1207261509110040 1207260412170009
140 2 5/11/2017 Pr 1207261003170010 1207264511170005
141 1 23-03-2019 Lk 1207261409091367 9999999999999999
142 1 25-11-2015 Lk 1207260202160016 1207262511160007
143 1 7/11/2017 Lk 1207262908170038 1207260711170006
144 2 16-02-2019 Lk 1207262908170038 1207261602190008
145 2 21-10-2016 Pr 1207263011120012 9999999999999999
146 4 9/8/2019 Pr 1207261709092540 9999999999999999
147 1 1/9/2017 Pr 1207261707170022 9999999999999999
148 1 16-03-2018 Lk 1271103008170005 1271101603180001
149 2 13-06-2019 Lk 1271103008170005 1271101306190002
150 5 9/8/2016 Pr 1271042904050018 9999999999999999
151 2 12/2/2019 Pr 1207261609099245 9999999999999999
152 3 9/2/2015 Lk 1207262206120041 1207260902150008
153 4 2/3/2019 Lk 1207262206120041 1207260203190004
154 2 6/10/2016 Pr 1207263009110031 1207264610160004
155 2 30-05-2017 Pr 1207261806140007 1207267005170005
156 3 4/10/2017 Lk 12072622702130025 1207260410170005
157 2 24-08-2018 Pr 1207262206120038 9999999999999999
158 5/3/2017 Lk 1207261610120004 9999999999999999
159 3 22-04-2016 Lk 1271040702180022 1271042204160002
160 1 9/12/2017 Lk 1207260205170010 1207260912170009
161 2 21-7-2019 Lk - -
162 2 13-9-20119 Pr - -
163 3 26/10/2019 Pr - -
164 3 13-11-2018 Lk 1207262103120069 1207261311180003
165 3 20-08-2018 pr 1207261709090876 1207266008180001
166 1 5/8/2018 Lk 1207263101180025 1207260508180002
167 1 11/3/2019 Pr 1207262301190001 -
 168 5 1/11/2018 Pr 1207260706130041 -
169 2 19-05-2017 Lk 1207261710170006 1207261906170003
170 2 28-01-2019 Lk 1207261710170008 -
171 5 29-10-2019 Lk 1271181309070033 -
172 1 28-05-2019 Lk 1207261004190012 -
173 1 12/2/2019 Lk 1207261302190025 1207261202190001

Keterangan

Kolom 11: Jika ayah tidak ada, maka diisikan nama ibu
Kolom 1 : Jika ayah tidak ada, maka diisikan NIK Ibu
Kolom 1 : Jika ayah tidak ada, maka diisikan no telp /Hp Ibu
Kolom 2 : Jika Pemantauan perkembangan menggunakan kuesioner pra skrining perkembangan ( SDIDTK), diisi DS (sesu
Kolom 3 : Jika Pemantauan perkembangan menggunakan ceklist buku KIA, diisi S, jika jawaban ya untuk seluruh pertany
Kolom 3 : Diisi SL (lanjutkan stimulasi dan jadwalkan kunjungan berikutnya) jika hasil pemeriksaan KPSP atau ceklist buk
: Diisi SU (Stimulasi ulang selama 2 minggu), jika hasil pemeriksaan melalui KPSP menghasilkan skor meragukan
: Diisi R (Rujuk) jika hasil pemeriksaan melalui KPSP menghasilkan penyimpangan (P) atau jika pemeriksaan mel
 FORMULIR PENCATATAN DAN P

Berat Panjang Kepemilikan IMD 1=

Nama Anak Badan Badan Buku KIA/KMS Ya 2= Nama Orang Tua
Lahir Lahir (cm) 1=Ya 2=Tidak Tidak

(7) (8) (9) (10) (11) (12)

Alya naira tanjung 3.2 48 1 1 Muhammad rifad
Muhammad nadim ara 3 50 1 1 Iwanara
Mhd abqori lubis 1.5 40 1 2 Muhammad arfan
Riana 3 48 1 1 Widno
Rafael hutabarat 3.4 50 1 1 Rafles hutabarat
Talita hasibuan 3.2 49 1 1 Ahmad bukhairi
Ralph sitompul 3.3 50 1 1 Zigo sitompul
Axel sitompul 3.1 49 1 1 Irfan sitompul
Alesha almeera 3,4 50 1 1 Soleman siregar
Nursifa salsabila sinaga 3,5 48 1 1 M.Rizal sinaga
Atha 3,2 45 1 2 M.IQBAL Lubis
Abdul Rahman 3,2 45 1 2 Yulida
Mufida 3.5 51 1 2 Reni
Khairan athar 3.2 49 1 2 zulvi
M.bima sakti 3.2 50 1 1 Sutomo
Intan 3.5 51 1 1 Arman
Aqsameka 3.2 49 1 2 Credirul pane
Alif khan almadani 3.2 50 1 1 Suryadi
Nurhalima 3.5 51 1 1 Darlena
Glory 3.5 51 1 2 Yarniwati hura
tiara aliza hasibuan 3 50 1 1 Mansyur hasibuan
naila 29 49 1 1 zulham effendi
mhd Ibra Azzikra 3 50 1 1 Andi suwantoc
SHBIL ADELA 3 50 1 cc ANRON
Nayya 3.3 50 1 1 Muri gutawan
akmal alfarizki 3.5 50 1 1 indra
sahila 4.1 49 1 1 rika wati
givandra 3,5 50 1 1 epi
gabriel 3.7 50 1 1 epi
naurah 3,5 49 1 1 azhari lubis
nazifah tulkhairah 3,3 50 1 1 mutia sari
butet 3,3 49 1 1 ria
mikayla azzahra 3,4 49 1 1 azhari lubis
putri ramadhani 3,2 49 1 1 rahmad hidayat
hafizah almahyra 3,2 50 1 1 zulfikar
sebastian 3,3 50 1 1 daniel ricardo
clarissa salsabila 2,8 46 1 1 dina salfina
revan jeremi 3,5 50 1 1 lintang terenggano
Alinkha audy 3,4 49 1 1 M taufik
aqila cahaya putri 3,2 49 1 1 rusliadi
Adzkia 3,5 50 1 1 adi putra silitonga
Parel 3,4 49 1 1 satman hulu
nuwairah 3,3 49 1 1 azhari lubis
Firma Chrisdianto Manullang 3,0 50 1 1 Sukarni siManullang
Gisella Meyvelsia 3,2 49 1 1 Roy Oppung Sunggu
Diben Rizky 3,5 49 1 1 Karmen
Tengku Nabila 3,0 50 1 1 Tengku Rustam
Mhd Taufiq 3,4 49 1 1 Mhd Taufiq
Al Risky Maulana 3,0 47 1 1 Arpan Maulana
Mayyadah Zahra 3,5 49 1 1 Dedi Irawan
Kenzo Yusuf 3,2 50 1 1 Hermanto
Ropinsen Sihombing
Tessalonika Sihombing 3,0 48 1 1
Herianto Sihombing 3,4 50 1 1 Ropinsen Sihombing
Sesep R Manalu 3,3 49 1 1 Dedi H Manalu
Sintya A Manalu 3,2 49 1 1 Dedi H Manalu
Rafly Swari Barus 3,1 48 1 1 Willy C Barus
Jekson
Dita A 3,0 48 1 1
Merita 3,3 49 1 1 Jekson
Ririn 3,0 48 1 1 Londi TP. Bolon
Selly 2,9 49 1 1 Londi
Jimmi TP.bolon
Ardi
Aqiusal 3,2 50 1 1
Khafif 3,5 50 1 1 Abdul
Clara FeliCa 3,3 48,5 1 1 Jusuf Ginting
Mhd.Yasin Naoki 3,2 49 1 1 Mhd.Yazid Nasution
Gladys arashel 3,0 49 1 1 Hengky sihombing
Zaskia nahda 3,1 50 1 2 Ade Andela
Attar Rizki 3,1 49 1 1 Abdul Basyid
Jade khalisa 3,3 49 1 1 Darwin Hamonangan
Thania 3,5 49 1 1 Darwin Hamonangan
Attar lintang 3,2 50 1 2 Zunaidi
Mhd.Abizar syahkran 3,4 50 1 1 Chairil lubis
lovely narumi barus 3,7 51 1 1 david barus
nur aliffa 3,2 50 1 1 anggari
indah 3,0 50 1 2 gunawan daulay
ersya aurelia 3,0 49 1 1 herman syahputra
nayla suhada 3,6 52 1 1 doddy suhada
audy icvi azzahra 3,3 51 1 1 fransisco
anugrah raditia Riski YS 3,3 50 1 2 Budiono YS
Alvin buulolo 3,1 49 1 1 baharuni buulolo
aerlin buulolo 3,4 50 1 1 baharuni buulolo
Putri agraini Caniago 3 49 1 1 Juniar afyani Nasution
Naila Caniago 3,6 49 1 1 Juniar afyani Nasution
Rayan 3,4 50 1 1 Pratiwi

jennieva Damanik 3,8 51 1 1 sarlen Damanik

cut daniyah El Gaara 3,2 50 1 1 Muhammad aprizal
Baihaqi Fathan suruuri 3,2 50 1 1 zefri Hamdani
Yosua Yosafat Simajuntak 3,3 50 1 1 putra Simajuntak
Jeremi Panjaitan 3.0 50 1 1 Franki Panjaitan
Daut Raja Liber Panjaitan 2.8 50.0 1 1 Franki Panjaitan
Geonathan Arelis Silalahi 3.1 50.0 1 1 Oloan Silalahi
Muhammad Pahri 2.6 50 1 1 Iman
Lutfi Adri Rafasya 3.1 50 1 1 Rini Ludmila Angraini
Denis Pratama 3.3 51 1 1 Khairun Nisya Siregar
Assyifa Nuryn Ardiny 3.0 50 1 1 Khairun Nisya Siregar
Cindi Claudia Br. Sinaga 4.0 51 1 1 Firman Suriyanto Sinaga
Daniel Alfonsius Sinaga 2.9 50 1 1 Firman Suriyantoy Sinaga
Junpiter Jogi Manahan Sinaga 3.0 50 1 1 Franky Halomoan Sinaga
ade bima _ 30 1 _ syafruddin
nugraha sandi pratama 3,3 1 1 nurizaldi septiadi
riki 3`3 51 1 2 rubini
shintia julia sari 2`7 47 1 2 masri
sudinah 2`8 49 1 2 sarudin
raihan aulia riski 3`5 53 1 1 mara dongan sihaputar
hatta zhicri alkvarado 37 52 1 1 ade hendra permayu
arya fandika 35 51 1 2 lukman hakim
athira ardilla mecca 33 55 1 1 m yakub harahap
Falisyah Zea Anggara 3,3 49 1 1 Aldi Anggara
Givandra Delano Simarmata 3,2 50 1 1 Adhy Booris Simarmata
Muhammad Alif 3,0 50 1 1 Jamalluddin Sikumbang
Atha Fawwas Lubis 3,3 49 1 1 Muhammad Iqbal Lubis
Aqilla Intan Asri 3,1 49 1 1 Muhammad Boby Pringadi
Alysha Humairah 2,9 49 1 1 Jhei Moleng
Daniel 2,9 50 1 1 Jasnimar
cindi 2,7 50 1 1 Nilawati
Raffa 3,0 51 1 1 leli
laura 3,2 50 1 1 jesaya
nayla 2,6 50 1 1 novrizal
dwi lestari 3,0 51 1 1 eko
reisyah 3,1 50 1 1 eko
wahyu 3,3 50 1 1 henri
khanaya 3,0 51 1 1 eko saputra
nabilah 3,0 50 1 1 rahmat
alziq 3,3 51 1 1 putra
aziza 3,1 50 1 1 armen
mella 3,0 50 1 1 rido
Ivanna calysta 2,6 48 1 1 Natanael siburian
Elazaro efraim 3,2 50 1 1 Natanael siburian
M.Davian rizky 3.2 50 1 1 Irwansyah putra
M.Danu syahputra 3,4 52 1 1 Irwansyah putra
Azzura putri 3.2 50 1 1 Harmansyah
Eduward nababan 3,2 50 1 1 Elieser nababan
Ailsie sitanggang 3,4 52 1 1 Maraden sitanggang
Rahmat hasri taringan 3,4 52 1 Ahmad Nasrul
Markus Rex Walker H 3,4 50 1 1 Amri hutasoit
Brian Marco Julius H 3,2 49 1 1 Amri hutasoit
Fachry ramadhan 3,3 49 1 1 Geri tanjung
Fatimah putri nurfindi 3,4 50 1 1 Muhammad khairunsyah
Rafli Akbar nasution 3,2 48 1 1 Ali Akbar Nst
Niana Amara Nst 3,2 50 1 1 Mhd.zaihar nst
Amar Mutakin 3,5 50 1 1 Anugrah halik
Theo Rafael sinaga 2,9 49 1 1 Johny sinaga
Diwa taqwa'sya 3,5 50 1 1 Wahyu masilfa
al-Fariq zahwan 3,1 50 1 1 Wahyu masilfa
Khoirunnisa 3,0 49 1 1 Ali Sofyan
Sri Alur Angraini 2,9 49 1 1 Wagimun
Evi putri 3,1 50 1 1 Ari Pujianto
Daichiro Ahmad 3,1 50 1 1 Aldino Akbar
Kaijiro 3,0 49 1 1 Aldino Akbar
Tika syahfitri 3,0 50 1 1 Zulkarnain Koto
Feby Ramadani 2,9 50 1 1 Suriadi
M. Hidayah 3,1 50 1 1 Riduan
M. Nur Hakim 3,0 49 1 1 Riduan
Rasyi Unaisa 2,8 48 1 1 Lukito
Alvira 2,9 50 1 1 Defry Irawan
Abizaro 3,0 49 1 1 M. Jamaluddin
Tiara putri 3,1 50 1 1 Agus
M. Byren s 2,9 49 1 1 Samuel
Ayaz Ilmi 3,0 50 1 1 Ahmad Rizki
M. Hanif Alkahfi 2,8 48 1 1 Wiguna
alpin fahreza akmal 3,0 50 1 2 frisca
aira 3,1 50 1 2 husnaini
sakina 3,2 50 1 1 yuni
mhd Rizieq alfatih 3400 gr 50 cm 1 1 awaluddin
Miftahul Jannah nst 3000 gr 50cm 1 1 m.yunus nst
abizard Maulana prasipta 3200 gr 51cm 1 1 jamal pranggono
Ayla faradila nst 3500 gr 51cm 1 1 abdi Akbar nst
 Novita sari 2900 gr 48cm 1 1 rahmad Salman lbs
m.arsyad maulana 3300 gr 49cm 1 1 altasmi nst
aydan Sayyid nst 3000 gr 49cm 1 1 fadli Hasyim nst
ruzain alfahrizza 3100 gr 50cm 1 1 khairatun
ahd Raka aditya 2900 gr 49cm 1 1 m.faisal lbs
mhd Aidan syam 3000 gr 50cm 1 1 deni syahputra

ning perkembangan ( SDIDTK), diisi DS (sesuai) jika skor KPSP = 9 - 10, DM (meragukan) jika skor KPSP = 7 - 8, diisi Dp (Kemungkinan Penyim
isi S, jika jawaban ya untuk seluruh pertanyaan, diisi TS jika ada satu atau lebih jawaban tidak utk seluruh pertanyaan
ika hasil pemeriksaan KPSP atau ceklist buku KIA menghasilkan sesuai (S)
melalui KPSP menghasilkan skor meragukan (M)
enyimpangan (P) atau jika pemeriksaan melalui buku KIA menghasilkan tidak sesuai (TS).
MULIR PENCATATAN DAN PEMANTAUAN PERTUMBUHAN DAN PERKEMBANGAN BALITA DI POSYANDU

Nama Posyandu :
Bulan : Januari
Tahun : 2020

No Telp/Hp Orang Tanggal

NIK Orang Tua Alamat RT RW
Tua Pengukuran

(13) (14) (15) (16) (17) (18)

1219030301930002 - Jl. jalak 9 no 250 4 1 6/12/2019
1207262711910004 - Jl. jalak 3 9/1/2020
1207262711630005 Jl. jalak 22 no 538 3 1 5/1/2020
1207250210710011 Jl. parkit 4no 124 20-12-2019
1207261904930007 Jl. parkit 6 20-12-2019
1207260609930010 Jl. parkit 4 20-12-2019
- Jl.parkit 20-12-2019
- Jl.parkit 20-12-2019
1271092507880003 Jl.jalak 11 no 301 6/1/2020
1207262511800008 pipit Xlll no.102 1 2 15-12-2019
1207260610790008 pipit V No.453 1 2 15-12-2019
cucak rawa 6 1 2 15-12-2019
pipit 1 2 15-12-2019
pipit 11 no.159 1 2 15-12-2019
1207261304740013 pipit 7/32 1 2 15-12-2019
1207262811880001 pipit 9/308 1 2 15-12-2019
1207260504610006 pipit IX.313 1 2 15-1-2020
1207250608880002 pipit 11.160 1 2 18-1-2020
120726490750011 pipit XII.123 1 2 18-1-2020
1207264501890009 pipit IX.303 1 2 18-1-2020
1206021512860002 082274900836 jl camar 15/497 0 0 15-12-2019
1207262606790002 - camar14/491 0 0 1+R32:W325-12-2
1271060509860002 082366559925 camar6 3 3 15-12-2019
1208112008780000 - NURI7/527 2 2 12/2/2019
1207261003850000 82152713917 nuri xv/538 2 2 12/2/2019
1207262012970006 jl murai 9 12/12/2019
9999999999999999 jl murai 11 12/12/2019
1207266007870009 jl merak 2 12/12/2019
1207266007870009 jl merak 2 12/12/2019
12072600707840009 jl murai 5 no 376 12/12/2019
1308045308930001 jl murai 10 no 174 12/12/2019
9999999999999999 jl murai 2 12/12/2019
1207260707840009 jl murai 5 no 376 12/12/2019
1207261308650001 jl murai 3 no 410 12/12/2019
1271182009130004 jl walet 2 no 287 9/12/2019
1207261908750005 jl murai 7 no 361 12/12/2019
1207266808820016 jl walet 2 no 277 9/12/2019
1207261005810014 jl murai 1 no 28 12/12/2019
1207262411860009 jl murai 9 no 236 12/12/2019
1218022512920007 jl murai XII no 120 12/12/2019
1202053009910001 jl walet kenangan 9/12/2019
1207261809930006 jl murai 2 12/12/2019
1207260707840009 jl murai V no 376 12/12/2019
1216061103800002 081361133458 jl.gotong royong dsn.1 Amplas - 18-1-2020
3275110105930001 081361133458 jl.kramat kuda Amplas -/- -/- 18-1-2020
1211022603880001 081361133458 Dsn lll-a Selambo Amplas -/- -/- 18-1-2020
1201021009133706 081361133458 Amplas -/- -/- 18-1-2020
1272020512836001 081361133458 Amplas -/- -/- 18-1-2020
1208241010810004 081361133458 Amplas -/- -/- 18-1-2020
1207260908870005 081361133458 amplas -/- -/- 18-1-2020
1207260406820016 081361133458 Amplas -/- -/- 18-1-2020
1207261809840023 081361133458 Amplas -/- -/- 18-1-2020
1207261809840023 081361133458 Amplas -/- -/- 18-1-2020
1211131105870002 Amplas -/- -/- 18-1-2020
1211131105870002 081361133458 Amplas -/- -/- 18-1-2020
1207261412910008 8136133458 Amplas -/- -/- 18-1-2020
1207260802790017 081361133458 Amplas -/- -/- 18-1-2020
1207260802790017 081361133458 Amplas -/- -/- 18-1-2020
1207261209700011 081361133458 Amplas -/- -/- 18-1-2020
1207261209700011 081361133458 Amplas -/- -/- 18-1-2020
1271040511890005 8136133458 Amplas -/- -/- 18-1-2020
1207262203140001 081361133458 Amplas -/- -/- 18-1-2020
120701150684001 081361133458 Amplas -/- -/- 18-1-2020
1207271312890001 - jl.puyuh 15 no.292 - - 10/12/2019
1207262909850009 - jl.nuri 18 no.138 3 1 17 /01/2020
1306031008920002 - jl.camar 7 no.518 - - 17 /01/2020
1213110710930003 - jl.camar 19 no.13 - - 17 /01/2020
1207261511840001 - jl.cucakrawa 1 no.74 - - 17 /01/2020
1207261511840001 - jl.cucakrawa 1 no.74 - - 17 /01/2020
1207261402800001 - jl.camar 6 no.428 - - 17 /01/2020
1207261604100010 - jl.perkutut Raya no.185 - - 15 /01/ 2020
1271081506740005 081360243765 dusun XI jl. Mesjid 12 6 18-01-2020
1207272109860002 - dusun III jl. utomo - - 18-01-2020
1207260309830022 - dusun IX jl beringin 1 6 18-01-2020
1271140507850003 - jl.pasar 9 gg pipit dlm III - - 18-01_2020
1271100609900006 - dusun VI gg P. bolak 6 2 18-01-2020
1208300905930003 - dusun XV pasar 3 - - 18-01-2020
1207262202730004 jl.gelatik 7 no153 15-1-2020
1214071310910004 081360602411 jl.gelatik 10 no 254 16-1-2020
121471310910004 081360602411 jl.gelatik 10 no 254 16-1-2020
1201016412820002 jl. gelatik 7 no 150 18-01-2020
1201016412820002 jl gelatik 7 no 150 18-01-2020
1207255204980010 jl.gelatik 11 no 364 18-1-2020
1207262404700017 8126475547 jl.gelatik 7 no 151 18-1-2020
1207260804830016 jl cendrawasih 1 no 371 18-1-2020
1271042705780006 jl. gelatik 11 no 366 18-1-2020
1207260903950009 jl.gelatik 7 no 176 18-1-2020
1207262611800003 081375339471 Jln. Belibis 16 no. 217 5 2 16/12/2019
1207262611800003 081375339471 Jln. Belibis 16 no. 217 5 2 16/12/2019
1271041303860002 081317981784 Jln. Belibis 17 no. 381 16/12/2019
1207262607900003 081375163307 Jln. Belibis 7 no. 436 16/12/2019
1207264605820004 081396666082 Jln. Belibis 4 no. 259 16/12/2019
1207267003960006 081397875158 Jln. Garuda Raya no. 56 1 1 18/12/2019
1207267003960006 081397875158 Jln. Garuda Raya no. 56 1 1 18/12/2019
1207260412820012 081263643649 Jln. Seriti 5 no. 313 18/12/2019
1207260412820012 081263643649 Jln. Seriti 5 no. 313 18/12/2019
1207261204820014 085277018287 Jln. Seriti 5 no. 312 2 1 18/12/2019
1207260502650008 085973892219 psr8 dsn 11 gg bersama psr 8 no 11 08-012020
1207261409840011 jln beringin dsn 8 1/8/2020
1207264305550002 dusun 9 1 4 1/8/2020
1207262703820011 jln beringin tembung 1/8/2020
1207262203770017 dsn 8 jln istirahat gg gelatik 1/8/2020
1207261809820019 dusun 9 gg belimbing 2 1 08`01`2020
1271042601800002 jln beringin pasar 7 gg cempedak 1/8/2020
1207260611800005 jln beringin dsn 9 gg cempedak 1/8/2020
1207261411800012 jln beringin tembung 3 7 1/8/2020
1207262312920005 085260922099 Jl. Pinguin 16 No. 567 12 003 10/1/2020
1207261410860011 082164427552 Jl. Pinguin 7 No. 156 10/1/2020
1207260101720004 081377495461 Jl. Pinguin 5 No.525 10/1/2019
1207260610790008 085261033107 Jl. pipit 5 No.453 6/1/2019
120726060890001 082363195077 Jl. pipit 6 No. 500 1 1 10/1/2002
7371070505920018 081370674470 Jl. Pinguin 16 531 1 1 10/1/2019
1207264512750010 pasar 5 dusun 14 5/12/2019
1207264608870007 pasar 5 dusun 14 5/12/2019
pasar 5 dusun 14 5/12/2019
1206061908700001 pasar 5 dusun 14 5/12/2019
1207261010740043 pasar 5 dusun 14 gang kamirin 5/12/2019
1207263112890062 dusun 14 pasar 5 no. 41 5/12/2019
1207263112890062 dusun 14 pasar 5 no. 41 5/12/2019
1271040902850002 dusun 14 gang pembangunan 7/12/2019
1218122604920002 pasar 5 dusun 14 gang salak 9 7/12/2019
1207265007910015 pasar 5 dusun 14 no. 7 7/12/2019
1305080707910002 pasar 3 dusun 15 6/12/2019
1207260101870003 pasar 3 dusun 15 6/12/2019
1271040808880011 pasar 3 dusun 15 6/12/2019
1207262312810008 085296859998 enggang 26 no 367 - - 11/12/2019
1207262312810008 085296859998 enggang 26 no 367 - - 11/12/2019
1271200511870002 085296859998 kiwi 27 no 502 - - 11/12/2019
1271200511870002 085296859998 kiwi 27 no 502 - - 11/12/2019
1207262302760002 085296859998 kiwi16 no368 - - 11/1/2020
2171072606920002 085296859998 kiwi 15 no 400 - - 11/1-2020
1207261209800010 085296859998 enggang 19 no 154 - - 11/1/2020
1207262112910006 085296859998 kiwi raya no 15 - - 11/1/2019
1202092508880005 082168300095 kenari 6no 281 2 1 8/1/2020
1202092508880005 kenari 6 no 281 2 1 8/1/2020
1207261806880007 kenari 17 no 440 4 1 8/1/2020
1207262805720003 082168300095 kenari raya 2 2 1 8/1/2020
1207260710770013 kenari raya8 no153 3 1 8/1/2020
1207262612900008 kenari 8 no 121 1 1 8/1/2020
1207262108890009 kenari 14 no 529 2 1 8/1/2020
1208170305870002 kenari 12no 387 2 1 8/1/2020
1207261905960007 kenari 10 no 292 3 1 8/1/2020
1207261905960007 kenari 10 no 292 3 1 8/1/2020
1207262903830018 Dusun 16 Tembung 3/12/2019
1207260709760006 082168055874 Dusun 16Tembung 5 2 3/12/2019
1207260505890009 Dusun 16 Tembung 3/12/2019
1271102503880006 Dusun 16 Tembung 33 17 3/12/2019
1271102503880006 Dusun 16 Tembung 33 17 3/12/2019
1271640307770007 Dusun 16 Tembung 3/12/2019
1207262009520002 082277388660 Dusun 16 Tembung 3/12/2019
1207262208830012 Dusun 12 Tembung 11/12/2019
1207262208830012 Dusun 12 Tembung 11/12/2019
1207261510820008 Dusun 12 Tembung 11/12/2019
1207261601880013 Dusun 12 Tembung 11/12/2019
1207261202860025 Dusun 12 Tembung 11/12/2019
1207261209960018 Dusun 12 Tembung 11/12/2019
1271010205880003 Dusun 12 Tembung 11/12/2019
1271041906960005 Dusun 12 Tembung 11/12/2019
1207260705910008 Dusun 12 Tembung 11/12/2019
- - dusun XI 10/12/2019
- - dusun XI 10/12/2019
- - dusun XI 10/12/2019
1207262912810011 dsn 1 jln benteng 20-01-2020
1207261010780005 dsn 1 GG.bersama 20-01-2020
1209181304930001 dsn 1 jln.benteng 20-01-2020
1205111802930003 dsn 1gg.pribadi 20-01-2020
 1207260308730009 dsn 1 jln.bsr tmbg 20-01-2020
1271102508860003 dsn 1 GG.pribadi 20-01-2020
120726270598000 dsn 1 jln.raya 20-01-2020
1271182712850001 jl.rencong mdn 20-01-2020
1207260910980009 dsn1 GG.istirahat 20-01-2020
1207263011940006 dsn 1 jln.benteng 20-01-2020

, diisi Dp (Kemungkinan Penyimpangan) jika skor kurang dari 7

ANDU

ASI EKSKLUSIF 1 = Ya, 2 = Tidak

Panjang Cara Ukur Vitamin A
Badan/Tinggi 1=Telentang BB (Kg) 1= Ya
Badan (cm) 2= Berdiri 2=Tidak
Umur 1 Umur 2 Umur 3 Umur 4 Umur 5
bln bln bln bln bln
(19) (20) (21) (22) (23) (24) (25) (26) (27)
71 1 6,8 1 1 1 1 2 2
62 2 6.5 1 1 1
72 1 6.8 1 2 2 2 2 2
60 1 5.5 2 1 1 1
67 1 8.5 2 1 2 2 2 2
66 1 7.4 2 1 1 1 1 1
72 1 8.5 2 1 1 1 1 1
61 1 5.9 2 1 1 1 2 2
60 1 5,8 2 1 1 1
72 2 9 2 1 1 1 1 1
61 1 6.1 2 T T T T T
62 1 6.3 2 Y Y Y Y Y
87 2 12 1 T T T T T
78 2 9 1 T T T T T
84.1 2 10.1 1 Y Y Y Y T
98 2 15.1 1 Y Y Y Y T
81.3 2 11.3 1 Y Y T T T
96 2 14.2 1 Y Y Y Y Y
89 2 10.9 1 Y Y Y Y T
74.3 1 9.8 1 Y Y Y Y Y
74 1 8 2 1 1 1 1 1
71 1 8 2 1 1 1 1 1
65 1 6 2 1 1 1 1 1
87 1 14 2 1 1 1 1 1
52 1 4.7 2 1 1 1 1 1
71 1 7,1 2 1 1 1 1 1
59 1 4,8 2 1
58 1 5,5 2 1 1
87 2 12 1 1 1 1 1 1
55 1 5,6 2
65 1 6,5 2 1 1 1 1 1
59 1 4,6 2 1
78 2 9,6 1 1 1 1 1 1
60 1 6,5 2 1 1 1 1 1
65 1 6,5 2 1 1 1 1
80 2 8,1 1 1 1 1 1 1
74 2 7 1 1 1 1 1 1
43 1 7,5 1 1 1 1 1 1
70 1 9,5 2 1 1 1 1 1
63 1 7,5 2 1 1 1 1 1
75 2 7,2 2 1 1 1 1 1
63 1 7,6 2 1 1 1
65 1 5,6 2 1 1 1
89 2 13 1 1 1 1 1 1
72 1 9 1 1 1 1 1 1
90 2 14 1 1 1 1 1 1
85 2 11,5 1 1 1 1 1 1
91 2 14 1 1 1 1 1 1
87 2 12,5 1 1 1 1 1 1
90 2 13 1 1 1 1 1 1
89 2 14 1 1 1 1 1 1
92cm 2 15kg 1 1 1 1 1 1
87cm 2 11kg 1 1 1 1 1 1
115cm 2 25kg 1 1 1 1 1 1
88cm 2 11kg 1 1 1 1 1 1
89cm 2 11,6kg 1 1 1 1 1 1
97cm 2 13,4kg 1 1 1 1 1 1
76cm 2 9,0kg 1 1 1 1 1 1
94cm 2 21kg 1 1 1 1 1 1
86cm 2 10,5kg 1 1 1 1 1 1
80cm 1 9,7kg 1 1 1 1 1 1
93cm 2 11,5kg 1 1 1 1 1 1
80,1cm 2 9,5kg 1 1 1 1 1 1
74 2 10,4 2 1 1 1 1 1
55 1 5,5 2 - - - - -
66 1 7,3 2 1 1 1 1 -
60 1 7,5 2 1 1 - - -
102 2 15,4 2 1 1 1 1 1
59 1 6 2 1 1 1 1 -
57 1 9 2 1 1 - - -
84 2 11,2 2 - - - - -
100 2 17.4 1 1 1 1 1 1
87 2 14.9 1 1 1 1 1 1
66 1 7.8 2 1 1 1 1 1
86 2 14.7 1 1 1 1 1 1
78 2 10.6 1 1 1 1 1 1
84.5 2 11.7 1 1 1 1 1 1
96 1 11 1 2 2 2 2 2
98 2 15,8 1 1 1 1 1 1
62 16 2 1 1 1 1 1
89 2 15,5 1 1 1 1 1 1
49 1 49 2 1
72 1 9 1 1 1 1 1 1
91 2 18,3 1 1 1 1 1 1
92 2 16,8 1 1 1 1 1 1
99 2 15 1 1 1 1 1 1
98 2 16 1 1 1 1 1 1
89 2 10,3 1 1 1 1 1 1
55.0 1 4.3 2 1
60.5 1 6.3 2 1 1 1 1
67.5 2 8.0 1 1 1 1 1 1
58.0 1 5.0 2 1 1
96.0 2 14.5 1 1 1 1 1 1
60.5 1 6.3 2 1 1 1 1
109.0 2 18.4 1 1 1 1 1 1
81.5 2 11.3 1 1 1 1 1 1
72.0 1 9.3 1 1 1 1 1 1
64 1 4`7 1 1 1 1 1 1
63 1 4`9 1 1 1 2 2 2
59 1 4`7 1 2 2 2 2 2
70 1 4`9 2 2 2 2 2 2
64 1 4`5 1 2 2 2 2 2
65 1 5 1 1 1 1 1 1
66 1 52 1 1 1 1 1 1
62 1 53 2 2 2 2 2 2
65 1 56 1 1 1 2 2 2
58 1 6 2 1 1 1 1
55 1 4,7 2 1 1
60 1 5,7 2 1 1
58 1 5 2 1 1 1
55 1 4,8 2 1 1
58 1 5,7 2 1 1 1
82,80 2 13.2 1 1 1 1 1 1
87,20 2 14.7 1 1 1 1 1 1
86,20 2 14.7 1 1 1 1 1 1
82,80 2 13.2 1 1 1 1 1 1
87,20 2 14.7 1 1 1 1 1 1
82,80 2 13.2 1 1 1 1 1 1
65,20 2 9.5 1 1 1 1 1 1
82,80 2 13.2 1 1 1 1 1 1
65,20 2 9.5 1 1 1 1 1 1
85,60 2 13.9 1 1 1 1 1 1
62,42 2 8500 1 1 1 1 1 1
62,42 2 8500 1 1 1 1 1 1
82,80 2 13.2 1 1 1 1 1 1
87,0 2 12,4 1 1 1 1 1 1
60,0 1 5,7 1 1 1 1 1 1
87,0 2 12,4 1 1 1 1 1 1
60,5 1 6,3 1 1 1 1 1 1
78,0 2 10,6 1 1 1 1 1 1
60,5 1 6,3 1 1 1 1 1 1
70,5 1 8,9 1 1 1 1 1 1
78,0 10,7 1 1 1 1 1 1
89 2 15 1 1 1 1 1 1
68 2 11 1 1 1 1 1 1
80 2 13 1 1 1 1 1 1
101 2 15 1 1 1 1 1 1
69.6 2 10 1 1 1 1 1 1
70.60 2 12 1 1 1 1 1 1
70.20 1 8.5 1 1 1 1 1 1
83.80 2 12.8 1 1 1 1 1 1
87.0 2 11.5 1 1 1 1 1 1
62.40 1 8.2 1 1 1 1 1 1
82 2 13 1 1 1 1 1 1
59 2 7.9 1 1 1 1 1
76 2 11 1 1 1 1 1 1
69 2 9.9 1 1 1 1 1 1
59 1 59 1 1 1 1 1 1
82 2 13.2 1 1 1 1 1 1
59 1 7.9 1 1 1 1 1 1
87 2 14.7 1 1 1 1 1 1
59 2 7.9 1 1 1 1 1 1
82 2 16.5 1 1 1 1 1 1
76 2 14.5 1 1 1 1 1 1
76 2 11.6 1 1 1 1 1 1
76 2 11.6 1 1 1 1 1 1
76 2 11.6 1 1 1 1 1 1
82 2 13.2 1 1 1 1 1 1
76 2 11.6 1 1 1 1 1 1
62 1 8 2 1 1 1 1 1
54 1 7.3 2 1 1 1 1 1
55 1 5 2 1 1 1 1 1
73 cm 2 11kg 1 1 1 1 1 1
76cm 2 11.1 kg 1 1 1 1 2 2
77cm 2 11.5 kg 1 1 1 2 2 2
70cm 1 8.8 kg 1 1 1 1 1 1
73 cm 2 11 kg 1 1 1 1 1 1
91 cm 2 13kg 1 1 1 2 2 2
71 cm 1 10.2 kg 1 1 1 2 2 2
57 cm 1 5.4 kg 2 1 1 1 1 1
67 cm 1 8.3 kg 1 1 1 1 1 1
72 cm 1 9.5 kg 1 1 1 1 1 1
= Tidak Perkembangan
LILA 6 - 59
Lingkar
bulan Kepala (cm)
(cm)
Umur 6 KPSP Buku KIA Tidak Lanjut
bln DS/DM/DP S/TS SI/SU/SR
(28) (29) (30) (31) (32) (33)
2

2
1
1
2

1
T
Y
T
T
T
T
T
T
T
Y

1 14,75 43
35
38
1 16,25 45

1 14,75 40
35
1 16,25 44
1 14,75 40
42
1 16,25 44
1 15,10 42
43
1 14,75 42
40
1 15,10 43
40
40
1 15
1 8
1 16
1 10
1 15,5
1 13
1 12,5
1 12
1 17cm
1 16.5cm
1 17cm
1 16,5cm
1 16cm
1 17cm
1 16,15cm
1 17cm
1 16cm
1 16cm
1 16,75cm
1 16,35cm
1
-
-
-
1
-
-
-
1 16.5 48.6
1 16 46.6
13 41
1 16.2 46.7
1 16 44
1 16.1 47
2 DP TS SR 11 49
1 DS S SL 16 40
1 Ds S SL
SL 36,5
1 Ds s 15 41
DS S SL
SL 26
1 Ds S 10,5 44
1 Ds S SL 16,5 40
SL
1 DS s SL 16 40
1 ds s SL 15 39
1 Ds S 15,3 40
1 S 16,25 45.7
S 35.3
S 40.4
1 S 14.75 42.7
S 37.9
1 S 16.50 48
S 39.3
1 S 17.00 48.4
1 S 16.00 46.0
1 S 15.10 44.1
1
2
2
2
2
2
1
2
2
S 40
S 39
S 41
S 39
S 39
S 39
1 16.75
1 17
1 17
1 16.75
1 17
1 16.75
1 16
1 17
1 16
1 16.75
1 16
1
1 16.75
1 - S - 16,25 45,7
1 - S - - 39,3
1 - S - 16,25 46,8
1 - S - - 40,4
1 - S - 16.00 44,2
1 - S - - 40,4
1 - S - 15.10 42,4
1 - S - 16.00 45,5
1 17,0 52,1
1 16,0 49,0
1 16,5 50,0
1 16,75 51,6
1 16,25 48,7
1 16,25 49,7
1 15,01 44,2
1 16,65 49,5
1 16,20 48,6
1 15,10 45,6
1 16
1 16
1 16,50
1 16,25
1 16
1 16.75
1 16
1 17
1 16
1 16.75
1 16.5
1 16.5
1 16.25
1 16.5
1 16.7
1 16.5
1 40
1 37
1 37
1 s 16 cm 45.5 cm
2 s 16 cm 47.2 cm
2 s 16 cm 47.7 cm
1 s 15.15 cm 44.6 cm
1 s 16 cm 46 cm
2 s 16.40 cm 49.5 cm
2 s 16 cm 44.9 cm
1 s - 38.3 cm
1 s 14.70 cm 44 cm
1 s 15 cm '44.5 cm