FORMULIR HASIL PEMERIKSAAN JENTIK BERKALA (PJB)

PUSKESMAS : KEC.KANIGORO
DESA : GOGODESO
BULAN/TAHUN : JUNI/2022

NAMA KK/TEMPAT JENTIK

NO ALAMAT KETERANGAN
UMUM POSITIF NEGATIF
1 2 3 4 5 6
1 NARWIS NGADE RT 1/4 - -
2 KATMIATUN NGADE RT 1/4 - -
3 ANSORI NGADE RT 1/4 - -
4 TUMIRIN NGADE RT 1/4 - -
5 TRIAS NGADE RT 1/4 - -
6 SUWARNO NGADE RT 1/4 - -
7 MUSTAKIM NGADE RT 1/4 - -
8 SITI MAHMUDAH NGADE RT 1/4 ✔ -
9 DWI RIYANTO NGADE RT 1/4 - -
10 MARDIYAH/JAENURI NGADE RT 1/4 - -
11 NAFSIAH NGADE RT 1/4 - -
12 WAHYU SOFI NGADE RT 1/4 - -
13 RIO PRIANTO NGADE RT 1/4 ✔ -
14 AHMAD RIFA’I NGADE RT 1/4 - -
15 M WIYANI NGADE RT 1/4 - -
16 BAGUS NGADE RT 1/4 - -
17 SUYITNO NGADE RT 1/4 - -
18 SUPARMI NGADE RT 1/4 ✔ -
19 YATIMI NGADE RT 2/5 - -
20 LATIFAH NGADE RT 2/5 - -
21 RONI NGADE RT 2/5 - -
22 YULIANA NGADE RT 2/5 - -
23 SUSIANTO NGADE RT 2/5 - -
24 TAMURUDIN NGADE RT 2/5 - -
25 ISMIATI NGADE RT 2/5 - -
26 KARMIATI NGADE RT 2/5 - -
27 MARSINI NGADE RT 2/5 - -
28 SAROAH NGADE RT 2/5 - -
29 MUNTIAH NGADE RT 2/5 - -
30 KATEMIN NGADE RT 2/5 - -
31 SLAMET NGADE RT 2/5 - -
32 MINI NGADE RT 2/5 ✔ -
33 MUT NGADE RT 2/5 ✔ -
34 SRIATUN NGADE RT 2/5 ✔ -
35 MUJIONO NGADE RT 2/5 - -
36 MINAL NGADE RT 3/7 - -
37 YAHMI NGADE RT 3/7 ✔
38 SURIP NGADE RT 3/7 - -
39 LUKMAN NGADE RT 3/7 - -
40 AFANDI NGADE RT 3/7 - -
41 SUDARTO NGADE RT 3/7 - -
42 MUJIANTO NGADE RT 3/7 - -
43 EKO NGADE RT 3/7 - -
44 SAELAN NGADE RT 3/7 - -
45 TOWILATUN NGADE RT 3/7 - -
46 ALI NGADE RT 3/7 - -
47 RUKAYAH NGADE RT 3/7 - -
48 PAINAH NGADE RT 3/7 - -
49 WIYANI DOGONG RT 1/13 - -
50 MISNO DOGONG RT 1/13 - -
51 RIYANTO DOGONG RT 1/13 - -
52 ETIK DOGONG RT 1/13 - -
53 SURATEN DOGONG RT 1/13 - -
54 RONI DOGONG RT 1/13 - -
55 NAHRUDIN DOGONG RT 1/13 - -
 56 MUHAIMIN DOGONG RT 1/13 - -
57 EDI DOGONG RT 1/13 - -
58 MINTEN DOGONG RT 2/13 ✔ -
59 SURAHMAN DOGONG RT 2/13 - -
60 ROHANDI DOGONG RT 2/13 - -
61 ABDUL GHOFUR DOGONG RT 2/13 - -
62 LULUK DOGONG RT 2/13 - -
63 RONI GOGODESO RT 3/13 - -
64 TUKINEM GOGODESO RT 3/13 ✔ -
65 KATIMIN GOGODESO RT 3/13 - -
66 BOIRAH GOGODESO RT 3/13 ✔ -
67 SIDIQ MULYONO GOGODESO RT 3/13 - -
68 SAEKONI GOGODESO RT 3/13 - -
69 EDI SULAEMAN GOGODESO RT 3/13 - -
70 AMIRULLAH GOGODESO RT 3/13 - -
71 YUSUF GOGODESO RT 3/13 - -
72 SITI ROWIYAH GOGODESO RT 3/13 ✔ -
73 MUKIYEM GOGODESO RT 3/13 - -
74 MARYATUN GOGODESO RT 3/13 - -
75 MULYONO GOGODESO RT 3/13 ✔ -
76 ARIF GOGODESO RT 3/13 - -
77 MISTO GOGODESO RT 3/13 - -
78 SUKARI SERUT RT 1/10 ✔ -
79 KARIYATI SERUT RT 1/10 - -
80 AMAN BUDI SERUT RT 1/10 ✔
81 BASORI SERUT RT 1/10 - -
82 AMIRUDIN SERUT RT 1/10 - -
83 SUNARTI SERUT RT 1/10 - -
84 KUSNAN SERUT RT 1/10 - -
85 SIGIT SERUT RT 1/10 - -
86 ISLAN SERUT RT 1/10 - -
87 KATIRAN SERUT RT 1/10 - -
88 KAMAR SERUT RT 1/10 - -
89 JARKASI SERUT RT 1/10 ✔ -
90 NURCHOLIS SERUT RT 1/10 - -
91 MINTAROH SERUT RT 1/10 - -
92 PRIYO SERUT RT 2/10 - -
93 SUPRAPMAN SERUT RT 2/10 - -
94 SUPADI SERUT RT 2/10 - -
95 PUR SERUT RT 2/10 - -
96 MUHANAN SERUT RT 2/10 - -
97 BADRUS SERUT RT 2/10 - -
98 SAMSUDIN SERUT RT 2/10 ✔ -
99 ABU BIDIN SERUT RT 2/10 ✔ -
100 SISWANTO SERUT RT 2/10 ✔ -

Mengetahui ........................................
Kepala UPTD Puskesmas Kec. Kanigoro Pengelola Program IVD

( ...................................... ) ( ...................................... )
NIP. NIP.
 FORMULIR HASIL PEMERIKSAAN JENTIK BERKALA (PJB)

PUSKESMAS : KWC.KANIGORO
DESA : GOGODESO
BULAN/TAHUN : JULI/2022

NAMA KK/TEMPAT JENTIK

NO ALAMAT KETERANGAN
UMUM POSITIF NEGATIF
1 2 3 4 5 6
1 NARWIS NGADE RT 1/4 - -
2 KATMIATUN NGADE RT 1/4 - -
3 ANSORI NGADE RT 1/4 - -
4 TUMIRIN NGADE RT 1/4 - -
5 TRIAS NGADE RT 1/4 - -
6 SUWARNO NGADE RT 1/4 - -
7 MUSTAKIM NGADE RT 1/4 - -
8 SITI MAHMUDAH NGADE RT 1/4 ✔ -
9 DWI RIYANTO NGADE RT 1/4 - -
10 MARDIYAH/JAENURI NGADE RT 1/4 - -
11 NAFSIAH NGADE RT 1/4 - -
12 WAHYU SOFI NGADE RT 1/4 - -
13 RIO PRIANTO NGADE RT 1/4 - -
14 AHMAD RIFA’I NGADE RT 1/4 - -
15 M WIYANI NGADE RT 1/4 - -
16 BAGUS NGADE RT 1/4 - -
17 SUYITNO NGADE RT 1/4 - -
18 SUPARMI NGADE RT 1/4 ✔ -
19 YATIMI NGADE RT 2/5 - -
20 LATIFAH NGADE RT 2/5 - -
21 RONI NGADE RT 2/5 - -
22 YULIANA NGADE RT 2/5 - -
23 SUSIANTO NGADE RT 2/5 - -
24 TAMURUDIN NGADE RT 2/5 - -
25 ISMIATI NGADE RT 2/5 - -
26 KARMIATI NGADE RT 2/5 - -
27 MARSINI NGADE RT 2/5 - -
28 SAROAH NGADE RT 2/5 - -
29 MUNTIAH NGADE RT 2/5 - -
30 KATEMIN NGADE RT 2/5 - -
31 SLAMET NGADE RT 2/5 - -
32 MINI NGADE RT 2/5 - -
33 MUT NGADE RT 2/5 - -
34 SRIATUN NGADE RT 2/5 - -
35 MUJIONO NGADE RT 2/5 - -
36 MINAL NGADE RT 3/7 - -
37 YAHMI NGADE RT 3/7 ✔
38 SURIP NGADE RT 3/7 - -
39 LUKMAN NGADE RT 3/7 - -
40 AFANDI NGADE RT 3/7 - -
41 SUDARTO NGADE RT 3/7 - -
42 MUJIANTO NGADE RT 3/7 - -
43 EKO NGADE RT 3/7 - -
44 SAELAN NGADE RT 3/7 - -
45 TOWILATUN NGADE RT 3/7 - -
46 ALI NGADE RT 3/7 - -
47 RUKAYAH NGADE RT 3/7 - -
48 PAINAH NGADE RT 3/7 - -
49 WIYANI DOGONG RT 1/13 - -
50 MISNO DOGONG RT 1/13 - -
51 RIYANTO DOGONG RT 1/13 - -
52 ETIK DOGONG RT 1/13 - -
53 SURATEN DOGONG RT 1/13 - -
54 RONI DOGONG RT 1/13 - -
55 NAHRUDIN DOGONG RT 1/13 - -
 56 MUHAIMIN DOGONG RT 1/13 - -
57 EDI DOGONG RT 1/13 - -
58 MINTEN DOGONG RT 2/13 ✔ -
59 SURAHMAN DOGONG RT 2/13 - -
60 ROHANDI DOGONG RT 2/13 - -
61 ABDUL GHOFUR DOGONG RT 2/13 - -
62 LULUK DOGONG RT 2/13 - -
63 RONI GOGODESO RT 3/13 - -
64 TUKINEM GOGODESO RT 3/13 ✔ -
65 KATIMIN GOGODESO RT 3/13 - -
66 BOIRAH GOGODESO RT 3/13 - -
67 SIDIQ MULYONO GOGODESO RT 3/13 - -
68 SAEKONI GOGODESO RT 3/13 - -
69 EDI SULAEMAN GOGODESO RT 3/13 - -
70 AMIRULLAH GOGODESO RT 3/13 - -
71 YUSUF GOGODESO RT 3/13 - -
72 SITI ROWIYAH GOGODESO RT 3/13 ✔ -
73 MUKIYEM GOGODESO RT 3/13 - -
74 MARYATUN GOGODESO RT 3/13 - -
75 MULYONO GOGODESO RT 3/13 ✔ -
76 ARIF GOGODESO RT 3/13 - -
77 MISTO GOGODESO RT 3/13 - -
78 SUKARI SERUT RT 1/10 - -
79 KARIYATI SERUT RT 1/10 - -
80 AMAN BUDI SERUT RT 1/10 ✔
81 BASORI SERUT RT 1/10 - -
82 AMIRUDIN SERUT RT 1/10 - -
83 SUNARTI SERUT RT 1/10 - -
84 KUSNAN SERUT RT 1/10 - -
85 SIGIT SERUT RT 1/10 - -
86 ISLAN SERUT RT 1/10 - -
87 KATIRAN SERUT RT 1/10 - -
88 KAMAR SERUT RT 1/10 - -
89 JARKASI SERUT RT 1/10 ✔ -
90 NURCHOLIS SERUT RT 1/10 - -
91 MINTAROH SERUT RT 1/10 - -
92 PRIYO SERUT RT 2/10 - -
93 SUPRAPMAN SERUT RT 2/10 - -
94 SUPADI SERUT RT 2/10 - -
95 PUR SERUT RT 2/10 - -
96 MUHANAN SERUT RT 2/10 - -
97 BADRUS SERUT RT 2/10 - -
98 SAMSUDIN SERUT RT 2/10 ✔ -
99 ABU BIDIN SERUT RT 2/10 - -
100 SISWANTO SERUT RT 2/10 ✔ -

Mengetahui ........................................
Kepala UPTD Puskesmas Kec. Kanigoro Pengelola Program IVD

( ...................................... ) ( ...................................... )
NIP. NIP.
 FORMULIR HASIL PEMERIKSAAN JENTIK BERKALA (PJB)

PUSKESMAS : KEC.KANIGORO
DESA : GOGODESO
BULAN/TAHUN : AGUSTUS/2022

NAMA KK/TEMPAT JENTIK

NO ALAMAT KETERANGAN
UMUM POSITIF NEGATIF
1 2 3 4 5 6
1 NARWIS NGADE RT 1/4 - -
2 KATMIATUN NGADE RT 1/4 - -
3 ANSORI NGADE RT 1/4 - -
4 TUMIRIN NGADE RT 1/4 - -
5 TRIAS NGADE RT 1/4 - -
6 SUWARNO NGADE RT 1/4 - -
7 MUSTAKIM NGADE RT 1/4 - -
8 SITI MAHMUDAH NGADE RT 1/4 - -
9 DWI RIYANTO NGADE RT 1/4 - -
10 MARDIYAH/JAENURI NGADE RT 1/4 - -
11 NAFSIAH NGADE RT 1/4 - -
12 WAHYU SOFI NGADE RT 1/4 - -
13 RIO PRIANTO NGADE RT 1/4 - -
14 AHMAD RIFA’I NGADE RT 1/4 - -
15 M WIYANI NGADE RT 1/4 - -
16 BAGUS NGADE RT 1/4 - -
17 SUYITNO NGADE RT 1/4 - -
18 SUPARMI NGADE RT 1/4 - -
19 YATIMI NGADE RT 2/5 - -
20 LATIFAH NGADE RT 2/5 - -
21 RONI NGADE RT 2/5 - -
22 YULIANA NGADE RT 2/5 - -
23 SUSIANTO NGADE RT 2/5 - -
24 TAMURUDIN NGADE RT 2/5 - -
25 ISMIATI NGADE RT 2/5 - -
26 KARMIATI NGADE RT 2/5 - -
27 MARSINI NGADE RT 2/5 - -
28 SAROAH NGADE RT 2/5 - -
29 MUNTIAH NGADE RT 2/5 - -
30 KATEMIN NGADE RT 2/5 - -
31 SLAMET NGADE RT 2/5 - -
32 MINI NGADE RT 2/5 - -
33 MUT NGADE RT 2/5 - -
34 SRIATUN NGADE RT 2/5 - -
35 MUJIONO NGADE RT 2/5 - -
36 MINAL NGADE RT 3/7 - -
37 YAHMI NGADE RT 3/7 -
38 SURIP NGADE RT 3/7 - -
39 LUKMAN NGADE RT 3/7 - -
40 AFANDI NGADE RT 3/7 - -
41 SUDARTO NGADE RT 3/7 - -
42 MUJIANTO NGADE RT 3/7 - -
43 EKO NGADE RT 3/7 - -
44 SAELAN NGADE RT 3/7 - -
45 TOWILATUN NGADE RT 3/7 - -
46 ALI NGADE RT 3/7 - -
47 RUKAYAH NGADE RT 3/7 - -
48 PAINAH NGADE RT 3/7 - -
49 WIYANI DOGONG RT 1/13 - -
50 MISNO DOGONG RT 1/13 - -
51 RIYANTO DOGONG RT 1/13 - -
52 ETIK DOGONG RT 1/13 - -
53 SURATEN DOGONG RT 1/13 - -
54 RONI DOGONG RT 1/13 - -
55 NAHRUDIN DOGONG RT 1/13 - -
 56 MUHAIMIN DOGONG RT 1/13 - -
57 EDI DOGONG RT 1/13 - -
58 MINTEN DOGONG RT 2/13 - -
59 SURAHMAN DOGONG RT 2/13 - -
60 ROHANDI DOGONG RT 2/13 - -
61 ABDUL GHOFUR DOGONG RT 2/13 - -
62 LULUK DOGONG RT 2/13 - -
63 RONI GOGODESO RT 3/13 - -
64 TUKINEM GOGODESO RT 3/13 ✔ -
65 KATIMIN GOGODESO RT 3/13 - -
66 BOIRAH GOGODESO RT 3/13 - -
67 SIDIQ MULYONO GOGODESO RT 3/13 - -
68 SAEKONI GOGODESO RT 3/13 - -
69 EDI SULAEMAN GOGODESO RT 3/13 - -
70 AMIRULLAH GOGODESO RT 3/13 - -
71 YUSUF GOGODESO RT 3/13 - -
72 SITI ROWIYAH GOGODESO RT 3/13 - -
73 MUKIYEM GOGODESO RT 3/13 - -
74 MARYATUN GOGODESO RT 3/13 - -
75 MULYONO GOGODESO RT 3/13 - -
76 ARIF GOGODESO RT 3/13 - -
77 MISTO GOGODESO RT 3/13 - -
78 SUKARI SERUT RT 1/10 - -
79 KARIYATI SERUT RT 1/10 - -
80 AMAN BUDI SERUT RT 1/10 -
81 BASORI SERUT RT 1/10 - -
82 AMIRUDIN SERUT RT 1/10 - -
83 SUNARTI SERUT RT 1/10 - -
84 KUSNAN SERUT RT 1/10 - -
85 SIGIT SERUT RT 1/10 - -
86 ISLAN SERUT RT 1/10 - -
87 KATIRAN SERUT RT 1/10 - -
88 KAMAR SERUT RT 1/10 - -
89 JARKASI SERUT RT 1/10 - -
90 NURCHOLIS SERUT RT 1/10 - -
91 MINTAROH SERUT RT 1/10 - -
92 PRIYO SERUT RT 2/10 - -
93 SUPRAPMAN SERUT RT 2/10 - -
94 SUPADI SERUT RT 2/10 - -
95 PUR SERUT RT 2/10 - -
96 MUHANAN SERUT RT 2/10 - -
97 BADRUS SERUT RT 2/10 - -
98 SAMSUDIN SERUT RT 2/10 - -
99 ABU BIDIN SERUT RT 2/10 - -
100 SISWANTO SERUT RT 2/10 - -

Mengetahui ........................................
Kepala UPTD Puskesmas Kec. Kanigoro Pengelola Program IVD

( ...................................... ) ( ...................................... )
NIP. NIP.
 FORMULIR HASIL PEMERIKSAAN JENTIK BERKALA (PJB)

PUSKESMAS : KEC.KANIGORO
DESA : GOGODESO
BULAN/TAHUN : SEPTEMBER/2022

NAMA KK/TEMPAT JENTIK

NO ALAMAT KETERANGAN
UMUM POSITIF NEGATIF
1 2 3 4 5 6
1 NARWIS NGADE RT 1/4 - -
2 KATMIATUN NGADE RT 1/4 - -
3 ANSORI NGADE RT 1/4 - -
4 TUMIRIN NGADE RT 1/4 - -
5 TRIAS NGADE RT 1/4 - -
6 SUWARNO NGADE RT 1/4 - -
7 MUSTAKIM NGADE RT 1/4 - -
8 SITI MAHMUDAH NGADE RT 1/4 - -
9 DWI RIYANTO NGADE RT 1/4 - -
10 MARDIYAH/JAENURI NGADE RT 1/4 - -
11 NAFSIAH NGADE RT 1/4 - -
12 WAHYU SOFI NGADE RT 1/4 - -
13 RIO PRIANTO NGADE RT 1/4 - -
14 AHMAD RIFA’I NGADE RT 1/4 - -
15 M WIYANI NGADE RT 1/4 - -
16 BAGUS NGADE RT 1/4 - -
17 SUYITNO NGADE RT 1/4 - -
18 SUPARMI NGADE RT 1/4 - -
19 YATIMI NGADE RT 2/5 - -
20 LATIFAH NGADE RT 2/5 - -
21 RONI NGADE RT 2/5 - -
22 YULIANA NGADE RT 2/5 - -
23 SUSIANTO NGADE RT 2/5 - -
24 TAMURUDIN NGADE RT 2/5 - -
25 ISMIATI NGADE RT 2/5 - -
26 KARMIATI NGADE RT 2/5 - -
27 MARSINI NGADE RT 2/5 - -
28 SAROAH NGADE RT 2/5 - -
29 MUNTIAH NGADE RT 2/5 - -
30 KATEMIN NGADE RT 2/5 - -
31 SLAMET NGADE RT 2/5 - -
32 MINI NGADE RT 2/5 - -
33 MUT NGADE RT 2/5 - -
34 SRIATUN NGADE RT 2/5 - -
35 MUJIONO NGADE RT 2/5 - -
36 MINAL NGADE RT 3/7 - -
37 YAHMI NGADE RT 3/7 -
38 SURIP NGADE RT 3/7 - -
39 LUKMAN NGADE RT 3/7 - -
40 AFANDI NGADE RT 3/7 - -
41 SUDARTO NGADE RT 3/7 - -
42 MUJIANTO NGADE RT 3/7 - -
43 EKO NGADE RT 3/7 - -
44 SAELAN NGADE RT 3/7 - -
45 TOWILATUN NGADE RT 3/7 - -
46 ALI NGADE RT 3/7 - -
47 RUKAYAH NGADE RT 3/7 - -
48 PAINAH NGADE RT 3/7 - -
49 WIYANI DOGONG RT 1/13 - -
50 MISNO DOGONG RT 1/13 - -
51 RIYANTO DOGONG RT 1/13 - -
52 ETIK DOGONG RT 1/13 - -
53 SURATEN DOGONG RT 1/13 - -
54 RONI DOGONG RT 1/13 - -
55 NAHRUDIN DOGONG RT 1/13 - -
 56 MUHAIMIN DOGONG RT 1/13 - -
57 EDI DOGONG RT 1/13 - -
58 MINTEN DOGONG RT 2/13 - -
59 SURAHMAN DOGONG RT 2/13 - -
60 ROHANDI DOGONG RT 2/13 - -
61 ABDUL GHOFUR DOGONG RT 2/13 - -
62 LULUK DOGONG RT 2/13 - -
63 RONI GOGODESO RT 3/13 - -
64 TUKINEM GOGODESO RT 3/13 - -
65 KATIMIN GOGODESO RT 3/13 - -
66 BOIRAH GOGODESO RT 3/13 - -
67 SIDIQ MULYONO GOGODESO RT 3/13 - -
68 SAEKONI GOGODESO RT 3/13 - -
69 EDI SULAEMAN GOGODESO RT 3/13 - -
70 AMIRULLAH GOGODESO RT 3/13 - -
71 YUSUF GOGODESO RT 3/13 - -
72 SITI ROWIYAH GOGODESO RT 3/13 - -
73 MUKIYEM GOGODESO RT 3/13 - -
74 MARYATUN GOGODESO RT 3/13 - -
75 MULYONO GOGODESO RT 3/13 - -
76 ARIF GOGODESO RT 3/13 - -
77 MISTO GOGODESO RT 3/13 - -
78 SUKARI SERUT RT 1/10 - -
79 KARIYATI SERUT RT 1/10 - -
80 AMAN BUDI SERUT RT 1/10 -
81 BASORI SERUT RT 1/10 - -
82 AMIRUDIN SERUT RT 1/10 - -
83 SUNARTI SERUT RT 1/10 - -
84 KUSNAN SERUT RT 1/10 - -
85 SIGIT SERUT RT 1/10 - -
86 ISLAN SERUT RT 1/10 - -
87 KATIRAN SERUT RT 1/10 - -
88 KAMAR SERUT RT 1/10 - -
89 JARKASI SERUT RT 1/10 - -
90 NURCHOLIS SERUT RT 1/10 - -
91 MINTAROH SERUT RT 1/10 - -
92 PRIYO SERUT RT 2/10 - -
93 SUPRAPMAN SERUT RT 2/10 - -
94 SUPADI SERUT RT 2/10 - -
95 PUR SERUT RT 2/10 - -
96 MUHANAN SERUT RT 2/10 - -
97 BADRUS SERUT RT 2/10 - -
98 SAMSUDIN SERUT RT 2/10 - -
99 ABU BIDIN SERUT RT 2/10 - -
100 SISWANTO SERUT RT 2/10 - -

Mengetahui ........................................
Kepala UPTD Puskesmas Kec. Kanigoro Pengelola Program IVD

( ...................................... ) ( ...................................... )
NIP. NIP.