Nama Puskesmas/Fasyankes/Pos

Kabupaten/Kota
Provinsi

No No. Tiket

5
6

10

11

12

13

14

15

16

17

18

19

20

21

22
23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39
40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60
61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77
78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94
95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111
112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128
 129

130

131

Keterangan
* Pekerjaan dikelompokkan menjadi:
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
 NIK

6302140304790000

6302144908990000

6302141304900002

6302142704890825

6302145501240001
6302140109580001

6302140505660001

63-2144611870001

6302146208930001

6302140102690001

6302145306970001

3302148909910001

6302146003670002

3306055109920001

6302146408000002

6302141010970001

6302081312840001

6302144808840001

6302140202820003

7105176408640003

6302140603870001

6302141808790002
6302140404810001

6302145505960001

630214020870002

6302141810930003

6302145205970001

6302145103750001

6302142101750001

6302142608760004

6302140105000001

6302140002780002

6302142106980001

63021419017460003

6302145202760001

6302141312370001

6302144210990001

6302142509750001

1808114911920001
6302144507920001

6302140510940001

6302140908030001

6302144210010001

630214100490001

63302140611780001

6302140201920001

630214203760001

6302141907710001

6302144406810001

6302142403840002

6302141506840005

6302142212960001

6302140304860002

6302145509930002

0302141603720002

6302145507950001

6302140811600001

6302140212630001

6302085010720002

6302140908820001
6302142612900001

6302140411800001

6302140210680001

6302142707620001

6302144801890001

6302141406860001

6302141205760001

631004141170001

6302146504850001

6302142507880001

6302145206990001

6302147101930001

1602131010960001

6310021307770002

6310025812770002

6302541208900001

3307080406720003
3307087112730042

6302145207790001

6302141502730001

6302140508510001

6302145709710001

302192107790002

6302141010490003

6302146007960001

6302141011670001

6302145703940001

6302140310910002

7373052512870003

6302141903820001

6302145906840001

7105170309630001

6302081107790002

6302147101970001
6310044704880004

1808110308010004

6302142807810001

6302142603000001

63021400110720002

6302141011580001

6302141011580001

6302144109690001

630214607010002

6302145810700002

6302141009670002

6302144204980001

6302146409810001

6302145288900001

6302145009800001

3528070504950003

6302141807670002
6302145808930001

6310041608720003

6302145212700001

6302141505670001

63021421109970001

6302144406640001

6302140107770065

6302192805790002

6302141602820001

6302140107730832

6302145209840001

6302141306810001

6302144107580826

6302142202790001

6302144907670002

6302145009010001

6302200303840005
 3306100805880001

6302142106830001

6302144807770002

litas Pelayanan Kesehatan

dapan langsung dengan masyarakat

Kelompok Umur:
18-30
31-45
46-59
Total
Pekerjaan:
A
B
C
D
E
Total
:
:
:

Jenis
Nama Penerima Vaksin Pekerjaan*
Kelamin

DALDI L B

ANIS NURLAILA P E

MIJOYANTO L B

MUGNI L B

JUMIAH P E
SUNARTO L E

MAHMUDI L D

SUMARIAH P D

SUMIYATI P D

PURNADI SUKMA L B

RIRIN KURNIYAWATI P B

SITI NORYANTI P D

SUPINAH P D

SUMARYANTI P D

KADEK WIDIANI P D

PURNA IRAWAN L D

ANDIK WIYONO L D

FEBE SUMARNI P D

DIDION WIDIATMOKO L D

HERTJE MALONDA P D

HERLIANSYAH L B

AGUS ARIADI L D
KATIRAN L D

SOMINI P D

AKHMAD YANI L D

MERI SUSANTO L E

PUSPITA NINGSIH P E

YULITA KASE P D

SISWONO L D

EKO PURWANTO L B

MUHAMMAD SAPINGI L E

KOMARIYAH P D

BERKAH TRI LAKSONO L D

JENER LAOH L D

FELMA RUTH PANGEMANAN P D

THAMRIN EMBONG L E

NADA OKTAMI P B

STEVEN SIWU P D

ADINIAH P D
SITI ROHMAH P D

AHMADDAN SYUKROMI L D

IBNU KRISNA HAMBALI L D

DESI RELAWATI P D

SUJARWO L D

ARISMAN L D

M. AKHYAR L D

SYAHRANI L D

ARIFIN , S.Ag L B

SULIS ASTUTI P D

RISTIWANTO L D

ANDI PRANATA L D

HERU L B

SAHRIANTO L D

SITI ZALEHA P D

MISNOHAN L D

NI WAYAN ASTUTI ASIH P E

PARJIMAN L E

BOHARI L D

OKTOFIANA HITARIHUN P D

SAMSUDIN SAHRI L D
ANDIKA NOVIANTO L D

DEDE SUGIANTO L D

ROYANI L D

ANJALI P D

DIRGAHAYU SEMBIRING P D

SUKIMAN L D

RAHDI L D

AHMAD ZAELANI L D

ASIH MARWANTI P D

MAS'UD SUPRIANTO L D

SARTIKA P D

ASSIDAH P D

WAHYU SUSILO L D

PANEMBAN REFLY ROMMY L D

ASSA DEBORA P D

MUHAMMAD LIKMANSYAH L C

TEGUH SURYANTO L D
PARIYAH P D

RABIATI P D

ILHAM L B

SELAMAT TARIYONO L D

NURHALIMAH P D

MASKUR L D

GABARDIANSYAH L D

TUTI JULIANI P B

WAGIMIN L D

SARTINAH P E

EKO KURNIAWAN L B

DEDI ALAMSYAH L D

ALEX SAPUTRA L B

RISA TRISIANA P B

DIDI LUMINTA L B

YUNIOR LEMBONG L D

SESI ERVINA P E
SITI FATONAH P D

AGUNG DWI P L E

SOKHEH YULIONO L B

ERDI SAPUTRA L D

HASAN BASRI L D

IMAM HANAFI L D

SITI MAIMUNAH P D

JAMIATUN KHUSNIAH P D

YUSAK L D

ONA OLGA KINDANGEN P B

STADIUS KAWARI L B

MILAWATI P B

ENTI SKU MOLONTONG P B

ERVI P D

SAHRAENI L D

ABDURRAHMAN L D

TRIMO L D
PONIRAN L D

TAUHID L D

WIJI LESTARI P D

SUROSO L D

IQBAL TAUHID HIDAYATULLAH L D

SARINAH P B

KURDI L B

JOKO SUSANTO L D

WAHYUDI L B

HARWANTO L B

MUNTIANAH P D

SUHARDIMAN L D

RUSNAH P D

AHMAD SISW0 L D

KARSIYAH P D

ADE HALIMAH P B

JAROT WAHYU HARYONO L B

 SLAMET HANDOYO L D

DULBAI L B

YARNI P D

***Merek Vaksin
A = Sinovac
B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes)

elompok Umur: Kepesertaan BPJS

7 BPJS PBI
7 BPJS Non PBI
4 Non Anggota
18 Total
Pekerjaan: Pemberian Dosis
0 Dosis 1
0 Dosis 2
0 Total
0
0
0
 FORMAT PENCATATAN PELAK
TINGKAT PUSKESMAS/FAS

Umur
Kelompok Umur
(18-59 tahun)

42 31-45

22 18-30

31 31-45

32 31-45

97 0
63 0

55 46-59

34 31-45

28 18-30

52 46-59

24 18-30

30 18-30

54 46-59

29 18-30

21 18-30

24 18-30

37 31-45

42 31-45

39 31-45

57 46-59

31 31-45

42 31-45
40 31-45

25 18-30

47 46-59

28 18-30

24 18-30

46 46-59

36 31-45

45 31-45

21 18-30

43 31-45

23 18-30

47 46-59

45 31-45

84 0

22 18-30

46 46-59

29 18-30
29 18-30

27 18-30

18 18-30

19 18-30

31 31-45

43 31-45

29 18-30

45 31-45

50 46-59

40 31-45

37 31-45

37 31-45

25 18-30

35 31-45

28 18-30

49 46-59

25 18-30

61 0

58 46-59

49 46-59

39 31-45
31 31-45

41 31-45

49 46-59

59 46-59

37 31-45

35 31-45

45 31-45

47 46-59

36 31-45

23 18-30

28 18-30

28 18-30

25 18-30

44 31-45

44 31-45

31 31-45

49 46-59
48 46-59

42 31-45

48 46-59

70 60-80

50 46-59

42 31-45

72 60-80

25 18-30

54 46-59

27 18-30

30 18-30

34 31-45

39 31-45

37 31-45

58 46-59

42 31-45

24 18-30
33 31-45

20 18-30

40 31-45

21 18-30

49 46-59

63 60-80

54 46-59

52 46-59

20 18-30

57 46-59

54 46-59

23 18-30

40 31-45

31 31-45

41 31-45

26 18-30

54 46-59
28 18-30

49 46-59

57 46-59

54 46-59

24 18-30

57 46-59

47 46-59

42 31-45

39 31-45

48 46-59

37 31-45

40 31-45

63 60-80

42 31-45

54 46-59

20 18-30

37 31-45
33 31-45

38 31-45

47 46-59

0
0
0
0

20
0
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Alamat

DESA HAMPANG

DESA LALAPIN (TRANS LAMA)

DESA LALAPIN

DESA HAMPANG

DESA LALAPIN (TRANS LAMA) RT. 06

DESA LALAPIN (TRANS LAMA) RT. 04

DESA LALAPIN (TRANS LAMA) RT. 04

DESA LALAPIN (TRANS LAMA) RT. 05

DESA LALAPIN (TRANS LAMA) RT. 04

DESA HAMPANG

DESA LALAPIN RT. 14

DESA LALAPIN (TRANS LAMA) RT. 04

DESA LALAPIN (TRANS LAMA) RT. 04

DESA LALAPIN (TRANS LAMA) RT. 03

DESA LALAPIN (TRANS LAMA) RT. 03

DESA LALAPIN (TRANS LAMA) RT. 06

DESA LALAPIN (TRANS LAMA) RT. 11 RW. 02

DESA LIMBUR (MAISIN)

DESA LIMBUR (MAISIN)

DESA CANTUKNG KIRI HULU (MUARA NAPU)

DESA PRAMASAN 2X9

DESA HAMPANG RT. 03

DESA HAMPANG

DESA LALAPIN RT. 06

DESA LIMBUNGAN RT. 03

JL ANTUIN RT. 04 DESA HAMPANG

JL ANTUIN RT. 03 DESA HAMPANG

DESA LIMBUNGAN RT. 05

DESA LIMBUNGAN RT. 05 RW. 02

DESA LIMBUNGAN RT. 04

TRANSBARU DESA LIMBUNGAN RT. 07 RW. 02

TRANSBARU DESA LIMBUNGAN RT. 06 RW. 02

PLAJAU BARU KUSAN HILIR RT.07 RW.03

DESA LALAPIN RT. 02 RW. 01

DESA LALAPIN RT. 02 RW. 01

DESA CANTUNG KIRI HULU (MUARA NAPU) RT. 01

DESA HAMPANG RT. 06 RW. 01

HAPIRING

DESA HAMPANG RT. 06 RW. 01

DESA LIMBUNGAN RT. 04

DESA HAMPANG RT. 01

DESA LIMBUNGAN (TRANS BARU) RT. 06

DESA LIMBUNGAN (TRANS BARU) RT. 07

DESA HAMPANG RT. 01

DESA LALAPIN

DESA LIMBUNGAN RT. 03

DESA LIMBUNGAN RT. 03

JALAN LINTAS RAYA HAMPANG

DESA HAMPANG

DESA HAMPANG RT. 06

BATU SAUNG RT. 02

DESA HAMPANG RT. 05

JLN. ANTUIN BATU SAUNG

DESA LIMBUNGAN RT. 01

JALAN LINTAS RAYA HAMPANG

DESA LALAPIN (TRANS LAMA)

TRANS BARU RT. 06 RW. 02

TRANS BARU RT. 06 RW. 02

LIMBUNGAN RT. 05 RW. 02

DESA LIMBUNGAN
DESA LIMBUNGAN (TRANS BARU) RT 07 RW 02

DESA LIMBUNGAN (TRANS BARU)

DESA LIMBUNGAN (TRANS BARU)

DESA LIMBUNGAN (TRANS BARU) RT 06 RW 02

DESA LIMBUNGAN (TRANS BARU) RT 05 RW 02

DESA LIMBUNGAN (TRANS BARU)

DESA LIMBUNGAN (TRANS BARU) RT 07 RW 02

DESA LIMBUNGAN (TRANS BARU) RT 07 RW 02

DESA CANTUNG KANAN

DESA CANTUNG KANAN

DESA MUARA URIE

DESA HAMPANG

DESA HAMPANG

TRANSBARU DESA LIMBUNGAN

TRANSBARU DESA LIMBUNGAN

DESA MUARA URIE

RT 01 Desa Hampang
RT 01 Desa Hampang

Jl.Lintas raya Antuin hampang

Jl.Antuin desa Hampang

RT 01 Desa Hampang

Translama Lalapin

Mandala Kelp.Hilir

Jl.Lintas Raya

Lalalpin Rt 09

Translama Lalapin RT 04

Translama RT 02

Translama RT 02

Desa Hampang

Hulu Sampanahan

LALAPIN

M.Napu Cantung Kiri Hulu

Lalalpin Rt 09

Jl.Antuin desa Hampang

Transbaru RT 07

Jl Lintas Raya Hampang

Lalapin

RT 03 Desa Hampang

Transbaru RT 06

Transbaru RT 06

Transbaru RT 07

Transbaru RT 06

Cantung Kanan

Cantung kanan

Cantung Kanan

Desa Hampang

Pramasan 2x9 Hapiring

Limbungan Rt 05

Transbaru Rt 07

Cantung Kanan

Hampang
Hampang

rt 01 Hampang

RT 01 HAMPANG

TRANSLAMA LALAPIN

TRANSLAMA LALAPIN

TRANSLAMA

Limbungan

TRANSLAMA LALAPIN

TRANSLAM LALAPIN

TRANSLAMA LALAPIN

TRANSLAMA LALAPIN

TRANSLAMA LALAPIN

RT 01 HAMPANG

TRANSLAMA LALPIN

TRANSLAM LALPIN

LALAPIN

LALAPIN
TRANSLAM LALAPIN

TRANSLAMA LALAPIN

JL ANTUIN HAMPANG

Pekerjaan
A
B
C
D
E
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp

BPJS PBI BPJS Non PBI

082250594192

082111235037

082150302079

085249738068

082198514301
081346000727

082198514301

081268089440

081351234120

081255169436

085157929559

081348803365

'085268624354

085849228660

081251754664

081390003204

082351017465

082154006225

081257948179
082256924464

082148254819

081289638814

082358533294

082154855205

082191530438

082351875094

081352871316

081253921034

082236089434

081292009292

085390676507

085156312229

082350086739

082353257799

085213492020

085217321067
085333591286

081321621024

081254177306

082150908188

081349584961

081348614099

085251829361

082351714499

082350630669

082159620379

082353378605

085389233585

081347649897

082159666211

081345462385

081257374422

085156265457

081256648220

081251845770

082159289248

082253039934
082155628728

081256325736

082250889260

082352685807

081250288489

081251124117

082358804558

081348248773

082152052091

081257811801

081254993994

081349584961

082269229560

085350547613

085245358172

082251562394

085252459280
085229681795

082152531904

082252059254

082158305291

082380881044

081348811261

085280492515

081254524760

082153651346

085246534135

082196836178

081257398463

082213859984

081244677179

081347628656

082256504488
085156414576

082251290010

082350135261

082256676784

082340324643

085349322480

085156946383

082352118660

082157444196

085386691655

082352501063

082251788048

085240341600

085158399383

081251348630

085349391656

081349768482
082253584614

085345159372

085345159382

082251059282

082251059282

082353930731

082158852513

085267141400

081348935427

085167160331

081352528616

085347854711

085245107293

081256564836
 081229046864

081250171948

085332924648

aan
0
0
0
0
0
0
a' pada kolom yang sesuai)

Tanggal Screening Nama/Jenis/Merek Vaksin***

Non Anggota

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC
26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC
26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC
26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC
 26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

A 6/26/2021
A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021
A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021
A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021

A 6/26/2021
A 6/26/2021

A 6/26/2021

A 6/26/2021
 Dosis I

Tanggal Pemberian
No. Batch No. Serial
Vaksinasi

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721
26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721
26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721
26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

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 26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

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6/26/2021 24200721
6/26/2021 24200721

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6/26/2021 24200721

6/26/2021 24200721
6/26/2021 24200721

6/26/2021 24200721

6/26/2021 24200721
 Dosis 2

Tanggal Pemberian
No. Batch No. Serial
Vaksinasi
LANJUT
LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT
LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT

LANJUT
 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Ditunda

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Nama Puskesmas/Fasyankes/Pos
Kabupaten/Kota
Provinsi

No No. Tiket
19

20

21

22

23

24

25

26

27

28

29
 30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

Keterangan
* Pekerjaan dikelompokkan menjadi:
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
NIK
litas Pelayanan Kesehatan
dapan langsung dengan masyarakat

Kelompok Umur:
18-30
31-45
46-59
Total
Pekerjaan:
A
B
C
D
E
Total
:
:
:

Jenis
Nama Penerima Vaksin Pekerjaan*
Kelamin
***Merek Vaksin
A = Sinovac
 B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes)

elompok Umur: Kepesertaan BPJS

0 BPJS PBI
0 BPJS Non PBI
0 Non Anggota
0 Total
Pekerjaan: Pemberian Dosis
0 Dosis 1
0 Dosis 2
0 Total
0
0
0
 FORMAT PENCATATAN PELAK
TINGKAT PUSKESMAS/FAS

Umur
Kelompok Umur
(18-59 tahun)
0
0
0
0

2
0
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Alamat
 Pekerjaan
A
B
C
D
E
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp

BPJS PBI BPJS Non PBI

aan
0
0
0
0
0
0
a' pada kolom yang sesuai)

Tanggal Screening Nama/Jenis/Merek Vaksin***

Non Anggota
26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC
26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC

26-Jun-21 SINOVAC
 Dosis I

Tanggal Pemberian
No. Batch No. Serial
Vaksinasi
26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721
26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721

26-Jun-21 24200721
 Dosis 2

Tanggal Pemberian
No. Batch No. Serial
Vaksinasi
 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut