FORMAT PENCATATAN HASIL PELAYANAN SUB PI

NAMA SEKOLAH SD 6
Nama Desa/kelurahan :
Tanggal :

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelami NIK
n (L/P)
a b c d e f
1 Aditya Irfanu Addin 2016-06-21 L 1108272106160001
2 Afifa Nahda Rafanda 2015-07-12 P 1115015207150001
3 Akifa Naila 2016-06-15 P 1108275506160003
4 Al fathir 2016-04-22 L 1108272204160002
5 Al Mahdi 2015-03-31 L 1108273103150001
6 Alisha Khaira 2015-11-22 P 1108276211150001
7 Amelia 2015-06-10 P 1108275006150001
8 Ananda Maulana 2015-09-29 L 1108272909150003
9 Aqifa Naila 2016-04-13 P 1108275304160002
10 Aylatul Humaira 2016-01-19 P 1108035901160001
11 Azzam Alfatih 2016-06-13 L 1108271306160001
12 Cut Aminah 2015-08-19 P 1108275908150002
13 Hanum Syakia 2015-09-24 P 1108276409150001
14 Haura Nafisah 2016-05-13 P 1108275305160001
15 Humayra Bilqis 2015-09-01 P 1117074109150001
16 Hunaifa 2015-10-14 P 1108275410150001
17 Intan Zahriah 2016-06-29 P 1108146906160002
18 Irwan Saputra 2015-11-13 L 1108271311150001
19 Linda Nabila 2015-03-14 P 1108275403150001
20 Muhammad Al Alifi Ardiansyah 2015-11-02 L 1108020211150001
21 Muhammad Alkhaidir 2015-09-18 L 1108271809150001
22 Muhammad Azzawir 2016-01-12 L 1108271201160001
23 Muhammad Isa 2015-11-05 L 1108150511150002
24 Muhammad Maulidin 2015-12-02 L 1108270212150001
25 Muhammad umam Al-haris 2016-01-21 L 1108272101160001
26 Naila Almahera 2016-01-08 P 1108274801160001
27 Najwa Maulidia 2015-12-19 P 1108275912150001
28 Natasya Ayunda 2016-01-28 P 1108276801160002
29 Nufa Aulia 2015-05-07 P 1108274705150001
30 Nuraida 2015-12-14 P 1108275412150002
31 Nuraini 2015-06-09 P 1108274908150001
32 Putri Asyifa 2016-04-18 P 1173035804160001
33 Raysul Istikbar 2015-10-08 L 1108270810150001
34 Salsabila 2015-05-13 P 1108275305150002
35 Salwa Maulisa 2015-08-13 P 1108275308150002
36 Syahiratul 2015-07-10 P 1108275007150001
37 Syakira 2015-04-07 P 1108274704150002
38 Wahyu Mahendra 2015-08-28 L 1108272808150002
39 Ahza Saputra 2014-03-18 L 1108275803140001
40 Azzaharatul Azkia 2014-11-10 P 1108275011140001
41 Fahrul Hajis 2013-06-03 L 1108270306130001
42 Farhan Maulana 2013-02-13 L 1108271302130001
43 Intan Nuraini 2014-09-14 P 1108275409140001
44 Karmila 2013-03-10 P 1108275003130001
45 Khairon Admi 2014-07-19 L 1108271907140001
46 Miftahul Jannah 2015-03-02 P 1108274203150001
47 Muhammad Ali Kadafi 2014-10-17 L 1108271710140002
48 Muhammad Alif 2014-12-15 L 1108271501150001
49 Muhammad Fajar 2013-11-07 L 1108270711130002
50 Muhammad Ikhsan 2014-10-12 L 1108151210140001
51 Muhammad Khairi 2014-10-11 L 1108271110140002
52 Muhammad Muhajir 2014-10-21 L 1108272110140001
53 Muhammad Mustakim 2014-06-13 L 1108271806140001
54 Muhammad Zikran Arafiq 2015-06-15 L 1108271506150001
55 Oratul Hafizah 2015-01-01 P 1108274101150001
56 Raja Ramadana 2015-06-19 L 1108271906150001
57 Rauzatul jannah 2013-08-04 P 1108274408140001
58 Siti Humaira 2014-04-29 P 1108276909140001
59 Sri Rahayu 2014-08-03 P 1108274308140002
60 Sultan Mu'ammar Al-atsyi 2014-11-06 L 1108150611140001
61 Syaila Miscka 2015-07-08 P 1103134807150002
62 Syifa Tul Aulia 2015-03-29 P 1108276903150002
63 Ulfa Humairah 2014-10-30 P 1108277010140001
64 Ulfiani 2014-08-05 P 1108274508140001
65 Zahrul Ula 2015-07-21 L 1173042107150001
66 Afzal Autami 2013-08-25 L 3173012508131004
67 arsil fata 2013-09-02 L 1108270209130001
68 Fairuz Aulia 2014-03-03 L 1108270303140001
69 Harfikri Al-mumajid 2014-06-18 L 1102011806140001
70 Irfan Maulana 2014-04-14 L 1108271404140002
71 Lita Alvia Zahra 2013-11-15 P 1108275511130001
72 Makfirah 2013-11-09 P 1108154911130002
73 Muhammad Fadhil 2013-07-27 L 1108272707130001
74 Muhammad Jufri 2012-01-05 L 1108270501130002
75 Muhammad Ra'jis 2013-06-01 L 1108270106130001
76 Muhammad Rivaldi 2014-03-05 L 1108160503140001
77 Muhammad Syarif 2012-05-04 L 1108270405130002
78 Muhammad Zaki AL-Mubaraq 2014-05-03 L 1108270305140001
79 Nadia Ulfa 2014-05-08 P 1108274805140001
80 Nafis Aliya Ramazani 2014-03-03 P 1108274303140002
81 Nurbaiti 2013-01-20 P 1108276001130001
82 Putri Amelia 2012-03-20 P 1108276003130001
83 Raisya Taqia 2013-01-22 P 1108276201130001
84 Silfa Ulfia 2013-06-01 P 1108274106140002
85 Siti Aliya Hummaira 2013-03-10 P 1108275003130002
86 Taufiq Ramadhan 2013-06-27 L 1108272706130001
87 Umam Almahri 2014-04-15 L 1108271504140001
88 Zumirza 2013-03-20 L 1108272003130001
89 Alfa Mahera 2012-07-27 P 1108026707120001
90 Alfira 2012-08-17 P 1108275708120001
91 Hafizul Furqan 2012-05-05 L 1108270505120001
92 Haikal Kamal 2012-10-06 L 1108150610120002
93 Intan Mutia 2012-11-03 P 1108274311120001
94 Muhammad Asyraf 2012-06-18 L 1108271806120001
95 Muhammad Fajri 2012-12-01 L 1108270112120001
96 Muhammad Tajul A'rifin 2013-02-10 L 1108271002130001
97 Muhammada Faris 2012-01-25 L 1108272501130001
98 Mustafa 2011-12-14 L 1103011412110002
99 Naila Humaira 2013-02-20 P 1108276002130001
100 Nur azizah 2012-05-27 P 1108276705120002
101 Nurfazillah 2013-08-09 P 1108274908130001
102 Rahmat Muliadi 2012-04-25 L 1108272504120001
103 Riska Humairah 2013-05-02 P 1108254205130001
104 Silvia Haura 2013-05-02 P 1108274205130001
105 Aril Yanda 2011-12-01 L 1108270112110001
106 Hendra Sukma 2011-05-26 L 1108272605110001
107 Ikbal Maulana 2011-07-17 L 1108271707110001
108 Ikram Maulana 2012-01-15 L 1108271501120001
109 Intan Wahyuni 2011-11-21 P 1108276111120001
110 Julia 2012-06-20 P 1108276006120001
111 M SYAHRIL RAMADHAN 2011-02-11 L 1108271102110001
112 MUHAMMAD DAFA RAIHAN 2011-01-05 L 1108270510110001
113 MUHAMMAD IQBAL 2011-12-08 L 1108150812110002
114 Muhammad Raffa 2012-06-30 L 1108273006120001
115 Muhammad Rayhan 2011-12-25 L 1108272512110001
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140

Jumlah vial Jumlah vial

Jumlah Vial Sisa
Jumlah Vial nOPV dibawa dipakai
0
ELAYANAN SUB PIN POLIO

Nama petugas :
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

pada kolom keterangan

Diimunisasi
Keterangan
Nama orang tua NIK Orang Tua Alamat No.Hp Polio
Dosis Dosis
1 2
g h i j k l m
Idawati 1108164204970002 SP 4 Sandi 1
Kiki Apriani SP 4 Sandi 1
Asma Mandarwati 1108164107830462 SP 4 Sandi 1
Fauziah SP 4 Sandi 1
Salbiah SP 4 Sandi 1
Nurlaili 1108164107880477 SP 4 Sandi 1
Masyitah 1108164107820512 SP 4 Sandi 1
Jamiah 1108036405940001 SP 4 Sandi 1
Yusrawati 1108164107840507 SP 4 Sandi 1
Ratna Juwita SP 4 Sandi 1
Jumiati 1108164107740319 SP 4 Sandi 1
Juniar 1108275003920001 SP 4 Sandi 1
Rosmani Sendi 1108166805940001 SP 4 Sandi 1
Anita SP 4 Sandi 1
Maryana 1108274701960001 SP 4 Sandi 1
Laina 1108164107860638 SP 4 Sandi 1
Rahmiati SP 4 Sandi 1
Rohaya 1108020211150001 SP 4 Sandi 1
Safariah 1108164107860585 SP 4 Sandi 1
Nunuk Safrina SP 4 Sandi 1
Marlaini 1108064106880002 SP 4 Sandi 1
Halimatus Sakdiah 1108164107790308 SP 4 Sandi 1
Sri Mutia SP 4 Sandi 1
Yusmawati 1108164107770331 SP 4 Sandi 1
Maulizar 1108164107770335 SP 4 Sandi 1
Zuhrinawati 1108164510960001 SP 4 Sandi 1
Suryati 1108274607870001 SP 4 Sandi 1
Rahyuni SP 4 Sandi 1
Nurmala 1108164107800590 SP 4 Sandi 1
Safrida 1173034107850267 SP 4 Sandi 1
Asmawati SP 4 Sandi 1
Zuraida SP 4 Sandi 1
Safrina SP 4 Sandi 1
Endayani 1111104107850057 SP 4 Sandi 1
Husnaifud 1108164107760388 SP 4 Sandi 1
Juliani 1108164107780513 SP 4 Sandi
Jasmani 1108154403900001 SP 4 Sandi
Manawiyah 1108164107850625 SP 4 Sandi 1
Yusra SP 4 Sandi 1
Salbiah Ishak 1108164107860622 SP 4 Sandi 1
yusnidar 1108164107890624 SP 4 Sandi 1
Nurnila SP 4 Sandi 1
Ainsyah 1108276507920001 SP 4 Sandi 1
Putro 1108277112860002 SP 4 Sandi 1
Juliani 1108166709890001 SP 4 Sandi 1
Lindawati 1108164107840401 SP 4 Sandi
Safrina 1108164107800585 SP 4 Sandi
Mulyani 1108154205890002 SP 4 Sandi 1
Ummi Kasum 1108164107820476 SP 4 Sandi 1
Khatijah 1108165202890001 SP 4 Sandi 1
Fauziah SP 4 Sandi 1
Ainsyah 1108275508880001 SP 4 Sandi 1
Fitriani 1108164107860674 SP 4 Sandi
Nurlela Nurdin 1108265908950001 SP 4 Sandi 1
Putriani SP 4 Sandi 1
Irma Yanti 1108164107780513 SP 4 Sandi 1
Nilawati SP 4 Sandi 1
Manawiyah 1108154206960004 SP 4 Sandi 1
Anidar 1103136005870001 SP 4 Sandi 1
Idayati 1108274502910001 SP 4 Sandi 1
Yusra 1108275706970001 SP 4 Sandi 1
Wardah 1108164106900001 SP 4 Sandi 1
Yusra 1108164107920473 SP 4 Sandi 1
Daryani 3173016003841002 SP 4 Sandi 1
Salmawati 1108164107840546 SP 4 Sandi 1
Maspupah SP 4 Sandi 1
nurma 1102014701850005 SP 4 Sandi 1
nurhayati SP 4 Sandi
Siti Hajar SP 4 Sandi
ti aminah SP 4 Sandi 1
Nurhayati SP 4 Sandi 1
Mutia 1108034107800286 SP 4 Sandi 1
Safriana SP 4 Sandi 1
Julaida SP 4 Sandi 1
Nurhayati SP 4 Sandi 1
Syafariah SP 4 Sandi 1
Marlaini SP 4 Sandi 1
Nasriah SP 4 Sandi 1
Jasmani 1108164107820503 SP 4 Sandi 1
Tiboidah SP 4 Sandi
Syarbaniyah SP 4 Sandi 1
Nurlina SP 4 Sandi 1
Musnawati 1174034206890002 SP 4 Sandi
Nurul Hayati SP 4 Sandi
Intan Kemala Putri 1108114107890258 SP 4 Sandi
Idawati 1108274101930002 SP 4 Sandi
Nurjannah SP 4 Sandi
Suryana 1108274107680002 SP 4 Sandi
Kiki Apriyani 1108164107740319 SP 4 Sandi
Fatimah 1108154107800395 SP 4 Sandi
Rosmani 1108164107870649 SP 4 Sandi
Suryani 1108164107810343 SP 4 Sandi
Zaidah 1108165202890001 SP 4 Sandi
Marliah 1108165506950003 SP 4 Sandi
Ainsyah 1108026607860001 SP 4 Sandi
Ti Aisyah SP 4 Sandi
HalimatusSakdiah 1108274902900001 SP 4 Sandi
Darnia Ishak 1108164107890528 SP 4 Sandi
Sari 1108274807780001 SP 4 Sandi
Tihawa 1108164107880609 SP 4 Sandi
Maryana 1108114705920001 SP 4 Sandi
Suryani 1108166408850003 SP 4 Sandi
Ecut Wati 1108164707840001 SP 4 Sandi
Mince Apriani 1108164107790328 SP 4 Sandi
Zainabon 1108164107760433 SP 4 Sandi
1108164107880603 SP 4 Sandi
1108164107740283 SP 4 Sandi
1108014107870487 SP 4 Sandi
SP 4 Sandi
1108164107840472 SP 4 Sandi
1108064106880002 SP 4 Sandi
1108164107810344 SP 4 Sandi
1108164107890387 SP 4 Sandi
SP 4 Sandi
SP 4 Sandi
74
 FORMAT PENCATATAN HASIL PELAYANAN

Nama SEKOLAH SDN 7

Nama Desa/kelurahan ALUE DUA
Tanggal : 07 DESEMBER 2022

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterang
Jenis Kelamin
No. Nama Anak Tgl lahir Umur NIK
(L/P)
a b #NAME? d e f
1 MAULA SYARIF 2016-02-08 P 1108274802160003
2 MUAMMAR KHADAFI 2016-02-25 L 1108272502160001
3 MUHAMMAD HAFIF RISKI 2016-03-11 L 1108271103160001
4 Muhammad Safwan 2015-05-02 L 1108160205150001
5 Naila Zahera 2016-03-20 P 1108276003160001
6 Raisa Hadiyanti 2016-01-20 P 1108276001160001
7 AZKIA MAULIZA 2012-03-20 P 1108162003120001
8 HUMAIRA 2015-05-13 P 1108275305150001
9 KASIRUL ABRAR 2015-07-07 L 1108270707150001
10 MAULIZAR AULIA 2015-01-04 L 1171030401150001
11 MIRJA ALFARI 2014-11-22 L 1108272211150001
12 MUHAMMAD RAMADHAN 2015-06-16 L 1108271606150001
13 RAIHAN PUTRA SALMAN 2014-09-21 L 1108272109140001
14 RIZKI MAULANA 2015-03-05 L 1108270503150001
15 ZULFAHMI WAHYUDILLAH 2015-01-22 L 1108272201150001
16 Lia Lukita 2013-10-21 P 1111026110130001
17 MUHAMMAD MOULIZI 2014-06-28 L 1108272806100002
18 Rofal Fatani 2014-05-13 L 1108271305140004
19 Syifa Aini 2014-06-26 P 1108276608140001
20 TASYA NAJUA 2013-10-28 P 1108276810130001
21 FAKRURRAZI 2012-03-20 L 1108162003120001
22 Ikbal Moulana 2013-04-20 L 1108272004130001
23 Mola Azkira 2012-08-23 P 1108276308120001
24 Mona Afrida 2013-03-22 P 1108276203130001
25 Muhammad Kadafi 2013-07-16 L 1173041607130001
26 Muhammad Yurnalis 2013-06-30 L 1108270204130001
27 Nazilatul Navira 2013-07-07 P 1108274707130001
28 Syahril Maulidin 2013-02-28 L 1108272802130001
29 Zaizatul Fittri 2013-02-26 P 1108022602130001
30 Zika Alfarud 2013-04-16 L 1108271604130001
31 MARTUNIS 2011-11-28 L 1108272811110001
32 Muhammad Zulfiadi 2011-11-19 L 1108271911110001
33 Muhammad Zulfiadi 2011-11-25 L 1108262511110001
34 RISKI MAULANA 2011-08-25 L 1103012508110001
35 RIZKI 2011-11-14 L 1108271411110001
36 Syibral Malasyi 2012-01-23 L 1108272301120002
37 Ulil Azmi 2011-11-11 L 1108271111110003
38 Ulul Azmi 2011-11-11 L 1108271111110002
39 AGUS MAULANA 2010-08-08 L 1108270808100001
40 AYU ASNITA 2011-10-29 P 1108276910110001
41 KHAIRUL RIZAL 2011-07-01 L 1108270107110002
42 MUHAMMAD FAISAL 2010-02-02 L 1108270202100001
43 NATASYA AYZURA 2011-03-17 P 1108275703110001
44 Rafi Almuzafil 2011-09-30 L 1108273009110001
45 RISKA ANANDA 2011-07-01 P 1108274107110001
46 SYAKBAN 2010-06-06 L 1108270606100002
47 ZAKIATUN NISA 2011-05-25 P 1108276505110001
48 Zakiul Fata 2011-05-25 L 1108272505110001
49 ZULFIADI 2010-05-05 L 1108270505100002
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

TOTAL

Jumlah
Jumlah vial
vial Jumlah Vial Sisa
Jumlah Vial nOPV dibawa
dipakai
0
HASIL PELAYANAN SUB PIN POLIO

Nama petugas :
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

sulan pada kolom keterangan

Tanggal Diimunisasi
Nama orang tua NIK Orang Tua Alamat No.Hp Polio (nOPV2)
Dosis 1 Dosis 2
g h i j k l
Darwati Hasbi 1108164107820509 Banda Seulamat 1
Fauziah 1108165506730001 Banda Seulamat 1
RAHMANI 1108164107900468 Banda Seulamat 1
Mawardiana 1108164107880398 Banda Seulamat 1
Dewi Darmawati 1108165201900001 Banda Seulamat 1
Suryani 1108164203920001 Banda Seulamat 1
MURSYIDAH 1108272703180001 Banda Seulamat 1
MARIANA 1108271901160002 Banda Seulamat 1
FATIMAH 1108160901080045 Banda Seulamat 1
ERLINA WATI 1171032903110004 Banda Seulamat 1
NURJANI 1108270701110043 Banda Seulamat 1
DARNI 1108271205150004 Banda Seulamat 1
RAHMIATI 1108270209150003 Banda Seulamat 1
HAYATULRIZA ZAUNU 1108271908080004 Banda Seulamat 1
NUR AFNI 1108272101150001 Banda Seulamat 1
Habsah Banda Seulamat 1
ZUBRIAH M ZUBIR 1108164407840001 Banda Seulamat 1
Lindawati Banda Seulamat 1
Nurmala Banda Seulamat 1
NURHAYATI Banda Seulamat 1
MAWARDIANA 1108164107880398 Banda Seulamat 1
Darni 1108164107930502 Banda Seulamat 1
Suriati Sjafari 1108164107820507 Banda Seulamat 1
Idawati Nurdin 1108166608890002 Banda Seulamat 1
Idawati 1108164107940451 Banda Seulamat 1
Mariana Harun 1108164107890614 Banda Seulamat 1
Maulida 1108276511950002 Banda Seulamat 1
Mariani Jalil 1108164107860619 Banda Seulamat 1
Nur Aisyah 1108164107900628 Banda Seulamat 1
Badariah Hanafiah 1108164107650515 Banda Seulamat 1
SRI WAHYUNI 1108164107900637 Banda Seulamat 1
Nurhayati Nurdin 1108274107860001 Banda Seulamat 1
Suryani 1108167008910001 Banda Seulamat 1
MURSYIDA Banda Seulamat 1
MAKAWIAH HAMZAH 1108164107700573 Banda Seulamat 1
Hajidah 1108164807840001 Banda Seulamat 1
Rukini 1108154107780425 Banda Seulamat 1
Rukini 1108154107780422 Banda Seulamat 1
KASMIATI 1108164507770002 Banda Seulamat 1
Dewi darmawati 1108165201900001 Banda Seulamat 1
Ramanu Ibrahim 1108164107750416 Banda Seulamat 1
HERLINA 1108274203840001 Banda Seulamat 1
Supriyati 1108276708840001 Banda Seulamat 1
Maryam 1108164107830531 Banda Seulamat 1
Yusrawati Jafar 1108164107750419 Banda Seulamat 1
SARBANIAH ABU BAKA1108164107750417 Banda Seulamat 1
ROSMANIAH 1108164107750452 Banda Seulamat 1
Rosmaniah 1108164107750452 Banda Seulamat 1
NURJANI 1108164105870003 Banda Seulamat 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
 1
1
1
1

130
 FORMAT PENCATATAN HASIL PE

NAMA SEKOLAH SD 1
Nama Desa/kelurahan :
Tanggal :

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin
(L/P)
a b c d e
1 Aira Fazila 2016-03-27 P
2 Asqila 2016-05-10 P
3 Cut Rosita Fajri 2014-12-10 P
4 Farid Arrasyi 2015-11-01 L
5 Fina Khaira 2016-02-08 P
6 Haura Faradisa 2016-06-09 P
7 Karen Elza Kazora 2015-12-27 P
8 Khairul Azmi 2016-09-27 L
9 Lira Shahira 2016-05-10 P
10 Mahyal Amin 2016-03-24 L
11 Mirza Afwadi 2015-11-13 L
12 Muhammad Afzal 2016-01-24 L
13 Muhammad Ibnu Sina 2016-02-29 L
14 Muhammad Khairil Azzam 2015-10-29 L
15 Muhammad Luthfi 2016-07-16 L
16 Muhammad Mumtaz 2016-02-10 L
17 Muhammad Saputra 2016-07-07 L
18 Muhammad Zaki 2015-07-24 L
19 Nadia Syafira 2015-09-09 P
20 Najlatul Nakiyah 2016-04-22 P
21 Nisaul Sabila 2016-04-03 P
22 Raysa Qisthy Hilma 2015-09-25 P
23 Salwatul Nafisha 2015-12-07 P
24 Zulkarnaini 2015-11-19 L
25 AHMAD KHAIRUL KHALKI
26 Alesya Zahra 2014-07-16 L
27 Alif Hafizd 2015-04-13 P
28 AMIR HAMZAH 2015-07-09 L
29 CUT NAZIRA ULFA 2014-10-09 L
30 CUT SYIFA VARAZILLA 2015-04-16 P
31 Dzunawanis 2015-03-06 P
32 FATAN ALFARIZI 2015-07-01 L
33 FATIMAH ZUHRA 2015-05-15 L
34 Hanis Maulana 2014-06-05 P
35 IKRAMMUDDIN 2014-10-18 L
36 Intan Zahra 2014-10-23 L
37 Khairul Nizam 2015-05-17 P
38 Luthfiyatunnisak 2015-02-20 L
39 MAULA ZIKRI 2015-06-06 P
40 MIRATUL HUSNA 2015-08-31 L
41 MUHAMMAD ALDI NUZULIAN 2013-12-22 P
42 Muhammad Auliya 2014-07-25 L
43 Muhammad Mudawali Al-Khalidy 2015-04-03 L
44 MUHAMMAD RAZAQ 2014-10-17 L
45 Muhammad Rizki 2015-05-08 L
46 Muhammad Rizki M 2015-08-01 L
47 MUHAMMAD UMAR BAHRI 2015-06-01 L
48 NAZILA HUMAIRA 2015-07-01 L
49 Rahmatullina 2015-03-18 P
50 RAISUL FATANI 2015-06-21 P
51 Rajul Kiram 2014-06-10 L
52 SALSABILA NAZHYRA 2015-01-24 L
53 SILNA FARA DISA 2014-12-13 P
54 Zira'atul Nazima 2014-07-16 P
55 Zunu Wanis 2015-01-05 P
56 Ajis Maulana 2015-02-16 L
57 Ananda Bilqis
58 Aris Munandar 2015-12-01 L
59 AYLA AZZUHRA 2014-03-23 P
60 Cut Mora Aulia 2014-06-08 L
61 LIA AZZURA 2013-09-18 P
62 Mudarrisul Ahyar 2014-08-11 P
63 Muhammad Fariz 2013-12-05 P
64 Muhammad Noval 2014-07-10 L
65 MUHAMMAD RIZKI MUBARRAQ 2014-05-13 L
66 Muhammad Yasier 2013-07-24 L
67 Muhammad Zafran 2014-04-21 L
68 MUHIBUL TIBRI 2013-01-05 L
69 NAUFAL AFKAR 2014-05-01 L
70 Nurhasyikin 2013-08-27 L
71 Quratul Aini 2013-09-18 L
72 Rozatul Husna 2014-10-08 P
73 Rozatul Jannah 2014-07-09 P
74 SAIDATUN NAFISAH 2014-06-01 P
75 SYIFAUL KHAIRA 2014-02-13 P
76 WALIYUL AMRI 2014-09-27 P
77 Zakia Tukhaira 2014-06-06 P
78 ZALFAUZ ZAKIAH 2013-11-21 L
79 ZALFAUZ ZAKIAH 2014-01-20 P
80 Alif Syibran Malasyi 2014-01-24 P
81 ALIYA KHALISA
82 Amalia 2013-05-19 L
83 Ashifa 2013-01-05 P
84 ASSYIFATUL HAIFA 2013-07-24 P
85 AZKIA SHAISTA 2012-09-03 P
86 FAHLUL NISWAN 2013-05-07 P
87 FATHUZ ZAKI 2013-01-18 P
88 FERDIAN SAPUTRA 2013-01-04 L
89 KHAIRATUL MORA 2013-05-25 L
90 MUHAMMAD AZIS 2010-09-25 L
91 MUHAMMAD FARMAZY 2013-01-05 P
92 MUHAMMAD ISA 2012-11-14 L
93 Muhammad Nazami 2012-10-08 L
94 MUHAMMAD RISKI 2013-03-08 L
95 MUJIBURRAHMAN 2012-05-30 L
96 NADIATUL ALIA 2012-10-15 L
97 NIA RAMADHANI 2011-04-16 L
98 RAHMATUL HAFIZAH 2012-03-31 P
99 Safriyani 2012-02-07 P
100 SYAKILA MAHIRA 2013-01-14 P
101 ULIFA MAHIRA 2012-12-18 P
102 ZAHRUL NUJI 2013-02-28 P
103 ARYA RADITYA 2012-10-09 P
104 ASYIFA WULANDARI 2012-10-28 L
105 AULIA RAHMAN
106 FARHAN MUNANDAR 2012-06-26 L
107 FATLIATUL HAFIZAH 2012-03-18 P
108 FERI ARISKI 2012-09-04 L
109 FIKA NAJIA 2011-12-14 L
110 IMAM SADIKIN 2012-03-01 P
111 IRNA MAHLIZA 2012-06-11 L
112 KHAIRUL AFIQ 2011-10-13 P
113 MUHAMMAD ARIF ARIZKI 2011-10-13 L
114 MUHAMMAD AZKAL 2011-02-09 P
115 MUHAMMAD FIKRAM 2012-01-26 L
116 MUHAMMAD ISKANDAR ZULKARNAEN2012-06-22 L
117 MUHAMMAD NAFI 2012-04-04 L
118 MUHAMMAD RAIS ARSYA 2011-09-06 L
119 MUHAMMAD SYAMWIL 2012-04-09 L
120 MULIA RAHMI 2011-05-06 L
121 MUSLIMAH 2012-05-18 L
122 NADIATUL HAFIZAH 2011-09-21 L
123 SHAFWANUDDIN 2012-06-26 P
124 SYIFA ULZUHRA 2012-01-20 P
125 SYIFAUL AINI 2012-01-17 P
126 ULIA MAULISA 2012-01-21 L
127 ZAKIA ULFA 2011-12-07 P
128 RAUZATUL AZKIAH 2011-08-12 P
129 AHMAD YANIS 2012-02-23 P
130 AKMALIA 2012-01-12 P
131 AKMALUDDIN 2012-05-01 P
132 ARISMUNANDAR
133 AYYATUL HUSNA 2010-06-10 L
134 BASRI 2011-04-08 P
135 CUT MAISARAH 2011-11-28 L
136 ELI MAISARA 2011-11-02 L
137 IRHAM MAULANA 2011-01-08 P
138 IRSYAD ABIDIN 2010-03-15 L
139 IZYA KARAMI 2010-08-13 P
140 KHAIRUL NIZAM 2010-06-28 P
2009-01-01 L
2011-10-19 L
Jumlah vial
Jumlah Vial nOPV dipakai
MAT PENCATATAN HASIL PELAYANAN SUB PIN POLIO

nisasi susulan pada kolom keterangan

NIK Nama orang tua NIK Orang Tua Alamat
f g h i
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1
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Nama petugas :
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

Tanggal Diimunisasi Polio (nOPV2) Keterangan

No.Hp
Dosis 1 Dosis 2
j k l m
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