FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Nama Puskesmas/Fasyankes/Pos :
Kabupaten/Kota :
Provinsi :

Dosis 2
Umur
Jenis Kelompok
No No. Registrasi NIK Nama Penerima Vaksin Pekerjaan* (18-59 Alamat Merek Vaksin***
Kelamin Umur Tanggal Pemberian
tahun) No. Batch
Vaksinasi

1 330210558870002 TRI AGUSTINI P MU 34 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

2 3302104404940003 PUJI SITI M P MU 27 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

3 3302100203630001 TARSO L MU 58 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

4 3302106112740002 RIYATI P MU 47 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

5 3302101706730001 NASIB L MU 48 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

6 3313152907810003 SUGINO L MU 40 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

7 3302105510770004 SULASTRI P MU 44 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

8 330210670680000 MULYANI P MU 41 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

9 3301102701780001 DIARTO L MU 43 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

10 3302100404980002 SUBEKTI WINARTO L MU 23 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

11 3302106109720002 DARTINI P MU 49 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

12 3302101312900003 MISWARYADI L MU 31 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

13 3302105505800003 SUHARTI P MU 41 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

14 3302103112700024 DARWADI KUWATDI L MU 51 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

15 3302100209800003 EDI LUKMAN SANTOSO L MU 41 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

16 3302190506780005 DARWANTO L MU 43 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

17 33021052006840003 MARYATI P MU 37 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

18 3302105403740001 SARWIATI P MU 47 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

19 3302105602780004 MUNJIYAH P MU 43 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

20 33021045098200002 SUPRIYATIN P MU 39 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

21 3302101505700003 PARTO L MU 51 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

22 3302105805760002 SUPARTINI P MU 45 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

23 3302104812840001 MASRIAH P MU 37 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

24 3302104206030002 IKE JUNITA SAHPUTRI P MU 18 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

25 3302106206030001 DHEA CANDU P P MU 18 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

26 3302100306880001 EDI PRAYITNO L MU 33 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

27 3302103011590003 RISWAN P LANSIA 62 0 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

28 3302106308900005 WAHYATI P MU 31 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

29 3302103112680031 TONGAT L MU 53 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

30 3302106707680002 SUYANI P MU 53 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

31 3302192801730003 MUHAMMAD SYAFRUDIN L MU 48 46-59 SOKARAJA TENGAH ASTRA ZENECA 12/15/2021 201300

32 3302104605820002 SUTARMI P MU 38 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

33 3302191202840004 NURDIYANTO L MU 37 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

34 3302100212680001 SUNARTO L MU 53 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

35 3302102003720001 SUPIKUN L MU 49 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

36 330210701280002 NUR FAIZAH P MU 39 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

37 3301155008880002 DARYATI P MU 33 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

38 3302100605000005 RIZAL YAUMUL BAKHTIAR L MU 21 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

39 3302101008020001 AGUS DWI ANTORO L MU 19 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

40 3302106509890001 ETIKA DWI N P A P MU 32 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

41 3302106010940001 INTAN TRIYANI D P MU 27 18-30 SOKARAJA ASTRA ZENECA 12/15/2021 201300

42 3305025502910002 SARNI FEBRIANI P MU 30 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

43 3302104202800006 HARTINI P MU 41 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

44 3302100301750001 SUDARYONO L MU 46 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

45 3302106503860003 CATUR HERAWATI P MU 35 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

46 3302102910970004 ALFA DIKA PRATAMA L MU 34 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

47 3302101607830002 SUKIRNO L MU 38 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

48 3302104105800002 HERNI YUWANTI P MU 41 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

49 3302101508780002 SUNYOTO L MU 43 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

50 3302105010750003 SITI FATONAH P MU 46 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

51 110/80 3302104205940002 TABAH KUSNAENI L MU 27 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

52 120/90 3302196303850004 LISTIANI P MU 36 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

53 100/70 3302101307820001 WAHYU L MU 39 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

54 130/80 3302103010970002 NOVIANTO P MU 24 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

55 130/80 3302103112700014 SUGIYANTO L MU 51 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

56 110/70 3302102504800003 TEGUH TRIYATNO L MU 41 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

57 120/80 3302196608860002 SULISTIYANI P MU 35 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

58 100/60 3302100511780002 SUROSO L MU 43 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

59 120/80 3302101608930001 AGUS SETIAWAN L MU 28 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

60 140/80 3302102705810004 SUPRIYANTO L MU 40 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

61 120/80 3302100904870003 HERI KUSNANTO L MU 34 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

62 120/90 3302105609670003 PARIYAH P MU 54 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

63 120/80 330210663860001 TARYATI P MU 35 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

64 100/70 3302106512770002 NISAH P MU 44 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

65 120/80 33021045069700 FIKA INDRIANA P MU 24 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

66 120/90 3302105508870001 TRI AGUSTINA P MU 34 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

67 100/70 3302105902930002 ERVITA ANGGRAENI P MU 28 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

68 110/70 3302104208900001 RUSWATI P MU 31 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

69 120/90 6402162507780006 FERDINAN SUGIHERSAPTO L MU 43 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

70 120/80 3302102008620002 FUAD BAWAZIR L MU 59 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

71 120/80 330210241690001 WARTOADY PRATAMA L MU 31 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

72 110/80 3302106204990002 REVI APRILIA SAPUTRI P MU 22 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

73 120/80 3302104604710002 KASWATI P MU 50 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

74 110/70 3302104410960002 INDAH PURNAWATI P MU 25 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

75 120/80 3302104407900001 MELIANA CAHYANI P MU 31 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

76 120/80 3302101501020001 FAUZI PRANOTO AJI L MU 19 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

77 120/80 330402008930001 AGUS UPRIANTO L MU 28 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300
 78 120/80 3302104201930002 TUMIATI P MU 28 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

79 110/70 330204308030002 RIFLI ARDIN ANANTA P MU 18 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

80 110/70 3302196607820003 YULIATI P MU 49 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

81 120/80 3302193108690001 EDY SUSANTO L MU 52 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

82 120/80 3302105509780001 MUNIMAH P MU 43 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

83 100/70 3302101603680002 RAWIN L MU 53 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

84 120/80 3174021212871002 JUMADI L MU 34 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

85 100/80 3302101411010000 DION WASKITO L MU 20 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

86 130/80 3302100912650002 SUPARNO L MU 55 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

87 110/70 3302244809850005 NUR SUSANTI P MU 36 31-45 JL. METENG BATA 15 ASTRA ZENECA 12/15/2021 201300

88 120/80 3302101312660002 SUNARDI L MU 55 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

89 110/80 3302101203010001 DENI MAULANA L MU 20 18-30 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

90 110/70 3303054606930002 YUNI HIDAYATI P MU 28 18-30 PEKAJA ASTRA ZENECA 12/15/2021 201300

91 110/70 3302105203780004 ENI PURWATI P MU 43 31-45 PEKAJA ASTRA ZENECA 12/15/2021 201300

92 130/80 33021065067700005 JEMINAH L MU 44 31-45 PEKAJA ASTRA ZENECA 12/15/2021 201300

93 100/70 3302102312830003 TUWARNO L MU 38 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

94 140/80 3302104067700023 KUSTINI P MU 44 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

95 110/70 3302106101970003 ENDANG SUSANTI P MU 34 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

96 120/80 3302102809790002 BUDIONO L MU 52 46-59 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

97 120/80 3302100101820003 WANTO L MU 39 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

98 110/70 3302114607880002 JANJANG JALIASIH P MU 33 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

99 100/70 3302105606860003 SITI NURJANAH P MU 35 31-45 KARANGDADAP ASTRA ZENECA 12/15/2021 201300

100 120/80 3302102109940001 ASEP NURJONI L MU 27 18-30 WLAHAR WETAN ASTRA ZENECA 12/15/2021 201300

Keterangan ***Merek Vaksin

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

Kelompok Umur: Kepesertaan BPJS Pekerjaan

18-30 23 BPJS PBI #REF! A
31-45 52 BPJS Non PBI #REF! B
46-59 24 Non Anggota #REF! C
Total 99 Total #REF! D
Pekerjaan: Pemberian Dosis E
A 0 Dosis 1 #REF! Total
B 0 Dosis 2 100
C 0 Total
D 0
E 0
Total 0
REKAP VAKSIN TGL 19 NOV 2021 D2 SINOVAC
PETUGAS : BENING ISMA

TOTAL MASY UMUM REMAJA LANSIA BUMIL

NO
D2 01 02 03 04 05 06 07 08 09 10 11 12 LW 01 02 03 04 05 06 07 10 11 12 LW 01 02 03 04 05 06 10 11 12 LW 03 01 02 04 05 10 11 12 LW
1 10 2 1 3 2 2
2 10 2 3 1 1 1 1 1
3 5 1 1 2 1
4 10 4 1 2 3
5 10 8 2
6 10 1 2 1 1 1 1 3
7 30 2 8 2 1 5 4 1 4 1 1 1
8 10 1 1 2 4 1 1
9 10 4 1 5
10 10 1 4 1 4
11 10 1 1 6 1 1
12 12 12
13 10 1 1 1 2 1 1 1 2
14 10 5 1 1 1 1 1
15 10 1 1 8
16 10 1 1 1 1 1 1 1 1 2
17 10 7 1 1 1
18 10 4 6
19 10 7 3
20 10 6 3 1
21 10 5 4 1
22 10 10
23 10 5 1 1 1 1 1
24 10 2 2 1 1 1 2 1
25 10 2 1 2 2 1 2
267 22 13 21 19 8 8 1 0 23 59 12 3 14 1 4 2 0 0 2 0 1 1 2 1 3 2 1 1 0 2 18 1 0 3 7 0 3 1 1 1 1 5 0

267