FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

Nama UMUR Kepemilikan BPJS / Asuransi Lainya Umur Kehamilan

Status Pekerjaan
No L P Nomor KK Nik Tgl Lahir BPJS Asuransi 1 2 3 4 5 6 7 8
Kepala Keluarga Anggota Keluarga Perkawinan KK
Lainnya
PBI Mandiri Askes Lainnya
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1 ROHIB Kawin 37 3604130711090044 3604130503780007 05-03-1978
HAJIJAH Kawin 31 3604134410840002 4/10/1984
JALALUDIN. M ABU BAKAR B. Kawin 6
3604130111090001 01-11-2009
ROHULUWLOH B. Kawin 4 3604132306110003 23-06-2011
JAKIYAH B. Kawin 27 3604135406880001 14-06-1988

2 SUKRO Kawin 43 3604131102073202 3604131004720004 10-0 4-1972

SITI SUHENDAH Kawin 39 3604134306760003 03-06-1976
IKHA MUFLIKHAH B. Kawin 18 3604134503970006 05-03-1997
ANDINI SURO NINGSIH B. Kawin 10 3604134707050002 07-07-2005

3 BADRI Kawin 30 3604130309140001 3604131511840002 15-11-1984

DARSINAH Kawin 29 3604134507860004 05-07-1986
NADIYAH B. Kawin 7 3604135812050003 18-12-2005

4 SAUDIN DUDA 3604131611090009 3604132610500001 26-11-1950

SUKENAH Kawin 3604136708880003 27-08-1988
FITROTUNNISAH B. Kawin 3604135703970005 17-03-1997
NENENG FAUZIYAH B. Kawin 3604134804030001 08-04-2003

5 SAEPUDIN Kawin 3604131005090005 3604130611730001 06-11-1973

FUDHOLAH Kawin 3604136008710001 20-08-1987

6 SAMSUL Kawin 3604131102073146 3604131503670002 15-03-1967

SUARIYAH Kawin 3604135005680004 1-05-1968
SUPRIYADI Kawin 3604131807870002 18-07-1987
 SULASTRI Kawin 3604136404910001 24-04-1991
SUIRAT Kawin 3604136006940003 20-06-1994
SULHAH Kawin 3604135503000002 15-03-2000

7 MUNAWIR Kawin 3604130401130001 3604121402850003 14-02-1985

SUSI SUSILAWATI Kawin 3604135810890001 18-10-1989
M. ABDUL ROHMAN B. Kawin 3604131001130001 10-01-2011

8 PURNAMA Kawin 3604131102073160 3604130408760001 04-08-1976

MAHDUDOH Kawin 3604134301770002 03-01-1977
HANAFIYAH B. KAWIN 3604130805960002 08-05-1996
ABDUL AZIZ B. KAWIN 3604132401060001 24-01-2006

9 MARSIM Kawin 3604131102073109 3604130602640001 06-02-1964

DASIYAH Kawin 3604134204760003 02-04-1976
MARISAH Kawin 3604134707910002 07-07-1991
SITI MARIYAM B. Kawin 3604137001110001 30-01-2011

10 ASPIHANI Kawin 3604132801140002 360413110840005 11-08-1984

ASMIRA Kawin 3604136402870004 24-021987
KHAERUL ANWAR B. Kawin 3604132104140002 21-04-2014

11 SOLIHIN Kawin 3604131811090009 3604130603770004 06-03-1977

RUMIAH Kawin 3604134502760001 05-02-1976
SELFIANA B. Kawin 3604134106060003 01-06-2006
SAFA B. Kawin

12 SUDIN Kawin 3604131102073152 3604132802740001 28-02-1974

MAHMUROH Kawin 3604136309790001 23-09-1979
M. MUHIT B. Kawin 3604131602970001 16-02-1997
MUHAMMAD GUFRON B. Kawin 3604130607080001 06-07-2008
NAJWATUN SOLIHA B. Kawin 3604137006090002 30-06-2009
13 JUWAHIR Kawin 3604131102073119 3604130608660001 06-08-1966
SITI AMINAH Kawin 3604135004700003 10-04-1970
ANDI SISWANTO B. Kawin 3604130101910004 01-01-1991
FIRMANSYAH B. Kawin 3604133001940001 30-01-1994
IMAM SAPEI B. Kawin 3604131003900001 10-03-1990
FIKRI B. Kawin 3604131712010001 17-12-2001

14 HUMAEDI Kawin 3604131102073250 3604130609680001 06-09-1968

ENIYAH Kawin 3604134704720001 07-04-1972
HANIPAH Kawin 3604136108890001 21-08-1989
HASANAH B. Kawin 3604134202940001 02-02-1994
HUMAEROH B. Kawin 3604134105980001 01-05-1998
INDRA B. Kawin 3604131807070002 18-07-2007

15 H. MADENI Kawin 3604130102120006 3604130107640001

SURIYAH Kawin 3604135407780001
ALFIYAH Kawin 3604134107920005
SITI SUFIAL AINI B.Kawin 3604135601120001

16 SALEH Kawin 3604131102073252 3604131506580001

ITA Kawin 3604134703610001
ETI NURAETI Kawin 3604134508870004
ROBIAH Kawin 3604134006040002
RUDOH B. Kawin 3604135204980001
MARJUKI B. Kawin 3604131001010002

17 BAKHRA Kawin 3604131308140007 3604121009750003

PATIMAH Kawin 3604135006760001

18 JARKASIH Kawin 3604131102073128 3604132701580001

NOKIYAH Kawin 36041134308680002
NOPAL B. Kawin 3604131706920001
JUFROH B. Kawin 3604134307970001
 NANANG NASRUDIN B. Kawin 3604132101060001

19 MUHAMAD NOH Kawin 3604131011140007 3604132507800011

MAHFUDOH INDRI YANI Kawin 3604124604910014
PUTRI WULANDARI B. Kawin 3604134406140011 04-06-2014

20 MUKRI Kawin 3604131303140002 3604130205650003

SUFIYAH Kawin 3604134403760004
HENDRI MAHESTA B. Kawin 3604132503990003

21 SYIBLI Kawin 3604131105110003 360413030170002

SA'ADIYAH Kawin 3604135203740001
RIZKY B. Kawin 3604132901070001

22 NURIMAN Kawin 3604131010090023 3604130602710002

MULYANAH Kawin 3604134106680002
DEWI NARTINI B. Kawin 3604134903910001
NABILA PUTRI ZAHWA B. Kawin 3604136109120002

23 MAHALI Kawin 3604132404120002 360413170380004

NURLELAH Kawin 3604135203810001
IQBAL B. Kawin 3604131211090006

24 EDI SURYADI Kawin 3604131102073190 3604130302790001

DALWAH Kawin 3604134906810003
DHAVID B. Kawin 3604132003100001

25 MOH. KARIM Kawin 360413409140001 3604130303870003

JANAH Kawin 3604134208840001
MOHAMAD REZA B. Kawin 3604130809140001

26 HERI SUDRAJAT Kawin 360413108140006 3604120202870005

LATIFAH Kawin 3604136809910002
 DAFITA NIZZA B. Kawin 3604135011140001

27 EVI SAEPUDIN Kawin 3604133107870003 36041311870003

HULELAH Kawin 3604134912860001
NUR KHOLIFAH B. Kawin 3604134706140001

28 SUNADI Kawin 3604130312120003 3604130171181001

PAOJAH Kawin 3604136007830004
SITI NAFISAH B. Kawin 3604135006130005

29 AMRI Kawin 3604131102073143 3604132507980001

SUMYATI Kawin 360415804970001
ALYA AFIFAH B. Kawin 3604136906130001

30 SUKENAH Janda 3604131609110013 36041300260002

KARTINI B. Kawin 3604134404920001
KARTIKA B. Kawin 3604134307950001
SAEPUDIN Kawin 3604131703850001

31 BAHAUDIN Kawin 3604131105150011 3604120801820001

MARIAM Kawin 3604134406840008

32 HUDARI Kawin 3604131811090010 3604130608690003

HALIMAH Kawin 3604134504700002
NASUKHA Kawin 3604131703870003
ABU NASEHUDIN B. Kawin 3604132903920001
HABIBI B. Kawin 3604130304980008

33 JUDHI B.MAHMUD Kawin 3604133007040129 3604130403500537

SULKAH Bt. SALEH Kawin 360413447610530
ENI B. Kawin 3604136710960539

34 SYAMSUDIN Kawin 3604132905090026 3604130404700003

 ARSI Kawin 3604136505770003
SAMINAH B. Kawin 3604134106950002
SAINAH B. Kawin 3604136707990002
SARWATI B. Kawin 3604134402020004

35 SARFIN Kawin 3604131102033139 3604130105690001

NURJANAH Kawin 3604135605690001
YAYAN INDRA SAPUTRA B. Kawin 3604132010900001
UKI FARTULHI B. Kawin 3604130702920001
IMAN KURNIAWAN B. Kawin 3604131304960001
IYAH HAMDIYAH SAFITRI B. Kawin 3604139107980012
FIRDA BAWADHANI B. Kawin 3604134410060002

36 UNTAMAH Janda 3604130606100009 3604134608650001

KHAPSAH Janda 3604135005780008
HOLILULLAH B. Kawin 360410807940008
EROH HUWAEROH B. Kawin 3604134708980001
PUTRI ZAHROTUSITA B. Kawin 3604136305090002

37 INDAH B. Kawin 3604132410050013 3604134402970060

38 SYUKRI B. JASMANI Kawin 3604131102073154 3604131407650001

YAYAH ZAKIYAH B. Kawin 3604134702690002
IRFAN FATUR ROHMAN B. Kawin 360413100390001
AFIF HUDDIN RIYANI B. Kawin 360413160793001
TAMAM TAIMULLAH B. Kawin 360413140396001

39 MULYONO 360413010914003 36041303850007

NASIFAH 360413540686001

40 ISMAIL 3604131102073197 360413120585001

ROSIDA 360413450589006
MAESAROH 360413691009002
41 RUSMIN 3604131102073198
RANTI 360413500578002
LARAS SAFITRI 3604134701960001
SAMSUL ANWAR 3604130107980017

42 KAMUSTOFA 3604132040412002
ROJANAH 3604134407760002
EKA DEA MUSTOFA 3604135106030002
ERIK MUSTOFA 3604131002100003
43 ROMLI Kawin 3604131102073187 3604130107670027
SITI Kawin 3604135005730002
NOFA B. Kawin 3604131112950003
NIKO B. Kawin 3604130902980001
AGUS MAULANA B. Kawin 3604131305000001
44 ASMAN Kawin 360413110273149 3604131308500002
EBAH Kawin 3604134406730001 3604134406730001
MUKTI ALI B. Kawin 3604131207870001
SULKI B. Kawin 3604131112900003
MARJUKI B. Kawin 3604132102960001
SYARIPUDIN B. Kawin 3604130811990001
MUKHIJI B. Kawin 3604131808800001
NURHASAN B. Kawin 3604130704040002
45 A SUDRAJAT Kawin 36041332705130034 3604130712840002
SUHERTI Kawin 3604134804790006
AJENG SAFITRI B. Kawin 3604135801060001
MAULANA ALUWI B. Kawin 3604131803130003
46 ALELAH Janda 3604132106100004 3604135105820005
MUHAMAD FAJRI B. Kawin 3604130807040002
47 JASIMAN Kawin 3604131102073137 3604131108500001
MARIAM Kawin 3604134505600002
JASMI Kawin 3604134407760001
MAD USMAN Kawin 3604130909850002
MAD SANAN Kawin 3604130548800003
 SUTIHAT ANGGRAENI B. Kawin 3604135708940004
YUNUS B. Kawin 3604131006990006
48 BABAT Kawin 3604132010110005 3604132105750002
RUMINAH Kawin 3604135406760004
ERWIN ROBILAH B. Kawin 3604131902020001
EVVA VALIYAH B. Kawin 3604136202060002
59 BAHODI B M. T Kawin 3604131102073140 3604130409630001
OTIYAH Kawin 3604134710720001
AFNI SUYANTI B. Kawin 3604134911920002
FIRLHI ALAINA B. Kawin 3604130207960001
OKAH KORIYAH B. Kawin 3604136210990001
50 EHA SOLEHAH Janda 3604133107010005 3604134106810002
INAH SYAKINAH B. Kawin 3604136710970002
51 HUDIRA Kawin 3604131102073246 3604131000860001
BARKAH Kawin 3604134406700002
ELIN AWARTI Kawin 3604134601860001

52 MARKANI Kawin 360413106100007 3604130102760004

NURHAYATI Kawin 3604134806670001
RIZKI FIRMAN B. Kawin 3604132508990002

53 SAIPUL ANWAR Kawin 360413807120008 3604130402870001

JUKRIYAH Kawin 3604135006900001
SYIFA FAUJIYAH B. Kawin 3604134706120002

53 NAHWINI Kawin 3604131020732142 3604131207530001

MASTU Kawin 3604135101570001
MASNUN B. Kawin 3604132103910001
NUTIKAH B. Kawin 3604135712960002

54 MASUDI Kawin 3604130111100010 3604130506880003

AMALIYAH Kawin 3604134408840007
DALIA ZAHROHTUNISA B. Kawin 3604134209140001
55 AFID HAFIUDIN Kawin 3604132404100011 3604131504840001
ELIAWATI Kawin 3604136098500001
M. AHDI FADHLISSALIM B. Kawin 3604132505110001

56 MUNAWAROH Janda 3604131102073155 3604135003580001

PIPIT SAIRAH Kawin 3604134409910003

57 KHOLIL Kawin 3604130608090005 3604130501700002

YAROH Kawin 3604130510020001
NANDANG KURNIYAH B. Kawin 3604132205070001

58 SARIP Kawin 3604130301070003 3604130609470312

SAMIAH Kawin 3604130508480001
SAPARI Kawin 3604130804780156
SUHENI Kawin 3604131798810089
SUMIROH B. Kawin 3604131205840270
SANUDIN B. Kawin 3604132104980510

59 ROUP Kawin 3604130807820001

ATI SUPRIYATI Kawin 3604130712110007 3604134607840001
RASTI MELINA PUTRI B. Kawin 3604136909110001

60 SUKRAH Janda 3604132306040002 3604130708590028

SERI B. Kawin 3604131206850294
SITI HAJAR Kawin 3604131803890231

PATMAH Janda 3604131303130001 3604134407470001

ROHMAN Janda 3604135003800004
AULIA PUTRI B. Kawin 3604134107110002

61 SAEPUDIN Duda 3604131102073212 3604131211580001

ANDI PUTRA Kawin 3604132808880001
 YANTI SUSANTI Kawin 3604136110900001
EFENDI B. Kawin 3604131204910007
DEVI EKA MARDINA B. Kawin 3604135903990002

62 MAFTUHI Kawin 3604131004140002 3604131408880004

ELA DIANA WATI Kawin 3604137106850001
MAULANA ZIDANA F B. Kawin 3604132005140002

63 KHAYATUDIN Kawin 3604131102073203 3604130104740002

SUPYANTI Kawin 3604134707880001
GILANG AL KHOLILI B. Kawin 3604130205060003
M BAYU ANDIKA B. Kawin 3604130808110001

64 MUNIR Kawin 3604131811090011 3604130506750004

TURMINI Kawin 3604134304860001
NA'IM B. Kawin 3604130302010001

65 RAPIUDIN Kawin 3604131208110001 3604131009860002

RUSIYAH WATI Kawin 3604134606880003
ADELIA RAMADANI B. Kawin 3604134508110001

66 SAHRONI Kawin 3604130105130001 3212068707790003

YATUN Kawin 3604136003620001

67 SAFRUDIN Kawin 3604131102073121 3604132505580001

MASANAH Kawin 3604136003610001
LILI MARYANI B. Kawin 3604135006880007
ABDULAH MUBAROK B. Kawin 3604130501890001
68 SUDRAJAT Kawin 3604130414200001 3604132501800007
YANTI UNTARI Kawin 3604196304910001
RIZKY AL FARIEL M B. Kawin 3604130314200003

69 TARMIDI Kawin 3604131102073273 3604131501520002

 RATUA Kawin 3604134408890002
NASRON B. Kawin 3604131404910002
FAHROJI B. Kawin 3604132104910002
NASRUL B. Kawin 3604132301940003
SITI ATIKAH B. Kawin 360413407980003
M MUHYIN B. Kawin 3604132505030004

70 RONI b SUDIN Kawin 3604130710080006 3604130506810599

AYANAH b AGUS Kawin 3604132102840013
SUBEHAH B. Kawin 3604130703070005

71 ARIYAH Janda 3604132607100005 3604136705500002

HERMAN B. Kawin 3604131709880008
LILIS NENGSIH Kawin 3604135207900003

72 ANTON RIANTO Kawin 3604131102073145 3604130111620001

MASTUAH Kawin 3604134204630001
IIS ISNAENI Janda 3604136504860002
RAGIL IRAWAN Kawin 3604130107940036
ANANG BUDI LAKSANA B. Kawin 3604130111960001
B. Kawin
73 HALWANI B. Kawin 3604131102073150 3604130608760002
SUKIROH B. Kawin 3604134607810002
AINUN NADIFAH B. Kawin 3604134501060002
AMARULLAH B. Kawin 3604131309100002

74 SUHERMAN Kawin 3604132812100001 3604132102820002

FITRIYAH Kawin 3604134201870005
SILA RAHAYU B. Kawin 3604135702880002

75 SAYIDI Kawin 3604132704120003 3604130807790002

HUSNA Kawin 3604136104770002
76 UMINAH Janda 3604131102073207 3604134101330002
NASLAH B. Kawin 3604135406810002
NUR ASIH B. Kawin 3604134704940002
WAHID B. Kawin 3604130610030001

77 GOJALI Kawin 3604132804090002 3604131205670003

RETI Duda 3604134406790007
RAHMAT HIDAYAT B. Kawin 3604130210980003
MAFTUHI B. Kawin 3604130709000001

78 HAMRONI Kawin 36041327061400002 3604135067900006

SUMYATI Kawin 3604135508860003
M. HARUN AL FAJAR B. Kawin 3604132711140001

79 SURYA Kawin 3604131102073129 3604131804710001

RUSNI Kawin 3604134801750001
FARID RIFQI B. Kawin 3604130209020001
OLIVIA PUTRI B. Kawin 3604130213000002

80 M SALEH b JASIR Kawin 3604131911000003 3604131004760002

JAMI'AH b JEBIDIN Kawin 3604132210740001
BUKHORI MUSLIM Kawin 3604130910920375
SUELA B. Kawin 3604132101960031
MUHAMAD SAE B. Kawin 3604132405050003

81 SAMANI Kawin 360413110273153 3604131105680004

JENAB Kawin 3604135604770002
SAM'AH B. Kawin 3604131609960003
JENURI B. Kawin 3604131205030002

82 HASANUDIN Kawin 3604131405120018 3604131104800001

KURATUL AINI Kawin 360413128200002
83 MASHUDI Kawin 3604131102073138 3604130401670001
FATOHAH Kawin 3604135704770001
ERIK FAJRI ANIK B. Kawin 3604132910970002
REZA FATHURRIDHO B. Kawin 3604132202303001

84 TURYANI Kawin 3604131102073132 3604130608500001

MARPUAH Kawin 3604135702590001
RUKIYAH Kawin 3604134605780002
NURHAYATI B. Kawin 3604135406820001
YUL TATI B. Kawin 3604135807900003
AISYAH B. Kawin 3604135707930002
REZA RIYADI B. Kawin 3604131401020001
MULFANI B. Kawin 3604130606770001

85 AFMA HAMID Kawin 3604130605140004 3604131804048011

JUBEDAH Kawin 3604135408880002
SITI FATIMAH B. Kawin 3604136302140001

86 BAMBANG PUJO Kawin 3604131502120001 3604131606800002

EVA GOLIYAH Kawin 3604135205830002
MUHANAD EGI JAULI B. Kawin 3604131710140001

87 ELI GOJALI s. Pd. i. M. Si Kawin 3604131102073125 3604130410540001

NANI MARYANI QOMARKawin 3604134701810001
RINI ELVALANI Kawin 3604134606890002
DUROTUNNAQIYAH B. Kawin 3604136511910001
IIP RIF'AH B. Kawin 3604135303940001

88 KANAH b KASAN Kawin 3604130112040011 3604135110740051

HANAFI B. Kawin 3604131108910052
KARIS B. Kawin 3604131509970053

89 ALFIYAH Janda 3604131102073233 3604134306760001

 TITI SUMIYATI B. Kawin 3604136105990001
MIF TAKHUL ILMI B. Kawin 3604131410090001
SOFI AL FIANTI F B. Kawin 3604138802110001
JALAYAH B. Kawin 3604135202910001
B. Kawin
90 MAD ALWIN Kawin 3604131102073278 3604130808740001
SOIMAH Kawin 3604135203770001
FEBRI HERMAWAN B. Kawin 3604132002990001
ALMA AL FIYANAH B. Kawin 3604134909100001
 Taksiran Peserta Status
9 Persalinan KB Kemiskinan

24 25 26 27
 FORMULIR PENDATAAN KESEHATA

Nama UMUR
Status
No Kepala Anggota L P Nomor KK Nik Tgl Lahir
Perkawinan
Keluarga Keluarga
1 2 3 4 5 6 7 8 9

1 '3604131303130001
'3604131303130001
IR PENDATAAN KESEHATAN IBU DAN BAYI

Kepemilikan BPJS / Asuransi Lainya Umur Kehamilan Taksiran Peserta KB

Pekerjaan
BPJS Asuransi 1 2 3 4 5 6 7 8 9 Persalinan
KK
PBI Mandiri Askes Lainnya Lainnya
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
 Status
Kemiskina
n

27
 FORMULIR PENDATAAN KESEH

Nama UMUR
Status
No L P Nomor KK Nik
Kepala Keluarga Anggota Keluarga Perkawinan

1 2 3 4 5 6 7 8

1 '3604131303130001
'3604131303130001
FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

Kepemilikan BPJS / Asuransi Lainya Umur Kehamilan Taksiran

Pekerjaan
Tgl Lahir BPJS Asuransi 1 2 3 4 5 6 7 8 9 Persalinan
KK
PBI Mandiri Askes Lainnya Lainnya
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
 Status
Peserta KB Kemiskina
n

26 27