FORMULIR PEND

NO NAMA Status Umur Nomor NIK

Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7 8
1 SADELI K 41 3604201102078177 36042046750001
MIMI K 31 36042048750002
SAENI BK 13 360420601030001
RINA BK 8 3604205907080002
REJA BK 6 3604201004100003
2 JAMIR K 36 3604201102078189 360420680500003
ENTIN K 35 3604204604510002
ELAS BK 15 3604206308010001
JENAH BK 6 3604204501100001
3 WASIMAN K 3604202912090098 3604201506700002
RUMENAH K 44 3604206709720001
APRIANTO BK 22 3604202304940001
ADAM BK 9 360420009307001
MUTIARA BK 7 36042070090002
4 S. ALAM K 31 3604200806110000 3604200101850023
ST. SUNGSI K 27 3604204508890003
5 ASMADI K 38 3604201102078154 3604200503790001
SUPIKAH K 35 3604205111810001
PIKRI BK 15 3604200508010001
AGI. F BK 11 360420182050001
INTAN BK 5 3604205710110001
6 IGO. S K 34 3604201102078187 3604200101820033
IIS.S K 30 3604204107860034
MB. PUTRA BK 11 3604202812050061
M. AKBAR BK 7 3604202009090001
7 M.NASIM K 53 3604200803630001
NURHATI K 44 3604205705720002
ILHAM BK 24 360420150920001
GAUSUL ALAM BK 19 3604201111970002
NAJATUN NIA BK 14 3604205107020003
8 UBAIDILAH K 36 3604202212100102 360420101800001
NURSITA K 32 36042068006840001
ST. AULIA NAJWA K 5 3604204206110003
9 HIKMAT K 44 3604201011720007
TOPIKAH K 28 3604205708880003
M.PAHRIL BK 9 3604201105070001
M.PAHMI BK 6 3604203112100001
10 A.ENDAM K 54 3604201465620059
MUHETI K 37 3604206606790001
ST.HOLIFAH K 23 3604204903930079
ST. LATIFAH K 21 3604204411950001
 TIKA BK 12 3604204808040171
11 ARIYANTO K 34 3604201102078174 3604201710830002
YULIANTI K 24 3604206707870002
SISKA BK 12 360420462040003
M RISKI BK 5 3604202007110001
12 THOYIB K 40 3604201102078183 360420158760001
SUPIAH K 35 360420510810001
SELVI Y BK 15 3604206510010001
GITA M BK 12 360420500304003
13 TURMUDI K 37 3604202107090017 3604201912790002
NURLELAH K 39 3604205101770002
ARIS NUROHIM BK 11 360420074050002
AYU SETIA NINGSIH BK 9 3604204512070001
14 M UNUS K 51 3604202611040004 360420016500016
SARMANTI K 48 3604205108680017
UMAENAH BK 21 3604205109950020
M SYOL BK 16 3604201907000021
UPIAH BK 12 3604205508040001
APRIJAL BK 10 3604201804060001
15 EDI R K 43 360420222100103 3604200766730002
IMAS K 32 3604205408840001
ELSE A BK 7 3604205207090002
16 EDI J K 59 3604201102078182 3604201812460001
HUSNUL HOTIMAH K 42 36042047011740001
UBAEDILAH BK 24 360420209920002
TOHARIAH BK 18 3604206811960002
TOHAROH BK 18 3604206911960001
TOHANAH BK 16 3604206203000001
TOHANIAH BK 14 3604206705020001
17 GARWADI K 41 3604201407080004 '3604201006750333
HERNAH K 37 3604205109790001
RIZKI R K 14 36042018110220002
ALDI R BK 8 3604202001080003
18 RUDI BK 28 3604203008130001 36042018108880001
SAADAH K 27 3604204411090005
M ERLANGGA BK 3 3604201305130001
19 MUHAYAT K 36 360420130309015 360420124800057
AMINAH K 41 3604205605750376
ST. MULYANAH BK 9 3604204108070001
ADI ZIANSYAH BK 8 3604202509080001
20 DEMAN K 29 3604201401150006 3604200703870004
KOKOM K 24 3604205307920004
ST. SIFA AZAHRA BK 3 3604206302130002
21 SAR'I K 45 3604201102078178 3604202112710001
MELI HARYATI K 36 36042048080003
M. RIZKI HARDIAN BK 18 3604200702980002
PUTRI ALZA S BK 15 3604204103010002
22 KASDI K 47 3604202611040029 3604201010690163
 SUMIATI K 38 360420447780164
ST. KHOLIAH K 22 3604204409940165
SRI OCTOVIANI BK 16 3604205710000166
SULISTIANINGSIH BK 12 3604206112040002
23 NANA K 38 3604201102078156 3604202808790001
NUR RAETI K 26 3604206811800001
REHAN BK 15 360420280100002
ARIF BK 11 3604200711050005
ANISA BK 5 3604205011110001
24 TAUFIK K 31 3604200805120006 3604202611850003
PUTUHA K 26 3604205606900002
M. AZKA PATUR BK 3 3604203004136001
25 JUPEDI K 29 3604201612130006 3604200103670003
SUMINI K 34 360420500780002
DINI AL-ISA PUTRI BK 6 360420704090002
M.RIKRI TORIIK BK 3 360420408130001
26 MUTAMI K 29 360420091430002 3604201103876004
ST. LATIFAH K 17 3604204411950001
27 HAERUDIN K 46 3604201811080009 3604200510700102
SUKIAH K 40 3604205260144
SUKRON FAUZI BK 20 3604200505960289
M. BUHORI BK 17 3604200711990108
ABDUL MUIS BK 15 3604202870101016
AL AFRIJA BK 13 3604200704030185
HAERUN NISA BK 10 3604201310060001
28 AZIMI K 46 360420140110001 3604201001700003
ENI K 43 3604204101730003
BURHANDIN BK 20 3604202810960001
BUKHORI BK 17 3604202803990001
ST. AMINAH BK 15 3604207112010002
29 JAENI K 44 3604200406080019 3604201009730015
LILIS K 43 3604205706740001
SUBANDI BK 16 3604202409000001
AGUNG BK 12 3604201803040003
ELAWATI BK 10 36042051060001
30 ABDUL A K 38 3604201102078236 3604200911790002
MAESAH K 28 360420610780001
M. MAUL MANSYUR BK 9 3604202105070002
AZZAHRA BK 1 3604205767140002
31 MARJIIH K 60 3604201102078188 3604202005520002
NURJANAH K 42 360420450740006
MARIDAH BK 28 36042004506660006
NULABA BK 24 3604201106910001
MA BK 22 36042015202940003
A. DIMYATI BK 16 36042021502030003
SAMBAS BK 13 3604201001070004
SIDKI BK 9 360420670240002
TAPRIJI BK 7 360420076290001
32 SUANDA K 54 3604201210090007 3604200801620001
JUHEDAH K 47 3604206806690001
ABU A BK 22 360420160790002
ST. CHOTIMAH BK 18 360420520203980002
ULWAN BK 15 3604201204010001
SAKINAH BK 12 3604205204040002
33 SALIM K 47 3604201102078168 3604201507670007
MUHANAH K 45 3604204902710003
MASLEHAH BK 21 360420680850002
ST. SOLEH BK 17 3604204910990001
34 BADRI K 54 3604201102070164 3604201605620002
JUHEMAH K 42 3604204406740005
SOHALIAH BK 20 3604204406740005
HARTATI BK 17 3604204111990003
MUHARIS BK 15 3604201809010002
TAUFIK BK 13 3604202465030001
35 MUSTOFA K 45 3604201102078165 3604200518700001
TATU K 36 360420519800001
TOPAN S BK 14 3604201707620001
ST. PATHA BK 9 3604205608070001
SUBHI A BK 7 3604201102090002
AMELIA BK 4 3604206111120001
36 MARDI K 54 3604201102078771 36042015056620002
MUHEMAH K 53 3604205001730002
FAJRI BK 24 36042000792002
NURENI BK 21 360420570950001
A MAHMUDIN BK 18 3604201009980002
MASRIAH BK 15 3604206007010002
AMUIN BK 12 3604200503040004
M YUSUF BK 10 360420660460001
37 JUHEDI K 43 3604201102078149 3604200468680002
ROHANIAH K 35 3604205107010001
UES ALQRIAH BK 17 3604201311990001
ITA SURURI BK 14 3604202904620001
ULUL AZMI BK 13 3604200104030001
BABUL ULUM BK 10 3604200151160006
38 MARSUDI K 36 3604201630110001 3604200909800004
SRI TUHALIAH K 27 360420706890004
A. MAULMASUM BK 5 3604201603110001
39 JAMSURI K 43 3604200710050004 3604202502730019
SATI K 38 3604204711780020
SHADI BK 18 3604202007980023
M. HAM BK 11 3604201009030021
40 SAFRUDIN K 44 3604202808150011 3173042109720001
UFIKOH K 39 3173044506770016
ARUL BK 17 3173042307991001
PIDRIL BK 8 3123041109081002
FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan Umur Kehamilan

Lahir BPJS Asuransi KK
1 2 3 4 5 6 7
PBI Mandiri Askes Lainnya Lainnya
9 10 11 12 13 14 15 16 17 18 19 20 21 22
6/24/1975 √ BURUH
7/8/1985 √
1/24/2003 √
7/19/2008 √
4/8/2010
5/8/1980 BURUH
4/8/1981
8/23/2001
1/5/2010
6/15/1970 BURUH
9/27/1972
4/23/1994
3/15/2007
6/7/2009
1/1/1985 BURUH
8/5/1989
3/5/1978 √ √ BURUH
11/11/1981
8/5/2001
2/18/2005
10/17/2011
7/1/1982 BURUH
7/1/1986
12/28/2005
9/20/2009
3/8/1963 √ BURUH
5/17/1972 √
9/15/1992
11/11/1997
7/11/2002
10/10/1980 BURUH
6/26/1984
6/2/2001
11/10/1972 √ BURUH
8/17/1988 √
5/11/2007
12/31/2010
5/14/1962 BURH
6/26/1979
3/9/1993
11/4/1995
 8/8/2004
10/17/1982 Buruh
7/27/1987 √
12/6/2004
7/20/2011
8/15/1976 Buruh
10/10/1981
10/25/2001
3/10/2004
12/19/1979 Buruh
1/11/1977
11/7/2005
12/5/2007
10/1/1965 Buruh
8/11/1968
8/11/1995
7/15/2000
8/15/2004
4/18/2006
6/7/1973 Buruh
8/14/1984
7/12/2009
12/18/1946 Buruh
1/7/1974
9/20/1992
11/28/1998
11/19/1998
3/22/2000
6/27/2002
6/10/1975 √ Swasta
9/11/1979 √
11/18/2002 √
1/20/2008 √
4/9/1988 Buruh
11/4/1989
5/13/2013
4/12/1980 Buruh
5/16/1975
8/1/2007
9/25/2008
3/7/1987 Buruh
7/13/1992
2/23/2013
12/21/1971 √ Swasta
8/8/1979 √
2/7/1998 √
3/1/2001 √
10/10/1969 Swasta
 7/4/1978
9/4/1994
10/17/2000
12/21/2004
8/28/1978 Buruh
11/28/1980
8/28/2001
11/1/2005
11/10/2011
11/25/1985 Buruh
6/16/1990
4/30/2013
3/1/1987 Buruh
7/10/1982
4/7/2010
8/24/2013
3/11/1987 Buruh
11/4/1999
10/5/1970 Swasta
6/12/1976
5/5/1996
11/7/1999
7/28/2001
4/7/2003
10/13/2006
1/10/1970 Buruh
1/1/1973
10/28/1996
3/28/1991
12/31/2001
8/10/1972 Buruh
8/17/1974
9/24/2000
8/18/2004
6/11/2006
11/8/1978 Buruh
7/21/1988
5/21/2007
7/17/2014
5/20/1952 Buruh
4/5/1974
8/5/1988
1/5/1992
8/5/1994
1/7/2000
12/5/2003
12/4/2007
2/1/2009
 1/8/1962 Buruh
8/28/1969
2/15/1994
3/12/1998
4/12/2001
4/12/2004
7/15/1967 Buruh
2/8/1971
8/28/1995
10/9/1999
5/16/1962 Buruh
6/4/1974
5/22/1996
11/1/1999
9/18/2001
5/24/2003
8/5/1970 Buruh
9/11/1980
7/17/2002
8/18/2007
2/11/2009
12/21/2012
5/15/1962 Buruh
1/10/1973
7/20/1992
1/27/1995
9/10/1998
7/20/2001
3/5/2004
4/8/2006
8/4/1968 Buruh
7/11/1981
11/13/1999
4/29/2002
4/1/2003
11/15/2006
9/9/1980 Buruh
6/7/1989
3/16/2011
2/25/1973 Buruh
11/7/1978
2/20/1998
9/10/2005
5/20/1972 Buruh
8/5/1977
7/23/1999
9/11/2008
amilan Taksiran Peserta Status
Persalinan KB Kemiskinan
8 9

23 24 25 26 27
KS 1
SUNTIK

KS 1

SUNTIK KS 1

KS 1

KS 1

KS I

KS I

KS I
SUNTIK

KS I
SUNTIK

KS I
SUNTIK
Suntik KS 1

KS 1

Suntik KS 1

Pra

Suntik Pra

KS 1

Suntik KS 1

Suntik KS 1

Pil Pra

Suntik KS 1

suntik KS 1

suntik KS 1
suntik KS 1

suntik Pra

Pil Pra

suntik Pra

Pil KS 1

suntik KS 1

Pra

Pra

Pil KS 1
suntik KS 1

suntik Pra

suntik Pra

Pra

suntik KS 1

suntik Pra

suntik KS 1

Pil Pra

suntik KS 1
NO NAMA Status Umur Nomor NIK Tanggal
Kepala Anggota KK Lahir
L P
Keluarga Keluarga
1 2 3 4 5 6 7 8 9
1 Robinhud 1/2/1992
Puspita 6/7/1992
2 Slamet 3604201211070228 1603690151 3/16/1969
Muhemah 5204710153 4/12/1971
Anisa F 5702010131 2/17/2001
Yogi C 1903070001 3/19/2007
3 Subai 3604201102078356 0107660011 7/1/1966
Masti 4107690010 7/7/1969
Madsuni 0706910002 6/7/1991
Ayu 6909990002 9/29/1999
Alfaraj 2501100001 1/25/2010
4 Habidudin 3604201703090005 0211690218 11/2/1969
Nurhayati 5103760112 3/11/1976
Perianto 0707940122 7/7/1994
Hamidah 5007960064 7/10/1996
A. Wahyu 0707030244 7/7/2003
5 Ahim 3604201102078388 1607730002 7/16/1973
Rohenah 4908760001 8/9/1976
Dewi .L 4508940002 8/5/1994
Pikri 0607040001 7/6/2004
Amelia 11/13/2013
6 Tatang 3604201102078382 1103740004 3/11/1974
Yayah 4405820005 5/4/1982
St. Wahyuni 5212030002 12/12/2003
M.Subhan 2012110004 11/20/2011
7 Iwan 3604201102078379 1107740001 7/11/1974
Satipah 6103760001 3/21/1976
A.madum 5/10/1999
8 Maman 3604202210120006 4809700002 9/8/1970
Patimah 0911860006 11/9/1986
April .R 74000006 4/7/2000
M. Pahri 050230002 2/5/2003
Yunita 4505070002 5/5/2007
9 Sulaeman 3604200805070003 1805710148 5/18/1971
Elawati 6609760001 9/26/1975
Hermawati 5201950201 1/12/1995
Eko. S 2710960121 10/27/1996
Eka. S 2710960123 10/27/1996
Ida. H 6012070001 12/20/2007
10 Saman 3604200504120003 0101810027 1/1/1981
Ipit. M 7005900006 4/5/1988
Safira 6304110003 4/23/2011
11 Saminan 3604200305130006 1110840001 10/11/1984
Karolina 4504880005 4/5/1988
Shanlia 6506100001 6/25/2010
Silpia
12 Rohman 3604202906090009 1610730001 10/16/1973
Rohayati 4709860003 9/7/1986
Teguh. I 0506050002 6/5/2005
Nuraisah 4109080001 9/1/2008
13 Iman 3604200909040045 0211700223 11/2/1970
Sukaesih 450379224 3/5/1979
Resa 2810980225 10/28/1998
Rifal 2807020226 7/28/2002
Siska 6805040019 5/28/2004
14 Jumadi 360420110608002 0507690297 7/5/1969
Saba'ah 5311790104 11/13/1979
A. Yusuf 2101000160 1/21/2000
Nurhaeni 4101040318 1/1/2004
Dede. M 2102080002 2/21/2008
15 Ujang 3604200909040024 0512747111 12/5/1974
Uun 4503830112 3/5/1983
Uminah 4702000113 2/7/2000
Tirman 050802114 8/5/2002
Asan 1109790115 9/11/1979
Umbaria 7/15/2007
16 Suhendi 3604201102078344 1103610003 3/11/1961
Suhayah 5705690002 5/17/1969
Sutisna 1304900002 4/13/1990
Mustofa 0705900006 5/7/1990
Hasbian 0504980004 4/3/1998
Tajudin 0401040001 1/4/2004
Nurholisoh 5407050003 7/14/2005
Royani 1901080001 1/19/2008
17 Hendar 3604201102078363 010740004 7/1/1974
Babay 4101820010 1/1/1982
A.Pudoli 1212040001 12/12/2004
A. Mujaki
18 Madudin 3604201910040004 0405590026 5/4/1959
Roheti 5204690021 4/12/1969
Miyanti 4512970001 12/5/1997
Raup 1108010098 8/11/2001
19 Edi 3604200909040033 1902760159 2/19/1979
Roiyah 7003780160 3/30/1978
 Sri Hartati 5903970162 3/19/1998
Erna 4106020163 6/3/2002
Rendi 0305080001 5/3/2008
20 Ajot .M 3604201102078370 0304590002 31/04/1959
Mulyanah 4202730002 2/2/1975
Helis 4607980003 7/6/1998
Muhidin 0409930002 8/4/1963
21 Husen 3604201209120009 06011790003 1/6/1978
Nurkiah 5305870001 8/13/1987
Nia. A 6204120001 4/22/2012
22 Wahid 360420110207836 1005770004 5/10/1977
Saedah 4907800003 7/9/1980
M.Rio 1702000002 2/17/2000
M.saepul 1602030003 2/16/2003
Wardayani 5507110002 7/25/2011
23 M. Fajri 3604201502130000 2611820001 11/26/1982
Dedeh 6306860001 5/23/1986
Dhea 6011060001 11/20/2006
Adila 4901130001 1/9/2013
24 Ramli 3604200909040029 140376137 3/14/1976
Eti 1706790136 6/17/1979
Ukiyah 1201960139 1/12/1996
Rosita 3101000140 1/31/1996
Rohiyat 0305030141 5/3/2003
25 Sukma 3604201102078378 2102740002 2/21/1974
Murnah 4706770202 5/17/1977
M. Heru 0506930004 6/5/1993
Muhodi 0107960002 7/1/1996
Cucu. M 1101040002 1/11/2004
Suci. Y 5912060001 12/19/2006
26 Supandi 3604202102140004 1111830002 11/11/1983
Maryati 4910800003 10/9/1980
Anggita 5502140001 2/15/2014
27 Mumum 3604201102078387 0304660003 4/3/1966
Mahpudon 4911780001 11/9/1978
Muspita 5901970004 2/15/1997
Pujiyatno 2104020003 4/27/2002
28 Murti 3604201607120001 47047800003 4/7/1980
Riki 050600001 6/5/2000
Ageng 0412060002 12/4/2006
29 Sukimo 3604201102078355 0110790002 10/1/1979
Sukmini 4405830005 5/4/1983
Gita. L 6611030002 11/26/2005
Pajar. R 2808080002 8/28/2008
30 Madsura 3604200909040034 0508320164 8/5/1932
 Asmeri 6101660165 1/21/1966
31 Samanan 3604202306080008 0509460178 9/5/1946
Asmunah 4703480001 3/7/1948
32 Rokayah 3604201710080003 4112670001 12/1/1967
Baehaki 1006910341 6/10/1991
33 Hindun 3604201105120002 5705540003 5/7/1954
Mahtum 1003780002 3/10/1978
34 Mamak 3604205110080004 1103630233 3/11/1962
Juhariah 4411640235 11/4/1964
Juned 1205820052 5/12/1982
Jamhari 1705840184 5/17/1984
35 Bahri 5/15/1984
Suhayat 55005840048 10/20/1984
Nazwa 5/9/2014
36 Kamsari 3604201102078380 211470001 11/21/1947
Patonah 7012570002 12/30/1957
Irma 4406950002 6/4/1995
M. Hani 00712970003 12/7/1997
37 Bai . R 3604201102078367 3670802450001 2/8/1945
Een 5004710002 4/10/1971
A. Ubai 0506070004 11/20/1997
Eva 854503440001 8/15/2002
Mipahum 4306900002 8/22/2005
Kiki 1106970002 6/5/2007
38 Rohanah 3604201102078385 4503440001 3/5/1944
Nurpalah 4306900002 6/5/1990
Nasrul 1106970002 6/11/1997
39 Supriana 3604201703090006 0702340200 2/1/1934
Aisah 5201550200 1/12/1955
Asep 0306880204 6/3/1988
Adi. R 0506890237 6/5/1989
Hastia 4201920210 1/1/1992
Cicih. S 4203970209 3/2/1997
40 Ali . G 360420030310027 2711760001 5/2/1981
Maesaroh 6704850001 9/10/1980
Putri. P 12/4/2015
Anggun 1/1/2005
Alip 4/26/2013
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

Kepemilikan BPJS / Asuransi Lainnya Pekerjaan Umur Kehamilan

BPJS Asuransi KK
1 2 3 4
PBI Mandiri Askes Lainnya Lainnya
10 11 12 13 14 15 16 17 18 19
√ BURUH
√
√ BURUH

BURUH

BURUH
√
√
√
√
√ BURUH

BURUH

BURUH

BURUH

BURUH

BURUH
 BURUH

BURUH

BURUH

BURUH
√
√
√
√
√ BURUH

BURUH

BURUH

BURUH
 BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

√ BURUH

BURUH

BURUH
√ BURUH

BURUH
Umur Kehamilan Taksiran Peserta Status
Persalinan KB Kemiskinan
5 6 7 8 9

20 21 22 23 24 25 26 27
KS II
desember
KS II

KS II

KS II

KS II

KS I

KS II

KS I

KS I1

KS I
KS II

PRA

KS II

PRA

KS I

KS II

PRA

KS I
KS II

KS II

KS I

KS II

KS I

KS II

KS II

KS II
KS I

KS II

KS II

KS II

KS II

KS II
 FO

NO NAMA Status Umur Nomor

Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 PATAWI K 43 3604201102078320
SUHA K 39
FUKON B 21
MUHIT B 18
PATONAH B 16
KHOTIB B 14
SUHEMI B 8
SUHELI B 9
2 MARSAH JANDA 80 3604201102078345
MUTIAH K 22
MUSLIH B 19
UUN B 17
3 PONAN K 47 3604201102078315
TATI K 41
SUKMA B 21
SUHARDIAN 10
SUPANA B 9
4 KASMIN K 59 3604201102078333
UMEN K 54
MUHEDI B 34
UBADI B 14
UUN B 10
5 MAHMUDIN K 39 3604201102078322
KASWAH K 36
KIKI M B 19
KOMARUDIN 16
NIA K B 15
M. KASWARA 10
6 SANA K 51 3604201102078330
UUM K 41
UES B 19
ST. SUARSIH 18
USULUDIN B 9
7 EMAN K 23
SANTI K 21
8 SAMURI K 67 3604201102078336
TABSIAH K 70
BUDIMAN B 25
9 SAHIM K 30
MUNIROH K 29
UNGGIL B 2
10 UMAYAH JANDA 45 3604201102078337
 AAN A K 21
A YUDI B 17
UBAIDILAH B 15
11 M.NOVAL A K 31 3604201102078340
ATI M K 28
BURHANUDIN 9
12 MADSAI K 72 3604201102078320
SAWINAH K 53
SUNANI B 16
SAEFUL B B 12
13 ENO K 22
MAEMUNAH 20
14 TOIP K 34 3604201102078318
ETI K 32
TAOFIK B 11
FAUJI B 1
15 H.SUKRI K 62 3604201102078339
HJ.UMANAH 54
MAHYUDIN 37
16 ADIT K 29 360420130810009
SUHARTATI K 28
AKMAL B 5
17 SAOMI K 30 3604201812090030
ERNA K 25
M.IAN B 5
18 ARJUDIN K 44 3604201102078314
IKAH K 39
NURAPIAH B 17
IPONG B 13
A.ARIPIN B 12
AGUNG B 11
MIROJATUL B 9
NURAENI B 4
DEDE SOPIA 2 bln
19 JUHDI K 42 3604201703100012
SUPIAH K 37
GUNAWAN B 16
NAJIB B B 13
HAJAH B 7
HADAD B 5
SITI H B 10 bln
20 ROHMAN K 35 3604201812090035
MASAMAH K 25
RAHMA B 7
21 HOLID K 23
MAMAH K 22
IMDAD B 4
22 APIPUDIN K 35
 RANI K 22
ALYA S B 7
23 HJ.DURIAH JANDA 56 3604201102078360
AIP R K 26
MUNDIAH B 26
ST.AMINAH B 21
24 YOMAN K 33 3604202912100001
NURAISYAH K 29
RESYA B 4
25 MAINAM JANDA 50 3604201102078300
AUGSIAWAN K 24
DEDE R B 16
TATANG B 18
26 SURGANA K 39 3604201812090037
MUHAYATI K 35
AMIRA B 3
27 SUHERI K 41 3604201102078346
ENJUN K 39
IRPAN B 19
SAPNAH B 15
PUTRI D B 5
M.ALAN B 4
28 BAHRUL U K 33
ST.MASITOH K 28
29 EMAN K 33 3604202709110005
JUHENAH K 25
JAENUDIN B 4
30 SUHERMAN K 49 3604200809488829
INING K 43
A.JOYALISI B 19
SRI WAHYUNI 18
A.PANK B 15
IJUL P B 14
SAEPUL B B 8
IPTAHUL K B 6
INAYAH B 4
31 SUHENDAR K 25 3604201102078307
WULANDARI K 25
RIKY R B 4 bulan
32 DARTO H K 31 3604201102078304
TUNI K 31
ADNAN H B 8
33 ASIM K 55 3604201102078311
ELAH K 49
A.ROHMAN B 23
MUTIATUL B 19
UMTINI B 17
SUSMIATI B 13
 ASEP H B 10
NOVI YANTI B 7
34 REZA K 30
NURHAYATI 26
RAFA B 6 bulan
35 MASRI K 40 3604201102078320
MARTINAH K 39
RAPIATUL B 13
36 HASANUDIN K 30 3604201102078331
KOMALA SARI 28
LELA C B 9
GILANG B 5
37 ROHIM K 40 3604201102078300
SUKAESIH K 39
HABIB P B 18
ROSDIANI B 17
ILMA Y B 13
NASRUL L B 10 3604201102078545
38 SAIMAH JANDA 33
SAMSUL B K 14
ROBIAWAN B 10
HAERUL A B 6
NELA B 2
39 NATA K 43 3604201102078341
SAIBIAH K 39
JAENAL A B 20
AGUNG P B 7
MEGA B 1
40 MASITO K 20
SRI W K 18
SUGENG B 2
41 SUHETI JANDA 26 3604201102078324
ASEP S K 21
ISNAWATI B 17
42 MADROIS K 37 3604201102078312
AMAH K 45
AMIR L B 17
43 OMAN K 26
NENGSIH K 25
44 ASEP K 21
ROSITA D K 19
45 RIADI F K 24
RATIH K 24
AKBAR B 3
46 SATRI K 44
YANI K 38
HARIRI R B 4
47 KAMAI K 55 3604201102078315
 AAS K 44
ADEN B 11
48 ADE IMROH K 25
MUMUS K 22
49 PUKUNG K 51 3604201102078316
SUANAH K 41
SULAEMAN B 24
WULANSARI 18
SUEPI B 20
MAULANA B 15
SUPRIYADI B 13
50 AMSAR K 39 3604201102078332
MARNI K 44
MUHIDIN B 7
51 DJAI K 48 3604201102078302
JUHARIAH K 43
52 SAPNUDIN K 42 3604201102078308
JUHENAH K 38
LASDANI B 17
INGGRIT B 11
OKTAVIANI B 3
53 DEDI K 34 3604201102078323
URYANAH K 33
NEBAL B 10
ANDRI B 7
DEVI B 4
RIZKI B 1
BAYI B 1 bulan
54 MASUNI K 65 3604201102078310
ROHANI K 60
MAULANA B 19
SULEHUDIN 16
ILHAM B 13
55 BADRUDIN K 31
NILA K 31
RENO B 3
56 MUSTOFA K 36 3604201102070040
SAEBAH K 29
57 SAHRONI K 35 3604201812090038
SUSI K 25
FIKRI B 3
58 ABDUL L K 55 3604201102078327
MURTAPIAH K 47
MUFAWAH B 25
ATOULIAH B 23
A.MUROPK B 21
ABDUL H B 17
NENG M B 16
 ST.MAIDAH B 13
MURTADO B 10
59 PATONI K 50 3604201102078303
SUNAH K 45
M.JANUDIN 23
MADSUNI B 19
DEDI S B 14
FITRIYANI B 12
HOLIK B 9
60 MAWI K 38 3604201102078319
MUNAWAROH 41
WIWIN B 10
61 ADONG K 51 3604201102078364
JAHROH K 44
ELI B 16
62 ACENG K 24
PRIANA D K 23
PUTRI AKILA 7 bulan
63 IWAN K 29
SUSI K 28
FEBRI B 4
64 SUHARI K 48 3604201102078338
ROSINAH K 38
UMROH B 21
ENTIN S B 19
TINAH S B 18
A TANTO B 11
M AWAL B 10
FITRI R B 3
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan

Lahir BPJS Asuransi KK
1
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15 16
0205720003 5/2/1972 √ Buruh
4807760003 7/8/1976 √
0506940003 6/5/1994 √
090100003 10/9/1997 √
4106990003 6/1/1999 √
0806010003 6/8/2001 √
4/18/2007 √
1511060001 11/15/2006 √
421350001 2/11/1935 √
2/9/1993 √
3/8/2009 √
1/2/1998 √
110207830001 11/12/1968 √ Buruh
4309740001 9/3/1974 √
0710940003 10/7/1994 √
7/20/2004 √
3/7/2006 √
101560019 1/1/1956 Buruh
4101610008 1/1/1956
1/1/1961
0101010026 1/1/1981
4101050012 1/1/2001
1204760002 1/1/2005 Buruh
4210790001 4/12/1976
0304960003 10/2/1979
4905000002 4/3/1996
0508990002 5/9/2000
0507050002 8/5/1999
0709640001 7/5/2005 Buruh
5102740002 9/7/1964
1206960003 2/11/1974
4809970001 6/12/1996
2109060001 9/8/1997
9/21/2006 Buruh
4712940002
2008480001 12/7/1994 Buruh
4101450032 8/20/1948
411900004 1/1/1945
11/4/1990 √ Buruh
4304860007 2/14/1985 √
4/3/1986
6106700002 5/30/2013 Buruh
0912940001 6/21/1970
210980001 12/9/1994
1101000002 10/2/1998
0803840002 1/11/2000 Karyawan
4602870003 3/8/1984
2906060002 2/6/1987
6/29/2006 √ Buruh
2404430001 8/10/2014 √
6904620001 4/24/1943 √
7009990003 4/29/1962 √
2008010002 9/30/1999 √ Buruh
5/10/1995
5005950002 5/10/1981 √ Wiraswasta
1005810002 6/5/1983 √
4506830002 2/29/2004
7/21/2014
0510510001 10/5/1951 √ PNS
5312610001 12/13/1961 √
209780001 9/20/1978 √
0603860003 3/6/1986 √ Buruh
4410870006 4/10/1987 √
7/28/2010 √
0404850005 4/4/1985 Buruh
5707900004 7/17/1990
10/5/2010
0602710003 2/6/1971 Buruh
7470970002 9/1/1976
4412980002 12/2/1998
0104020003 4/1/2002
0704030003 4/7/2003
0101040021 1/1/2004
0211060001 11/2/2006
211060002 10/2/2011
8/26/2015
0305730003 5/3/1973 √ Buruh
5202780002 2/12/1978 √
0405970004 5/4/1997 √
1512020002 12/15/2002 √
4305080002 5/2/2008 √
4305080002 2/14/2010
1402100001 1/18/2015
1111800003 11/11/1980 √ Buruh
4404900002 4/4/1990 √
12/6/2008
3/20/1992 Buruh
4101950052 1/1/1993 √
5/3/2011
0101860203 1/1/1980 Buruh
 6/3/1993
2/26/2008
5012590003 10/12/1959 √ IRT
0501890001 5/1/1989 √
4501890001 1/5/1989 √
4807940001 7/8/1994 √
2505820005 5/25/1982 √ PNS
4705860001 5/7/1986
4512110001 12/5/2011
5001650002 1/10/1965 IRT
0710970002 10/7/1991
2912940001 12/12/1999
3105940001 5/31/1991
1103780040 9/9/1978 Buruh
4410870206 10/4/1987
9/13/2012
0107740012 7/1/1974 √ Buruh
4107760291 7/1/1976 √
0107860027 7/1/1996 √
4107900027 7/1/2000 √
5/29/2010
9/15/2011
5/22/1985 Buruh
4104870003 4/1/1987 √
195820002 5/19/1982 Wiraswasta
5202900002 2/12/1990
8/15/2011
612660133 12/6/1966 Wiraswasta
58087202134 8/18/1972
115966137 5/11/1996
5003960138 3/10/1997
3007000139 7/30/2000
2011010140 11/20/2001
2203070001 3/22/2007
2305090001 5/23/2009
490110001 9/7/2011
1301900001 1/13/1990 √ Buruh
7/5/1990
7/1/2015
111284002 2/1/1984 Guru
10/6/1984
5/4/2007
1201600001 1/12/1960 Buruh
5505650003 5/15/1965
231920001 1/23/1992
5805960001 5/18/1996
307980002 7/30/1996
6903020002 3/29/2002
 9/29/2005
11/28/2008
6/21/1985 Guru
5001890003 1/10/1989
4/20/2015
1712650001 12/17/1975 Buruh
6103700001 3/21/1976
0112020001 12/1/2002
1612850003 2/16/1985 Wiraswasta
4408870001 8/4/1987
6706060001 6/27/2006
8/17/2010
1001750002 1/10/1975 Buruh
5503760001 3/15/1976
0101970059 1/1/1997
4601980001 1/6/1998
5512020003 12/15/2002
2311050001 11/23/2005
4606820002 6/6/1982 √ Buruh
2608010001 8/25/2001
2508050001 8/25/2005
5/16/2009
1/20/2013
0710720002 10/7/1972 Buruh
4509760004 9/5/1976
1011952005 11/10/1995
6/1/2008
7/6/2014
7/27/1995 Buruh
6006970002 6/20/1997
9/29/2013
5104890001 4/11/1989 √ IRT
2705940002 5/27/1994 √
5001980002 1/10/1998 √
77680202 7/7/1968 √ Wiraswasta
4809700002 9/8/1970
0111980003 10/1/1998
6/2/1989 √ Wiraswasta
4605900202 5/6/1990
9/27/1994 Wiraswasta
4105960001 5/1/1996
3/30/1991 √ Wiraswasta
560992001 7/6/1992
8/15/2012
5/19/1976 √ Wiraswasta
5/8/1977
8/4/2011
0708600001 8/7/1960 Buruh
5704690002 4/17/1969
2511040001 11/25/2004
5/26/1990 Wiraswasta
4908930001 8/9/1993
1903630003 3/19/1963 √ Buruh
6109740001 9/21/1975 √
0106910002 6/1/1991 √
6607970002 7/26/1997 √
0709950003 9/7/1995 √
0707000006 7/7/2000 √
0702020002 2/7/2002 √
01017600024 1/1/1976 Buruh
4101690037 1/1/1969
2/10/2006
1301670001 1/13/1967 Buruh
5202870002 2/12/1987
1005730003 5/10/1973 Buruh
6106770002 6/21/1977
4303980001 3/3/1998
1809040001 9/18/2004
10/22/2012
2008790003 8/20/1979 Buruh
4304820007 4/3/1982
3107050002 7/31/2005
9/20/2008
4/10/2011
1/27/2014
9/27/2015
0101500029 1/1/1950 √ Buruh
4101550025 1/1/1955 √
0611960003 11/6/1996 √
1002990003 2/10/1999 √
0410020201 10/4/2002 √
01018400047 1/1/1984 Buruh
8/7/2012
9/15/1979
1509790002 4/12/1986 Wiraswasta
4412860004 6/17/1980
1706800005 9/25/1990
8/15/2012 √
8/10/1960
1008600003 3/12/1968 √ Buruh
5203680003 11/16/1990 √
1611900001 2/14/1992 √
1402920001 10/1/1994 √
0204960001 2/10/1998
1002980004 5/10/1999
5005990005 2/25/2002
5602020002 1/25/2005
2501050001 9/9/1965
0909650002 11/10/1970 √ Buruh
5011700006 9/1/1992 √
0109920003 1/1/1996 √
0101960045 1/1/2001 √
0101010025 11/25/2003 √
6511036002 8/6/2006 √
0608060001 6/6/2007 √
0606770001 6/6/1977 Wiraswasta
4406740006 6/4/1974
501050005 10/10/2005
104610002 4/10/1961 Wiraswasta
5203760001 3/2/1976
5111990002 11/11/1999
5/10/1991 Wiraswasta
4310920003 3/10/1992
3/23/2015
10/20/1986 Buruh
2511870002 11/25/1987 √
2/19/2011
1308670001 8/13/1967 √ Buruh
6004770002 4/20/1977 √
5408940001 8/14/1994 √
5104960001 4/21/1996 √
5507970004 7/15/1997 √
1102040003 2/11/2004 √
0707050001 7/7/2005 √
5208120001 8/12/2012
 Umur Kehamilan Taksiran Peserta Status
Persalinan KB Kemiskinan
2 3 4 5 6 7 8 9

17 18 19 20 21 22 23 24 25 26 27
KS I
Suntik

PRA

KS I
Suntik

KS I

KS I
√ April

KS I
Suntik

KS I

KS II

KS II
Suntik

PRA
 KS I
Suntik

KS I

KS I

KS I
Suntik

KS III

KS I
Suntik

KS I
Implant

KS II
Suntik

KS I
Suntik

KS II
Suntik

KS I
Suntik

KS I
 KS III

KS IIII

KS I

KS II
Suntik

PRA
Suntik

KS I

KS II
Suntik

KS III

KS II
Suntik

KS II

KS II
 KS II
Suntik

KS I

KS II
Suntik

KS II
Suntik

KS I

KS II
Implant

KS I
Suntik

PRA

KS II
Suntik

KS II

KS II

KS II
Suntik

KS II
Suntik

KS II
 KS I

KS I

KS II

KS II

KS II

KS II

KS II
Suntik

KS II

√ Maret

KS I
 KS I

KS II

KS III

KS II
Suntik

KS II

KS I
Implant
NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 USMAN 50 3604201102077600
ROPIKAH 43
UNAYAH 24
KHOIRUNISA 15
CECEP SAEPUDIN 13
2 MUSOPA BASIR 41 360420110277662
ROSITA DENI 32
MUJIROTUL 11
M.HAQQI N 6
IRSYAD B 3 BLN
3 ABDUL BAHRI 34 3604201611090012
IIS MUISAH 28
NURAIDA 6
NUKAILA 1 BULAN
4 MUKSIN 3604202708070004
SARYATI 43
SARIPUDIN 24
TOPIK HIDAYAT 22
NURUL IMAN 13
5 OHIM 60 3604202110040027
MUPLIHAH 28
S.ROSIDAH 16
A. MULYANA 13
MUZMATUL.H 6
KHOIRUL F 4
6 SAMSUDIN 62 3604202010040019
AMINAH 61
A.BAIHAQI 22
S.NOPIAH 21
7 AHMID 35
RUSIDAH 34 3604200706070001
NUZAVNI 14
ILHAM J 3
8 ROSID 41 360420211040009
SURNI 33
AINU ROHMAN 11
AQILA NURUL 28 BULAN
9 TUSRAFEI 3604201102077598
MUSIDAH
M.IQBALUDIN
M.BALQIS 4
10 KOSASI H 37 3604200612110005
UMIMAH PUDOH 13
 EVA NURYATI 11
11 SALEH 39 3604201102077594
JUJU 35
A.NAZARUDIN 17
S.UMU GHOIDA 13
M. GUIVARI M 18 BULAN
12 TARI M 48 3604201908100004
ELI 44
SUHANDI 19
HARYANTO A 15
ENTU TUHAENI 5
13 MADKALAM 83 3604201102077595
RUKIAH 63
BADRIATUL A 22
14 ROHMAT R 42 3604203101120010
YAYAN 39
RAIHAN R 7
15 ASEP KUSNADI 54 3604202206150001
ASNAMAH 48
MUHADI 13
16 JUNED 52 3604201102077600
UUN UNAENAH 45
RIZKA APRIYANTI 17
NUR NIATI LUTFI 13
WAHIDATUL MAULIDA 10
17 NURYAMAN 47 3604201102077602
ANAMAH 48
ANHARUDIN 20
S.NURLELA 16
18 SUMARLI 3604201910040034
NURYATI 28
19 SUMAENI 45 3604201910040035
HERMANSYAH 13
20 ROBIH 54 360420211040011
SUPIATI 55
SURYADI 25
DIDI RIZKI 20
RIVKI 14
21 SARBENI 48 3604202110040007
SUSI A NINGSIH 31
RIZKI HUBAIDILAH 14
BENI BELIA 8
22 SALI 69
MASNI 49
ELISAH 20
WAWAN S 20
HAERONI 18
ROMDHONI 15
23 MUHKI 54
JUNENAH 43
TAJU SOLIHIN 20
HENDRA F 17
A. RIVALDI 11
24 NURSAL 28
HUMAIROH 25
FAISAL P 10 BULAN
25 SEPTIANA 23
USWATUN H
FAQIH 21 BLN
26 JALI 36 3604202107120009
JAMSANAH 36
RINA KARIMAH 19
MILA JAMILA 19
27 JAKARIA 47 3604201102077582
MUPIAH 47
FATU SALIM 28
MUHIMATUL 15
28 MAOTOHA 47 3604201702090010
BAYINATI 44
M. BAHRUM 21
FAHRUL 13
M. RUDI 11
AMELIA PUTRI 5
APRILIA 18 BULAN
29 A. MUIS 33
PATMAWATI 23
ERLINDAYANTI 3
30 ROHMAN 38 3604202112100168
NURASIAH 28
REZA 4
31 SAIP 50 3604201410080001
UMYANAH 48
ASEP HIDAYAT 17
ASEP ISMAIL 16
M.BUKIA 11
32 UMRIAH 65 3604202110040036
MIFTAHUDIN 25
AJIBUDIN 21
S.KHOTIMAH 18
33 A. AJIS 30
FATILLAH 28
ADIM 6
34 YAKUB 49 3604201102077612
ARHAYATI 39
A.SOFYAN 23
LELA SARI 14
35 ARMIN 45 32604201102077631
SUKARSIH 42
KHORUL H 20
S. NURKHOLIJAH 15
ARDIANSYAH 7
36 BUSRO 49 3604201803090012
SARNATI 45
NANA SURYANA 24
ASEP SAEPUDIN 18
S. KHOLIFAH 15
37 RIAWAN 28
UUN UNAYAH 19
BAI UUN 3 HARI
38 HERI BEKA 33 3604201504030000
USMAWATI 28
39 MAD NUNUNG 59 3604201102077596
ENOK SUTIAH 39
EKA PERMANA 18
NINA HERLINA 16
MUHIDIN 14
DAMANHURI SAHARA 11
ALIWARDANA SAHAR 9
DANIL SAHARA 6
KARTIWA SAHARA 4
40 JONNY 38
MUDAWIAH 36
M. ANDRI K 18
M.ARDI WIJAYA 13
M. ALDISELA 13
41 SUHALI 49 3604200107090004
JUMAH 42
JUMAEDI 23
NURASIAH 18
ARYA 12
RIPAI 11
ALYAROSITA 8
RAPHEI 4
42 M. AMIN 43 3604201102077504
UMAENAH 33
KHOIRUN AZWAR 17
INDRA MAMAN 12
43 ROSID 46 3604201102077605
MARNI 33
ABDUL FATAH 18
AAT MUSLIHAT 15
44 DADAN HERDIAWAN 38 3604202709110002
IDA SOIDAH 30
ABIL ROLANSYAH 13
45 SUANDI 37 3604202112090038
IIN ROMDONAH 33
INRI YANI SAFITRI 16
M. INDRA SETIAWAN 4
46 HATIB 30 3604200611120005
ROSMIATI 31
AGUSTIANSYAH 15
47 ENJEN 43 3604202112100169
UMYATI 43
NANANG KOSIM 27
UMAEDI 25
PAHRUROJI 20
AHMAD SUPIAN SAOR 18
M. UHAR 15
48 NASAN 35
SURNAWATI 34
A. SURYANTO 10
A. VIRMANSYAH 3
49 AMSAH 48 3604200611120000
M. ASRUL 33
MEGA MUSTIKA 11
50 M. RAMON 45 3604202112100169
MUNASAROH 28
MADITIA PRATAMA 7
M.RIZKI SYAHPUTRA 4
51 M. FAILANA 33 360420180310007
SUMIATI 14
52 USRI 39
MURNI 28
NOVI ADIA 5
53 MATROJI 38 3604202112090040
NU'AH 29
RIKA MUNGTAHANAH 11
RIDWAN 8
54 SASMITA 43 3604201102077599
MUKHLISAH 42
WAHYUDIN 32
YOGI SASMITA 15
IRWAN SASMITA 11
VIKI ANDIKA SASMITA 7
55 DADANG MUHARAM 55 3604200716130001
AGIS WULAN SARI 14
ODENG SUDIRJA 14
HENDRA PRATAMA 2
56 TATANG 35
ROHENI 33
M. WAHID AWALUDI 3
57 KASURI 41 3604202110040017
 EEN 26
RIKA FITRIANA 12
AHMAD JUNAEDI 8
NIDA AULIA NADIFA 3
58 JAKARI 24
UUM 20
APRILIA UTARI 3
59 RONY A RHESA 47
ENY 38
RYAN ANGGA RHESA 18
DEWI FEBRIANI 15
KEYLIA PUTRI 2
60 ROHMAN 43
BAI ROHMAN 33
M. YOSEP MAULANA 9
YOSSI KURNIA N 7
YULIANA PUTRI 2
RINDU KARTIKA 5 BULAN
61 SAHAM 53 36042011020117628
IYAH 48
HIDAYATULLAH 19
INDAH 17
SANTINAH 14
62 SAPRUDIN 36 360420250412003
NAHLATI 26
SAHRUL NURHUSEN 3
PUTRI
63 M. YASIN 34
UMI SUMIATI 26
ST. SOLIHATUN NAJWA 3
64 MA'RUP
NURAIPAH
65 MUHAYAT 35 3604201303090015
AMNAH 40
ST. NURJANAH 8
ANDRIANSYAH 7
SRI MULYATI 4
AMIRUDIN 1
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya
Lahir BPJS Asuransi
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14
3604201205650022 12/5/1965 PBI
3604025308720004 8/13/1972 PBI
3604205904912201 4/19/1991 PBI
3604204306000006 6/3/2000 PBI
3604202310020001 11/23/2002 PBI
36042007040006 4/14/1974 ASKES
3604205904790000 4/7/1992 ASKES
3604205302040001 1/11/2004 ASKES
3604203010090001 10/30/2009 ASKES
4/24/2013 ASKES
3604202210790003 10/22/1981 LAINNYA
3604205105910003 6/15/1987 LAINNYA
3604207009030002 1/14/2009 LAINNYA
3604204906140001 6/9/2014 LAINNYA
3604200110690070
3604204907710001 7/9/1971
3604202110940001 10/21/1994
3604202804960018 4/25/1996
360420042030060 12/4/2003
3604202807650133 7/28/1965
3604206104870134 4/21/1987
3604206104990135 4/21/1999
3604200302030136 2/3/2003
3604204101420347 9/6/2009
12/12/2011
3604201107630091 7/11/1963
3604204512640092 12/5/1964
3604203103860003 9/18/1995
3604206603900095 3/16/1996
3604208088000125 8-Aug
3604205204810346 4/12/1981
3604207110010098 10/31/2001
Oct-12
3604202308730042 8/8/1974
3604206003820129 3/20/1982
3604205008040003 8/10/2004
3604205006130001 6/19/2013
3604202405760001 5/24/1976
3604206007820001 7/20/1982
360420008060200001 7/8/2002
3604201111100000 11/11/2010
36042017080002 8/17/1978
3604209511020003 11/5/2002
3604204204606840001 8/6/2004
36042024010760001 10/24/1976
3604205207800002 7/12/1980
3604200411980002 11/4/1998
3604204906020003 6/9/2002
360420404140001 3/4/2014
3604201146670003 8/11/1967
3604205502710002 2/15/1971
360420290680002 4/8/1996
3604200712020003 12/7/2000
3604205702100001 2/17/2010
3604201002320001 2/10/1932
3604204604520002 4/6/1952
3604204306930002 8/3/1993
3604200505730003 5/5/1973
3604205011760004 11/10/1976
3604202409080001 9/24/2008
3604202012610001 12/20/1961
3604204707670002 7/7/1967
3604200405020002 5/4/2002
3604201306630002 6/13/1963
3604205407700005 7/5/1970
3604204704980004 4/7/1998
33604206211020002 11/22/2002
3604205004050002 4/10/2005
3604200508680002 8/5/1968
3604204711670001 11/7/1967
3604200101950025 1/1/1995
3604206108990002 8/21/1999

3604205708870002 8/17/1987
3604203105780001 1/1/1970
3604200507020003 7/5/2002
3604200708610165 8/7/1961
3604205204600166 4/12/1960
3604201608900168 8/16/1990
3604200502950165 2/5/1995
3604202208010170 8/22/2001
3604200710670171 10/7/1967
360420420840172 4/2/1984
3604200807010173 7/8/2001
3604206203070001 3/22/2007
360420091460049 11/9/1946
3604205205660050 5/12/1966
3604204309890002 9/3/1989
3604201408950053 8/14/1995
3604201309970054 9/13/1997
3604202012000055 12/20/2000
3604201709610030 9/17/1961
3604206011720031 11/20/1972
3604202403950034 24\3\95
3604201003980035 3/10/1998
3604203105040036 5/31/2004
3/26/1988
3604204401900032 1/4/1990
12/3/2015
3604200909920002 9/9/1992
8/16/1995
1/20/2014
3604201906790004 6/19/1979
3604204110190003 10/1/1979
3604206604960002 8/26/1996
3604204105960001 5/1/1996
3604201806680002 5/1/1968
3604204703690002 3/7/1968
3604200101880037 1/1/1988
3604204709000001 9/7/2000
3604202007660001 7/20/1966
3604204512710048 12/5/1971
3604202006940049 6/20/1994
3604206006920349 7/24/2002
3604201608050002 8/16/2005
2/20/2010
4/3/2014
7/15/1982
6/9/1992
10/7/2012
3604200509770001 9/5/1977
3604205305870001 5/13/1987
10/6/2011
3604200812650151 12/8/1965
3604204406670152 6/4/1967
3604201111980117 11/11/1998
3604201005990089 5/10/1999
364201006040085 8/10/2004
3604204907500126 7/9/1950
3604201210900130 10/12/1990
3604202407940131 7/24/1994
3604206601970132 1/26/1997
3604200510850056 10/5/1985
12/22/1986
8/24/2009
3604201202660001 2/12/1966
3604205205780003 5/12/1976
360420040890005 8/4/1992
3604200408920005 1/10/2001
360420611700001 11/6/1970
3604205909730003 9/19/1973
3604200712950002 12/7/1995
3604204505000003 5/5/2000
3604202804080001 4/28/2008
3604200511660144 11/5/1966
36042048027081998 2/8/1970
3604200601910148 1/6/1991
3604200506070156 6/5/1997
3604205210000252 10/12/2000
3/20/1987
10/24/1996

3604200506820003 5/5/1982
3604207000570001 6/30/1987
3604200510500001 10/5/1956
3604206208760001 8/22/1976
3604206005970004 5/20/1997
3604206408990001 6/24/1999
3604201008010002 8/10/2001
360420140740003 7/14/2004
3604200909080001 9-Sep
3604201809090003 9/18/2000
3604200109110002 9/1/2011
7/7/1977
5/18/1976
12/17/1997
1/2/2002
1/2/2002
360420100660002 6/10/1966
3604204505730005 9/5/1973
3604200501920001 1/6/1992
3604204909970003 9/9/1997
3604200306030001 6/3/2003
3604200709040001 9/7/2004
3604205610070001 10/16/2007
3604200904110001 4/9/2011
3604200406720000 6/4/1972
3604204203220004 3/2/1982
36042019009980002 9/19/1998
3604204200701030001 1/7/2003
3604202710690003 10/22/1969
3604206003820004 3/20/1992
3604201205972001 5/12/1997
3604201909900001 9/19/2000
3604201403770003 3/14/1977
3604206007850001 7/20/1985
3604202704020109 4/27/2002
36042001002780003 2/1/1978
3604204203820002 3/2/1982
3604205510990001 9/5/1999
10/29/2011
3604201112850003 12/11/1985
3604204304840004 4/3/1984
3604200608080001 8/6/2008
3604200107720072 7/1/1972
3604204608720073 8/6/1972
3604200709880075 9/7/1988
3604202410900076 10/24/1990
3604200507950077 7/5/1995
3604200405970078 5/4/1995
3604201603000079 3/16/2000
3604201407800001 7/14/1980
3604204503810003 3/5/1981
3604202105050002 5/21/2005
3604201305120003 5/13/2012
12/7/1967
360420101920003 10/10/1992
3604205708020004 8/17/2002
3604200104700004 4/1/1970
3604204702870001 2/7/1987
3604202801080001 1/28/2008
3604203001120001 1/30/2012
3604200202820005 2/2/1982
3604204907960002 7/9/1996
3/6/1976
5/4/1987
11/10/2010
3604200507770007 7/5/1977
3604206509860001 9/25/1986
3604204206040003 6/2/2004
3604202906070002 6/20/2007
3604200505720003 5/5/1972
3604206006730001 6/20/1973
3604201507430001 7/15/1993
3604202604000000 4/26/2000
3604200209020005 9/2/2002
360420290480001 4/29/2008
3604230112600003 1/12/1960
36042065061140002 9/5/1994
3604230410010005 10/4/2001
3604231703080001 10/1/2013
12/1/1980
12/1/1982
2/5/2012
3604201007740085 7/10/1974
360420403890086 3/2/1984
360420341050001 11/11/2003
3604200106070004 6/1/2007
11/4/2012
11/20/1991
5/16/1995
4/4/2012
3604200303680000 3/3/1968
3604204710770001 10/7/1977
3604200806970004 6/8/1997
3604204402000003 2/4/2000
11/19/2013
3/5/1972
30/02/1982
7/30/2006
1/14/2008
3/30/2013
4/30/2015
3604201005620000 10/5/1962
3604204611670001 6/11/1967
3604201204960006 8/4/1996
3604204906980005 9/6/1998
6/18/2001
3604203008790001 8/30/1979
36042058038900021 3/18/1989
3604200602120001 2/6/2012
11/10/2015
8/6/1981
1/6/1989
8/10/2012
1/1/1988
5/11/1992
3604201204800057 4/12/1980
360420580575076 5/16/1975
3604204108070001 6/1/2007
3604202509060001 9/25/2008
10/9/2011
10/4/2014
N IBU DAN BAYI
Pekerjaan Umur Kehamilan
KK
1 2 3 4 5 6 7 8 9

15 16 17 18 19 20 21 22 23 24
BURUH

PNS

BURUH

TANI

LAINNYA

LAINNYA

LAINNYA

BURUH

BURUH

BURUH
BURUH

BURUH

TANI

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH
BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH 5 BLN

BURUH
BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH
BURUH

BURUH
BURUH

BURUH

BURUH

BURUH

BURUH

BURUH 5 BLN MARET

Taksiran Peserta Status
Persalinan KB Kemiskinan

25 26 27
KS II
S

KS III
S

KS II
PIL

KS I
PIL

KS I
S

KS II

KS II
S

KS II
S

KS I
 KS II
S

KS I
MOW

KS I

KS I

KS III
MOW

KS II

KS II
S
KS II

KS II
S

KS II
 KS II
S

KS II
S

KS II

KS II

KS II
S

KS II
PIL

KS II
S

KS II

KS II
 KS II
S

KS I

KS I

KS II

KS I

KS I
S

KS I
S

KS II
PIL

KS I
PIL

KS II
 KS II

KS II

KS II

KS II

KS I

KS II
S

KS II
S

KS II
S

KS I
S

PRA KS

KS I
S

KS I
S

KS I

KS I
S

KS I
S

KS I

PRA KS
NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 MAKUDI K 43
SUHAYAH K 42
FAHMI BK 18
NURIL WIDI BK 15
2 KH. A BADRUDIN K 72
FATMAWATI K 45 3604201102077732
A. YUDI TQ BK 26
AWAN BK 22
ZAHROTUL Q BK 19
NIDAUL F BK 14
3 MUNAWAR K 58 3604201102077811
TUHTI K 47
M. RASIDI BK 29
A.NAWAWI BK 23
ST. SUNENGSIH BK 20
RODAD BK 18
MUSRIPAH BK 15
4 M.SOLEH K 49 3604200302050006
MURDIAH K 45
TATU FARIDA BK 21
FITRIAWATI BK 19
5 WAHYUDI K 32 3604202606120001
IIN MUNIROH K 34
AMANDA BK 3 3604200302050031
6 A. DIMYATI K 34
TUTI SUMAROH K 26
ST. WILDA BK 7
7 TEJO SUWARNO K 33 3604202606120001
SAROH K 26
8 SUWANDI K 41
EMAH K 36 3604201611090010
ELA BK 18
ASEP BK 13
9 HAERUDIN K 34 3604202112100188
ST. SOHIMAH K 31
ISMAIAH BK 6 3604201102077683
ST.UNENGSIH BK 20
ST. MUSRIPAH BK 15
10 KOMARUDIN K 36
MISKIYAH K 31 3604201902100002
11 ASIRI K 83
HAERIAH K 59
UUS RUSIAH BK 19
12 ABDULOH K 26
ROSILAH K 24 360420030112002
13 ROHIM K 41
TITIN P K 32 3604200302050023
14 BADRUDIN K 57
RUBIYAH K 51
ROPUDIN BK 21 3604200602130003
NURAENI BK 20
15 UDIN K 49 3604202509120003
AISYAH K 54
HOPIDOTUN N BK 17 3604200111040018
ST. SUSANTI BK 15
16 NAZARUDIN K 40
ISWATI K 27
17 BAEHAKI K 39 3604202307040037
TATU AMALIAH K 27
20 YAYANG K 38
TOLIAH K 30
21 M.MEMED K 44 3604202112100192
PATHIYAH K 38
ST.UNSIAH BK 21 3604192704100005
A.FAHRUDIN BK 18
ST.MARYANTI BK 15 3604200611070008
22 KAHFI K 65
UMUL BAROHIYAH K 54 3604031010500008
USNIDAH BK 20
23 SARAN K 43
MARSAH K 35
24 SUPRIATNA K 34
IMAS R K 33 3604201102077698
25 ARIPUDIN K 43
WASIAH K 32
26 IBAD S K 43 3604202112100185
MUTOHILAH K 34
ST. ANISA BK 18 3604201102077679
27 HAPIPI K 33
SITI K 31 3604202307040036
28 JAENUDIN K 51
HAYATI N K 44 3604201102077680
30 M.ROJI K 43
IYAH HIDAYAH K 34
31 A.FARID MUKIM K 39 3604207112090022
LILIS T K 42
TIKA P BK 22 3604202307040016
32 HERI K 36
NINA MULYANA K 31 3604201102077733
33 PATONI K 41
MUTMAINAH K 35 3604201102077542
34 SAHIYAH K 54
TUSIAH K 20
35 ROHMAT K 31 3604202605100015
UMINAH K 20
36 ROHIMI K 39 3604201102077713
SUTIHAT K 39
37 MUZDALIFAH K 38 3604201102077729
IIS SAEHILA K 19
LISDA T BK 15
LISNA P BK 13
38 A. SUJAI K 33 3604200503130003
ST. NURBAETI K 23
39 SAADUDIN K 43 3604201102077736
HERLINA K 40
ISHMA BK 21
LUSI BK 18
40 NURUL GOMAM K 34 3604202803120001
ROHIMAH K 24
41 SUBHKI K 39 3604201002140003
MARYATI K 18
42 BAHRUM K 38 3604201810070006
SARTIAH K 36
ST. ROHAYATI BK 15
43 ASMUDIN K 44 3604201102077708
ROSIAH K 28
44 JUNED K 45 360420211210078
ALIAH K 44
45 MASYHURI K 39 3604201102077697
MAHDANIAH K 36
46 A JAYA K 35 3604200302050025
SUKASIH K 29
47 KAMSO K 32 3174041710131024
YULIA S K 30
48 ADE LAHAD K 48 3604200308090001
NENENG L K 35
49 SAEPUDIN K 27 3604200305130004
JIROH JAZIROH K 21
50 MASHUDI K 39 3604201102077748
IIN NURSILAH K 30
51 SALIM K 47 360420110207778
MURNAWIAH K 43
52 ABDUL MALIK K 44 3604201102077682
LISNAWATI K 32
53 M.MUHAROJI K 39 3604201102077794
UMROH K 35
54 DUDI JUNAEDI K 31 3604202304130003
ACIH MINTARSIH K 27
55 SAMSUL BAHRI K 24 3604200302150005
 MASWATI K 23
56 ASEP S K 26 3604203009150003
EVA MULYATI K 21
57 JAHRAN K 51 3604202511090001
OMAH K 46
HERI FATMAWTI BK 15
58 SARMAN K 28 3604202706130041
SITI BASARIAH K 23
59 SAIBATUL HAMDI K 32 3604202112100184
SUSILAWATI K 29
60 MADSUNI K 39 3604201612140003
JIRAH K 22
61 FRANS K 36 360420702120002
IIM HALIMAH K 32
62 DUPRATI K 49 3604201102077691
ST. MATORIAH K 17
63 ACEP K 35 3604201102077770
TITIN PATIMAH K 32
64 BAHUDIN K 39 3604202112100190
LILIS JAJILAH K 32
65 WAWAS S K 45 3604201102077700
1 BAI BADARIAH K 45
TITA NURDIANI BK 20
NITA NURDIYANI BK 14
66 ALEX IBRAHIM K 42 3604200304130003
TATI HERAWATI K 32
67 ASEP S K 45 3604201102077817
UMI LAELATUL H K 40
68 ANWAR K 14 3604201102077728
ENENG K 38
ST. ANDRIYANI BK 26
69 BUDIMAN K 25 3604202604130004
LIA WAROKA K 25
70 DEDEN S K 42 3604201702120001
JULAEHA K 38
71 MUHIT K 29 3604203101850015
EMI K 31
72 MULYADI K 38 3604202709120003
ST. ROMLAH K 35
73 EDY SABIHIS K 34 3604201306120002
ROISAH K 28
74 H HAMBALI K 34 3604202112100174
NENENG MAESAROH K 28
75 SUHARJA K 35 3604202912090073
MAFFUHAH K 27
76 BAI MAHDI K 50 3604201102077805
HOLIDAH K 39
ST. TOIPAH BK 18
77 IING SOLIHIN K 37 3604200403130001
SUHERTI K 27
78 MUKHLIS K 48 3604200302050021
ENTIN K 41
YAYAN BK 24
ELIYAH BK 18
79 HILMA BK 23 3604201102077685
NINA BK 18
80 A. MATORI K 43 3604202212090054
ETI HAYATI K 31
81 ARI K 56 3604200205110002
IYAM K 42
82 MAMI K 49 3604201910070001
SODIKOH K 41
ST. MAHIYAH BK 22
ST. NURMALA BK 17
83 SUPRANI K 40 3604201702100028
NURELAH K 31
84 ABD HAKIM K 43 3604202212100150
KOMARIYAH K 30
85 YANA SUNARYA K 50 3604202509120005
AYI NURANI K 40
86 IYEP ZAENAL K 28 3604202006140006
TIKA K 24
87 ABD MAJID K 42 3604201102077768
ST. AMINAH K 33
88 ROMDANI K 46 3604202107090006
ST. HASANAH K 40
TITI WIDIYANTI BK 15
89 SAMUN K 54 3604201102077741
SUHADAH K 46
AAM S BK 22
ST. SUMAIROH BK 18
NURWATI BK 15
90 ASPURI K 38 360420110207756
ELIYAH K 38
91 TATANG I K 46 360420110207701
MELASARI K 34
92 SUBARTA K 64 3604201102077703
NURHAYATI K 52
SUMIATI BK 18
SUNTIAWATI BK 17
93 SATORI K 31 3604200608120003
ST. ANISAH K 28
94 MUMUN F K 18 3604201102077773
MIMIN M K 18
95 NURHADI K 34 3604200706120008
ILAS SULASTRI K 27
 96 HAMZANI K 46 3604201102077727
ASMENAH K 44
EMAN S BK 23
LAELATUS S BK 15
97 TUGINI K 53 3604201102077750
IDRUS KAMIL K 22
NATIK M.U BK 18
98 PATONI K 72 3604202107040033
JUMAENI K 52
A. NAWAWI BK 18
DAMAIYAH BK 17
99 A. MUTANI K 38 3604201102077696
YULIYANTI K 34
100 MA'RIFAT J 30 3604202112090020
101 JAMJURI K 30 3604201401150009
SULANI K
102 ARI K 360420020510002
IYAM K
SULAEMI BK
A.ADUDI BK
SULISTIAWATI BK
103 SAEFUL BAHRI K 3604201104120004
ANAH K
IYAN SURYANA BK
M.FADLI BK
ST. NURAJIZAH BK
104 SAMADHURI K 3604200309120001
KHUSNUL KHOTIMAH K
NIA NURFAJRIAH BK
HARIS FADILAH BK
105 SUBARTA K 3604201102077703
NURHAYATI K
AEP BK
SUMIATI BK
SUNTIAWATI BK
106 JAHRAN K 3604201102077791
ENDAH K
MUHTAHIMI BK
NENG KHAERIAH BK
107 ALI MUHTAR K 3604201102077685
HAPSAH K
HILMA BK
NINA BK
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan
Lahir BPJS Asuransi KK
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15
3604201003730003 3/10/1973 BURUH
3604206805740002 5/28/1974
3604202109980001 9/21/1998
3604205301010001 1/13/2001
3604201504570001 4/15/1957 WIRASWASTA
3604204305740004 9/1/1971
3604201107900001 7/11/1990
3604201312940001 12/13/1994
3604204203970004 3/2/1997
3604205810030003 10/18/2003
3604201007580034 7/10/1958 BURUH
3604205008690035 8/10/1969
3604200404870037 4/4/1987
3604201109930039 9/11/1993
3604206110960040 10/21/1996
360420508980041 8/6/1998
3604206103010042 3/21/2001
3604201011670150 11/10/1967 BURUH
3604205202710151 2/12/1971
3604204101950152 1/1/1995
3604204602970153 2/6/1997
3604230403850004 3/4/1985 BURUH
3604204705820001 5/7/1982
3604206606120008 6/26/2012
3604200103770003 3/1/1977 BURUH
3604205507890001 7/15/1989
3604207009090001 9/30/2009
3604201006820002 6/10/1982 BURUH
3604204504890002 4/5/1989
3604202710750001 10/27/1975
3604205010800007 10/10/1980 √
3604206002980002 2/20/1998
360420241203004 12/24/2003
3604201104620005 4/11/1982 WIRASWASTA
3604204112860003 12/1/1986
3604206501100001 1/25/2010
3604206110960040 10/21/1996
3604206103010042 3/21/2001
3604201710800001 10/17/1980 BURUH
3604205008860004 8/10/1986
3604200506330107 6/5/1933 BURUH
3604204203570108 3/2/1957
3604204101880110 10/25/1997
3604201212990002 12/16/1989 BURUH
360420456069200004 6/5/1992
3604200408760002 8/4/1975 BURUH
3604204111830003 11/1/1983
3604200101590079 1/1/1959 BURUH
3604206307650060 7/23/1965
3604201005950082 5/10/1995
3604205003980083 6/10/1996
3604200801670176 1/8/1967 BURUH
3604204308620076 8/3/1962
3604205203990180 3/12/1999
3604205010000181 10/10/2000
3604200711760001 11/7/1976 BURUH
3604204705890003 5/7/1989
3604191002770003 2/10/1977 WIRASWASTA
3604194707890003 7/7/1989
3604202506780005 6/25/1978 BURUH
3604204711860214 11/7/1986
3604202501720037 1/25/1972 PEDAGANG
360420450680038 6/5/1978
3604202309950039 9/23/1995
3604200508980040 8/5/1998
3604205512010041 12/15/2001
3604200103510002 3/1/1951 BURUH
3604204408620002 8/4/1962
3604204102960003 2/1/1996
360420101730002 10/21/1973 BURUH
3604206504310002 4/25/1981
3604200405920002 5/4/1982 BURUH
3604206805830001 8/28/1983
3604200305750172 5/3/1973 PEDAGANG
36042041018405173 1/1/1984
3604200102730002 2/1/1973 BURUH
3604204203820005 3/2/1982
36042070079800001 7/30/1998
360420608830001 8/6/1983 BURUH
3604205103850007 3/11/1985
3604202002650080 2/20/1965 BURUH
3604204101720081 1/1/1972
3604201804730001 4/18/1973 WIRASWASTA
36042048020002 2/8/1982 √
3604200206770004 6/2/1977 BURUH
3604207103740001 3/31/1974
3604206206940001 6/22/1994
3604201009800002 9/10/1980 √ BURUH
3604204402850003 2/4/1985
3604202006750002 6/20/1975 PEDAGANG
3604204607810002 7/6/1981
36042050046200003 4/10/1962
3604205708960006 8/17/1996
3604200101850003 1/1/1985 BURUH
3604204512860003 12/5/1986
3604200408770001 8/4/1977 √ BURUH
3604204206770001 6/2/1977 √
3604205706780002 6/17/1978
3604204812970001 12/8/1997 √
3604205902010001 2/19/2001 √
3604204402030003 2/4/2003
3604201005930003 5/10/1983 BURUH
3604206904930001 4/29/1993
3604200103730004 3/1/1973 BURUH
3604206512760001 12/25/1976
3604206809950001 9/28/1995
3604206409960001 9/24/1998
3604201708820003 8/17/1982 BURUH
3604204107920003 7/1/1992 BURUH
3604201202870003 2/12/1987
3604206510880001 10/25/1988
3604201011780167 11/10/1978 BURUH
3604204603800010 3/6/1980
3604205112000001 12/11/2000
360420110720002 10/10/1972 BURUH
3604204101880023 1/1/1988
3604201707710002 7/17/1971 BURUH
3604204812720001 12/8/1972
3604201402770003 2/14/1977 √
3604204308780001 8/3/1980
3604201010810115 10/10/1981 BURUH
3604204507870116 7/5/1987
317444140484007 4/14/1984
3174046707860007 7/27/1986
3604200605680002 5/6/1968 KARYAWAN SWASTA
3604205708810002 8/17/1981
3604201408090004 8/14/1989 BURUH
3604204806960003 5/8/1995
3604200908770001 8/4/1977 BURUH
3604204507860001 7/5/1986
3604202303690001 3/23/1969
3604206105730001 5/21/1973
3604200707720003 7/7/1972 BURUH
3604204204840005 4/2/1984
3604200407770001 7/4/1977 BURUH
3604204707810005 7/7/1981
3604201210850002 10/12/1985 BURUH
3604206707090002 7/27/1989
3604200604920006 4/6/1992 BURUH
3604206409930001 9/24/1993
3208182908900001 8/29/1990 KARYAWAN SWASTA
3604204201960004 1/2/1995
3604202306650001 8/23/1965 BURUH
3604204101700040 1/1/1970
3604205004000003 5/10/2000
3604191308880003 8/13/1988 BURUH
3604204503930002 3/6/1993
3604200910840001 10/9/1984 BURUH
3604205909870001 9/19/1987
3604202002770001 2/20/1977 BURUH
3604204404940004 4/4/1994
3604201606800003 6/16/1980 BURUH
3604204707840002 7/7/1984
3604206808670001 8/28/1967 IRT
3604204508990002 8/5/1999
3604201404810003 4/14/1981 BURUH
3604206405640004 5/24/1984
3604200807770003 7/8/1977 BURUH
3604204303840005 3/3/1984
3604200304700002 4/3/1970 BURUH
3604204101700032 1/1/1970
3604206102960003 2/21/1996
3604205112020003 8/12/2002
3604200704740004 4/7/1974 WIRASWASTA
3604204507830005 7/5/1983
3604200107740003 7/1/1974 BURUH
3604204703830004 3/7/1983
3604200101700042 1/1/1970 BURUH
3604204101750033 1/1/1975
3604204708020001 8/7/2002
3604203012780007 12/20/1978 BURUH
3604206005890004 5/20/1989
3604202111880003 11/21/1988 √ WIRASWASTA
3604200205660002 6/12/1988 √
3604200811740081 11/8/1974 BURUH
3604204507780082 7/5/1978
3604202403870003 3/21/1987 BURUH
3604205806860002 6/18/1985
3604201607780004 7/16/1978 PEDAGANG
3604204905810002 5/9/1981
3604201507820001 7/5/1982 BURUH
3604204404880001 4/4/1988
3604201206810005 6/12/1981 BURUH
3604207005890003 5/30/1989
3604200607660001 7/6/1966 BURUH
3604205908770001 8/19/1977
3604204310980002 10/28/1998
3604240902790002 2/9/1979 BURUH
360425408890001 8/14/1989
3604200101670098 1/1/1967 BURUH
3604204101750099 1/1/1975
3604200101920100 1/1/1992
3604204101980101 1/1/1998
3604205008930002 8/10/1993 PELAJAR
3604205309980002 9/13/1998
3604201207730005 7/12/1973 BURUH
3604205502850001 2/15/1985
3604200500600001 8/5/1960 WIRASWASTA
3604204506740003 8/5/1974
360420505670012 5/5/1967 WIRASWASTA
3604204503750001 3/5/1975
3604204206940001 6/2/1994
3604204407990233 7/4/1949
3604201205760001 5/12/1976 BURUH
3604205108850004 8/11/1985
3604201011730002 11/10/1973 BURUH
3604205407860001 7/14/1986
3604200303660001 3/3/1966 KARYAWAN SWASTA
3604206008760003 8/20/1976
36042017128800011 12/17/1988 KARYAWAN SWASTA
3604206109910002 9/21/1991
3604202104740003 4/21/1974 PEDAGANG
3604205901830001 1/19/1983
3604201511700002 11/15/1970 √ BURUH
3604205807760002 7/16/1976 √
360420620500003 5/22/2000 √
3604201304620001 4/13/1962 BURUH
3604204507700006 7/5/1970
3604206210940002 10/22/1994
3604204809980002 9/8/1998
3604205611000002 11/16/2000
3604201608780001 8/16/1978 BURUH
3604204808780003 8/8/1978
3604201111700002 11/11/1970 √ WIRASWASTA
3604204403810001 3/4/1983 √
3604200101520016 1/1/1952 WIRASWASTA
3604205503540001 3/16/1964
3604204511980002 11/5/1998
3604206011990002 11/8/1969
3604201412950002 12/14/1985 KARYAWAN SWASTA
3604204754890005 4/7/1988
3604204905980002 5/9/1998
3604204805900001 5/9/1998
3604201908820002 8/19/1982 BURUH
3604205107890004 7/11/1989
3604201202700002 2/12/1970 BURUH
3604206109720003 9/21/1972
3604203009930008 9/30/1993
36042048903000002 3/8/2000
3604206901630001 1/29/1963 IRT
3604201202940002 2/12/1994
3604204504970001 4/5/1997
3604201011440151 11/10/1944 BURUH
3604204407640152 7/4/1964
3604200306970157 6/3/1997
3604204503990158 3/5/1999
3604202406780002 6/26/1978 BURUH
3604204403820002 3/4/1982
3604206311860001 11/23/1986
3604201507870004 7/15/1987 BURUH
3604205502920001 11/14/1990
3604200500800001 8/5/1960 BURUH
3604204508740003 8/5/1974
3604201110910001 10/11/1991
3604201106960003 6/11/1996
3604206707990003 7/17/1999
3604200607640002 7/6/1964 BURUH
3604205405690001 5/14/1969
3604200810910003 10/8/1991
3604200206940002 6/2/1994
3604206011980002 11/20/1998
3604200405870001 5/4/1967 KARYAWAN SWASTA
3604204805750004 5/8/1975
3604204706960005 6/7/1996
3604202010990004 10/20/1998
3604200101520016 1/1/1952 WIRASWASTA
3604205505640001 3/16/1964
3604206808940001 12/16/1995
3604204511980002 11/5/1998
3604206011996002 11/8/1999
3604202607740001 7/26/1974 BURUH
3604205006680003 6/10/1968
3604200510950004 10/5/1995
3604202310970002 10/23/1997
3604202310350001 10/23/1935 BURUH
3604206205450001 5/22/1945
3604205006930002 8/10/1993
3604205309980002 9/13/1998
 Umur Kehamilan Taksiran
Persalinan
1 2 3 4 5 6 7 8 9

16 17 18 19 20 21 22 23 24 25

WIRASWASTA

Mar-16

DESEMBER

WIRASWASTA
WIRASWASTA

PEDAGANG

PEDAGANG

WIRASWASTA

DESEMBER

PEDAGANG
 Mar-16

KARYAWAN SWASTA

JANUARI
KARYAWAN SWASTA

WIRASWASTA

WIRASWASTA

PEDAGANG
Feb-16

Apr-16

OKTOBER
WIRASWASTA

WIRASWASTA

KARYAWAN SWASTA

KARYAWAN SWASTA
Dec-16
PEDAGANG

Jun-16
WIRASWASTA

WIRASWASTA

KARYAWAN SWASTA
 Jun-16
Jul-16

KARYAWAN SWASTA

WIRASWASTA
 Peserta Status
KB Kemiskinan

26 27
KS II
S

KS III
S

KS II

KS II

KS II

KS II
DESEMBER

KS II
S
KS II
IMPANT

KS II
S

KS II
S
KS II
 KS II
S
KS II

S KS I

KS II

KS II

KS II
S
KS II
S
KS II
S

KS II

KS III
S
KS II
S
KS II
S
KS II

KS II
S
KS II

KS II

KS II
DESEMBER

KS II

KS II
 PRA KS

KS II
IMPLANT

IMPLANT
KS II
S

KS II
S
KS II

KS II
S
KS II
S
KS II

KS II
S
KS II
S
KS II
S
KS II

KS II
S
KS II

KS II
S
KS II
S
KS II
S
KS II

KS II
S
KS II
S
KS II
 KS II

KS II
MOP

KS II
S
KS II
S
KS II
S
KS II
IUD
KS II
S
KS II
S
KS II
S
KS II
S

KS II
S
KS II
IUD
KS II

KS II
S
KS II
S
KS II
S

S
S

S
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KS I
S

KS II
S

S
KS II

KS I
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S KS II

KS II

KS I

KS II

KS II

KS II
 KS II
S

KS II

KS II

KS II

KS II
KS II
S
KS II
S

KS II

KS II

KS II

KS II

KS II
 F
NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 AHMAD UP K 49 360420012090002
RUMI K 47
UMIN BK 26
MULYATI BK 22
UNAYAH BK 19
NANI BK 17
A YANI BK 14
DARTO BK 18
2 EMAN. S K 31 360420070108007
ARPAH K 24
ARIS BK 8
AGUN BK 1
3 KOMARUDIN K 36 3604201001140001
SAINAH K 30
ALFIRA . N.A BK 3
4 SOMA K 30 3604201709140002
SUNTI K 22
5 MARHANI K 28 360420110207784
ISPAH K 31
MARYATI BK 12
AAP PRIANI BK 3
6 AHYANI K 51 360402107040025
MAMAH K 40
ANISAH BK 10
7 SUKAEMI K 77 3604201102077845
UMSI K 43
JUMHANI BK 23
RONI BK 20
IIN . N BK 17
INTAN. S BK 15
RIZAL BK 12
LIVIA BK 8
8 JUPRI K 44 3604201102077849
IKOH K 41
EPRIA . N BK 16
ENDANG . S BK 10
EVA . R BK 1
9 MADALI K 44 3604201102077843
JUMSINAH K 38
MUHENI BK 19
MARHANAH BK 14
SEPTIA. R BK 1
10 HASANUDIN . B K 32 3604202709120002
 AMINAH K 23
NASYA . K BK 3
11 JUNAEDI K 43 36042011020777831
SANTINI K 40
DENI BK 14
SIFA.A BK 2
SOFI.L BK 2
12 WAGIONO K 30 3604202112100197
SUTINI K 27
RIZKI.M BK 5
13 YANTO K 37 3604201102077839
IMAS K 32
IMAMUDIN BK 14
HANDRIH BK 7
14 NUROHIM K 43 3604201709140001
RUSTIANA K 33
BAYU.S BK 15
MEGA DS BK 12
FAUZAN BK 7
15 JAMHARI K 44 3604201102077864
ASMI K 38
RAMADIN BK 8
RUSITA BK 6
16 BAHRONI K 46 36042015060400038
ROSIAH K 42
NURSAENI BK 24
ROSYID BK 20
HERYANTI BK 14
17 UTI S K 45 3604202001110008
UMAMAH K 41
BAINAS BK 21
YUYUN BK 14
SUHENDRA BK 13
18 DUL KOID K 58 3604201102077865
NURLELA K 46
NURSIAM BK 27
NOVITRI BK 9
IBNU A BK 7
19 ROHALI K 57 3604201212050014
RUMENAH K 48
M RUHIYAT BK 22
M ROHMAN BK 19
20 FALAK K 37 3604201102077859
UUM K 35
UMAEDI BK 12
M BISRI BK 5
21 MARHAFI K 32 3604203112090055
NURLINA K 26
 M ANGGA S BK 6
22 SANALI K 55 3604200710050017
RASTI K 62
RAMIN BK 27
23 MIHLAT K 51 3604201102077842
BAI K 49
CATONO BK
EMI BK
24 JAENAL A K 3604202111040036
TUNENAH K
M DIYAS BK
25 LUTFI K 36 3604200809070002
ROHAETI K 41
ANISA.F BK 14
26 GOPUR K 38 3604201912060001
AMINAH K 32
HAFID BK 14
27 NASRUDIN K 38 3604203001060006
MARYAM K 33
RIKA.S BK 15
M.FARHAN BK 10
28 MASKA K 48 3604202111040027
TAWIYAH K 43
TARMIDI BK 19
TARSIM BK 16
MASITOH BK 13
29 ALIYONG K 47 3604202607040027
APIAH K 40
APTI P BK 21
DICKY P BK 13
30 ARJAYA K 57 3604201102077823
OMEH K 35
OBI BK 20
SUPINA BK 19
HAMSI BK 16
AMI BK 12
31 BAHRUM K 43 3604201102077846
ONAH K 30
HAMID BK 12
NURBAETI BK 5
32 SARDI S K 40 3604200803060001
NENI K 34
M.FADILAH BK 12
FAJRI.U BK 8
33 ARHANI K 35
ST.JAHROH K 30
ST.ASIAH BK 5
34 SUKIA K 55 3604202906060005
 ESIH K 52
SULASTRI BK 21
SUHESTI BK 21
35 M YUSRO K 46 3604200206100013
NURSI K 42
M YANI BK 24
YAYAH BK 18
ST.NURSIANA BK 13
YUNINGSIH BK 8
36 M NURASYID K 41 3604202309100001
MUNJIAH K 40
SURNAJA BK 16
FITRIANAH BK 15
NURELINA BK 13
M FAHMI BK 8
M SURJANA BK 4
37 ABDUL YUSI K 34
NYAI YATI K 27
ST.KHAERANI BK 9
38 MUHRIJI K 45 36042002104100006
BABAY K 40
MUHARI BK 18
M.RIYAN BK 6
39 SUKI K 38 3604201102077837
SARNITI K 34
SUNARTI BK 16
REVALDI BK 12
RISMAN BK 4
40 ATMA W K 36 3604800710050012
TASWINI K 28
M.PURNADI BK 9
LIA BK 2
41 YUSUF K 50 3604202307090015
SARTI K 35
MILDA S BK 12
ALVIN A BK 9
42 RUSDI R K 53 3604202311090001
MUNTINI K 53
M.RIDWAN BK 28
M.RIKY BK 21
43 MUKLISIN K 40 3604201102078007
ENTI K K 36
NURHUDA BK 11
44 SAHRONI K 33 3604203011090016
ILAH K 32
M.IRFAN BK 5
45 A MULYANI K 29 3604201002120012
RAMLAH K 27
 SAEFUL BK 2
46 NAJIRIN K 40 3604202112100209
TASLINAH K 33
UMAEDI BK 16
FAJAR BK 11
NAISILA BK 6
47 MADEONI K 43 3604201102077848
IYUM K 38
AMUD BK 16
MAEMUNAH BK 15
48 H.EDI K 37 3604201102077262
NURJANAH K 33
M.IKBAR BK 20
JAENUDIN BK 18
WARMAN BK 13
49 HAMDAN K 35 3604201102077853
ISAH K 31
HASMAN BK 12
ST.HALIDAH BK 6
50 IRWAN D K 38
HAYATI N K 28
NENENG I BK 14
NURUL A BK 8
KHAERUL F BK 6
LUIS IRA BK 3
51 SUBRANTO K 40
NEWI K 34
RIFQI A BK 10
M RAFIQ BK 6
52 SALAM K 61 3604201102077838
RUSLI K 28
RAMADAN BK 19
53 MULYANA K 30 3604202112100205
NOVI E K 28
NAZIHRA BK 7
54 SAIDIH K 33 3604202806110003
TINI K 24
WILEHAM A BK 2
55 PENDI K 42 3604201102077875
MUTIAH K 45
MANSORI BK 19
AHMAD BK 9
56 HAERIAH K 59 3604201506040040
ISMI AJIZ K 26
57 TASMI K 66 3604201710050005
58 SUPARMAN K 56 3604201102077867
HAMDAH K 51
SURANI BK 24
 SUHERTI BK 19
RAHMAT BK 35
59 HUDORI K 72 3604200710050015
ASIH K 43
60 SUMALAH K 70 3604282111840036
61 NARJO K 84 3604202111840037
JANAH K 75
62 SANI K 57
63 KARSA K 57 3604202111040035
BADRIAH K 56
64 M.MADUN K 68 3604202007040020
MURTI K 64
65 MISNAENI K 65 3604201102077850
66 ASMARIAH K 75 3604204107400123
67 SURAI K 63 3604201102077862
AHERI K 27
68 NURDIN K 66 3604201102077221
ARSINAH K 64
NURHALIM BK 35
69 TASMI K 80 3604201122777840
TARSAN K 24
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan
Lahir BPJS Asuransi KK
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15
3604200105660001 √ BURUH
3604204101680029 √
360420060389003
3604206001930002
3604204107960001
3604206212980001
3604201208010002
3604200312970002
3604200880984002 √ BURUH
360420410786000
3604201304070002

36042023067090002 √ BURUH
3604204705850001
3604208504120001
3604200305950005 √ BURUH
360420702930004
3604200203870001 √ BURUH
3604206011840002
3604205406030002
3604206110412004
360420270864014 √ BURUH
3604204101750142
3604205706056001
3604201206380001 √ BURUH
360420430572002
3604201203920001
3604206502950005
3604204508990003
3604204769000002
3604200809030004
36042041070700017
3604201107710002 √ BURUH
3604205205740002
360420690999004
3604201365050001
3604205267140001
3604201801710001 √ BURUH
3604205103770003
3604205907960001
3604206707010002
3604206009140002
3604201006830001 √ BURUH
 3604205903920001
3604206707120001
3604205508750001 √ WIRASWASTA
3604205508750001
3604201906010002
3604204401130001
3604204401130002
3604200508850006 √ BURUH
3604206709880001
3604200902100002
3604200908780001 √ WIRASWASTA
36042041018330022
3604202202010001
3604201707080001
3604200101720003 √ BURUH
3604205907820001
3604202407000001
3604204806030001
3604203008080002
3604201507710001 √ BURUH
3604204809770001
3604202502010002
3604206111090003
3604200101690161 √ BURUH
3604204101750162
3604206306910163
3604201512950164
3604205310010165
3604200101700089 √ BURUH
3604204512740009
36042000804990091
3604205105010092
3604201807020093
3604201012570001 √ BURUH
3604204708690002
3604204805880004
3604206311060001
3604200606070003
3604200107580017 √ BURUH
3604204107640012
3604200205930002
36042017039600001
3604201604730146 √ BURUH
3604206408800197
3604204905830148

3604200303830003 √ BURUH
3604205705890004
3604200412090004
3604200305600088 √ BURUH
3604204612630089
3604200107880099
3604200804640003 √ BURUH
3604205110660001
3604201302940001
3604204805980005
3604201107840051 √ BURUH
3604204710880176
3604200810080002
360420208790006 √ BURUH
3604205012740234
3604206407010175
3604202706770001 √ BURUH
3604206607830192
3604201608010001
3604201311770003 √ BURUH
3604205012820002
3604204506010003
3604202312050001
3604201009670271 √ BURUH
3604205210720272
3604200304960273
3604200605980274
3604205112020273
√ WIRASWASTA

3604202612020153
3604202306580081 √ BURUH
3604206002800085
3604200308930216
3604205608960020
36042050079900088
3604204301030068
3604201005720002 √ BURUH
3604204201850003
3604201105030005
3604206209100001
3604201705750108 √ BURUH
3604200206610001
3604200804990185
3604202800030205
3604240204800012 √ BURUH
3604244507800012
3604246901100002
3604200101600333 √ BURUH
3604205602630001
3604204603960359
360420463960358
3604201708690002 √ BURUH
3604204303730002 √
3604200807910003 √
3604205710970003 √
3604204511020002 √
3604204607070006 √
3604201010740002 √ BURUH
3604205504750001 √
3604201101990002 √
3604206208000002 √
3604206808020002 √
3604200611070002 √
√
3604200710810001 √ BURUH
3604204110880001 √
3604206910060001 √
3604200101700061 √ BURUH
3604204205750006 √
3604200812970004 √
3604202704090002 √
3604200101770019 √ BURUH
3604204603810003
3604204810990002
3604200505030005
360420291110002
3604201007790069 √ BURUH
3604204905870070
3604201511070001

3604202506650001 √ BURUH
3604204507800006
3604205605030002
3604201210050005
3604200903620031 √ √ BURUH
3604205212620032
3604201411870034
3604200207940036
3604202305750002 √ BURUH
3604206305790001
3604200501050002
3604200908820003 √ BURUH
36042041018300025
3604201809100003
3604201908860002 √ BURUH
3604205705890006
 360420111750001 √ BURUH
3604204505820002
3604201504990001
3604204308040002
3604204801090002
3604200506720071 √ BURUH
3604204912770072
3604201408990076
3604205510000077
3604200605780002 √ BURUH
3604294908820001
3604200506050003
360420251970001
3604200303020002
3604200805800001 √ WIRASWASTA
3604205506840002 √
3604201005030002 √
3604205100000001 √
3604201007770003 √ BURUH
3604206104870001
3604205608010004
3604206306070002
3604200708090003
3604205204120002
3604200101750048 √ BURUH
3604204204810003 √
3604200508050001
3604200212090001
3604200101540028 √ BURUH
3604201302870006
3604202007960001
3604200706850006 √ BURUH
3604206302870001
3604200805080001
360420050020003 √ BURUH
3604204301910003
3604202305130001
3604200107730023 √ BURUH
3604204107700003
3604204107930020
3604202310060002
3604204112500171 √ IRT
36042005058901731
3604204101490002 IRT
3604201606690001 BURUH
3604206306640001
360420660910001
 3604204505060007
360420231900001
3604200201430079 BURUH
3604205111720080
3604204101450200 IRT
3604200101310201 BURUH
3604204101400202
3604204107580003 IRT
3604201010500195 BURUH
3604204706590196
3604200101470135 BURUH
3604204101510136
3604205262500001 IRT
3604204107400123 IRT
36042002105520001 BURUH
3604201307880003
3604200706800002 BURUH
3604204304510001
3604200706800002
3604204101350018 IRT
3604201608880002
 Umur Kehamilan Taksiran Peserta Status
Persalinan KB Kemiskinan
1 2 3 4 5 6 7 8 9

16 17 18 19 20 21 22 23 24 25 26 27
KPS

KPS
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NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 ENDANG K 50 360420190810003
PATIMAH BK 47
AGUNG GUMELAR BK 20
ST PUJIYANTI BK 17
FIRMANSYAH BK 15
2 SAEP K 44 36042015120400000
EMEN K 37
ELI BK 21
RONI BK 14
MUDIN BK 9
3 SAOMI K 43 3604202109040020
AAS K 40
AJIS BK 19
4 SUDRAJAT K 37 3604200812100000
NENG SARNAH K 33
ST SA'DIAH BK 12
M FATURROHMAN BK 47
5 MAMAT RAHMAT K 40 3604202202100000
SITI SAWINAH K 36
DEDEN SUMANTRI BK 17
M SANTANA BK 12
6 ROSID K 43 3604200510110000
SOPIAH K 27
S NURLAILA ASSYIFA BK 4
7 SUPRI K 43 3604202009120000
UNAISIH K 36
YUSUP BK 14
AJI BK 8
ST NURAENI BK 4
8 SAENI JANDA 68 3604200603080000
ASMARIYAH 32
9 MUSLIM K 65 3604201102071440
ARNI K 46
MASYAROH BK 17
10 SUGAENI K 49 3604201102071440
NANI K 4
ERNASARI BK 17
RAIHAN SUDRAJAT BK 8
11 PEPEN EPENDI K 45 3604201909130000
JUETI K 40
 SUPIANA BK 20
SUKMAWATI BK 16
12 SOLEHHUDIN K 35 3604201307090000
ST URYANAH K 30
ST NILAAGUSTIN BK 6
13 IDIM PARIDI K 26 3604201504110001
SUHAETI K 27
DEWI CAHYATI BK 5
14 RUIN K 73 3604201206040018
SAENAH 68
AHYAR 26
JULI 21
15 HOLID K 35 3604200402100004
SUAMAH K 29
16 ALI K 51 3604201102071437
JARSINAH 44
JAELANI 18
PAHRI ARDIANSAH 8
17 SARKA K 51 3604201102071584
ROHENAH K 47
RODIANI 20
18 SA'AMAH K 51 3604203108090015
SULIAH K 20
19 SAR'AH K 50 360420
MUSLIH K 25
SAEPUDIN 6
20 DIAN K 41 360420
HAELINA K 30
LAELA CAHYANI 9
21 RUDI K 30 360420
SAMSIAH K 24
RUSTIYANI 30
22 AMSAH K 56 360420
23 AYU SUTEJO K 24 360420
NENI LINAENI K 25
NAFA ANGGRAENI 23
24 HASAN K 48 360420
YATI K 41
SUBAI 21
YENI YULIANTI 14
25 AGIS BACHTIAR K 28 360420
ST SUHELAH K 25
ALFRATAMA BACHTIAR 6
26 SAJA K 41 360420
RUMINI K 36
 SATI 18
SOPIAH 11
RIFAI 6
SYIFA 5
27 SOPE'I
SUKAESIH
ALFIANTO
DWI KARTIKA PUTRI
M PAHRIJAL PATULLOH
28 ASEP SUHAEMI
NURHEDI
M RAHADI
29 RAHMAT K
TINAH K
RASTI
M RIFKI K
30 M SAAD K
OCAH K
SALSA KALILA
31 SABRAWI K
MUINAH K
PEPEN EPENDI
MUHIDIN
NURYANAH
32 KATMA K
SUMIYATI K
ROSADI
ALDI SOLIHIN
CITA CAMELIA
32 IDHAM KHOLID K
AMSONI K
IMANUDIN
ARIPIN
IQBALLUDIN
33 EDI BAMBANG PRAYEKNO K
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ZULFIKRI MAULID
34 SARIPUDIN K
ST INAYAH K
ERIK IRAWAN
35 MURDIYONO K
ST NURHAYATI K
M YAYANG ALMURDIKI
M DIO ALMURDIKI
36 MA'ANI K
 SUHAYATI K
SAEPUDIN
ANHAR
SULISTIAWATI
SURYANI
NUJIATUL ULUMIAH
SUHENDI
37 KUSEN K
UNAH K
ULIK
UMAEDI
38 JOHAN K
MAE K
SAEPUL BAHRI
AIRIN
M SENGKO
39 RUSMAN K
PINA K
SITI NURPADILAH
40 ARBAI K
SARIKAH K
ST RIYANA
41 M JAJA K
RENTIYAWATI K
AQILA KHANSAHAURA MUJA
43 SAMUN K 3604202511040036
SUKMIATI K
A GOFUR BK
QOTRULU BK
B QOMAR BK
44 MUSLIH K 3604202511040039
DEDE UL K
ADI S BK
HAKIN M BK
45 NURMAN K 3604203110070430
LISNAWATI K
SUHAYATI BK
AJI YANA BK
SUCIPTO BK
46 ABDULLAH K 3604203005090013
NAPSAH K
JABARUDIN BK
MALA BK
ROHIMAH BK
47 SUITNO K 3604200404120003
 MAUHIAH K
ISMUTU BK
48 M.D.QUTNI K 3604202312130003
ITA R K
ST ZAHRA BK
49 WAHYUDIN K 3604201002100008
SUIRAT K
K NASTAIN BK
50 M SIDIK K 3604202212100145
HATIJAH K
IMAT M BK
RIZKI M BK
51 RASWDIN K 3604200503130001
ELAH K
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan
Lahir BPJS Asuransi KK
1
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15 16
3604201804650003 18/04/1965 BURUH
3604205201680002 12/1/1968
3604200602950003 6/2/1995
3604206704980004 17/04/1998
3604202804000003 28/04/2000
3604200511710103 5/11/1971 √ BURUH
3604206006780104 20/06/1978 √
3604201608940105 16/08/1994 √
3604201703010106 17/03/2001 √
3604202806060001 28/6/2006
3604201004720089 10/4/1972 BURUH
3604205102750090 11/2/1975
3604200402960091 4/2/1996
3604201801780001 18/01/1978 BURUH
3604204501820002 5/1/1982
3604206512030001 25/12/2003
3604203112110002 31/12/2011
3604200609750003 6/9/1975 √ SOPIR
3604204210790002 2/10/1979 √
3604200206980002 2/6/1998
3604200212030002 2/12/2003
3604200505720001 5/5/1972 BURUH
3604205508880003 25/08/1988
3604204611110001 6/11/2011
3604201507720002 15/07/1972 WIRASWASTA
3604205512790005 15/12/1979
3604200303010003 3/3/2001
3604201102070001 11/2/2007
3604204605120002 6/5/2012
3604204703470001 7/3/1947 √ IRT
3604204611830154 6/11/1983
3604201401500001 14/01/1950 BURUH
3604205101690001 11/1/1969
3604204311980002 3/11/1998
3604200101660001 1/1/1966 WIRASWASTA
3604204805710002 8/5/1971
3604205109980001 11/9/1998
3604201210080001 12/10/2008
3604201505700002 15/05/1970 BURUH
3604204904750001 9/4/1975
3604201101940001 12/5/1995
3604205212990001 12/12/1999
3604201011800004 10/11/1980 √
3604204509850002 √
3604205008090001 √
3604200204890003 4/2/1989
3604204304880004 4/3/1988
360420430810003 8/3/2010
3604200507420089 7/5/1942
3604205203470089 3/12/1947
3604200101890090 1/18/1989
3604200108940094 8/1/1994
3604201208800007 8/12/1980
3604206010860003 10/20/1986
3604200812640001 12/8/1964
3604205702710001 2/17/1971
3604200107970020 7/1/1997
3604200508070001 8/5/2007
3604201103640002 3/11/1964
3604205207680001 7/12/1968
3604201304950001 4/13/1995
3604205002640004 2/10/1964
36042055003950001 3/15/1995
3604206603690002 5/12/1965
3604200101900044 1/1/1990
3604200701090001 1/7/2009
3604200210740002 10/2/1974
3604206508850001 8/25/1985
3604205504060002 8/25/1985
3604200306850001 1/2/1991
3604204201910001 5/10/2013
3604205005130003 7/20/1959
3604206007590001

360420
360420
360420
360420
360420
360420
360420
360420
360420
360420
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360420
360420
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360420
360420
360420
360420
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360420
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360420
360420
360420
360420
360420
360420
360420
360420
360420
360420
360420
360420

360420

360420
360420 √ BURUH
360420 √
360420 √
360420 √
360420 √
360420 BURUH
360420
360420
360420
360420 BURUH
360420
360420
360420
360420
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360420
360420
360420
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360420
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360420 √ BURUH
360420 √
360420 √
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360420 √
360420 √
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360420
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360420
 Umur Kehamilan Taksiran Peserta
Persalinan KB
2 3 4 5 6 7 8 9

17 18 19 20 21 22 23 24 25 26

√ 17/01/16
SUNTIK

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 Status
Kemiskinan

27
PRA KS

KS III

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KS II
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NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 SARNAN K 40 3604201102077421
JUEMAH K 33
M. SADIAH BK 16
A ROMDONI BK 11
AZIZI RIFAI BK 4
2 M OMAN K 28 3604202112100084
NURJANAH K 24
NURUL FATIMAH BK 4
3 MUKWIN K 37 3604202212100153
LUMAROH K 26
M. HAYKAL BK 7
A.M. SURUPI BK
4 JAENUDIN K 42
LELA K 29
ELIS JAJILAH BK 9
FAJRI BK 2
5 SAPTO K 46 3604201102077397
MURNI K 39
BAMBANG BK 16
TIYAS BK 7
6 MUSTOPA K 61 3604201102077399
ANIS K 56
7 KEMED K 84 3604201102077435
MARNI K 53
8 SARJO K 55 3604201102077430
ROHIMAH K 41
UMI ROHMAH BK 17
DZ NURAQLI BK 4
9 FATHUR R K 29
SUPRIYATI K 22
10 ASTAWI K 65 3604201102077428
WATI K 33
ST AISAH BK 15
ST KHOLIPAH BK 5
11 MUMU K 45 3604201102077442
HERMIAH K 44
TINI PRIHA BK 15
12 IYAS K 74 3604201102077430
RAPIAH K 66
NURALI BK 31
13 KARYONO K 36 3604201102077444
 ST KHOPIAH K 29
M.RIPQI AH BK 8
NOVITA HV BK 2
14 RIDWAN K 41 3604201102077429
IDA K 40
ST RIKA N BK 14
M. ANDRI BK 8
15 NURRODIN K 35 360420211210008
SARNAH K 27
LINDA BK 7
ST MELA BK 2
16 MAE K 68 3604203004090005
17 ADAM MALIK K 45 3604201102077001
IAR K 42
M ANDRIAN BK 5
18 A. SALAHUDIN K 45 3604201102077449
JUARNI K 34
FAIZA K BK 5
MARWAH BK 4
ZEIN M.A BK 2
HANUM BK
19 JAENUDIN K 60 3604201102077396
PIROH K 52
ABID FAHRI BK 25
20 JAENUL A K 58 3604201102077446
NENGSIH K 58
DIAH M BK 22
AZI A BK 18
21 MUHADI K 37 3604202112100091
AYUM K 34
ARI PRATAMA BK 14
YARIS RIYADI BK 7
22 ROYADI K 42 3604202511090026
SARIPAH K 38
SITA BK 19
RISMA BK 7
23 DARYUM K 32 3604202112100089
ST ROHMAH K 29
ANNISA P. A BK 7
24 GOUSUL K 39 3604200207100025
EVA K 32
M. KHADAFI BK 8
SYABIB MH BK 5
MUHFID BK 1.5
25 JUNAENAH K 63 3604202112100092
26 SYUKUR K 73 3604201102077395
MARTINI K 39
PASNI BK 25
 PAHRI BK 25
27 NASRUDIN K 33
ENTIN S K 27
ST AGENG R BK 8
28 ASRIP K 41 3604201803740001
RUMHAYAH K 39
RUYANI BK 21
ST ASMAWATI BK 15
29 SATIKAH K 79 3604205204360001
HABUDIN BK 27
30 AGUS S K 45 3604200708700001
JOHARIAH K 41
A.JUHERI BK 17
A.N ARIPIN BK 15
ST MELINDA BK 5
31 TUAMAH K 68 3604202303100002
32 MARYAMAH K 48 3604200110277452
MILDA H K 22
33 IMAN S K 35 3604202112100095
MUTOHAROH K 32
RAKA M G U BK 7
RADITIA MS BK 4
34 SUKRA K 57 3604202112100095
SOEDAH K 58
SUBHAN BK 24
35 MASRADI K 47 3604201102077425
SUJIAH K 35
R. AENI BK 11
36 DEDEN MULYADI K 36 3604202805090009
MARSITI K 33
M. NOUFAL S BK 8
ST KHADIJAH K BK 4
37 A ROHMAN K 42 3604201102077433
ST. MASRUROH K 36
IIK R BK 14
38 PATONI K
PATIN K
39 SUBAI K 37 3604202112100087
AAS R K 30
ALIF P.I.R BK 9
ZAHRA C R BK 5
40 JUNED K 43 3604201102077441
JAAH K 43
JUHETI BK 27
JANURI BK 23
PITRI I BK 11
41 RONI SAHRONI K 40 3604201601130002
SHRIYAWATI K 40
 RINI N BK 18
INAYA R Z BK 2
42 NURSEN K 75 36042023006100007
MARWIAH K
NELI A BK
43 NARIYAH K 65 3604201309060002
44 NARJA K 39 3604202112100085
NASINAH K 33
NASMUDIN BK 14
NANDITA BK 8
45 PARJO K 65 3604202112100044
JAHROH K 56
SYAFRIKA D BK 12
46 YATI P K 42 3604202112100093
JULIA S U K 18
PITRI H BK 16
NAZWA S BK 10
PAUJI S BK 8
47 EBAH K 48 3604202207090006
SUPRIYADI K 31
SUHARI BK 29
KHAERUDIN BK 21
ST ALMAIDAH BK 12
48 M MAMAN I K
ST KHADIJAH K 24
49 JOHANI K 80 3604201102077404
HINDUN K 78
ANITA BK 26
50 MAKMUN K 57 3604201102077427
SUHAEMI K 49
SAEFUL BK 24
KHAERULLAH BK 20
ST MAULIDA BK 13
SOPIYATUL BK 8
51 MUNIKAH K 50 3604201102077418
M. SYAFEI K 20
52 MUKMIN K 23
RODIAH K 20
SAPARIAH BK 2
53 JAJA K 79 3604201102077417
MUNJAH K 60
NENENG BK 22
54 HUMAEDI K 40 3604203005110004
JUMROH K 29
IDA P BK 8
IIP M BK 2
55 SAKAR K 3604201906140003
JARSIH K 38
 ROHMANS BK 14
JUJUN J BK
56 SUNARYA K 3604201407150003
ROHANIAH K
SAKILA R BK
57 MUHTADIN K 3604203005110003
MARPIAH K
GINA F BK
R ABI BK
58 ELIZA K K 3604200811130008
NESA K
59 AMIN K 3604202912090090
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ALPIYATUNNISA BK
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APTORIAH BK
A BAEDUWI BK
60 MAHFUDOH K 3604202112100090
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ILA H BK
61 ANJAR R K
YENI R K
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62 ASNADI K 47 3604201102077415
AISYAH K 43
JUNAENI BK 19
M. AKMAL BK 11
ST NUR R BK 3
63 SUPRIYANTO K 23 3604200610110007
ANIS L K 23
M JABAR BK 3
64 GOJALI K 32
LINDA A K 30
NAZWA S BK 2
65 ANDRIYANAH K 50 3604201102077430
MARDAN M K 22
M DANY F BK 17
NURSAMSI BK 10
MUTIA R BK 7
66 M NASUHA K 29 3604202112100081
MALIAH K 26
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67 TARYO K 29 3604201709130013
SANTINAH K 26
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68 SINAN K 58 3604201102077426
MULYATI K 49
MULYADI BK 28
 NINGRUM BK 22
69 SUPIAH K 59 360420161109011
SUPRIYANTO K 33
70 YAKUB S K 24
JAENI K 23
71 NGATENO A K 31 3604201405120002
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MUAMAR BK 24
MUNIB BK 12
SUKIAH BK 61
72 SARPI K 73 3604202730390005
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73 A AZIS K 40 3604201002100010
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ASILAH BK 10
M. RIZKY BK 4
74 ABU SOLEH K 37 3604202112100082
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NOVI BK 8
NURSOLIHAT BK 3
75 MAJID K 68 3604200205120001
RIYADOH K 56
MUTAKIN BK 29
MUKRI BK 19
MUNAWIAH BK 17
76 UMAENAH K 53 3604201102077407
WAHYU A BK 24
M.ASHARI BK 16
77 SOLEMAN K 26 3604272508140001
RIAN A K 26
M. RIZQI BK 1
78 ALI MISRI K 82 3604201102077406
NURMAH K 70
IPTI R H BK 28
HARTATI BK 24
79 BAKRIAH K 57 3604201510090010
80 BUETI K
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81 HASAN BASEH K 82 3604201102077348
MUFLIHAH K 73
RIZQI R BK 21
AAZ M BK 36
82 EDI JUNAEDI K 53 3604201102077963
BASTIAH K 52
BULUM BK 24
 FEBI N BK 13
LINDA M BK 12
83 BAHRUM K 85 3604201102077390
SAPRAH K 79
SAIFUL B BK 45
84 ASIRI K 56 3604201102077412
HERTI K 48
UCI S BK 27
AMTIAH BK 23
KHOPIPAH BK 16
85 JAMAL K 41 3604201102077392
KESIH K 41
JARONDAH BK 20
M. KEMAL L BK 12
86 M.SYAIR K 66 3604202703090007
NAPSAH K 64
87 SUHAEDI K 50 3604202005090001
RUYANAH K 43
R NUFUS BK 24
RIZAL F BK 21
ALPI B BK 20
AILATUS BK 6
AIDA S BK 4
88 JAKRONI K 56 3604201102077460
AZIMAH K 45
UBADRI BK 16
89 JAWIAH CERAI MATI
90 EDI K 54 3604202003150006
MARYATI K 47
91 M. PADZRI K 22 3604201809150009
AYU F A K 18
92 ROKEMAH K 57 3604201102077462
93 IWAN S K 29 3604202004120004
M. NURILHAM K 4
94 ANTA WIRA K 75 3604201102077380
MARHANAH K 60
95 AMIRUDIN K 36 3604202112100086
AWINAH K 30
ST AMILA L BK 10
96 AGUS S K 43 3604201102077908
HAMDIAH K 37
NANDA BK 15
NADIA BK 5
97 ROBANI K 41 3604201102077409
HAPSAH K 39
HABI BK 15
SIFA L BK 4
98 SAPRUDIN K 39 3604202703090002
 SUMYATI K 41
ST NURHA BK 21
99 M. RAMDAN K
ANI R K 21
100 SUPIANAH K 44 3604201102077411
SUPRIATNA K 21
101 AKA WAHYUDI K 25
EHA K 20
MAKBAR BK
102 HARIRI K 35
NANI R K 23
103 M ADNAN K 43 3604201102077416
MARYUNI K 41
M.NURWANDI BK 16
BAGUS F BK 13
INDRA M BK 9
PUTRI I BK 2
104 MAHDUM K 49 3604201102077414
SUKRAENI K 46
AULIA BK 8
105 HASANUDIN K 56 3604201102077438
NURWASIH K 67
HAMBALI BK 20
HUDRI BK 18
HAMBALI BK 16
UBAIDILAH BK 14
ABADWI BK 13
FITRIA BK 11
SUBHI BK 9
106 MARJUKI K 3604201102077970
UMU K K
IRMA M BK
ILA BK
107 AJRUM F K 45 3604202008090010
ENTIN K 34
RIZQY Z F BK 6
NISA Z T F BK 12
JAHIRA BK
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan

Lahir BPJS Asuransi KK
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15
3604200605750002 6/5/1975 BURUH
360420028200003 2/1/1982
3604204708990001 08/071999
3604201011040001 11/10/2004
3604202311110003 23/11/2011
3604200305870001 3/5/1987 BURUH
3604204705910002 1/5/1991
3604205608110001 16/08/2011
3604200903780002 9/3/1978 WIRASWASTA
360420650389000 23/03/1989
3604202007080002 20/02/2008
4/9/2015
36042018040730001 4/6/1973 BURUH
36042185206860009 12/6/1986
11/3/2006
16/06/2013
3604201906690001 19/061969 √ PNS
3604204905760005 9/5/1976 √
3604201809990001 18/09/1999 √
360420440508000 4/4/2008 √
360420080854000 8/8/1954 WIRASWASTA
3604205302590001 13/02/1959
3604202404310001 24/041961 BURUH
3604205011620005 1/11/1962
3604200101600002 1/1/1960 √ BURUH
3604206703740001 27/03/1974 √
3604204611480003 6/11/1998 √
3604200303110001 3/9/2011 √
18/06/1986 √
3604205809930001 18/09/1993 √
3604201402500002 14/02/1950 √ BURUH
3604205304820003 13/04/1982 √
3604206508000001 25/08/2000 √
3604204701100003 7/1/2010 √
3604200104700003 1/4/1970 BURUH
3604206401710001 24/011971
3604206707000003 27/07/2000
3604202410001 14/12/1941 √ BURUH
3604204104590002 1/4/1959 √
3604201112840001 11/12/1984 √
3604202103790001 21/02/1979 BURUH
3604204309860003 3/9/1986
3604203107070001 31/07/2007
3604207006130001 30/06/2013 BURUH
3604201408740001 14/08/1974
3604204507750005 5/7/1975
36042044090100002 4/9/2001
3604204107070016 15/07/2007
360420060880001 6/8/1980 BURUH
3604204211880003 2/11/1988
3604206410080004 24/10/2008
9/4/2013
3604204406470002 4/6/1947
3604201204700002 12/041970 √ BURUH
3604205101730003 11/1/1973 √
3604200101120004 1/1/2010 √
36042011060700001 11/6/1970 √ PNS
3604204807610001 8/7/1981 √
36042046078100001 6/7/2010 √
3604207110110001 31/10/2011 √
3604201210130002 12/10/2013 √
15/06/2015
3604200610550001 6/10/1955 BURUH
3604205203630001 12/3/1963
3604203101900002 31/01/1990
3604201609570001 15/09/1957 WIRASWASTA
36042005509570001 15/09/1957
3604204205930006 2/5/1993
3604200409970003 4/9/1997
3604200505780001 5/5/1978 BURUH
3604204101810013 1/1/1981
3604202907010001 29/07/2001
3604200305080001 3/5/2008
3604200504730001 5/4/1973 BURUH
3604206712770003 27/12/1977
3604206610960001 26/10/1996 √
3604204111060002 1/11/2008 √
3604204810860002 20/06/1983 √ BURUH
3604204810860002 8/10/1986 √
3604206806080002 7/12/2008 √
3604200508760002 5/8/1976 HONORER
3604206808830002 18/08/1983 √
3604200210070003 2/10/2007 √
3604202909100002 29/09/2010 √
14/05/2014 √
3604200502810003 5/2/1952 √ IRT
3604200101420015 1/1/1942 √ BURUH
3604205910760001 19/10/1976 √
3604201010900003 10/10/1990 √
3604201010900002 10/10/1990 √
23/10/1982 BURUH
6/12/1988
8/10/2007
3604201803740001 18/03/1974 √ BURUH
360420500710002 9/7/1976 √
3604201008940003 10/8/1994 √
3604205007100002 10/7/2002 √
3604205204360001 12/4/1936 IRT
3604202510880003 25/10/1988
3604200708700001 7/8/1970 BURUH
3604204508740002 5/8/1974
3604202012980002 20/12/1998
360420280300003 28/03/2000
3604204808100002 8/8/2010
3604205104470001 11/4/1947 IRT
3604204107670023 1/7/1967 IRT
3604204906930002 9/6/1993
3604200110800004 1/10/1980 BURUH
3604205103830004 11/3/1983
3604202410080003 24/10/2008
3604200509110001 5/9/2011
3604201404580002 14/04/1958 BURUH
360420410750024 1/7/1957
3604200511890001 5/11/1989
3604201210680002 12/10/1968 BURUH
360420520480000 12/4/1980
3604207005040001 30/08/2004
3604201502790002 15/02/1979 √ PNS
3604205407820003 14/071982 √
3604200402070001 4/2/2007 √
3604206908110001 29/08/2011 √
3604201607730001 16/07/1973 WIRASWASTA
3604204703790001 7/3/1979
3604202409010002 24/04/2001
BURUH

3604201408780002 14/08/1978 BURUH

3604205306850001 13/06/1985
3604202603060001 26/03/2006
3604205808100001 18/08/2010
3604200409720002 4/9/1972 BURUH
3604204208720001 2/8/1972
3604204704880004 7/4/1988
3604206206920001 22/06/1992
36042047004040003 7/4/2004
3604201503760004 15/03/1975 √ KARYAWAN
3604204905760003 9/5/1975
3604204311970003 3/11/1997
3604207005130002 30/05/2013
3604201012400002 10/121940 BURUH
3604204812570002 8/12/1957
3604205205040004 12/5/2004
360420550450000 15/04/1950 IRT
3604200905760001 9/5/1976 BURUH
3604205306820002 13/06/1982
3604200907010001 9/7/2001
3604206303070001 23/03/2007
3604200302500001 3/2/1950 PEDAGANG
3604206012580001 20/12/1959
3604205906030001 19/08/2003
3604205403730003 14/03/1973 IRT
3604207005970001 30/05/1997
3604205412990003 14/12/1999
3604206710050002 27/10/2005
3604201010070003 10/10/2007
3604205912670002 19/12/1967 IRT
3604202710840001 17/10/1984
3604202005860002 20/05/1986
3604200101940044 1/1/1994
3604204111030004 1/11/2003
BURUH
8/25/1991
3604202401350001 1/24/1935 PETANI
3604206808370001 8/28/1937
3604204107890027 07/011989
36042002111480001 11/2/1948 BURUH
3604204607660002 7/6/1966
3604202505910001 5/23/1991
3604202305950001 5/23/1995
3604206305020002 5/23/2002
3604205004070002 4/10/2007
3604205303650002 3/13/1965 √ IRT
3604202410950001 10/24/1995 √
1/20/1992 √ BURUH
5/15/1995
12/31/2013
360420221036000 10/22/1936 PETANI
3604206412550002 12/24/1955
3604205102930000 2/11/1993
3604200810750001 10/8/1975 BURUH
3604206303860001 3/23/1986
3604205907070002 7/19/2007
3604205410130001 10/14/2013
BURUH
3604205109770002 9/11/1977
3604200301010005 1/3/2001
3604201707040003 07/072004
36042030909810001 9/8/1981 BURUH
3604205004960004 4/10/1996
3604207108150001 7/31/2015
3604201112580001 12/11/1958
3604204209770001 9/2/1977
3604205009030002 9/10/2003
3604201509130001 9/15/2013
3604206207970001 7/22/1997
5/9/2014
3604202503560001 3/25/1958 TANI
3604204809660001 9/8/1966
3604206208980003 8/22/1996
3604202809980002 9/28/1998
3604201511010003 11/15/2001
3604201511060002 11/15/2006
3604200712690001 12/17/1969 √
3604202209960001 9/22/1995 √
3604204703020001 3/7/2002 √
6/9/1985 √
5/19/1991 √
4/18/2014 √
3604201503650002 8/17/1968 BURUH
3604204204720002 4/2/1972
3604206409960001 9/24/1996
3604201003040003 3/10/2004
3604204810120001 10/8/2012
3604201505920004 5/15/1992 BURUH
3604203103920005 3/11/1992
360420006013120001 3/6/2012
3/11/1983 BURUH
7/12/1985
8/13/2013
36042054002650003 2/14/1965 √ IRT
360420220393000 3/22/1993 √
3604203012980002 12/30/1998 √
3604200810050001 10/8/2005 √
360420470608000 6/7/2008 √
3604200711860003 11/7/1986 BURUH
3604205209890003 9/12/1989
7/27/2014
3604201405860003 14/15/1986 BURUH
3604206511890002 11/25/1989
36042006109130001 9/21/2013
3604202808570002 8/28/1957 BURUH
3604204510660002 10/5/1966
3604201207870003 7/12/1987
3604206010930003 10/20/1993
3604206701560002 1/27/1956 IRT
3604201502820003 2/15/1982
8/14/1991 BURUH
5/23/1992
3604202707840003 7/27/1984 BURUH
3604205202750003 2/12/1975 √
3604200810910005 10/8/1991
360420270203000 7/27/2003
3604205011540001 11/10/1954
3604200911420002 11/9/1942 PETANI
3604204809470002 9/8/1947
3604200202840003 2/2/1984
3604200512750002 12/5/1975 BURUH
3604205600800002 4/16/1980
3604204507050004 7/5/2005
3604201502110001 2/15/2011
3604200701780002 1/7/1978 BURUH
3604206505870003 3/25/1987
11/11/2007
6/27/2012
3604201012470001 12/10/1947 PETANI
360420624590001 4/22/1959
3604201406860003 6/14/1986
3604201203950002 3/12/1996
3604204907980002 7/9/1998
3604204911620001 11/9/1962 √ IRT
3604201507910003 7/15/1991 √
3604201609990003 9/16/1999 √
3604270809890071 9/8/1989 HONORER
3604206801890001 9/17/2014
3604201709140001 11/7/1933
3604200711330001 1/12/1945 √ PNS
3604204112450001 4/24/1987 √
3604202404870001 7/23/1991 √
3604206307910002 11/4/1958 √
3604204411580002 IRT
BURUH

3604200101330002 1/1/1933 √ PNS

360420420142000 1/2/1942 √
360420220440002 9/22/1994
3604201805790003 5/18/1979 √
3604200107620075 7/1/1962 PETANI
3604205009630002 1/10/1963
3604200303910002 3/3/1991
3604204802020001 2/8/2002
3604205003030002 3/10/2003
3604202512300001 12/25/1930 PETANI
3604206010340001 10/20/1936
360420180870001 8/18/1970
3604200402590004 2/4/1959 BURUH
3604205107670003 7/11/1967
3604201108880002 8/11/1988
3604204709920002 9/7/1992
3604205905990001 5/19/1999
8/26/1974 BURUH
3604205912790001 10/3/1995
360420431095000 1/20/2003
3604202001030003 1/1/1949
3604200101490013 1/1/1951
3604204101510005 4/14/1965
3604201404650001 6/12/1972 √
3604205206720003 4/6/1991 √
3604204604910002 4/8/1994 √
3604200804990007 6/29/1995 √
3604202906950002 7/10/2009 √
3604205007090001 4/2/2011 √
3604204204110001 11/10/1969 √
3604201011690002 1/10/1970 √ BURUH
3604206008680001 8/10/1999 √
√
√
3604200507610001 7/5/1961 √ BURUH
3604204801680001 1/8/1968 √
3602180510910008 2/2/1993 BURUH
3604206405970001 5/24/1997 √
3604204107580014 7/1/1958 √
3604200406860003 6/4/1986 BURUH
3604201211110001 11/12/2011
3604202607400001 7/26/1940 BURUH
3604206708550001 8/27/1955
3604201005790001 2/23/1979 BURUH
3604204101840006 1/1/1985
3604204905050001 5/8/2005
3604201807720003 7/10/1972 BURUH
3604204610780002 10/6/1978 √
360420234000001 4/23/2000
3604204502100001 2/5/2010 √
3604200608740002 8/6/1974 BURUH
3604204812760001 12/8/1976
3604202211000002 11/22/2000
3604207009110001 9/30/2011
3604200112760001 2/1/2016 BURUH
3604204808740001 8/8/1974
360420560490001 4/16/1994
4/1/1992 BURUH
11/3/1994
3604206912710001 12/29/2011
36042008109450002 10/8/1994
3604201005900005 5/10/1990 BURUH

5/25/2015
3602180302800006 2/3/1980 BURUH
3604204210920001 2/10/1992
36042011011720005 11/10/1972 BURUH
3604205608790001 8/16/1974
3604201203990002 3/12/1999
3604201003020001 3/10/2002
3604201511060004 11/15/2006
3604207101130001 1/31/2013
3604200809660002 4/8/1966 BURUH
3604205201690002 1/12/1969
3604206411070001 11/24/2007
3604201102590002 2/11/1959 √ BURUH
3604205012480001 12/10/1948 √
3604202001970001 10/14/1995 √
3604201611970002 11/16/1997 √
3604202007990001 11/20/1999 √
3604202402010001 1/24/2004 √
3604202801020001 1/28/2002 √
3604204304040002 4/3/2004 √
3604202507060001 2/25/2006 √
3604201503830002 3/15/1983 BURUH
3604206510850003 10/25/1985
3604204107040001 7/1/2004
3604205504090001 4/15/2009
3604200310700003 10/5/1970 √ PNS
3604205509810003 4/15/1981 √
3604202007090001 7/20/2009 √
3604206205030002 5/22/2003 √
6/22/2015
 Umur Kehamilan Taksiran
Persalinan
1 2 3 4 5 6 7 8 9

16 17 18 19 20 21 22 23 24 25

WIRASWASTA

WIRASWASTA
WIRASWASTA

HONORER
WIRASWASTA

KARYAWAN
PEDAGANG
HONORER
 Peserta Status
KB Kemiskinan

26 27
KS I
IMPLANT

KS I
SUNTIK

KS II
SUNTIK

KS I
SUNTIK

MOW KS II

KS II

KS I

KS I
SUNTIK

KS I

KS I
SUNTIK

KS I
SUNTIK

KPS

KS I
SUNTIK

KS I
SUNTIK

KS I
SUNTIK

KPS
KS I

KS II

KS I

KS I

KPS
SUNTIK

KS I

KS I
IUD

KS II
IUD

KS II
KS II
 KS I
PIL

KS I
SUNTIK

KPS

KS I

SUNTIK

KS II
KS I

KS II
IMPLANT

KS I

KS I
 FORMULIR PEND

NO NAMA Status Umur Nomor

Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 MUJID K 48 3604201102078098
MURNI K 45
M MULYA BK 23
M HIDAYAT BK 22
M.JAMIL BK 20
IRA MUJAERAH BK 15
APRIANSYAH BK 13
MUNAJAT BK 11
2 SUPRIYADI K 47 3604202307040054
HERMAWATI K 38
AGUNG HERMAWAN BK 18
EUIS LAELATIN BK 15
INDAH NURIL A BK 7
3 PULUNG K 60 3604202501050024
SUHENDA K 48
SUHENDAR BK 28
SUHENDRA BK 24
FITRI KOMALA BK 22
PURNAMA ENDAH BK 19
4 SANTA K 58 3604200806040044
SUHARYATI K 33
5 AS'ARI K 60 36042006111140002
YATI K 50
DEDI ARIANSYAH BK 30
IYAD ARIYADI BK 24
MISQI ARAPIAN BK 19
EVA ARYANAH BK 17
ANAS ARPAN BK 15
YOGA APRIANSYAH BK 13
YOGI AQLIANSYAH BK 13
DEVI AGUSTINA BK 9
DIVA AGUSTINA BK 7
6 RIPAI K 32 3604202402120001
EVA ARYANTI K 28
M. RASYAD F BK 3
7 ASEP S K 28 3604201611090009
SRI HANDAYANI K 23
MEGA AGUSTIN BK 6
8 SUPARDI K 37 3604201806140003
LILIS S K 37
SYAHRI ALPIRMAN BK 15
RIJKI MAULANA BK 14
 9 NANING Y K 56 3604201102078101
YAYAH R K 46
INTAN NURFAIZI BK 19
MUTIARA L.H BK 13
10 ABDUL HANAN K 45 3604201308100003
SITI AMINAH K 39
SOPIATUL APIAH BK 16
SITI NURKHOLISAH BK 15
SITI ROSIPAH BK 13
MUSTOPA MURTADO BK 10
LULUIL FAUJIAH BK 8
RIFATU SOLIHAH BK 5
RIJKO MUBAROK BK 3
JAMILATUL K BK
11 UDIN K 39 3604202007100014
YULIA K 36
MIFTAHUL JANAH BK 7
M WILDAN BK
12 ARSIMAN K 48 3604201102078113
SUMIYATI K 47
UMDATUL ALAWIAH BK 23
NENG NIHAYAH BK 20
SRI LUTFIANI BK 17
SHOLIHAH BK 16
NURHASANAH BK 14
NINA HAERANI BK 5
13 HAEDIR K 35 360420110207078123
SUPENTI K 32
AMSIKAH BK 14
DINA OlIVIA BK 8
HERLIYANA BK 1
14 RISWANEPENDI K 3604200501100007
FATMAWATI K
RIFASASI R.D BK 8
M. WAHABUL IZZA BK
15 ERAH SUHARIAH K 45 3604201102078030
HERWAN K 26
BAYU ILHAM BK 22
AJENG WIHELMINA BK 15
16 DADIN RIANDI K 30 3604200307080021
HIMATUL ULIS BK 29
AMALIA EKA F BK 7
17 JUMIN K 43 3604201102078114
ADE YULIATI BK 34
ADISTI EGA F BK 11
AURA ANINDITA BK 4
18 BUDIYONO K 35 3604200106110002
MELAENI K 22
 RIKA AMELIA BK 5
19 ASEP SOPANDI K 44 3604202004150008
SUHERNA K 31
NOVA SAGITA BK 16
SINDI MEGA BK 15
MEVIA SEPTIANA BK 14
ANGGUN NURESA BK 9
LEDIANA M BK 4
20 NURJEN K
RISMAWATI K
JIDAN P.R BK
21 H ENDI K 49 3604201102078110
HJ ENI K 41
FUJI WAHYUDIN BK 25
GILANG AMALIA BK 17
22 HUSEN K 52 3604201008090005
NYI ACIHS K 45
AGUS APRIAL BK 25
FIRMAN BK 22
RIJKI PURNAMA BK 14
ANDRI YANSAH BK 12
23 SUKMARA K 41 3604201102078117
SUHERIYAH K 39
FAIJAL ABDAOE BK 20
YUSUP IRAWAN BK 16
M. REJA P BK 12
BALQIS SAPIRA BK 3
24 ROMDANI K 49 360420408090004
JUHERTI K 42
M AGUNG BK 17
25 EDI M K 42 3604201102078096
SUMIYATI K 35
KHAERUL ULUM BK 15
VIA KHAERUNISA BK 11
AKMAL MAULANA BK 4
DEVI SUPIATI BK 16
26 HAMID K 47 3604201102078109
WARTI K 41
LUKMANA BK 20
IING KURNIA BK 14
HAMIDATUN BK 8
27 AHMADI K 45 3604201102078106
SUKIYAH K 38
EKA PURWANTI BK 20
28 GANDA K 44 3604202110100010
SUKAESIH K 47
SUKRON MAMUN BK 30
YENI BK 23
 M. TOMI BK 21
ELIS SUSANTI BK 14
29 FAEDULLOH K 34 3604202702130002
UMAROH K 31
SEGA ARDIANSYAH BK
30 AS'ARI K 63 3604201102078125
BADRIAH K 54
SUHANDI BK 26
SAMSUL BAHRI BK 23
EVA HERAWATI BK 18
31 NURFALAH K 43 3604201012100014
IYOL K 39
SUNTIAH BK
DEDE SUMARNA BK 22
NURHASANAH BK 19
NURHANANI BK 17
ALDI SAPUTRA BK 14
32 SARMAWI K 45 3604201003700002
ACEM K 40
AAN SUHENDAR BK 26
HANIPAH BK 12
SARMILA BK 10
AJI M BK 5
SARLINA K 21
33 AAM HAMDANAH K
FADILAH BK
LUKMAN HAKIM BK
34 SURYADI K 3604203100810004
ANNISA BK
AGISYA BK
35 UCI SANUSI K 57 3604203008100010
TASRIP K 30
SITI NURJANAH BK 23
SUSI BK 17
H TINI BK 33
AL MUTAQIN BK 5
36 MURSIDI K 51 3604201102078113
DIAN IHAMSYAH K 20
MURNAYAH BK 19
A. APRIJAL BK 29
37 ROHMAN K 53 3604202906060010
WAMI K 57
M. YUNUS BK 26
M. ILHAM BK 22
M. ROHADI BK 13
SITI NUROHMAN BK 11
38 SULAEMAN K 29 3604202004150006
SITI KHAERUNISA K 5
39 ASRIP K 40 3604201102078119
MELI HARTINI K 55
IKBAL RIJA P BK
ANGGA PURNAMA BK
CHE-CHE M.T BK
LIANA INTAN BK
40 HALIMI K 34 3604201102070130
YAYAH MUINAH K 31
ANNISA F. S BK 11
BAETUL AMALIAH BK 4
41 SUHARNA K 80 3604201102078127
TOIROH K 55
ROHMAWATI BK 23
ARI INDRIYANA BK 15
FITRI R.D BK 12
42 CECEP K 57 3604200307080013
MURSINAH K 50
DADANG S BK 29
WAHYUDIN BK 21
ERIK MAULANA BK 14
WINDA PERMATA BK 12
43 ARIPUDIN K 28 3604202209110001
CICIH K 23
M.RIPKI BK 3
44 PUDNI ROHMAN K 28 3604203005110002
MARHAENIS K 26
ASILA BK 5
45 DEDI K 45 3604201102078132
YENI K 33
MEDIANA LUTFHI BK 11
PERI HERLAMBANG BK 6
DEBI SILVIA BK 2
46 SUHERMAN K 39 3604201102078120
HASTUTI K 34
SINTA AWALIA BK 13
FAREL FEBIANO BK 7
47 SUBLI AL K 40 3604201102078124
HEDIYATI S.AG K 36
FAJAR MAULAN BK 12
FAHRI ALAMSYAH BK 5
FITRIA ULFAH BK
48 UBAD SABADRI K 36 3604201102078126
IMA SAROH K 34
ELVAN WAHYUDIN BK 12
AMELINA RIJKI BK 4
49 ERI SAHIRI K 38 3604201102078141
ETIK PURWATI K 35
DELLA AMANDA BK 4
 DEKA PEBRIANSAH BK 9
50 H HALIL K 61 3604202307040055
HJ SUHAENI K 56
HARYANTI BK 19
KHUSNUL KH BK 11
51 IMAM G K 44 3604201102078118
HERAWATI K 38
AHMAD ZULFIKRI BK 16
M.HARTAWAN BK 10
YUANITA BK 4
52 ARSANI K
MAESAROH K
ASYILA DAMAYANTI BK
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan Umur Kehamilan

Lahir BPJS Asuransi KK
1 2 3 4
PBI Mandiri Askes LainnyaLainnya
8 9 10 11 12 13 14 15 16 17 18 19
36042008020 2/8/1967 √ PNS
3604205305700001 6/13/1970 √
3604200702920001 2/7/1992 √
3604201005930004 5/10/1993 √
3604200802950001 2/8/1995 √
36042048022000002 2/8/2000
3604200204050001 4/2/2005
3604200203070002 3/2/2007
360420270668259 6/27/1968 BURUH
3604205007770280 7/10/1977
3604202411970261 11/24/1997
3604205605000243 5/16/2000
3604205505080001 5/15/2008
3604200503550109 3/5/1955 BURUH
3604204305580110 2/3/1975
3604201304870118 4/13/1987
3604200408910115 8/4/1991
3604208907930116 7/29/1993
3604205804960117 4/18/1996
3604201209570049 9/12/1957 √ PNS
3604205604620084 4/16/1982
3604200705550004 5/7/1955 BURUH
360425008650002 8/10/1965
3604200104850005 4/1/1985
3604201404910004 4/14/1991
3604201801960004 1/18/1996
3604207003980002 3/30/1998
3604201907000006 7/19/2000
3604201009020003 9/10/2002
3604201009020004 9/10/2002
3604204308060003 8/3/2006
3604206701080003 10/27/2008
3604200710830001 10/7/1983 BURUH
3604205504370002 4/15/1987
3604202205120001 5/22/2012
360420150887000 8/15/1987 BURUH
3604204708920002 8/7/1992
3604204608090002 8/6/2009
3604202008700001 3/29/1978 √ BURUH
3604204304760003 1/3/1978 √
3604202009000002 9/20/2000 √
3604201205010003 5/12/2001 √
3604202105590002 5/21/1959 √ PNS
36042041016900034 1/1/1969 √
3604204406960002 6/4/1996 √
3604205208020003 9/12/2002 √
36042001067300003 6/1/1970 BURUH
3604204608760003 8/6/1976
360420490990005 9/9/1999
3604204206000004 6/2/2000
3604204305020003 5/3/2002
3604201710050002 10/17/2005
3604206510070003 10/25/2007
3604204806100001 6/8/2010
3604200905120002 5/9/2012

360420110370002 3/11/1977 BURUH

3604205202800004 2/12/1980 √
3604206812090001 12/18/2009 √

3604200604680003 4/6/1968 √ PNS

3604204402690002 2/4/1969 √
360420559930001 4/15/1993 √
36042046008950003 8/6/1995 √
360420530797970001 7/13/1997 √
360420581000001 1/18/2000 √
3604206102020001 2/21/2002 √
3604205111110001 11/11/2011
3604207810004 7/12/1981 BURUH
360420540480002 4/14/1984
3604206712020003 12/27/2002
3604205902080001 2/19/2008
3604205050001 5/10/2015
BURUH

3604206109080001 9/21/2008
360420
3604205708210001 8/17/1971
360420090290002 2/9/1990
3604202808940001 8/28/1994
3604206110010002 10/21/2001
3604202006860206 6/20/1986 √ BURUH
3604205802870047 2/18/1987 √
3604204402090001 2/4/2009 √
36042012037900020 3/12/1973 BURUH
3604204206820004 6/2/1982
3604206001050002 1/20/2005
3604207006120001 6/30/2012
3604202604810001 4/26/1981 BURUH
3604204101640004 1/1/1964
3604206305110001 5/23/2011
3604201507720003 7/15/1972
3604204101650012 1/1/1985
3604204403000002 3/4/2000
3604204101010013 1/1/2001
3604204103020005 3/1/2002
3604206707020001 7/27/2007
3604206403120001 3/24/2012
1/1/1983 BURUH
1/1/1990
12/11/2012
3604201108670002 8/11/1967
3604204106750001 6/1/1975
3604200311910001 11/3/1991
3604205805990004 5/18/1999
3604200101640030 1/1/1964 BURUH
3604205408700001 8/14/1970
3604202304900002 4/23/1990
3604202505930001 5/9/1993
36042008008010002 8/8/2001
3604200906030002 6/9/2003
3604200206740001 6/2/1976 BURUH
3604204802760001 2/8/1976
3604201308950001 8/13/1995
3604200311990001 11/3/1999
3604200209030004 9/2/2003
3604205701120001 4/17/2012
3604201905660001 5/19/1966 BURUH
3604206006730000 5/20/1973
3604201306990001 8/13/1998
3604200906730003 6/9/1973 BURUH
360420501080008 10/10/1980
3604200511000002 11/5/2000
3604204503040003 3/5/2004
3604200203110002 3/2/2011
3604205909990002 9/19/1999
3604200907680001 7/9/1968 BURUH
3604204708740003 8/7/1974
3604202205950001 5/22/1995
3604201701010002 1/17/2001
3604205905070002 5/19/2007
3604203112700001 12/31/1970 BURUH
3604205509770002 9/15/1977
3604205810950002 10/18/1995
3604200603710004 3/6/1971 BURUH
360420517690001 7/11/1968
3604202004850006 4/20/1985
3604204606920003 6/6/1992
3604200512940002 12/5/1994
3604204610010002 10/6/2001
3604200701810002 1/7/1981 BURUH
3604204309840002 9/3/1984
3604201606060001 5/18/2005
3604200101520017 1/1/1952 BURUH
3604205202610002 9/12/1961
3604201002890004 2/10/1989
3604200303920001 3/13/1992
3604205709980003 9/17/1998
3604201502720001 2/15/1972 √ BURUH
360420410176024 1/1/1976 √
√
3604203108930002 31/08/1993 √
3604200505960007 5/5/1996 √
3604204506980006 5/5/1998 √
3604200106040001 1/6/2004 √
3604201603700002 16/03/1970 BURUH
36042063067600003 13/06/1975
3604201509890003 15/09/1989
3604205606030001 16/05/2003
3604206110050001 21/10/2005
3604200103100001 1/3/2010
3604205306940001 13/06/1994 √
√ PNS
√

BURUH

3604201901580001 19/01/1958
3604201703050002 17/03/1985 BURUH
3604204707920002 7/7/1992
3604206610980001 28/10/1998
3604205608820001 16/08/1982

3604202908100001 29/08/2010
3604201403040002 14/03/1964 √ BURUH
3604200803950001 8/3/1996 √
3604206410980001 24/10/1996 √
3604202505860003 25/05/1986 √
3604201610620001 16/10/1962 √ BURUH
3604205006680001 10/6/1968 √
3604201003890224 10/3/1989 √
3604203009930110 30/09/1993 √
3604201505020149 15/05/2002 √
3604205607040001 18/07/2004 √
3604201303860003 13/03/1986 √ BURUH
3604205807100004 18/07/2010
3604201408750001 14/08/1975 BURUH
3604204708800004 7/6/1960

3604200503810002 5/3/1981 √ BURUH

360420511840001 12/11/1984 √
3604207005040002 30/05/2004 √
3604203103110002 31/03/2011 √
36042001013600013 1/1/1935 √ BURUH
3604204101600051 1/1/1960 √
3604206708920004 5/27/1992 √
3604201605000003 5/19/2000 √
36042006005030001 5/10/2003 √
3604202111580174 11/21/1958 √ BURUH
3604205002650095 2/10/1965 √
3604201909860097 9/19/1986 √
3604201207940153 7/12/1994 √
3604200505010102 5/5/2001 √
3604204505030094 5/5/2003 √
3604200204870004 4/2/1987 BURUH
3604205505920002 5/15/1992
3604202602120001 2/26/2012
3604201204870003 4/12/1987 BURUH
3604205105890003 5/11/1989
3604206507100001 7/25/2010
3604201004700004 4/10/1970 BURUH
3604204502820004 2/6/1982
3604205604040002 4/16/2004
3604200807090001 7/8/2009
3604207003130001 3/30/2013
3604200905769004 5/8/1976 √ BURUH
3604206301810001 1/23/1981 √
3604206411020003 11/24/2002 √
3604202402080001 2/24/2008 √
3604202104750001 4/21/1975 BURUH
3604202104700001 1/23/1979
3604200406030001 8/5/2003
3604200503100003 3/5/2010

3604200506790002 6/5/1979 BURUH

36042047606810001 6/7/1981
3604202704030003 4/27/2003
3604206301110002 1/23/2011
3604201706770002 17/06/1977 BURUH
3604204111800002 11/1/1980
360420661100100002 11/26/2011
3604201402060001 2/14/2006
3604200705540263 5/7/1954 BURUH
3604204101590264 1/1/1959
3604206806980266 6/28/1996
3604204311040002 11/3/2004
3604202411710002 11/24/1971 BURUH
3604204705770002 5/7/1977
3604202109990001 9/21/1999
3604200207050001 7/2/2005
3604204205110001 6/2/2011
BURUH
Umur Kehamilan Taksiran Peserta Status
Persalinan KB Kemiskinan
5 6 7 8 9

20 21 22 23 24 25 26 27
KS II
S

KS II

PRA KS

KS II

KS I

KS II

KS I

KS II
 KS III
IUD

PRA KS

PRA KS

PRA KS
S

KS I
PIL

KS I
S

KS III
S

PRA KS
S
 PRA KS
IUD

PRA KS
S

KS III

KS II

KS I

KS I

KS II

PRA KS

KS I
 PRA KS
S

KSII

KS I

PRA KS

KS III

KS III

KS II

PRA KS

KS I

KS I
PRA KS

PRA KS

PRA KS

PRA KS

KS I

KS I

KS I

KS III

KS III

KS I

KS I
KS III

KS II

KS I
NO NAMA Status Umur
Kepala Anggota
L P
Keluarga Keluarga
1 2 3 4 5 6
1 ANDRI RISWANDI K
IDIATUL MILAHI K
AVIA ZARA S BK
2 JULAEHA CERAI HIDUP
INDAH L K
HAETAMI BK
RESTI AGUSTIN BK
A NAJILI BK
3 INAH CERAI MATI
ILHAM K
4 MUHAEMIN K
MARDIAH K
NAULIAH BK
MAHPUD BK
AZMI BK
ULUM BK
5 AMARUDIN K
LILIS K
SALSA BK
ULAN BK
NAILA BK
6 AHMAD K
ARMINI K
PAHRUROJI BK
BUDI MUHTADI BK
7 OMI H CERAI MATI
INAYAH K
IRAWATI BK
INARSIH BK
INDRIYANI BK
OMBI BK
ISWARSIH BK
OKANDI BK
8 SUMI CERAI MATI
9 SALPA K
SUKATMAH K
MAMAD DH BK
SUSI R BK
10 DARSO K
SURNAWATI K
11 ALI K
 ASMAINAH K
12 SANA K
ESIH K
ADING BK
SUHARMID BK
13 KASTURI K
NURHASANAH K
NURYADI BK
HADIJAH BK
M FEBRI BK
UMI CERAI MATI
14 INAN K
ARNENGSIH K
PAHRULROJI BK
ALWAN SH BK
AAN ROHAENI BK
ARUMANAH BK
15 ATMA K
ETI ROHETI K
AYU WANDIRA BK
AKBAR S BK
16 TETEN K
SARTINI K
SARJALI BK
M RIDWAN BK
ARIS S BK
17 MADTOHA K
ONIH K
18 NURHASIM K
UTI KULSUM K
NURAIDA BK
M ALWI H BK
RIKI H BK
OKTOPIA BK
19 RUSLAN K
NURHEDAH K
FITRI'A BK
M YUDI B BK
ALDI F BK
RIAN H BK
NURJAYA BK
AFANDI BK
20 SUNARYA K
ROSNAWATI K
NAJILA F BK
WIRA H BK
BARLINA BK
21 DULYAMIN K
 YOYOH K
NURANISA BK
RESTU BK
22 IMAT K
BAI F K
WINDA H BK
HAMDANI BK
BUHORI BK
23 DUWNAN K
ADAM K
FIFIN BK
AFIKA BK
24 SAKINAN K
ASMI K
AS'ARI BK
25 PIRDAUS K
NAPIAH K
NUB R BK
A RIFA'I BK
NIA K BK
ANISA I BK
26 MUNJI K
PATONAH K
PARID H BK
A ALAYUBI BK
RIJIK AL BK
27 A SARIMALA K
ST TUNAH K
A HADIANSAH BK
ADILA P BK
28 HARTONO K
ENI K
MULKI BK
RASIAH BK
ELAWATI BK
ENDANG S BK
29 SUNTIKA K
MAEMUNAH K
A ROHMAN BK
KAMILAH BK
NUFUS BK
30 UMAR K
TUTI M K
TIRANI BK
31 UJEN K
MAR'AH K
32 SUJANA K
EUIS M K
 ENGELISTA BK
M REGI D BK
IBAD G BK
33 DADI K
WANAH K
DIDIN U BK
PARYATI BK
DINDA BK
DEWI BK
34 YUNETI K
MARTA K
SRI ULTA BK
35 SUHENDI K
AISAH K
ANGGA BK
ABDURROHMAN BK
LUKMAN BK
M YUSUP BK
36 SAMHUDI K
ASWATI K
37 AAN NANI K
ADFA H K
38 MAMAT K
NURLELAH K
DIAN SRI BK
M AFGAN BK
A FAJRI BK
39 TB ABDUL ROJAK K
RUKIAH K
TB DIKA P
40 SAPRI S K
EYI N K
CIKA S BK
41 IKSAN K
UYAN K
A SANTONI BK
A SUNARYA BK
SUMENDRA BK
42 ROHANDA K
RUMSARI K
BADRY BK
M RIJKI BK
43 NINGRAT K
44 DARSO K
SURMAWATI K
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

Nomor NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya

KK Lahir BPJS
PBI Mandiri Askes Lainnya
7 8 9 10 11 12 13
3604200201130003 360420260484001 9/26/1984
3604204704970003 7/4/1991
3604205001130002 1/1/2013
3604200212040004 3604204804770001 8/4/1977
3604206102050003 2/21/2005
3604200508460002 5/8/1996
3604206408140001 8/24/2014
3604201608470001 8/10/1997
360420030210006 3604204101430043 1/1/1995
3604200207720001 7/1/1973
3604201102077301 36042001077500247 7/1/1975
3604207101810001 1/3/1981
3604204504040001 28/01/2004
3604202801040001 28/01/2009
3604206611060002 26/11/2006
23/11/2014
360420110277302 3604201210780002 10/12/1978
3604204112780001 12/11/1978
3604207011020001 30/11/2002
3604206406440001 24/06/1999

3604201102077303 3604200711580001 11/7/1958 √

3604204706670001 6/7/1967 √
360420010440007 7/1/1999 √
3604202208440001 22/08/1994
3604201102077303 360420560680001 16/06/1968
3604205802870001 18/02/1987
3604205703980001 17/03/1998
3604202004890002 20/04/1989
3604204512070002 12/5/2009
3604200107950006 7/1/1995
36042045060003 5/5/2006
3604200107010003 7/1/2001
3604201102077306 3604204101550017
3604201102077306 3604200102600003 02/011960
360420430170002 1/3/1970
3604202912030002 24/12/2003
3604206603000001 26/03/2000
3604201102077304 3604203112440001 12/3/1944
3604204107570023 7/1/1957
3604201102077317 3604201311620002 1/11/1966
 360420510166001 6/5/1972
3604201102077310 3604200705600005 5/7/1957
3604205407630001 7/14/1963
3604200603410005 2/10/1990
360420037840002 8/3/1984
36042011077311 3604200111670002 11/1/1967
3604205112810002 12/11/1981
360420110110001 20/11/2001
3604205001120003 1/10/2012
360420282090001 28/02/2004
36042041014500036 1/1/1945
3604201102077313 3604202205550001 22/05/1955
3604206508770002 25/08/1977
3604202704930002 27/04/1993
3604202612980001 20/12/1998
3604202612980001 10/8/2002
3604206506080001 25/08/2008
3604201102077313 3604200203710003 2/3/1971
3604204307800005 5/7/1980
3604206040001 22/08/2004
3604201809100001 18/09/2010
3604201102077314 3604200807620002 6/8/1962
3604205202720002 2/12/1972
3604201808890002 8/10/1989
3604200801030002 1/8/2003
3604200811900001 11/8/1990
3604201102077316 3604202711500001 27/11/1950
3604206012530001 13/111953
360420112077317 360420050672004 6/5/1972
3604205911770001 14/11/1977
3604205004460005 4/10/1996
3604200807030001 7/8/2003
3604201803040001 18/03/2009
11/2/2014
360420112077315 3604200507720004 7/5/1972
3604204704730003 4/7/1973
360420507950004 7/5/1995
360420301097000 30/10/1997
3604202512100003 25/12/2010
3604203010970001 12/5/2004
360420070686002 6/7/1986

3604201102077314 3604200107780027 7/1/1978

3604204509770001 9/5/1977
360420550280001 13/02/2008
3604201994940002 19/04/1994

3604201102077320 3604201102077320 2/10/1975

 360420450380001 3/3/1987
3604206080001 6/2/2008
3604202011760001
3604201102077322 3604204107800025 20/11/1976
360420660380002 7/1/1980
3604200404440001 26/03/2008
3604200409990001 4/4/1994
3604200706010001 6/7/2001
3604201102077323 3604204107700018 7/1/1970
3604200107870026 7/1/1987
11/10/1989

36042802560001 36042802560001 18/02/1956

3604206106590002 21/06/1959
3604202106900001 21/06/1990
3604201102077327 3604200503570002 3/5/1957
3604204407740002 7/4/1974
3604205103020002 3/11/2002
3604200101120052 1/1/1992
3604204703940001 3/7/1999
360420670840002 8/2/2004
3604201102077324 3604200505760003 5/5/1976
3604205408810003 14/08/1981
3604202003090004 20/03/2004
3604202704970002 27/04/1997
3604202804020001 4/3/2002
3604201102077321 3604202309760001 23/09/1976
3604204704790003 4/7/1974
3604200709000003 9/7/2000
3604206904120001 29/04/2010
3604201102077333 3604200109560001 09/011956
3604204210600001 10/2/1960
3604201010420006 10/10/1992
3604205211870002 11/12/1987
3604206309980001 23/09/1998
3604201404850001 14/04/1985
3604201102077334 3604201212600002 12/12/1960 √
3604206508760002 8/25/1976 √
3604200504920002 S √
3604204903110002 4/3/2011 √
360420430120001 6/4/1994 √
3604201605120003 3604200611720001 6/11/1972 √
3604205105820004 11/5/1982 √
3604205004010005 10/4/2001 √
3604201812090028 3604200107320004 1/7/1932
3604204107500012 1/7/1950
3604201812090028 3604202607780003 7/26/1978
3604206506810002 6/25/1981
 3604206112040003 12/21/2004
36042012020004 12/2/2013
3604200802070003 8/2/2007
36042018020400024 360421708730004 8/17/1973
3604205804790001 9/18/1979
3604201011960003 1/22/1995
3604205405980002 12/28/1998
3604205211100001 12/11/2010
3604205508060001 2/7/2007
3604202112100060 3604204504860001 5/4/1986

3604206705040003 5/27/2004
36042020112100066 3604200101700013 1/1/1970
3604201503000004 5/1/1970
3604201610420001 3/15/2000
360420230420001 10/16/1992
3604202309110005 9/23/2011
3604201909060001 9/23/2006
36042020113100068 3604201011540002 10/11/1954
360420550950001 9/15/1950
36042020112110069 3604205311820002 11/13/1982
3604201306680001 10/14/2008
3604202306100010 3604201306680001 6/13/1968
3604205702760001 2/17/1976
3604205609950003 9/16/1995
3604202209140001 9/22/2014
3604201909030004 9/19/2003
3604202403110005 3604201606830001 6/16/1983
3604204407890001 4/7/1984
3604201005100003 10/5/2010
3604202701120007 3604200908890001 4/8/1987
3604205810920001 10/10/1992
3604205605140001 5/16/2014
3604202709110006 10/14/1970
3604205112780001 11/12/1978
36042070910006 10/4/1994
360420031480001 3/1/1998
360420211050001 4/5/1978
3604202806110002 3604200405780003 12/12/1979
36042021279002

11/11/1992
N IBU DAN BAYI

ansi Lainnya Pekerjaan Umur Kehamilan

Asuransi KK
1 2 3 4 5 6 7
Lainnya
14 15 16 17 18 19 20 21 22
BURUH

IRT

BURUH

TANI

DAGANG

BURUH

TANI

TANI

TANI
 TANI

SWASTA

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH
BURUH

BURUH

BURUH

SWASTA

BURUH

BURUH

BURUH

BURUH

BURUH
BURUH

BURUH

SWASTA

BURUH

BURUH

BURUH

TANI
DAGANG
 Taksiran Peserta Status
Persalinan KB Kemiskinan
8 9

23 24 25 26 27
KS I
S

KS I

KPS

KS I
S

KS I
S

KS I
S

KS I

KPS
KS I

KS I

KS I
 KS I
S

KS I
IMPLAN

KS I
S

KS I
S

KS II
S

KS I

KS I

KS I

KS I

KS I
S

KS I
S

KS I
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KS I

KS I
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KS I
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KS I

KS I

KS I
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KS I

KS I

KS I
KS I

KS I

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KS I

KS I

KS I

KS I

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KS I

KS

KPS
KS I
NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga

1 2 3 4 5 6 7
1 SOHAR K 31 3604202701120015
SUDIHARNA K 29
SONIA BK 11
BAYI BK 0
2 A DINURI K 56 360420300408003
NENENG K 31
R DANIATI BK 9
3 JAMANI K 52 360420110277345
HERNI K 45
LIA FITRIA BK 19
ALIKA BK 7
4 GOPFUR K
IIN K
SAHDAN BK
5 SUPRIAH K 46
AGUS K 6
ST TOYIBAH BK 18
6 M ROIS K 25 3604201303140006
SARTIKA K 25
ZAHRAENI BK 1
7 SURNAH K 71 3604202406040012
8 KOSIM K 26 3604202112100076
ST NURAENI K 26
M RAMDANI BK 6
9 SULANI CERAI MATI 65 3604202505040014
WAHYUDIN K 20
HARDIANA BK 12
MUDINAR BK 9
10 MAD NUR K 35 3604201812090018
SUWILIS K 25
REHAN A BK 5
11 MANGSUR K 18 3604201102077373
ARTINAH K 63
12 MASRETI K 34 3604201710130001
TARIAULIA K 10
TIARA BK 1
13 UMAYAH K 60 360420110207735
MUHARI K 25
14 EMANG K 59 3604201817090016
 MAEMUNAH K 33
EVA R BK 20
ABRORI BK 6
15 IWONG K 33 3604201102077374
EGI G BK 16
ISLAH M BK 3
16 A SUDRAJAT K 23
ENI A K 20
SULISTIAWATI BK 0
17 SAHANI K 51 3604203009100012
MAHMIAH K 48
MAHMUDIN BK 29
SALWA BK 9
18 SAEPULLAH K 29 3604201812090019
NURHAYATI K 28
RIKI S S BK 10
M DAFFA P BK 3
19 SARIPUDIN K 38 3604201911120003
YENI K 21
WIDIYA S BK 3
20 MADRIA K 53 3604202209070008
SUPIAH K 50
SANTANA BK 28
YUDI BK 10
21 MARYATI CERAI HIDUP 35 3604200411130011
YUDI P K 20
22 ARKAYA K
EMI K
23 ALIS M K 25 360420211108002
WULAN D K 7
24 JAMSURI K 61 3604201812090021
SUKMARIAH K 59
25 MISJAYA K 35
YENI K
AZMI BK
26 ALI YUSRO K 51 3604202506090022
NAINAH K 43
EFIT Y BK 17
ARSIKAH BK
27 A AZIS K 26
MARIA K
AZILAH BK 1
28 ASMANI K 39 3604201102077380
MARSINAH K 38
HENI BK 12
29 SUPIAN K 51 3604201102077365
ASMINAH K 55
30 BAHRUDI K 35 3604201102077375
SUSILAWATI K 26
M PAJARUDIN BK 6
31 DUL YASIR K 30
SAPIAH K 30
SAEPUDIN BK 10
32 HERI K 33 3604201102077370
BAETI K 30
HERIAWATI BK 12
RAHMATULLAH BK 6
33 SARNATA K 55 3604201102077368
SUKRABAH K 41
IMAM BK 13
34 RIDWAN K 43 3604201102077367
SUNENGSIH K 36
ST RIKA S BK 14
M RIFKI BK 6
35 SAMSUDIN K 68
SALMAH K 67
SURNADI 26
SURNATA 25
SUMARNA 21
36 SATIBI K 52 3604201102077360
SURENAH K 48
DIAN FATHU 14
37 MAHRUDIN K 45 3604201102077371
UTIS P K 40
SUTISNA A BK 25
SUMANTRI BK 23
EUIS M BK 22
DUMYATI BK 15
38 BASRI K 58 3604201102077378
SARIYAH K 55
APIAH BK 24
39 UMAR K 58 3604201102077380
ASWANAH K 55
40 UKIS K 35 3604201102077383
UNIT F K 31
RIZAL S BK 11
41 SAHIR S K 40 3604201102077424
ST ARNITI K 42
AGUS S BK 18
IMAS I BK 10
42 LADI K 42 3604201102130002
WIWIT K 38
SUHENDRA S BK 17
ELIZA L BK 9
43 SUPRANA K 46 3604201303140009
MASAYUM K 39
SUNENDA BK 5
FITRI A BK 20
FINA M BK 9
44 ADNAN I K 36 3604201409110002
NURSIAH K 30
SUNAENI BK 13
A NAJILI BK 10
45 MURSIKAH K 71 3604201510090014
46 YAYA SURYA K 36 3604201812090002
MAESAROH K 31
SILVIANI BK 6
47 KARNIMAH CERAI MATI 72 3604201102077339
48 SUNEDI K 27 3604200702130002
ST KHADIJAH K 20
M ROHIMI BK 3
49 WAWAN K K 31 3604201008090004
ROSITA K 25
M ADITYA BK 4
50 SAPRI K 70 3604201102077335
SUPATMAWATI K 44
SUKMAWATI BK 31
R DEDEN M BK 16
51 ANYAR K 55 3604201102077337
SINAH K 50
IYAN BK 21
YANA BK 24
52 JARI K 50 3604201102077338
HAYATI K 38
MARTIN BK 4
HANJANI BK 17
HARMONI BK 23
HERMANSYAH BK 28
ST HASANAH BK 10
53 MAHMUD K 71 3604201102077340
SARWITI K 60
RUKMAN BK 32
54 SARNA K 50 3604201102077541
LAELAH K 62
M NUR BK 26
55 MUKTAR K 47 3604201102077342
UMIYATI K 38
FITRIAH BK 21
DIAH P N BK 16
DEA A P BK 2
56 IKNA K 48 3604201102077348
JURIAH K 42
UJANG S BK 19
A DUDI BK 12
57 SUHERMAN K 32 3604201102077349
SUHARTINI K 36
SUTRIANA BK 8
NMULYANA BK 18
HELDAWATI K 2
58 SARAH cerai hidup 39 3604201812090019
BAGUS S BK 11
INDAH L BK 11
59 TAJUDIN K 38 3604201102077352
SAIROH K 31
TASIH BK 15
TASYA BK 5
60 SUHENDAR K 35 360420112077354
ETIH N K 27
SITI S BK 2
ERIK S BK 11
61 ENGKUN S K 51 360420112077355
SAKIMAH K 52
M SUKARIA BK 25
62 SUARTA K 55 3604201102077356
SARMUNAH K 46
SARMAN BK 24
JEPRY BK 15
CAHAYA M BK 12
63 ROHANAH CERAI MATI 54 3604204808610001
ROKEDAH CERAI MATI 85
64 OJI M S K 47 360420112077360
TUTI K 39
A SADELI BK 20
ST ANISA J BK 15
ST UNDIAH BK 10
65 ASNAH K 50 3604201812090001
YULIANTI K 18
66 MUSLIH K 60 3604201812090003
SURIAH K 57
AHMAD S BK 19
 MULYADI BK 27
SUTARYANA BK 17
IWAN BK 28
ABIRA S BK 6
MULYA AJI BK 21
ROHMAT BK 19
NUR H BK 14
A MUALIM BK 11
67 HENDRIK K 31 360420181090020
YUYUN K 28
TANTIA H BK 8
REVANO H BK 3
68 MUIN K 27 3604201812090010
HALASTRI K 27
M HAFIDZ BK 7
ADINDA P BK 2
69 PULUNG K 71 3604201812090006
CICIH K 44
HERNAWATI BK 27
IPUL B BK 23
LUKMAN BK 21
70 SUKARI K 30 3604201812090008
YANAH K 27
71 SARINAH K 54 3604202407090009
RIZKI A W K 17
72 ALIUDIN K 51 3604202112100073
AMINAH K 45
HARIWADI BK 23
MILAWATI BK 15
73 JARMINAH CERAI MATI
74 KOMI CERAI MATI
75 ALEK K 41 3604202506040030
ITI K 38
JULITA BK 11
76 ARWANI K 38 3604201102077350
SUTIHAT BK 31
ENCEP BK 12
SUTISNA BK 3
77 MULYATI K 40 3604201812090012
HERDIANA S K 21
PERDIANSAH BK 11
78 JAJANG K 43 3604202112100071
MAR'AH K 33
MARHENDI BK 12
SELVI BK 7
79 NANA S K 46 3604202811110006
SURYATI K 38
ASEP S BK 19
FERDO R BK 12
80 ARMIN K 45 3604201102077351
MAESAROH K 40
SAMSUL B BK 17
A DANI BK 7
81 IQRA K 44 3604201402130002
ENI K 36
MUAMAR BK 14
ADI M BK 4
82 HAIRUL K 45 3604202212090055
DIAN M K 38
HENI D BK 14
SYIFA A BK 6
83 MISRA K 49 3604202112100074
SUANAH K 47
TOBING BK 15
ST NURMAIDAH BK 11
84 SUANDI K 38 3604200909140001
ST AISAH K 32
TUHFATUL R BK 13
DEVITA AL BK 6
85 JOHANI K 65 3604203101120003
UMSIAH K 65
86 A MAJID K 35 3604201702100023
ERNAWATI K 29
M AKBAR F R BK 8
87 SUKATA K 35 3604202310120013
SUNARTI K 22
A RIZKI K BK 3
88 GAESUL A K 32 3604201904120002
ST UTIAH K 23
M KHARUL A BK 3
89 SUKNA K 60 3604202112100078
SAMI K 53
A SUPRIATNA BK 19
90 SUHAR K 49 3604202112100075
TUAMI K 49
ST SUHAENI BK 13
91 EDI K 43 3604201102077347
SUPRIYATI K 43
ANDI BK 17
SELI A BK 6
92 UJANG S K 27 36042023110120006
SELAWATI K 25
AINA BK 3
93 JULEHA K 39 3604201812040015
UPUS K
GALIH BK
94 MUSROHUL H K 33 3604202112100070
MUKIANAH K 28
EZA M A BK 9
95 ALWAN K 3604201812090004
NGASIYATI K
BAYU D BK
NISSA A R BK
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan

Lahir BPJS Asuransi KK
1
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15 16
3604202201640001 22/01/84 BURUH
360420216860005 6/6/1986 √
3604205410040002 14/10/04
360420 18/10/05
3604200101590261 1/7/1959 BURUH
3604205903840001 19/03/84
360420610306000 21/03/06
3604200204630001 2/4/1963 √ PNS
360420510970000 11/4/1970 √
3604205301960001 13/01/96 √
3604205505050001 16/06/08 √
WIRASWASTA

360420550490002 15/04/64 IRT

3604201708040003 17/08/09
36042050897005 10/8/1997
360420040890006 4/6/1990 BURUH
3604204205900003 2/5/1990
3604206401140001 24/01/14
3604205505440058 15/05/49 IRT
3604200505890003 5/5/1989 BURUH
3604205308880003 18/08/89
360420059090003 5/9/2009
3604201508500065 15/08/50 √ BURUH
3604202104950071 21/04/95 √
3604201012030072 10/12/2003 √
3604201101060001 11/1/2006 √
3604200102800002 1/7/1980 BURUH
3604204101800010 1/1/1990
3604201610100001 16/10/10
360420037370002 3/7/1937 BURUH
360420420740001 2/7/1942
3604206605810001 26/05/81 IRT
3604205207050005 12/7/2005
14/07/14
3604206001550002 20/01/55 IRT
3604200209910002 3/9/1990
3604201209560001 12/9/1956 BURUH
3604205506820002 15/06/82
3604205609950002 16/09/95
3604202801090002 28/01/09
3604204107820029 1/7/1982 IRT
3604200106990001 1/6/1999
360420505120002 5/5/2012
17/04/92 √ BURUH
16/08/95
22/07/15
3604201212640001 12/12/1964 BURUH
3604205011670002 10/11/1967
3604201906860002 19/06/86
3604205810060002 18/10/06
3604201602810001 16/02/86 BURUH
3604204408870005 4/6/1987
36042005030500007 5/3/2005
3604201909120001 19/09/12
3604200705770002 7/5/1977 BURUH
3604206108940001 21/08/94
3604204411120001 4/11/2012
3604201209620001 12/9/1962 BURUH
3604205301650001 13/01/65
3604200107870031 1/7/1987
3604200107050004 1/7/2005
3604204107800005 1/4/1980 BURUH
3604202102050002 21/02/95
PETANI

3604206502860001 25/02/86 IRT

22/12/08
3604201006540001 10/6/1954 BURUH
3604203560001 2/3/1956
15/08/80 BURUH

3604202204600100 22/04/64 PETANI

3604201510720101 15/10/72
3604200704890100 21/02/98

7/4/1989 BURUH

25/08/14
3604202001460001 20/01/76 BURUH
3604204502770001 3/2/1977
3604205004030001 10/4/2003
3604201502640001 15/02/64 BURUH
3604206003600001 20/03/60
3604201106800002 11/6/1980 BURUH
3604205710890002 17/10/1989
3604200707090002 7/7/2009
3604200702850002 7/2/1985 BURUH
3604206511850001 25/11/85
3604201402050001 17/02/05
360420205820001 20/05/82 BURUH
3604206304850001 23/04/85
3604206403030003 24/03/03
3604201309090002 13/09/09
3604200101600033 1/1/1960 BURUH
3604205410740004 14/10/74
3604200101020002 1/1/2002
3604201807720002 18/07/72 BURUH
3604205907790001 19/07/79
3604206707010004 27/07/01
3604200801090001 8/1/2009
360420707470001 7/7/1947 √ BURUH
3604204608480001 6/8/1948 √
3604202009890003 20/09/89
3604202109900001 21/09/90
3604201807940004 18/07/94
3604201108630001 11/8/1963 WIRASWASTA
360420580670002 18/05/1967
3604205707010001 17/07/01
3604201504700004 15/04/70 WIRASWASTA
3604206108750001 21/08/75
3604200505900001 5/5/1990
3604202102920003 21/02/92
3604204512930001 5/12/1993
3604202512000002 25/12/00
3604200107470009 1/7/1947 BURUH
3604204107500009 1/7/1950
3604206307910001 23/07/91
3604201208570001 12/8/1957 BURUH
3604205301600003 13/01/60
3604201008800004 10/8/1980 WIRASWASTA
3604205811840001 18/11/84
360420053040003 5/3/2004
3604202010750002 20/10/75 √ PNS
3604205510730001 15/10/73 √
3604200608970005 6/8/1997 √
36042042060050003 2/6/2005 √
3604201510730001 15/10/73 WIRASWASTA
3604204510770002 5/10/1977
3604200606980002 6/6/1998
3604205105060004 11/5/2006
3604160509690003 5/9/1969 BURUH
3604205504760001 15/04/76
3604165504100001 15/04/10
3604202404950001 20/02/95
3604204101060010 1/1/2006
3604201209790002 12/9/1979 BURUH
3604205604850001 16/04/85
360420596020001 14/06/02
3604201001050001 14/01/05
3604204106440002 1/6/1944 IRT
3604201707790001 17/07/79 BURUH
3604205301840001 13/01/84
3604204501090001 3/1/2009
3604205012430001 10/12/2003 IRT
3604200509880001 5/9/1988 BURUH
3604206802950003 28/02/95
3604202403120002 24/03/12
3604202612890001 26/04/84 BURUH
3604205506900001 15/06/90
3604200112110001 1/12/2011
36042001014500021 1/1/1945 PETANI
360420460671000 6/6/1971
3604206504840002 25/04/84
3604201908990002 19/08/99
3604201403600002 14/03/60 PETANI
3604204205650002 2/5/1965
360420229940001 22/09/94
3604200112910001 1/12/1991
3604202001650003 20/01/65 BURUH
3604204304770004 3/4/2011
3604202001110001 20/01/11
3604200305480003 3/5/1998
3604202302420001 23/02/92
3604200304870004 3/4/1987
3604204502050003 5/2/2005
3604201002440001 2/10/1944 PETANI
3604205504550001 4/15/1955
3604201505830004 5/15/1983
3604202004650001 4/20/1965 WIRASWASTA
3604204605530001 5/6/1953
3604202606890002 6/26/1989
3604201006680001 6/10/1968 WIRASWASTA
3604204708770002 8/7/1977
3604204603990001 4/6/1994
36042057990002 7/17/1999
3604204311130001 11/3/2013
3604201110670002 10/11/1967 BURUH
3604205006430003 6/10/1973
3604200303960002 3/3/1996
3604200212020001 12/2/2003
360420025830003 5/2/1983 BURUH
3604205408740001 8/14/1979
3604200802070002 2/8/2007
3604202207970001 7/22/1997
12/15/2013
3604206306760001 5/16/1976 IRT
3604201605040001 5/16/2004
3604205605000001 5/16/2004
3604200708770001 8/7/1977 BURUH
3604204911840001 11/9/1984
3604204802000001 2/8/2000
3604206905100001 5/15/2010
3604202109800001 9/21/1980 BURUH
3604204407880009 1/4/1988
3604205505130003 5/15/2013
3604200906040003 6/9/2004
3604202001640001 1/20/1964 BURUH
3604206503630001 3/25/1963
3604200208940001 6/12/1990
3604201011600005 11/10/1960 WIRASWASTA
3604205502690001 2/15/1969
3604200101930001 1/1/1991
3604201404000003 4/14/2000
3604204503030001 3/5/2003
3604204808610001 8/8/1961 IRT
3604206802300001 2/28/1930
360420274680001 4/27/1968 BURUH
3604207001760001 1/30/1976
3604200405950002 5/4/1995
3604204603000001 3/6/2000
3604204403050002 3/4/2005
3604205502650002 2/15/1965 IRT
3604205908970002 8/19/1997
3604200101550031 1/1/1955 BURUH
3604204101580020 1/1/1958
3604201201960001 1/12/1996
3604202003870001 3/20/1988
3604201004980002 4/10/1998
3604202505870002 5/23/1987
3604201511090002 11/15/2009
3604201705940003 5/17/1994
3604202601960001 1/26/1996
3604204408010001 8/4/2001
360420044040003 7/4/2004
3604202803840001 2/28/1984 BURUH
3604204109870003 9/1/1987
3604204103070004 3/1/2007
3604201207120003 7/12/2012
3604202707880003 7/27/1988 BURUH
3604205305880002 5/13/1988
3604200501080001 5/10/2008
3604205307130002 7/13/2013
3604202002440001 2/20/1944 BURUH
3604204202710003 2/2/1971
3604205005880007 5/10/1988
3604202606920002 6/20/1992
3604200905940001 5/9/1994
3604200408850002 8/4/1985
3604204504880002 4/5/1988
3604206108610001 8/21/1961 IRT
3604202510980003 10/25/1998
3604201512640003 12/15/1964 BURUH
3604205709700001 9/17/1970
3604201412920003 12/14/1992
3604204408000002 8/4/2000
IRT
√
360420210470130 4/21/1974 BURUH
360420450677131 6/5/1977
3604204102040133 4/1/2004
3604201507770004 7/15/1977 BURUH
3604206109840001 9/21/1984
3604200809030003 9/8/2003
3604202508120001 8/25/2012
3604204405750006 5/4/1975 IRT
3604202809940002 9/28/1994
36042026110400001 11/26/2004
3604201408720004 8/14/1972 BURUH
3604204101820003 1/1/1982
3604202604030004 9/26/2003
3604206012080004 12/20/2008
3604200101690003 1/1/1969
3604205509770004 9/15/1977
3604202104960004 4/21/1996
3604200512020004 12/5/2002
360420401700002 1/14/1970
3604206901750002 1/29/1975
3604203011980002 11/30/1998
3604202005080001 5/20/2008
3604201704710002 4/17/1971 BURUH
3604204101790011 1/1/1979
3604200608010002 8/6/2001
3604201107110002 7/11/2011
360420070370002 3/7/2073 PEGAWAI SWASTA
3604204712770001 12/7/1977
3604204309010003 9/3/2001
3604204104090004 4/1/2009 BURUH
360420120660002 6/12/1966
3604204311680001 11/3/1968
3604200603020004 6/13/2000
3604205507040002 7/15/2004
360420090770001 7/9/1944 KARYAWAN SWASTA
3604205011830006 11/10/1983
36042009020002 9/9/2002
3604204702090001 2/7/2009
3604201201500001 1/12/1950 BURUH
3604206001550003 1/20/1950
3604202203800001 3/22/1980 BURUH
3604205708860003 8/17/1986
3604202112070003 12/21/2007
3604201410800001 10/14/1980 BURUH
3604206705930003 5/27/1993
3604202112120001 12/21/2012
3604202107830002 7/21/1983 BURUH
3604205705920004 5/17/1992
3604200703120001 3/7/2012
360420160550001 5/16/1955 BURUH
3604205007620001 7/10/1962
3604200107960002 7/1/1996
3604202110600001 10/21/1966 BURUH
36042055026600021 2/15/1966
3604206512020001 12/25/2002
3604200812630001 12/8/1972 BURUH
3604204101720027 1/1/1972
3604201103980001 3/11/1988
3604205802090001 2/18/2009
3604200406880001 6/4/1988 BURUH
3604205006900005 6/10/1990
3604206111120003 11/11/2012
3604206503760001 3/25/1976 IRT

3604202112100070 12/3/1982 BURUH

3604206203870001 3/22/1987
3604201405060001 3/14/2006
3604200304740002 4/3/1974
3604204311780003 11/3/1978
3604200205020004 5/2/2002
3604205409080001
 Umur Kehamilan Taksiran
Persalinan
2 3 4 5 6 7 8 9

17 18 19 20 21 22 23 24 25

√ 18/10/15

1/3/2016
√ 10/12/2015
√ 3/1/2016

√ 5/1/2016
√ 5/15/2016
 Peserta Status
KB Kemiskinan

26 27
KS I

KS I
S

KS II
S

KS I

KS I

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NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 JUHRONI K 39 360420110207873
IDA. L K 40
FAUZAN L BK 12
ALPI Y BK 7
2 HARYANTO K 19 360420290414000
INA.E.S K 19
3 SUKRON .U K 38 3604200806040038
SUMIATI K 38
NUR. K BK 13
M. ARIP BK 10
4 UPAD K 47 3604201102078044
YULIA . W K 42
SUPIADI BK 22
IMAS. S BK 19
LISA. S BK 8
AAN. A BK 19
5 OMAN K 42 3604201601130001
SUMARNI K 49
ALPIN. S BK 14
6 SANA K 35 3604202411840080
SUHERTI K 31
YUSUF. R BK 10
7 JUHERI K 46 3604201108078034
ADE.S K 43
WAGI. H BK 24
JUMAR BK 20
SIGIT. MN BK 14
FIRMAN . A BK 10
JIHAN .A BK 7
8 CAHYO K 42 360420110207817
SUIKAH K 42
ASEP. S BK 21
ASEP. S BK 14
DIAS H BK 9
9 KANAWI K 43 3604201102078042
WATI K 38
SUMARDI BK 18
WINI. Y BK 14
NOVI.A BK 12
ADAM.K BK 5
10 DADANG .M K 30 3604202609120002
MULYATI K 22
AMANDA BK
11 UMANG K 55 360420110207885
YATI K 44
NURHASAN BK 28
JURKON BK 19
NENENG. A BK 13
12 JEJEN K
NURLELA K 31
NURKOMALA BK 6
13 H. DALIMI K 58 3604201102078080
HJ. JANAH K 56
JAMIKUN BK 25
DEVI. N BK 18
A. HOJI BK 10
14 YAYA. HF K 41 3604201102078090
WINDINI K 29
WIDDA. R BK 9
GIFAR BK 2
15 IWAN K 34 3604200406080022
ERSIH K 28
WINARSIH BK 16
IMELDA BK 9
16 A. SAHROJI K 39 3604201912090033
ARISKA K 31
ARI. AP BK 7
ANINDITA. N BK 1
17 ARHALI K 45 3604201102078023
EEN. H K 42
ISMI BK 21
NELI BK 14
EDO. ARAJI BK 9
18 DADANG. S K 49 3604201102078077
KHUSNUL .K K 32
RISMA . NP BK 22
AGUS .P BK 13
RISKA. MR BK 7
19 RAHMAT K 55 3604200706040022
PARIAH K 46
PRIANA BK 17
20 DEDI. S K 32 3604200909070002
ROHATI K 31
RISKI. A BK 9
PAKIH BK 18
21 JUHEDI K 40 3604201102078053
ANISA K 39
VINDI. A BK 13
NURWITA. S BK 9
VEHIEVI. K BK 8
22 H. JUNEDI K 63 3604201102078055
HJ. ICEU K 53
NURLELA BK 24
IRMAWATI BK 21
23 ARDAYA K 38 3604203011090019
NURHAYATI K 54
ARDIA BK 8
24 LATIF K 46 360420120612000
IROH K 36
AAM. N BK 20
ANA WIDIYA BK 17
TEDI. S BK 15
SAMSUL. B BK 10
25 SUTIAR K 32 3604201206120006
HAFSOH K 26
SITI. H BK 14
26 MADSALEH K 62 3604201704120002
ATMIATI K 44
MA.MUN BK 12
27 YUDI. AW K 35 3604201102078029
PARDAH K 32
YULIANA BK 12
M. PAUJAN BK 6
28 SULASTRI JANDA 67 3604200528120004
DAPIT. A BK 28
29 DOLONG K 36 3604200806040020
NURSIAH K 63
NURUL. K BK 28
M. FADLI BK 9
30 KHOSRI K 43 3604200806040018
MULKIAH K 46
LAELIA. A BK 22
M . SOHIB BK 15
31 DRS. ADNAL K 57 3604200811070001
ADE IRMA K 40
MAJESTI BK 25
ELISA. E BK 22
YOSEPH BK 18
ZULKARNAIN BK 17
SELLY BK 15
32 SARBI K 39 3604200808090009
MUSAROPAH K 31
SERLI P BK 12
SARMILA BK 10
SABASTIAN BK 5
SABIT. W BK 28
33 SAPRONI K 38 3604201102078066
ELAH K 33
SAHRUL. H BK 10
34 ANTAMIN DUDA 48 3604200706040007
SRI. R BK 21
PIPIT. P BK 18
SITI. N BK 11
35 JAMHARI K 49 3604201102078032
ROHAYATI K 45
ROSADI BK 23
JIHAT. H BK 16
ROHMANTO BK 18
JUMRIAH BK 14
JULAEHA BK 12
RIAN . P BK 9
JELITA. A BK 8
RIPAT. J BK 4
36 ROHMAT K 40 3604201811110001
JUHENAH K 26
FRIDA. U BK 4
37 JAKARIA K 41 3604200806040031
IPAH K 37
IIP BK 17
RIZKI. S BK 12
38 DAYAT K 33 3604201912090032
SUHENI K 26
ASEP. S BK 6
39 SARNAN K 87 3604200806040039
IPAH K 47
NIRWAN BK 27
IRYADI BK 24
ILHAM BK 20
AJI. M BK 13
FITRI. S BK
40 A.CHAIDIR K 67 3604201102078063
SULASTRI K 48
ANDIKA. R BK 28
RANY. P BK 20
41 MANTA K 49 3604201102078058
 INAH K 42
MARYATI BK 17
MARLINA BK 13
MAHIRA BK 5
42 JUMHUR K 45 3604201102078065
ATI K 40
HASAN. B BK 23
SOPIAH BK 15
DIAN AH BK 10
M.APRIL BK 5
M.ASEP M BK 3
43 JAHRONI K 49 3604201102078031
NASBAH K 52
NASAR BK 23
YANA.S BK 21
NALIM BK 18
PARHAN . H BK 15
JELIS. P BK 9
44 JANIANTO K 48 3604200706040006
NURJANAH K 40
MALIKA. Z BK 15
ABYAN. N BK 9
45 DEDEN K 26 3604202711120003
SITI. MAE S K 25
SAPUTRA BK 3
46 A. HOTIB K 42 3604200706040019
NENG ELA K 34
RIKI. G BK 16
IIM. H BK 14
M. PERDI BK 12
47 RASIDI K 47 3604201102078051
SUPIANTI K 35
RULY BK 18
RENI BK 13
RENA BK 13
INDRA. G BK 9
48 BAMIN K 59 3604200706040026
EDAH K 57
MUKTAPIN BK 16
49 IDRUS B K
NURYAMI K 32
AZFAR BK
50 ACONG K 39 3604200706040017
PARINAH K 37
NURYAMAN BK 18
 M.DAPID BK 16
A.JAJI BK 13
51 OMAN K 73 3604200706040012
SITI K 50
SUPRANI BK 33
SANITRA BK 30
LAMSARI BK 28
UMUN BK 18
52 SARTONO K 40 3604202212100115
NENAH K 34
SULIAH S BK 5
53 WAWAN M K 49 360420080604001
AMNI K 44
APAN BK 21
ELITA M BK 14
ADILVI B BK 8
54 POHIR K 63 3604200806040027
EMAH K 74
HAMDANI BK 37
A YANI BK 32
55 SUHEMI JANDA 52 360420110278056
SUTIAR BK 32
SUTIADI BK 30
SUHARJA BK 28
SOBRI BK 24
SUBRO BK 24
YUNI S BK 20
56 HASAN B K 39 3604200706040030
MUSAMAH K 38
HAERUL A BK 31
ST UMAEROH BK 12
RIZKI.M BK 8
57 RIDWAN G K 41 360420310810007
SUKARTINI K 41
FITRI A S BK 11
58 UJANG D K 60 3604201102078049
SUMI K 42
SAHLAH S BK 22
SAHRA BK 16
SAHROJI BK 10
59 YANIH K 35 3604202212100117
PATONAH K 31
RENDI P BK 15
60 SUTISNA K 38 3604201102078079
RISNA K 35
 TINSIH BK 15
TINA M BK 5
61 SAPRUDIN K 58 3604201101070003
MUPLIHAH K 50
SANDI W BK 26
A GHAPUR BK 12
62 HENDRIK K 45 360420110207806
UTI K 42
IRPAN G BK 23
HILAH H BK 14
M.SEPKI BK 12
DIMAS P BK 9
63 SUDANA K 40 3604201102078025
JAHROH K 36
JAHRAN BK 13
PIRDA Y BK 6
64 HAERUL A K 31 3604201811110002
NURHASANAH K 25
M NUSRUL BK 15
65 IMIK H K 70 3604201102078097
ESNI K 58
ADE H.P BK 27
HASAN B BK 24
SITI N BK 22
TAMI M BK 16
66 NURYAMAN K 45 3604201912090034
UCU S K 43
RIYAD H BK 19
A JUHANI BK 13
KAILA A BK 7
67 BASRI K 42 3604201102078088
ASRIAH K 35
M.P.U.PARUK BK 14
SITI LAELI BK 13
NIBNU S BK 7
68 NANA S K 40 3604201102078068
ENCUN S K 35
EKA S BK 16
ISNIA SN BK 9
SURYA G BK 2
69 AHROM K 50 3604201002100007
JUMSI K 45
BOBI H BK 28
M HUSNA BK 22
IKBAL H BK 20
 IBDAL B BK 16
IBDAL B BK 16
SITI S BK 13
70 ARJANI K 43 3604200706040009
NAPISAH K 40
IRNA YANTI BK 20
A NASRI BK 15
EKA N BK 9
71 SUMARTA K 54 3604200712070029
JUHANAH K 50
LAMSURI BK 35
SUPINAH BK 23
SUKNI BK 21
SUHETI BK 19
SUKBI BK 16
JUHADI BK 12
SUNESAH BK 18
72 SOPIAH K 28
ROYANAH K 36
BUHORI M BK 21
A TRI H BK 20
FIKI P L BK 11
ANISA BK 18
73 TABRI DUDA 68 3604201102078075
SAMSURI BK 26
SUNANI BK 48
74 K 3604201102078072
E SUHITA K 33
ANDIARA BK 10
M PADIL BK 5
75 HAS A K 56 3604202511090021
ROYATI K 55
SURYADI BK 31
ILHAM BK 26
76 DAYAT K 43 360420070604008
SUHERNI K 38
RIPKI F BK 20
ANA H BK 17
NUKI R BK 12
77 SAEPUDIN K 41 3604200306080002
SITI A K 36
SHELA D BK 15
SHELIM M BK 8
78 PUJIANTO K 25 3604202806110001
DAMAYANTI K 29
 SHERINA A BK 3
79 JAINI K 61 3604200806040008
SAKRIAH K 61
ITA R BK 22
INDAH P BK 17
80 NIAH G JANDA 35 3604200208110001
JUNA A BK 9
81 SUGANDA 25
JENAH 28
SISKA 7
SULIS 4
82 PA'I K 43
YUYUN K 23
YAHYA BK 5
YUDI BK 2
83 JENAB
REZA
84 INDRA K 3604202503150007
NURLELA K
AULIA BK
85 NAMIN K 35 3604201303140005
NARTI K 26
HABIB BK 19
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan
Lahir BPJS Asuransi KK
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15
3604200602760002 2/6/1976 BURUH
3604207006760001 6/30/1975
3604201503030002 3/15/2003
3604202811080002 11/28/2008
3604201108960004 8/11/1996 BURUH
3604204811960002 11/8/1996
3604200111770207 11/21/1977 √ WIRASWASTA
3604204701770208 11/7/1977
3604204306020209 6/3/2002
360420010105050002 5/1/2005
3604200711680001 11/7/1968 WIRASWASTA
3604204104730002 4/1/1973
3604200211930003 11/2/1993
3604205004960005 4/10/1996
3604205406070001 6/14/2007
3604205002960001 2/8/1996
3604200506730003 6/5/1973 BURUH
3604205703660001 3/17/1966
3604201704010003 4/17/2001
3604202505800354 5/25/1980 WIRASWASTA
3604204603840355 6/6/1984
3604202706050161 6/27/2005
3604200710690002 10/7/1969 WIRASWASTA
3604204505720003 5/5/1972
3604200304910001 4/3/1991
3604200404950002 4/4/1995
3604202507010002 7/25/2001
360420251050002 12/25/2005
3604205111080001 11/11/2008
3604201212730001 12/12/1973 BHL
3604204509730001 9/5/1973
3604201709940002 9/17/1994
3604201610010002 10/16/2001
3604200410050006 10/4/2006
3604201908720001 8/19/1972 √ WIRASWASTA
3604204205770001 5/2/1977 √
3604200602970001 2/6/1997 √
3604206807010001 7/28/2001 √
3604205208030003 8/12/2003 √
3604202801100002 1/28/2010 √
3604200506950001 6/5/1985 √ BURUH
3604204507930004 7/5/1993 √
√
3604200904600001 4/9/1960 √ BURUH
3604205507710001 7/15/1971
3604200108870003 8/1/1983 √
3604200706960002 7/6/1996 √
3604205003020001 3/10/2002
BURUH
3604204808840001 8/8/1984
3604204909090001 9/9/2009
3604202507570001 7/25/1957
3604205104590001 4/11/1959
3604200706900003 6/7/1990
3604206511970001 11/25/1997
3604205206050001 6/12/2005
3604200212740001 12/2/1974 LSM
3604205104860003 4/11/1986
3604205404060004 4/14/2006
7/27/2013
3604202708810001 8/27/1981
3604206005870056 5/20/1987
3604206705990032 5/27/1999
3604206802060002 2/28/2006
3604203010780001 10/31/1978 √ WIRASWASTA
3604205407840002 7/14/1984 √
3604200206080001 6/2/2008 √
3604207011140001 11/30/2014 √
3604201505700001 5/15/1970 BURUH
3604204411730003 11/4/1973
3604202011940005 12/20/1994
3604206706010002 6/27/2001
3604203105060001 5/31/2006
3604203010660003 10/30/1966 √ PNS
3604204104830001 4/1/1983 √
3604206202930001 5/2/1993 √
3604202002020003 2/20/2002 √
3604206511080001 11/25/2008 √
3604201107600106 7/11/1960 √ PNS
3604206405690107 5/24/1969 √
3604202704980110 4/27/1998 √
3604200810830133 10/8/1983 √ √ WIRASWASTA
3604204507840109 7/5/1984 √ √
3604202408060001 8/24/2006 √ √
√
3604200205750001 5/2/1975 WIRASWASTA
3604205008780003 8/10/1978 √
3604206302020002 2/23/2002 √
3604204706060001 6/7/2006
3604202903070003 12/29/2007 √
3604202710520001 10/27/1952 PETANI
3604205204620001 4/12/1962
3604206403910001 3/24/1991
3604204508940004 8/5/1994
3604201008770002 8/10/1977 BURUH
3604204504610001 4/5/1961
3604206606070001 6/26/2007
3604200507690006 7/5/1969 √ BURUH
3604204101790010 1/1/1979 √
3604206010950002 10/20/1995
3604206303980003 3/23/1998 √
3604201010000003 10/10/2000
3604201011050005 11/10/2005
3604201111830004 11/11/1983 BURUH
3604206410890001 10/24/1989
36042051011100002 1/11/2011
3604202411630001 11/24/1953 √ BURUH
3604205011710001 11/10/1971 √
3604202403030004 4/24/2003 √
3604202908800001 8/29/1980
3604204201830002 1/2/1983
3604205203030004 3/12/2003
3604200404090001 4/4/2009
3604204404480001 4/4/1948 IRT
3604200303870001 3/3/1987
3604200101790118 1/1/1979 √ BURUH
3604207112520119 12/31/1952 √
3604202908980121 9/29/1987 √
3604200303060001 3/3/2006
3604200302720109 2/3/1972 WIRASWASTA
3604206507690110 7/25/1969
3604204504930111 4/5/1993
3604202305000112 5/23/2000
3604201202580102 2/12/1958 √ WIRASWASTA
3604205908750002 8/19/1975 √
3604206410900003 10/24/1990 √
3604206606930111 6/26/1993 √
3604201102970236 2/11/1997 √
36042003004980087 4/3/1998 √
3604205611000196 11/16/2000 √
3604200305760005 5/3/1976 √ BURUH
3604206206840002 6/22/1984 √
3604206203030002 3/22/2003 √
3604206505050003 5/25/2005 √
36042005100001 10/5/2010 √
3604202512870001 12/25/1987 √
3604200504770002 4/5/1977 √ WIRASWASTA
3604206003820002 3/20/1982 √
3604200311050003 11/3/2005 √
3604202304670026 4/23/1967 P.SWASTA
3604206408940027 8/24/1994
3604206211970029 11/22/1997
3604205208040002 8/12/2004
3604201907660001 7/19/1966 √ K.BUMN
3604204210700003 10/2/1970 √
3604202702920001 2/27/1992 √
3604204706990005 6/7/1999 √
3604200708970001 8/7/1997 √
3604206202010002 2/22/2001 √
3604204601030003 1/6/2003 √
3604202712060002 12/27/2006 √
3604205612070003 2/16/2007 √
3604201809110001 8/10/2011 √
3604200209750002 9/2/1975 BURUH
3604204304890002 1/3/1989
3604204212110002 12/2/2011
3604200104740171 4/1/1974 WIRASWASTA
3604205107780172 7/11/1978
3604201105980173 5/11/1998
3604204203030174 2/3/2003
3604200111820004 11/1/1982 BURUH
3604205210890003 10/12/1989 √
3604201001090005 1/10/2009
3604203011280211 11/30/1928 √
3604205010680212 10/10/1968 √
3604201102880213 2/11/1988 √
3604200507910214 7/5/1991 √
3604202709950215 9/27/1995 √
3604201904020216 4/19/2002 √
√
3604201004480002 4/10/1948 √ PENSIUNAN
3604205106670002 6/11/1967 √
3604201804870002 4/18/1987 √
3604205501950001 1/15/1995 √
3604201206660002 6/12/1966 √ WIRASWASTA
3604205808730002 8/18/1973
3604205704980002 4/17/1998 √
3604205408020002 8/14/2002
3604205707100002 7/17/2010 √
3604200101700049 1/1/1970 BURUH
3604204101750036 1/1/1975
3604203008920002 8/30/1992
3604206005000002 5/20/2000 √
3604205005050002 5/10/2005
3604200103100002 3/1/2010
3604202702120003 2/27/2012
3604201009660002 9/10/1966 BURUH
3604204505630001 5/5/1963
3604200809920003 9/8/1992
3604200510940002 10/5/1994 √
3604202603970001 3/26/1997
3604200102000003 2/1/2000 √
3604205612060001 12/16/2006
3604200101670023 1/1/1967 BURUH
3604205409750024 9/14/1975
3604201109000025 9/11/2000
3604200505060001 5/5/2006
3604200107890002 7/1/1989 BURUH
3604205806900001 6/18/1990
3604202703120003 3/27/2012
3604201603730093 3/16/1973 P.SWASTA
3604205709810094 9/17/1981
3604201309990095 9/13/1999
3604204604010096 4/6/2001
3604200608030097 8/6/2003
3604201207680003 7/12/1968 BURUH
3604204909800001 9/9/1980
3604202910970004 10/29/1987
3604202511020003 11/25/2002
3604202511020002 11/25/2002
3604202303060002 3/23/2006
3604200303560135 3/3/1956 BURUH
3604205507580136 7/15/1958
3604201408990138 8/14/1999
4/1/1985 GURU
3604204605830137 5/6/1983
5/29/2013
3604200907760075 7/9/1976 BURUH
3604200410780076 10/4/1978
3604202110970077 10/21/1997
3604202611990078 11/26/1999
3604201004020079 4/10/2002
3604200507420119 7/5/1942 BURUH
3604205509650120 9/15/1965 √
3604200907820121 7/9/1982 √
3604202505850122 5/25/1985 √
3604200907870124 7/9/1987 √
3604200406970125 6/14/1997 √
3604200311750003 11/3/1975 √ BURUH
3604206506810004 6/25/1981 √
3604206103100001 3/21/2010 √
3604200402660060 2/4/1966 √ WIRASWASTA
3604204607710061 7/6/1971 √
360420040894062 8/4/1994 √
3604205105010063 5/11/2001 √
3604200607070002 7/6/2007 √
3604201109520153 9/11/1952 √ PETANI
3604206909410154 9/29/1941 √
36042015037800155 3/15/1978 √
3604201704830156 4/17/1983
3604205706630001 6/17/1963 IRT
3604201406830002 6/14/1983
3604201704850001 4/17/1985
3604200605870004 5/6/1987
3604200101910038 1/1/1991
3604200101910039 1/1/1990
3604205212950001 12/12/1995
3604201708760151 8/17/1976 √ PETANI
3604204608770152 8/6/1977 √
3604201607840056 7/16/1984
3604204503030153 3/5/2003 √
3604202909070001 9/29/2007
3604201807740002 7/16/1974 √ BURUH
3604206702740002 2/27/1974 √
3604205811040001 11/10/2004
3604200508550001 8/5/1955 √ BURUH
3604200308730001 8/3/1973 √
3604201407930002 7/14/1993 √
3604201507990001 7/15/1999 √
3604201612050001 12/16/2005 √
3604201508800002 8/15/1980 √ BURUH
3604205606840002 6/16/1984 √
3604201009090001 9/10/2000 √
3604200104770002 4/1/1977 √ WIRASWASTA
3604204707800005 7/7/1980
3604207001000001 10/30/2000 √
3604204402100001 2/4/2010
3604200304570166 4/3/1957 √ P.SWASTA
3604205704650167 4/17/1965 √
3604201812890166 12/18/1989 √
3604201412030001 12/14/2003 √
3604201607700002 7/16/1970 BURUH
3604205606730001 6/16/1973
3604201206020005 6/12/1992
3604206507010002 7/25/2001
3604200512030002 12/5/2003
3604201411060001 11/14/2006
3604201204750006 4/12/1975 BURUH
3604206205790001 5/22/1979
3604200209020004 9/2/2002
3604207006090001 6/30/2009
3604201807840003 7/18/1984 BURUH
3604201608900005 8/20/1990
3604201610000005 10/16/2000
3604201708450001 8/17/1945 P.SWASTA
3604205007570001 7/20/1957
3604201708880001 8/17/1988
3604201805910002 5/18/1991
3604205506930001 6/15/1993
3604206104990002 4/21/1999
3604200904700002 4/9/1970 BURUH
3604205803720004 3/18/1972
3604202502960001 2/25/1996
3604200103020002 3/1/2002
3604206809080001 9/28/2008
3604201208730001 8/12/1973 BURUH
3604204107800029 7/1/1980
3604203101010001 1/31/2001
3604205402020002 2/14/2002
3604200108080001 8/1/2008
3604201209750001 9/12/1975 √ WIRASWASTA
3604204207800002 7/2/1980 √
3604205810990002 10/10/1999 √
3604205303060002 3/13/2006
3604200907130001 7/9/2013
3604200909650003 9/9/1965 BURUH
3604204101700046 1/1/1970
3604200403870003 3/4/1987
3604202612930001 12/26/1993
3604202709950001 9/27/1995
3604202709990002 9/27/1999
3604202709990003 9/27/1999
3604205202020002 2/12/2002
3604201111720035 11/11/1972 √ WIRASWASTA
3604205510750036 10/15/1975 √
3604206905950037 5/29/1995
36042016110000038 11/16/2000 √
36042001110800039 11/1/2008
3604201209610082 9/12/1961 BURUH
3604205105650117 5/11/1965
3604200909800126 9/9/1980
3604205602920088 2/16/1992
3604202806940001 6/28/1994
3604204208960139 8/2/1996
3604201607990002 7/16/1999
3604200601030001 1/6/2003
3604202209970003 9/22/1997
8/22/2007 √ BURUH
3604204205790147 5/2/1979 √
3604203110940148 10/31/1994 √
3604202612950149 12/26/1995 √
3604204104040150 4/1/2004
4/6/2014 √
3604200712470002 12/7/1947 BURUH
3604201305890001 5/13/1989
3604206204670002 4/22/1967
BURUH
3604204707820001 7/7/1982
3604200304050003 4/3/2005
3604200505100001 5/5/2010
3604200804590002 4/8/1959 √ BURUH
3604205401600003 1/14/1960 √
3604202403840002 3/24/1984
3604201605890002 5/16/1989 √
3604200702720030 2/7/1972 √ WIRASWASTA
3604204106770031 6/1/1977 √
3604201102950032 2/11/1995
3604205305980033 5/13/1998 √
3604201911030034 9/19/1993 √
3604201407740004 7/14/1974 BURUH
3604204706790003 6/7/1979
3604205107000270 7/11/2000 √
3604206803070003 3/28/2007 √
3604202202900001 2/22/1990 BURUH
7/27/1986
 5/26/2012
3604201007540047 7/10/1954 BURUH
3604207007540048 1/30/1954
3604206311930053 11/23/1993
3604207005980054 5/30/1998
360420630880001 8/23/1980 IRT
3604202308060002 8/23/2006
7/21/1990 √
5/3/1987 √
4/7/2008 √
2/6/2011 √

4/25/2004
5/13/2010
11/19/2013

36042015131200002 12/13/1990 √ SWASTA

3604206403910001 4/24/1991 √
3604204501150001 1/5/2015 √
3604201404760002 4/14/1976 BURUH
3604206002880001 2/20/1988 √
3604200101140001 3/12/2014
 Umur Kehamilan Taksiran
Persalinan
1 2 3 4 5 6 7 8 9

16 17 18 19 20 21 22 23 24 25
√
√
Peserta Status
KB Kemiskinan

26 27
KS II
SUNTIK

KS I
SUNTIK
KS II
SUNTIK

KS I
SUNTIK

PRA

KS I
SUNTIK

KS I
SUNTIK

KS II

KS II
SUNTIK
 KS I
SUNTIK

KS I

PRA

KS II
SUNTIK

KS II
SUNTIK

KS II
SUNTIK

KS II

KS II

KS II

KS I
SUNTIK
 KS I
SUNTIK

KS I
SUNTIK

KS II

KS I
SUNTIK

PRA

PRA

KS I

KS II

KS II
 KS I
SUNTIK

KS I
SUNTIK

KS I

KS II

KS I
SUNTIK

KS I

PRA

KS II

PRA
SUNTIK

PRA
MOP

KS I

KS I
SUNTIK

KS II
SUNTIK

KS I
IMPLANT

KS I

KS I
SUNTIK

PRA
SUNTIK
 KS I

KS I

KS II
SUNTIK

KS II

KS I
SUNTIK

KS II

KS I
SUNTIK

KS I
SUNTIK
 KS II

KS II

KS II
SUNTIK

KS I
SUNTIK

SUNTIK

KS I
SUNTIK

KS II
 PRA
SUNTIK

KS I

KS II
SUNTIK

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PRA

KS II

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SUNTIK

KS I
SUNTIK

KS I
SUNTIK
 KS II

PRA

PRA

PRA

PRA

KS II
SUNTIK

PRA
SUNTIK
 FORMULIR PENDATAAN KE

NO NAMA Status Umur Nomor NIK Tanggal

Kepala Anggota KK Lahir
L P
Keluarga Keluarga
1 2 3 4 5 6 7 8 9
1 ISMAIL K 47 3604201006130003 3604201006120003 8/13/1988
ROSUTIATI K 43 3604205204710002 4/12/1971
IPAT L BK 22 360420830493000 3/23/1993
INDRI R BK 19 3604200103970001 3/1/1997
AJI H BK 13 3604201202030001 2/12/2003
IMAM AL BK 7 3604202011080001 11/20/2008
2 MULYADI K 39 3604201102077902 3604201102077902 12/9/1976
YUSNIA S K 34 3604206605810002 5/25/1981
MAULANA BK 12 3604202003040002 3/20/2004
NAJWA BK 8 3604204303080001 3/3/2008
RAHMA BK 3 3604207001130001 1/30/2013
3 SAEPUL P K 30 3604202112100223 36042010011000001 1/1/1985
UYUNIAH K 26 3604200101000002 10/16/1988
WIDIA BK 5 3604204106110002 6/1/2011
4 TOBRI K 50 3604201102077899 360420160350001 3/16/1985
ENJUH K 41 3604204507680002 7/5/1989
MUTOHARI BK 20 3604201905040002 5/19/1984
M HOLIK BK 19 360420305980004 5/3/1998
M. UTAD BK 16 3604200406010006 8/4/2001
RIMANSAH BK 13 3604202210030001 10/22/2003
A. HUTAMI BK 5 3604200801100001 1/9/2010
5 USUP K 49 3604201102077937 3604201407630002 7/14/1963
UMYATI K 45 3604204312760001 12/3/1978
JAJA BK 23 3604202101920001 1/21/1992
LELASARI BK 22 3604204701930003 1/7/1993
HAPIPI BK 13 3604202312020001 12/23/2002
6 ROHIM K 30 3604202801150008 360420101830005 1/1/1983
PIPIN K 26 36042088050004 5/29/1985
CUCU BK 22 3604205902860001 2/19/1988
7 DEDE S K 24 3604202812110002 3604201502860001 2/15/1986
ANITA K 22 3604204101900005 1/1/1992
KURNIA F BK 5 360420481010001 10/8/2010
8 MAD SOLEH K 26 3604200309120003 3604201705850002 5/17/1985
NURMAU K 22 3604204700920003 5/7/1993
PUTI S BK 4 3604206305120001 5/23/2013
9 SYARIPUDIN K 47 3604202212100095 3604200301630003 1/5/1963
RENI F K 37 3604206402800002 2/24/1980
10 WAWAN H K 43 360420 3604201805760002 5/18/1970
WIWIN S K 27 3604204508880001 9/5/1988
HERUMAN BK 5 360420020210002 2/2/2010
RUMANDANU BK 2 3604200205130005 5/2/2013
11 NURDIN K 37 360420 3604201002790005 2/10/1978
 ENONG K 24 3604204211810002 11/2/1981
NURHAYATI BK 15 360420550600002 6/16/2000
LILIS BK 8 3604204603070001 3/6/2007
12 AS'ARI K 55 360420 3604200101600047 1/1/1960
UAT K 42 3604204101730019 1/1/1973
ALBAENI BK 22 3604200503930007 3/5/1993
AMBIA BK 18 3604202905970004 5/29/1997
UNUN N BK 7 360420631108003 11/23/2008
13 SANUSI K 41 360420 36042016067020001 6/16/1972
MULYANAH K 43 3604206103740001 3/21/1974
ST HAOLIAH BK 11 3604205408040001 6/14/2004
AZAHRA BK 5 3604207006100002 6/5/2010
A AIDI BK 4 9/14/2012
14 SALAM K 42 360420 3604201203730004 3/12/1973
YUYUN K 37 3604205407750001 7/23/1978
SUPRIYADI BK 21 3604200102940002 2/1/1994
IIK BK 15 3604201802000002 5/25/1999
ROSYANTI BK 11 3604204110050002 10/1/2005
15 ARMANI K 35 360420 3604291505800007 5/15/1980
HERNAWATI K 32 3604205400030003 4/14/1983
A YANI BK 8 3604201600060001 6/16/2008
16 SIGIT M K 38 360420 360420071070002 10/7/1977
AISAH K 34 3604205006810003 6/10/1981
AINUN M BK 4 3604206203110001 3/23/2011
17 KARJAYA K 36 360420 3604200102390001 8/7/1979
A HUJAIRI K 3604200102390001
IKA KARTIKA BK 29 3604204706790001 11/27/1986
IMAS M BK 26 3604205711690002 11/17/1989
18 A SUBAIKI K 41 360420 3604200707740208 7/7/1974
SARIKA K 34 3604204610810209 10/6/1981
M AZKIYA BK 10 3604201311040210 11/13/2004
19 MARHANI K 33 360420 3604200204800004 4/7/1990
BARSAH K 32 3604204808820002 8/8/1982
M HUSEN BK 13 36042026030002 3/26/2003
JUJUN BK 8 3604200800006 8/8/2008
ST MAYANI BK 15 3604206806140001 6/28/2014
20 AMANAN K 58 360420 3604200308570002 5/3/1957
ENAH K 53 3604204101620023 1/1/1962
HENDI BK 21 3604200101450024 4/2/1991
LINDA BK 22 3604204101930037 1/8/1993
WAWAN BK 18 360420010197005 2/1/1997
NURYOSEP BK 12 36042016040200031 4/16/2009
21 NURDIN K 39 360420 3604201510760003 10/15/1976
SOPIAH K 31 3604205804840004 4/15/1984
M DIPA BK 12 36042012041020004 4/12/2002
PANI BK 5 3604205708090002 8/17/2009
RIPKI BK 4 3604201112140002 2/17/2011
22 SAPRI K 35 360420 3604200101600035 1/1/1980
 SAPRAH K 55 3604204101630018 1/1/1960
ROPIAH BK 24 3604205509910001 3/15/1991
RUSWANI BK 22 3604200405930006 5/4/1993
RUPIANA BK 15 3604204101980002 1/1/1998
HABIBI BK 13 3604201009020002 9/10/2002
23 SUMARDI K 31 360420 3604201202040004 2/12/1984
MUTIAH K 45 3604205611700001 1/15/1970
MUNAIM BK 21 3604201204940001 4/7/1994
AJIS M BK 17 3604200704980005 4/4/1995
S SUNDARI BK 11 3604200002050002 2/20/2005
24 MAMAT K 30 360420 3604201203650002 3/12/1985
KOKOM K 42 3604205905730001 5/12/1973
HERWANDI BK 13 3604201012000002 2/10/2000
MASKAH BK 13 3604206100020002 5/21/2002
M FIKRI BK 5 3604201303110002 3/13/2011
25 BAYI NASARI K 42 360420 3604201512730002 12/15/1973
MURSIDAH K 42 3604205605750003 3/16/1973
IHAB M BK 23 3604201503910001 3/16/1992
BEDI Z BK 21 3604202008940002 5/17/1994
MAHMURI BK 14 3604202109960002 8/20/1996
S ROHMAH BK 6 3604204308040002 4/3/2009
26 MALIK K 49 360420 3604202608660002 8/26/1966
ICIH K 39 36042002100201000 10/12/1976
M ILHAM BK 23 3604203004950002 4/3/1993
NABILA BK 16 3604205307000002 7/13/2000
M AZIZI BK 13 360420210502004 5/21/2002
NANDINI BK 10 360420510506002 5/11/2006
AZKA BK 2 3604201508130002 6/15/2013
27 SUBI K 32 360420 3604200102630001 2/1/1983
KARWINI K 44 3604205202720003 2/12/1971
LINA BK 32 3604200501100003 11/10/1983
M HANA BK 25 3604200303900003 3/3/1990
SINTA BK 19 3604206105940002 6/21/1998
NOPI BK 18 3604206111970001 11/21/1997
28 ILMI K 35 360420 3604201208800004 8/17/1980
ELI K 30 3604204610850001 10/5/1985
29 KOMDANI K 37 360420 3604201008760001 8/10/1978
SUANAH K 37 3604204501790002 1/5/1978
SUNJAYA BK 23 3604200206910002 6/2/1991
SAEPUDIN BK 15 360420100500003 5/10/2000
TUJI BK 3 3604206004120001 4/20/2012
30 AAN S K 35 360420 3604201006600002 5/10/1980
IAH H K 45 3604206001700001 1/20/1970
IIN H BK 20 3604206812940003 12/26/1995
NURUL H BK 15 360420421000002 10/3/2000
ST HOTIMAH BK 14 360420270200002 2/17/2003
RAHMA BK 6 3604205103090002 3/17/2008
31 M ISNAENI K 35 360420 36042006049005 4/4/1980
 SAPTA K 33 3604205509920004 9/13/1982
SYAMIL BK 5 BLN 3604200207160001 7/2/2015
32 JAKA K 41 360420 3604200707740002 7/7/1974
HARYATI K 33 3604207005820002 5/3/1982
SISKA BK 18 3604206009990003 6/20/1999
ROSITA BK 13 3604204110030003 10/1/2003
NOPA A BK 2 3604207011130002 11/30/2013
33 NURHANI K 35 360420 360420090880003 5/8/1980
NURLENA K 26 3604206309890001 9/13/1989
ST NURFADILAHBK 3 3604205812120001 18/13/2012
34 JUNED K 43 360420 3604200208720001 6/7/1972
MARDIAH K 39 3604204407760002 7/4/1976
KODAR BK 13 3604202306030001 5/23/2003
ILMAN BK 9 3604201911070001 11/19/2007
NADIA BK 5 3604206010100002 10/20/2010
35 HUBAESI K 35 360420 3604201904800001 4/10/1980
EUIS K 30 3604205807830052 7/16/1983
AJRUM BK 10 36042047019900002 4/18/2005
ALDI BK 9 3604202304660001 1/3/2007
NAYANI BK 5 3604204101680024 15/02/21010
36 MUSTASAROH K 27 360420 3604205103600002 9/17/1988
WIDIA K 18 36042047019900002 1/7/1999
37 SARIMAN K 49 360420 3604202304660001 4/23/1966
TUNENAH K 47 3604204101680024 1/1/1968
NURMAN BK 28 3604200507870004 7/5/1987
AMINUDIN BK 26 3604201209890002 9/12/1989
NURHADI BK 18 360420010990001 9/1/1999
SASTRI BK 13 3604206710030001 10/27/2003
38 ERIK K 39 360420 36042001017100026 1/1/1976
NYAI K 27 3604205048800004 4/20/1988
EVA J BK 9 360420560200001 7/18/2006
JUHANAH BK 7 3604206304090001 4/23/2008
JULIA QORI BK 12 BLN 3604204308140001 9/3/2014
39 ALEK K 41 360420 3604201507740003 7/15/1974
PATMAH K 34 3604204606810002 8/5/1981
PERA BK 14 3604206706020003 5/27/2002
M ANDI BK 8 3604202406080001 8/24/2008
HAIKAL BK 25 3604200608120001 8/8/2012
40 JUHDI K 27 360420 3604200908660001 8/8/1988
TITIN K 40 3604204101750034 1/1/1975
YAMUJU BK 20 3604206212930003 12/25/1995
HABI BK 19 3604202610960003 10/25/1996
CIBI BK 9 3604204201080001 1/2/2008
41 JUNED K 44 360420 3604200606710002 5/5/1971
MARIAM K 27 360420401800022 1/1/1988
ATIKAH BK 17 3604204101980007 5/1/1998
JUNAENI BK 9 3604204301060002 6/3/2005
IRWAN BK 5 3604202710110002 10/27/2011
42 ALAN S K 64 360420 36042005060001 5/5/1951
AEM M K 57 36042005201580002 1/12/1958
LELA N BK 29 3604206001860002 1/20/1986
TIA F BK 23 3604205404930001 4/19/1993
REJA BK 13 3604201111990001 11/11/1999
YANA S BK 13 3604200707010003 7/7/2001
43 SUKANDI K 38 360420 3604200604770001 4/6/1977
SUHERNA K 39 3604200402790002 2/24/1979
PEBRIANA BK 16 3604200602990001 2/5/1999
FIKRIAH BK 13 3604206207030001 7/22/2003
RAMADANI BK 4 3604202407110002 4/2/2011
44 MUHIMIN K 42 360420 3604201205730001 5/12/1973
JUMANAH K 39 360420511760002 11/10/1976
MAULIDA BK 19 3604204606980003 5/5/1998
MURNI BK 14 360420570600003 6/17/2000
AKBAR BK 7 3604200911070002 11/9/2007
45 ASNANTO K 39 360420 3604200501760002 1/5/1976
SUNTI K 39 3604206107790001 7/24/1979
M IKBAL BK 17 3604200107990031 7/3/1999
INDAH K BK 6 360420703100001 3/7/2010
46 MASRIAN K 35 360420 36042042315078002 7/15/1980
ROHIMAH K 28 3604204505870002 5/5/1987
M PAJAR BK 5 3604200402110001 2/4/2011
47 MURAD K 41 360420 3604201800740002 6/16/1974
ETI S K 38 3604200312770001 12/23/1977
M RIZKI BK 14 3604201804020002 4/10/2002
MIA A BK 5 3604205402100006 2/14/2010
48 NANANG K 45 360420 36042030101700046 1/1/1970
NUNUNG K 45 3604205207720001 7/12/1970
ARIS BK 27 3604200711860002 11/7/1988
ANIH BK 19 3604204101950011 1/1/1992
DEWI BK 13 3604205507470003 1/1/2003
49 SUDIN K 26 360420 3604203003890001 5/20/1989
ARNAH K 24 3604204702410002 3/7/1991
ARJUN BK 4 3604203006120003 6/30/2012
50 DAYAT K 32 3604202707110007 3604202006830003 6/20/1983
SURNAH K 26 3604204302870009 5/23/1989
SUWENDI BK 7 3604202710080003 10/27/2008
51 IDRUS K 27 360420 36042110610900004 2/17/1988
CUSNI K 25 3604204603400002 3/8/1990
52 SUHERMAN K 36 360420 36042021067900001 5/25/1979
S PATIROH K 23 3604204210030002 5/3/1993
PERBI BK 10 3604202711040001 2/1/2004
REPI BK 4 3604202209110001 4/13/2011
53 MAMAN K 45 360420 360420 9/20/1970
NURHAYATI K 39 360420630776032 7/23/1976
AHMAD BK 27 3604201209990323 9/12/1988
TUTI BK 13 3604207103030324 3/31/2003
 AWAL BK 7 BLN 2/18/2015
54 UJANG S K 33 3604201912090012 3604200712820001 12/7/1982
NURUL K 27 3604204611860001 11/5/1988
HOLIK BK 5 3604200706100001 5/7/2010
55 HERI S K 35 3604201102077967 3604200202800002 2/2/1980
ST SAROH K 30 3604206711830001 11/27/1983
AGUS S BK 12 3604201708030003 8/17/2003
HULPAH BK 3 3604204702120001 2/7/2012
SYAKI BK 2 3604200304130001 4/3/2013
56 M SOLIHIN K 29 3604203111014000 36042029200586009 5/20/1986
IKA K K 23 360420420393002 3/2/1993
M ALIP BK 5 BLN 3604203009140001 9/30/2014
57 BANDI K 40 3604201110207793 3604200101750038 1/1/1975
SUTIATI K 32 3604205508850002 8/15/1983
SIPA BK 19 3604204203960003 3/2/1996
HILDA BK 10 3604204512040001 12/5/2004
58 JANATA K 31 3604201702140004 3604200511840002 11/5/1984
JULIANAH K 23 3604206803930001 3/28/1992
UUD P BK 2 3604201404130003 4/14/2013
59 RUSLAN K 26 3604201203150001 1/1/1989
JUNARIAH K 28 3604206606870002 4/26/1987
ALIP BK 5 3604201211090001 11/12/2011
60 ERNAWATI K 26 3604201712140001 3604206003880002 3/20/1988
RAYA W K 5 3604202003100005 4/2/2010
61 PEMI F K 26 3604202912110002 3604201512860001 2/15/1988
JULAENI K 26 3604206002990001 2/10/1988
TIPANI J BK 3 3604204611120001 11/6/2012
62 JAENI K 46 3604201203080010 3604200101690392 1/1/1969
HERNI K 45 3604204101700290 1/1/1970
JARINAH BK 18 360420401970344 1/2/1997
63 AHMADI K 35 3604201102077904 3604200101600034 1/1/1980
IKAH K 33 36042041410168002 1/1/1982
TOPIK BK 19 3604200101970057 2/12/1996
IKE M BK 15 3604204101990038 11/9/2000
IKNE P BK 13 3604204101020030 1/1/2002
64 USUP K 53 3604201102077927 3604200407620003 7/4/1962
WAHYUNI K 19 3604206009960001 9/20/1996
65 SARAN K 33 3604201102077966 3604201804620001 4/18/1982
NINING K 26 3604204903660001 3/9/1988
M IRPAN BK 15 3604200804010001 4/8/2001
66 HERUDIN K 53 3604201102077963 3604200409620001 8/4/1962
JANAH K 30 3604207006660002 6/30/1985
YANTI BK 13 360420480020002 5/8/2002
SUJADI BK 10 3604200204060003 4/2/2005
JUPRI BK 8 36042001070600461 1/7/2006
67 SUPRANI K 35 3604201102078000 3604202512600001 12/25/1980
ELI K 36 2/18/1979
A HARIS BK 28 3604200602870007 2/6/1987
 SEPUL B BK 25 3604208803910005 3/8/1991
DEVI YANI BK 21 3604204512940002 12/5/1994
68 ANAH K 59 3604201102077969 3604204101590026 1/1/1956
SUNTIA K 18 3604204704990000 4/7/1999
69 DANU K 45 3604200607090014 11/14/1970
LINA H K 39 3604200401780003 1/24/1978
MILANDARI BK 13 36042005001040003 8/10/2002
70 SUHENDAR K 44 3604202611040004 3604202504710234 4/25/1971
YAYAH U K 40 360420450770235 7/5/1975
ALWAN BK 17 3604200704970236 4/7/1998
YOGA BK 15 3604200500000237 5/5/2000
FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI

Kepemilikan BPJS / Asuransi Lainnya Pekerjaan Umur Kehamilan

BPJS Asuransi KK
1 2 3 4 5 6 7 8 9
PBI Mandiri Askes Lainnya Lainnya
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Taksiran Peserta Status
Persalinan KB Kemiskinan

25 26 27
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NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 SADELI K 46 3604201102077621
SUHETI K 42
S.NURLINA BK 24
S.AMALIA BK 20
M.CEPI BK 13
M.APIP AZIZAN BK 20 B
2 ENDI ROHENDI K 29 3604200409130007
IIN SUHENI K 28
M.AZKA PRATAMA BK 21 B
3 SUDIRMAN K 69 3604201409090023
SUHAETI K 63
MADSUNI BK 29
SUTARIAN BK 24
MAULANA AGUS BK 18
4 MUHID K 28
IMAS SHOLEHA K 22
5 HALIL SUJATNA K 45 3604201102077638
TUTI K 37
NEHA NUR NADIANTI BK 14
AGAM FIRDAUS BK 12
NATASYA N.R BK 39 B
6 AHMAD JAKA K 38 3604201102077607
IYAS MINI K 24
NENI NURFAUZIAH BK 18
AHMAD TEJA BK 15
S.RATNAWATI BK 13
S.HALIMAH BK 9
DESTA PANCA APANDIBK 6
ANA MARIA BK 22 B
7 DEDI MULYADI K 38 360420307040009
ROSDANIAH K 38
AHMAD SAMSUL FAZRBK 11
DEWI MUMTANAH BK 10
8 BAYI NURYANI K 25
SUMIAH K 27
SUBADRA BK 11 B
SUBADRI BK 11 B
9 BUYUNG RAHMAT K 37 3604202111130004
SUHAETI K 30
BILGIS R BK 6
 SINDI BK 1
10 JEJEN HUJAEMI K 34 3604202112100163
LENI MAYATI K 29
AULIA SAHRIA BK 5
11 IYAN HEMANTO K 33 3604201511110003
RIWAYATI SURUR K 27
AJENG GINA SHOLEHABK 36 B
12 LILIS INDRAWATI J 36 3604202112090010
IIS MARLISA BK 19
SINTIA LISA PRATAMA BK 11
FATHUL ZULHIAN BK 9
13 ROHETI J 46 3604202012120001
RAHMAT HIDAYAT BK 23
SAMSUL H.D BK 19
YATI HARTATI BK 16
S.KAMSIATUL J.N BK 15
14 AHMAD MUHROBI K 39 3604200412070006
S.MASITOH K 40
A.MASUM BK 19
DINAR NUR SALBIAH BK 8
AMARULLAH BK 7B
15 RAHMAT HIDAYAT K 38 3604201102077667
SUHETI K 33
ADI SUHENDRA BK 10
AHMAD SUHELI BK 5
16 JAENUDIN K 33 3604200412070007
ROIAH K 32
FEBRIAN MUTHORI BK 12
MAHESA ASHARI BK 45 B
17 HENGKI K 47 3604201102077665
KUSMARIAH K 44
FERI IRAWAN BK 16
FERAWATI BK 16
M.FAJRI MAULANA BK 9
18 GUGUM GUMILAR K 26
MUTIA K 24
GINA HANIFAH BK 4
19 TB.SAFARUDIN K 37 3604201102077623
SUTIAH K 35
FIKRI AMARULLAH BK 14
S.IZATULHIFA BK 11
20 SHOLEHA J 37 3604200605140001
MUTASAPIRA BK 15
ST.NAJIATUL ULYATI BK 10
M.AKASA BK 19 B
21 ARIS K 37 3604201511110002
SUMIATI K 34
HASBILAH BK 46 B
A.ZULFADLI BK 5B
22 SAHIM K 40 3604201102077636
IYOH K 36
SAHUL ROJI BK 20
NANA SURYANA BK 19
ROBIAH SHOLEHATI BK 17
S.SAADAH BK 12
SUSILAWATI DEWI BK 7
M.RIZKI BK 5B
23 NURHANI K 55 3604201212050017
JURIAH K 43
JUMRONI BK 21
NOVALA SARI BK 19
RIRIN NOVITA SARI BK 5
24 AGUS SOPIAN K 24
ISMAWATI K 25
S.FATHIA TUNNADINDBK 3
25 TOVA SETIAWAN K 34 36042041905140016
HEVI YOLANDA PUTRI K 24
PRISCILL C BK 1
26 AHMAD DORIP K 43
KOMARIAH K 23
MAFUPATILAN BK 2
27 M.BAHGJA K 41 3604201206120001
S.ULIANAH K 31
BAEDHOTUL RAMALIABK 11
BADUIATUL ASYIQOH BK 9
28 NUDIN K 45 3604201102077632
ZENAB K 45
FEBI NURUL RINI BK 15
29 SUHERI K 71 3604202412100097
PIPIT AGUSTINA K 24
ENTIK HARUNI BK 4
30 HERMAN K 40 36042010021004
HAMSIAH K 31
BADEN MULYANA BK 18
DEDEH HERMAYANTI BK 15
EYA HUDAEPA BK 11
ERNA NURAPRIANI BK 3
31 MADROJI K 44 3604201102077624
YAYAH K 46
ROHAYATI BK 21
32 NAHRAWI HUSEN K 53 3604202604070002
NURHASAN K 44
ISNAENI BK 25
INA FUTAR SEPTIANI BK 15
ANI FITRI SEPTIANI BK 15
A.MIFTAHUL JANAH BK 12
33 KAMALUDIN K 25
MELAWATI K 20
A.IJAMALUDIN BK 1B
34 NASRUDIN K 43 3604201102077649
BARIAH K 44
INDAH PERMATA SARIBK 21
MIPTAHUDIN BK 19
HIJRATUN NASIHIN BK 15
RIZKI ROMDONA BAROBK 5
35 YAYAN SOPIAN K 24
PERTIWI PERMATA.P K 24
AQILA BK 18 B
36 BASUNI K 25
ST.AWALIAH K 23
RIYAN BK 7B
37 SANDI HADI WIJAYA K 29
NURLIAWATI K 25
ST.INDYRAHAYU BK 54 B
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan U
Lahir BPJS Asuransi KK
1 2
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15 16 17
3604202507690001 BURUH
3604204211730001 IRT
3604206012910002 BURUH
3604204812950003 BURUH
3604201008020002
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3604232010830001 DOKTER
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3604200707970005
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 Umur Kehamilan Taksiran Peserta Status
Persalinan KB Kemiskinan
3 4 5 6 7 8 9

18 19 20 21 22 23 24 25 26 27
KS II
S

KS II
S

KS II
TIAL

KS I
√
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S

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KS II
S
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S

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S

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S

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S

KS II
IMPLANT

KS I
S

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S

KS I
S

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S

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√ JANUARI

KS I
S

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S

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 KS III
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S
 FORMU
NO NAMA Status Umur Nomor NIK Tanggal Kepemilikan BPJS / Asur
Kepala Anggota KK Lahir BPJS
L P
Keluarga Keluarga PBI
1 2 3 4 5 6 7 8 9 10
1 NURKIKI k 28 3604201903604202904880003
IIS SASWITk 25 3604205703910001
ST NURSO bk 2 3604204407130001
2 JAMHURI k 40 360420110360420070864602 √
MUNI k 38 3604204510720002 √
MUKTI ALIbk 20 3604202904940002 √
SYAUKI bk 19 3604200201960002 √
ST MUSDALbk 10 3604205209050001 √
3 HERMAN k 29 3604202413604202103860002 √
ONAH k 27 3604205006880002 √
RIZKY bk 8 3604202506070002 √
4 SULTI k 25 3604202703604200710900001 √
DAMINI k 23 3604205107920003 √
5 SUGENG k 27 3604202103604201507850249 √
FITRIAH k 21 3604205812860001
ALDI FUTRbk 8 3604202803070002
6 SUKARDI k 27 3604201303604200906860002
MIMIN k 24 36042042018800004
RAHMAWAT bk 4 3604205708110002
7 SURYANO k 28 3604202113604201904201000
ST NURHAk 25 360420000289000
MUHAMADbk 7 3604200312080003
AZAHRA bk 2
8 SAEPUL BAK k 31 3604201613604201212820011 √
MIMIN K k 27 36042043078700033
AULA SAF bk 8 3604205612070002
9 SARMUDI k 28 36021728036042172606850001
DIAH MARIk 23 36042175104910007
SEKIRAY bk 2 36042176406120001
10 RIBUT k 37 3604201603604200406750
KAYAH k 35 3604204501050012
11 LUTFI k 36 360420988360420020879000
ROHAETI k 30 360420501274023
ANISA FITRbk 14 360420640701017
12 MUSKI k 42 3604202703604200402640078
MUSRIPAHk 40 3604204203670077
AISAH TOI bk 18 3604204206930079
UFON FANbk 15 3604206104980080
KARINA bk 14 3604204801000081
NIKEN bk 12 360420440702020
 MURSIAH j 50 3604204109440114
13 TAMRI k 58 3604201103604201011400003
SARYAMALk 55 3604204110450000
SUTI bk 15 360420440899000
14 DARSO k 47 360420110360420150954000
NURHANAk 39 3604204308750002
SUNARYO bk 23 3604200201920004
LAELAH bk 22 360420550393000
ABDUL L bk 15 360420160449
DIANA bk 8 360420430506
DIATI bk 8 36042043050500
15 IMANUDIN k 37 360420110360420150877000
SRI MULYAk 26 360420640985000
ST NURUL bk 13 36042058080200
M MUZTAHbk 9 36042001109050002
MASRI bk
16 RONI k 40 3604201103604201505750001
JUMANAHk 26 3604204107890039
M ENDANGbk 9 36042020080600
ST NATALIAbk 7 360420651208000
17 SANTOSO k 35 3604201103604200101700051 √
SUHATI k 29 3604205407820003 √
RENI bk 24 36042066039900001√
YANI bk 10 36042058070500007√
YANTI bk 10 36042058070500001√
18 SUPRIADI k 39 3604202113604200801750002 √
ROMLAH k 22 3604204902870001
ROBI bk 8 3604201005070002
ST NIA bk 5 3604206107100003
19 MUHAYAR k 28 3604201103604200412010002
ST SAJAAHk 27 36042044078700004
NURUL MUbk 9 3604206408060002
M DINUL bk 3 3604201606130002
20 SAMUKRI k 36 3604202403604203006790 √
ENDAR k 26 3604204411790066 √
SARTIKA bk 15 36042056060002 √
SANTI bk 9 3604204302060002 √
21 SUMINTA k 66 36042023036042021065500
SUHENDAHk 55 360420430600003
SUSANAS bk 22 3604204605930003
22 BALUNI k 60 3604201103604200101640028 √
SUANAH k 59 36042056036500
ASYARIPUDbk 20 3604200501950004
ST UMAERbk 18 3604200906560007
23 TURIAH k 35 360420110360420041267000
 ROHIMIN k 33 360420041267000
TOHEMI bk 27 3604200611810001
RUYANI bk 27 3604201401880001
PARMINI bk 20 3604201107940001
MUGATOKbk 18 360420070597000
24 MULYATI k 31 3604201103604206306820002
M ADMUKLk 13 3604200104020004
ANITA bk 12 3604204601030001
25 SUHENDI k 37 360420161360420010178000
SUKTI k 28 3604204101860090
AHMAD FAbk 10 360420010105009
26 SAHRONI k 29 36042028136042003108200
DEWI S k 27 36042044068700
A AWALUDbk 3 3604201209110002
JUMRONI bk 20 36042057076000
MAHMUDIbk 32 360420130810072
ASEP bk 19 36042006111100
27 SURAI k 44 36042024136042001077100
YANAH k 30 3604200107710004
SURYADI bk 20 360420407830004
YULIANTI bk 19 3604200401950001
CHAERUL bk 14 3604204502960001
NOVIAH bk 12 3604202305010002
JUANI bk 4 3604204303040003
YUDI POWbk 3 36042020010810003
28 SUKARTA k 57 3604202513604201211690061 √
SALAMAH k 50 3604205107640062
SUHADI bk 24 360420070688004
SARMAN bk 20 3604200101900397
29 JUHRO k 42 360420110360420025720001
NINING k 38 360420520677000
YUYUN bk 22 3604204601930001
SAHILAH bk 13 3604206608030001
NOAHARI bk 5 360420010210003
30 FUADI k 48 3604200113604201404690002 √
BAETI k 29 360420550584004 √
ST HOLILA bk 14 360420700801003 √
MUNAZABbk 12 3604201009030001 √
M NURAL bk 7 36042029030800 √
ST FATIRO bk 4 360420631112001 √
31 HARORI k 40 360420420360420300667001 √
WARSIH k 48 3604205711690001 √
NURHEDI bk 22 36042029059300 √
NANI bk 20 36042051069900 √
RISKA WATbk 16 3604206900990001 √
 AGUS HAEbk 14 3604202510010002 √
IPIT MUT bk 12 3604205306040002 √
32 SAHRONI k 43 3604202303604201000720003
YATNI k 42 3604205603720001
A DIMYATI bk 15 3604200201100002
ST MUTOHbk 14 360420511100003
M FAHMI bk 8 3604202712070001
MAYA SAPIbk 3 3604205812120001
33 DZAJULI k 51 360420270360420070553000
JUMAENI k 50 3604204507620001
M ROSDI bk 30 360420252950001
SANUSI bk 28 3604201203880003
M ARSYADbk 25 360420140190002
ST JULEHAbk 18 3604205010950001
34 SUAEBI k 40 360420100360420030561000 √
SUNIAH k 38 36042047016600 √
SUHENDRIbk 16 360420230989000 √
SUHENI bk 15 360420802910002 √
SUGAI bk 14 360420105920002 √
SUNARJA bk 12 360420020794000 √
SUKARMA bk 7 360420270399000 √
SUNANA bk 6 360420181200002 √
SUMO bk 5 3604202510020002 √
35 RAHMAT k 57 3604201103604200101540006
MUHAYAHk 56 3604204101550001
SARIP HID bk 17 3604200603990004
36 HANSOLIHAN k 29 36042016036042070801680004
ANIS REN k 25 360420690190001
M HABIBI bk 1 360420210514000
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
Kepemilikan BPJS / Asuransi Lainnya Pekerjaan Umur Kehamilan
BPJS Asuransi KK
1 2 3 4 5
Mandiri Askes Lainnya Lainnya
11 12 13 14 15 16 17 18 19 20
buruh

buruh

buruh

buruh

buruh

buruh

buruh

buruh

buruh

buruh

buruh

buruh
√
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buruh

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buruh

buruh

buruh

buruh

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√
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√
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guru

buruh

buruh
Umur Kehamilan Taksiran Peserta Status
Persalinan KB Kemiskinan
6 7 8 9

21 22 23 24 25 26 27
suntik

suntik

pil

suntik

pil

suntik

pil

suntik

suntik

pil
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suntik

pil

suntik

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pil

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NO NAMA Status Umur
Kepala Anggota
L P
Keluarga Keluarga
1 2 3 4 5 6
1 KIKI BAEHAKI K
SARINAH K
ST KURNIA KHOLIFAH BK
M RAFA FADILAH BK
FAJAR MULYAWAN BK
2 MULYANA K
NUR LELA K
NATSUYA ADINDA SARI BK
3 SARIPUDIN K
SURYANAH K
MUMUH ALARASYAH BK
IIN PITRIANTI BK
4 MAHFUDIN K
DARWINAH K
M AFAN MAULANA BK
5 MAJID K
UMARAH K
EVAN SETIAWAN BK
ANGGA PUTRA PERMANA BK
6 ARI HERMAWAN K
ULPIANING SITI K
NAILA DURNA BK
7 RIDWAN ARIFIN K
SUSILAWATI K
IMELIA PUTRI BK
8 HARIRI K
HAERIAH K
EDWIN WIJAYA BK
IMAN NURDIAN BK
AGUNG INDRA SUKMANA BK
ALFI AHMAD BK
BUNGA HAERUNISA BK
9 DULMANA F K
JAHROH K
ABIDIN BK
HUJPAH BK
IBDU AZHAR BK
FADIA MUAKBAR BK
10 KACUS K
AMRIAH K
 ARIS SAPUTRA BK
A WAHIDIN BK
11 WARTA K
MASROH K
NOPITA KRISTIN BK
NURSELA BK
12 SAMSUL HADI K
TITI WIANTI K
13 AHMAD K
DITA K
14 ILMI K
MUHLISOH K
ST FATIMAH BK
RIZKI AL BUBAROK BK
15 YOSEP GUNAWAN K
MISNAWATI K
M HATAMI BK
16 HERMAN K
ASWINAH K
NASYA AZIZAH BK
17 MADTOIB K
EDAH K
INTAN YUNIKA BK
M ADITIA MULYA BK
ANGGUN AULIYA BK
18 SADILI K
ENCUN K
AGIP HERMAWAN BK
RIFKI HIDAYAT BK
19 NURDIN K
SAETI K
ENDANG MULYANA BK
HANI TRIHARSARI BK
YUSUP HANAFI BK
20 BARJA K
ANI K
21 NURASIIN K
OOM K
NURAENI BK
NURMANSAH BK
22 ZAKIR K
ST.ULABNAH K
NINA TASYA BK
23 DARJAT SUDRAJAT K
SUPRIYATI K
 M.RIZKA NUGRAHA BK
WISNU AGUSTIAN BK
24 YAYAN SAHYANDI K
KURNIA K
ANANSYAH YANDI BK
MADREHAN BK
25 SODIKIN K
EUIS EKA DEWI K
AIVA SYAIKHONA RANADITA BK
26 MUSA K
NINGSIH K
ALDIANSYAH PRADANA BK
CIKA ALIFIA RAMADHANI BK
BEBY AULIA MESWA BK
27 MULYANA K
YULI KARTIKA K
FIQI HIMAWAN BK
DIKA MULYA YUDIKA BK
NANDA MESKA YURI FUMI BK
28 MAMAN K
TITIN HANDAYANI K
RAMA ADITYA PUTRA BK
29 SLAMET K
NENENG TITIN KURNIAWATI K
LUTFI MAULANA YUSUF BK
NUR RIZQI AGHNIA BK
30 RODIH K
TINI K
ST.RINA FEBRIANA BK
M.ERLANGGA BK
31 UJANG K
NURHASANAH K
BAGAS SUTIADI BK
TIA BK
NIKE BK
32 MARSIM K
ST.HAMIDAH K
MAMAD DAIRIN BK
REZI HERDIANSYAH BK
33 RAHMAT K
ELI K
LISMANIA SAPITRI BK
YUGNI MAULANA AZIZ BK
M.REZA BK
34 BAHRUDIN K
 YOYOH HUMAEROH K
RINA LESTARI BK
35 HUMAEDI K
ST.ALFIAH K
M.ALPIN MA'TIAR BK
36 HAJALI K
ENDARIAH K
LUPIAN SARI BK
ELI RISTIANI BK
37 HIKMAT ARIEF K
NURABAI K
38 FERI MULYADI K
IDA HARYATININGSIH K
HINDI PATIN UJIAH BK
ST.NAILAH PAOJIAH BK
39 ASEP ILYAS K
NURIL FADILAH K
M.AISYI NAZMI ILYAS BK
40 MAD UMAR K
UMAENAH K
BOBY YULIANDO BK
HAPID UBAEDILAH BK
M.UMAEDI BK
41 AANG SUNARNA K
NURLAELATIN K
FARID MUKIM BK
NAJAH DAHLIA BK
M.NAFIS AZIZI BK
42 ASEP SUPRIATNA K
SUHERMI K
RIMA SANYIA KHAERANI BK
SYIFA NUR KHODIJAH BK
43 SUPRAPTO K
SAIYAH K
SUMARNI RAHAYU BK
KRISMANTORO BK
APRILIA GITA SAFITRI BK
M.ROHIT AL FARIZI BK
44 HARI HIDAYAT K
MULYANI K
NURANI AURA HARYANI BK
PUTRA LULU NUMKHOTIMAH BK
45 ISMONO K
ATIK ATIKAH K
DEVA MONPCA BK
 M.RESTU FRANDIKA BK
46 NANA SUPRIATNA K
SUNARSIH K
MELI YUNITA AGUSTIN BK
BELA TRIA YUANA PUTRI BK
47 ADI HIDAYAT K
NINA PRIHATIN K
A. DANI MURTADO BK
48 WAHYU HIDAYATULLAH K
ROHIMAH K
NAUFAI AZFAR R BK
49 SAKIMAN K
UCU K
M.HERNI BK
50 SUPIANI K
HENI K
NAURA BK
51 ADE SUTION K
MEILANA AYUNINGRUM K
CIRANA AMELIA PUTRA BK
OKTALIA NAURA BK
52 HIDAYAT K
RINAWATI K
PUTRI CHINTA T BK
53 MAT ALI K
JUMAENI K
M.YULI BK
SURNANDRA BK
SUMIALA JANDA
SUMITRA BK
ADAM HERMAWAN BK
ANJAR JANDA
54 ATIAH JANDA
NURTATI BK
NURWANDA BK
55 IIS ESTI L JANDA
SUCITA SELAWATI BK
KAVITA DIAN P BK
YUANITA AZZURA BK
ZAHWA LUSIANA D BK
56 UDING AMIRUDIN K
SUHENDA K
MARHAM BK
BARIYAH BK
RISAH BK
 SAUNA BK
57 HILMI SUDRAJAT N K
ST.ROSNI K
SUSI NINGSIH BK
M.SUBKI BK
58 UBANDIAH K
BENI SOFIAN K
YASYARUDIN BK
ELI YULIANAH BK
RAJUDIN BK
59 H.HUDORI NUR K
HJ.MARYAMAH K
USWATUN HASANAH BK
ST.INDAH PUTRI BK
MOH.BAGUS SUTISNA BK
M.NURHAJI BK
ST.HUMEROH BK
60 ENDING RAFIUDIN K
HAPNAH K
SYARIF HIDAYAT BK
DIAN NURMALA BK
61 KURDI K
SRI K
SIGIT BK
ELSA BK
ELFIRA BK
62 JUNARIAH JANDA
JUHENI BK
YADI BK
NANA BK
DEWI SARTIKA BK
63 MUSA K
MARIYAM K
CINDY ROHMAWATI BK
64 RASIDI K
NASIATI K
MILAWATI BK
RIKAWATI BK
RAISA NADIRA BK
65 LEBAR K
SUNINGRAT K
66 JAENI K
YATI K
YAZIHURI BK
ST.NAJILAH BK
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
Nomor NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya
KK Lahir BPJS
PBI Mandiri Askes Lainnya
7 8 9 10 11 12 13
3604201102078004 3604201501780003
3604204711830003
3604204911040001
3604203004130002
3604200101950052
3604202709110024 360420085900002 √
3604204402880005 √
3604204112100002 √
3604202611040043 3604200101680219 √
3604204101760221 √
3604202102960221 √
3604200101350225 √

3604201102077945 3604201801670001
3604205807710001
3604200704950002
3604200108010004
3604202401140001 3604202605910002 √
3604204501930001 √
3604206508140001 √
3604202212100002 3604201005730005
3604204106830001
3604205912130002
3604201102077973 3604202107670002 √
3604204401740001 √
3604200805930005 √
3604200805960002 √
360420080720001 √
3604201311040004 √
3604206408080001 √
3604201102077973 3604200309570001 √
36042005201720003 √
3604202901900001 √
3604205104930004 √
3604201503950001 √
3604200509010002 √
3604201102077999 3604200101700048 √
3604204303830002 √
 3604203008040002 √
3604205609080002
3604202611040079 3604200101690387
3604204101720388
3604205711980391

3604202212100098 3604201806810001 √
3604205004870003 √
3604205001100001 √
3604202912140001
3604202603140003 3215101205920003
3604204708880004 √
3604202709130001
3604202503150001 3604200802890001
3604205303890002 √

3604201102077881 3604201203680001 √
3604205006720001 √
3604206811980001 √
3604202507080001 √
3604204401100001 √
3604201102077981 3604200101790036
3604204108800003
3604201609020001
360420101120001
3604202907040025 3604202503720120 √
3604205208770121 √
3604200906960122 √
3604206807020123 √

3604201203150010 3604240806888004 √
3604205305870004 √
3604202501050033 36042001017140155 √
3604206304850155 √
360420500500157 √
3604202107050001 √
3604201702140002 3604201506860008
3604204701900001
360420505120002
3604201102077891 3604200805800002
3604205607840001
 3604200708070001
3604200808090001
3604201102077987 3604202512810001
3604205801840001
3604202605040002
3604202002100001
3604202611040072 3604201709720115
3604205108790356
3604205112010002
3604201102077955 360420510600004
3604206706680001
3604201811990001
3604205910040002
360420570606003
3604201102077952 3604201505660001
3604207007700001
3604206203940001
36042001019500051
3604205705100001
3604200602120003 3604200506840005
3604206202870001
3604200911090003
3604201604090003 3604201605680001 √
360420440740218 √
3604202305970001 √
3604206911080001 √
3604201102077888 3604201212760004 √
3604206012760001 √
3604205402030004 √
3604202803090004 √

3604205703820001
3604201909020002
3604205507080001
3604205208100001
3604202112090024 3604201912750001 √
3604204903900003 √
3604202505090001 √
3604200102120001 √
3604202917040006 360420100260024
3604205003680025
3604204204920027
3604201905970028
3604201109020029
3604201102077957 3604200101740044 √
 3604204911790001 √
3604204107050030 √
3604202204090009 3604200308790006 √
3604205608880099 √
3604202302070001 √
3604202307040008 3604201509600034 √
3604204212670035 √
3604200506830037 √
360420202990038 √
3604201102077908 3604201211470001
3604204504670003
3604200809110001 3604200511830001 √
3604206106850003 √
3604207007110002 √
3604206209140002 √
3604203107130002 3604202212890022
3604204603880001
3604201412130002
3604201307090007 3604200301600001
3604205706690001
3604202807910001
3604202605950002
3604201701070002
3604200504130001 3604202108810002 √
3604205006770002 √
3604200812010002 √
3604205411070003 √
3604201005130001 √
3604200504130001 3604201305640001
3604205110790002
3604205205970001
3604204412080002
s 3604201010720003
3604204808750001
3604206512950002
3604203004980002
36042055060003
3604202706040003
3604202212100092 3604203012770002
360420675860002
3604207003100003
3604207005030002
3604201102077975 3604200610710003
3604206606730002
3604205912010002
 3604201301070003
3604201102077980 3604201012600002 √
3604204306690002 √
3604204207950002 √
3604204511000002 √
3604202212100091 360420059820001
3604204112840002
3604200605110001
3604201501130001 3604201011880023 √
3604206007860001 √
3604200212130001 √

√
√

3604201102077949 3604200804830001
3604204805830003
3604204704030004
3604206010100001
3604202112100226 3604200904850003 √
3604206106850001 √
3604205807110001 √
3604201102077959 3604201006560002 √
3604205804580001 √
3604200705850002 √
3604202308930004 √
3604204911960001 √
3604200504990003 √
3604200504020002 √
3604207112450001 √
3604201102077288 3604204103660002 √
3604206901000002 √
36042054050200002 √
3604201102077950 3604206303770001
360420511980002
3604205005010002
360420606070001
3604205803120001
3604201102077962 3604201511530001 √
3604204101550022 √
3604202907940002 √
3604205709970001 √
3604206110980002 √
 3604201005010003 √
3604201102077958 3604202707400001 √
3604205801450001 √
3604205902950002 √
3604202110910001 √
3604200407080003 3604206905650001 √
3604202506830138 √
3604202306890096 √
3604204507940126 √
3604200508990210 √
3604202212080004 360420402500146
3604204503590029
3604206510940005
360420510398053
3604201103980072
3604200806010112
3604206608060001
3604201102077960 3604202709390001
3604204404610001
3604201708900003
3604202907960002

3604201102077985 3604204101600048
3604200107900028
36042001070000027

360420511090030 3604200706560002
3604206005600001
3604204911000001
3604201102077892 3604203101520001 √
3604204511600003 √
3604205601970002 √
3604204104900001 √
U DAN BAYI
ransi Lainnya Pekerjaan Umur Kehamilan
Asuransi KK
1 2 3 4 5 6 7 8
Lainnya
14 15 16 17 18 19 20 21 22 23
PNS
IRT

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH
 BURUH

BURUH

BURUH
√
BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

PEG.SWASTA

BURUH

BURUH
 BURUH

BURUH

BURUH

BURUH

KARYAWAN

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH
 BURUH

BURUH

BURUH

KARYAWAN SWASTA

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

BURUH
 BURUH

BURUH

BURUH

BURUH

BURUH

BURUH

KARYAWAN

BURUH

MRT

MRT

BURUH
BURUH

MRT

BURUH

BURUH

BURUH

MRT

BURUH

BURUH

BURUH
 Taksiran Peserta Status
Persalinan KB Kemiskinan
9

24 25 26 27
KS
IMP

PRA KS
SUNTIK

PRA KS

PRA KS

PRA KS
KONDOM

PRA KS
SUNTIK

PRA KS

SUNTIK

PRA KS
PIL

PRA KS
PIL
 PRA KS
SUNTIK

PRA KS

PRA KS

PRA KS
SUNTIK

PRA KS
SUNTIK

PRA KS
SUNTIK

PRA KS
SUNTIK

PRA KS
PIL

PRA KS

PRA KS

PRA KS
SUNTIK

PRA KS

PRA KS
SUNTIK
 PRA KS
SUNTIK

PRA KS

PRA KS
SUNTIK

PRA KS

PRA KS
SUNTIK

PRA KS

PRA KS

PRA KS
SUNTIK

PRA KS
PIL

PRA KS
SUNTIK

PRA KS
 PRA KS
SUNTIK

PRA KS

PRA KS

PRA KS
SUNTIK

PRA KS
SUNTIK

PRA KS

PRA KS
PIL

PRA KS

PRA KS

PRA KS

PRA KS
 KS

PRA KS
SUNTIK

PRA KS
SUNTIK

PRA KS

PRA KS
SUNTIK

PRA KS

PRA KS
SUNTIK

PRA KS

PRA KS

PRA KS

PRA KS
PRA KS

PRA KS

PRA KS

PRA KS

PRA KS

PRA KS

PRA KS

PRA KS

PRA KS
NO NAMA Status Umur Nomor
Kepala Anggota KK
L P
Keluarga Keluarga
1 2 3 4 5 6 7
1 WARTIM K 360420110207804
SUMARTINI K
ANISATU.S BK
2 AHYANI K
HAYATI RUPUS K
3 SAIMIN K 3604201102078270
SUPARSIH K
SAEPUL PIRDAUS BK
4 YUDI HARTO K 3604202912110001
EVAYANTI K
AZZAHRA SW BK
5 HENDIR W K
NURLELA K
HERU BK
M.RAMADHAN BK
6 SAMSUL B K
FITRI N K
FINSA Z BK
SALSA M BK
7 AAM K
MURHAAN K
FAIZ BK
8 AHMAD TOMI K 360420070006
SRI M K
M.RIZKI P BK
9 DIDING S K 36042001110007
TUPIROH K
NENENG U BK
AENI S BK
ADROHWI BK
SUPRI WAETI BK
IIS RIMILAYA BK
10 ISMAIL K 3604200302050008
SARI ULAN K
ISMASARI BK
ZAJA JAUHARI BK
11 ANTO N K
NORIYANTI K
PRATAMA BK
12 ROMLI K 3604200810044007
 EMAH K
AHMAD M BK
LIA DAHLILAH BK
13 SAMSU J K 3604201208050001
SITI A K
AKWANUDIN BK
14 SAMIUM K 3604202411040035
EBAH K
15 RIDWAN K 3604201171040022
PUTANAH K
M.FAUJAN BK
RIPAL H BK
16 AZIZI K 360420241040082
ZUHARIAH K
AHMAD K BK
SITI A BK
SITI S BK
17 UYUNG S K 3604202411090039
MUHAYAH K
KOMARIAH BK
M PIKRI BK
ANIS P BK
18 DARMAN K 3604202411040040
ROHAMAH K
19 ALI K 3604202411040038
ROKAYAH K
YANTI K BK
M RUSDI BK
IMA Z BK
NUNUNG M BK
KADI BK
MUTI BK
20 SUPANDI K 3604202411040043
RUMSI K
AJI R BK
NINING S BK
21 SURYANA K 3604202411040013
SUSMIATI K
M ADI BK
22 K.H.SUBKI K 3604202411040044
ITOH K
AHMAD T BK
M SADUKI BK
SITI UMUH BK
23 UJANG I K 3604202411040043
 UNAH K
JUMLI BK
SITI A BK
24 ABDULAH K 3604202511040020
AGUSTINI K
ISTIKOMAH BK
AGUS S BK
NURHIDAYAT BK
ABDUL AZIZ BK
M.FAISAL BK
INAYAH BK
25 ARMIN K 3604202511040024
SAMSIAH K
M.ARIF BK
26 AMIN K 3604202511040026
RUMSIAH K
ANITA BK
ASRIF BK
27 WANDI K 3604202212100108
HARTATI K
RESTI W BK
M RIDWAN BK
NANI BK
28 ABAS BASORI K 3604205211040030
SUANAH K
29 KARWILA K 3604202511040031
KASNIAH K
SITI NURLAELA BK
30 SUWITO K 3604202511040033
RAMINAH K
SUWARNA BK
SUNJANI BK
HOPIPAH BK
31 IRAWAN K 3604202511040034
ASTI K
IRNAWATI BK
32 DULMUTI K 3604202511040036
MINI K
ASEP BK
DEWI ASIAH BK
NANDANG P BK
33 SUHERI K 3604202511040037
JUHARIAH K
SUHENI P BK
HERLINA O BK
 NOVA VITRIA BK
34 AMIN K 3604202511040038
JANAH K
A JAKA BK
ADHARI BK
ARNI BK
35 ARSYAD K 3604202511040003
UUM K
SOLEHA BK
UMIN BK
YULIA BK
RIZKI BK

36 HERNAWATI K 3604202511040040
SUHERTIS BK
NURHIDAYAT BK
ST HADIJAH BK
37 KASNAH K 3604202511040041
SUHEDI K
KUSNADI BK
38 DUDI K 3604202511040042
ROHMAN K
NENGEMIN BK
39 A TURA K 3604202511040043
MULYATI K
K IMANUDIN BK
ZAQIATULA BK
ST HAPSAH BK
M NAZILI BK
A DAEROBI BK
40 EMI K 3604202511040044
A DAHLAH K
M WILDAN BK
41 NAPSAH K 3604202511040046
AYU S K
42 SUHEMI K 3604202511040048
APRILENI K
A SUMANTRI BK
A AFANDI BK
43 SAMUN K 3604202511040036
SUKMIATI K
A GOFUR BK
QOTRULU BK
B QOMAR BK
44 MUSLIH K 3604202511040039
 DEDE UL K
ADI S BK
HAKIN M BK
45 NURMAN K 3604203110070430
LISNAWATI K
SUHAYATI BK
AJI YANA BK
SUCIPTO BK
46 ABDULLAH K 3604203005090013
NAPSAH K
JABARUDIN BK
MALA BK
ROHIMAH BK
47 SUITNO K 3604200404120003
MAUHIAH K
ISMUTU BK
48 M.D.QUTNI K 3604202312130003
ITA R K
ST ZAHRA BK
49 WAHYUDIN K 3604201002100008
SUIRAT K
K NASTAIN BK
50 M SIDIK K 3604202212100145
HATIJAH K
IMAT M BK
RIZKI M BK
51 RASWDIN K 3604200503130001
ELAH K
ALIYAH BK
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
NIK Tanggal Kepemilikan BPJS / Asuransi Lainnya Pekerjaan
Lahir BPJS Asuransi KK
1
PBI Mandiri Askes Lainnya Lainnya
8 9 10 11 12 13 14 15 16
36042010710003 10/10/1971 √ BURUH
3604204509760003 9/3/1976 √ IRT
3604204907090001 7/9/2008 √
7/9/1985 BURUH
4/15/1998
360420166240001 2/15/1948 √ PENSIUNAN
3604204401630001 1/4/1963 √
3604201611000002 11/18/2000
3604202605800001 5/26/1980 BURUH
3604205304840001 4/23/1984
3604204303130001 3/3/2013
10/20/1978 BURUH
7/5/1993
1/21/2013
1/1/2013
3604201609840002 9/18/1984 BURUH
360420490688503 6/9/1986
3604202205100001 5/22/2010

7/19/1984 BURUH
20/021973
8/5/2012
3604200704800176 4/7/1980 √ BURUH
3604206411900092 24/111990
3604200106070001 6/1/2007
3604201509750227 4/12/1975 √ DAGANG
360420122047507 10/18/1978
36042004804780203 11/18/1995
360420581195000 1/1/1999
3604204111990365 5/17/2000
3604201512010076 12/14/2001
3604205210040077 10/12/2000
3604200203540081 3/2/1954 √ PENSIUNAN
3604204602630083 2/6/1963 √
3604206509890086 4/25/1989 √
3604200501950087 05/011995 √
1/5/1974 √
10/4/1976 √
10/31/2011 √
36042084104000031 1/4/1940 BURUH
3604204211960032 11/2/1946
36042001018600037 1/1/1986
3604204000470038 8/6/1997
360420150424001 4/15/1971 √ DAGANG
3604204101830001 1/1/1983
3604201911050002 11/19/2000
360420010051002 4/1/1951 √ SWASTA
1/1/1950
3604201011720110 11/1/1972 √ BURUH
36042068128000111 12/18/1980
3604202906110112 10/29/1999
360420070606001 10/7/2006
3604201212190145 12/12/1959 BURUH
3604204101730153 1/1/1989
3604202411870148 11/24/1987
3604201912920150 2/19/1992
36040670843700157 8/20/1997
3604202212180158 12/22/1958 √ BURUH
360420427530159 2/20/1952 √
3604205004610161 4/10/1981 √
3604200901850163 5/4/1985 √
360420600583002 1/24/1997 √
3604200101670166 1/1/1962 √ BURUH
360420710640167 1/17/1964 √
36042024056570112 5/24/1967 BURUH
360420101233015 1/1/1973
36042023009500155 6/30/1995
36042023085950155 8/20/1995
36042065099800126 4/25/1998
3604200885022057 5/20/2002
36042001005010193 1/1/2005
3604201144070601 1/14/2007
BURUH

3604201604840174 4/16/1989 √
360420505420180 5/10/1992 √
3604200403790145 4/24/1984 BURUH
3604206404840178 3/1/1979
3604200407050001 2/4/2005
3604200710590182 1/2/1995 √ BURUH
3604206101916183 4/21/1975 √
360420300201840185 1/22/1991 √
3604202406436128 6/24/1993 √
3604205704030188 4/11/2003 √
3604201006680189 6/10/1968 BURUH
3604204511690190 05/111992
3604200711420141 11/7/1992
36042043030193 3/3/2003
3604200906690000 6/9/1969 BURUH
3604205708720100 8/17/1972
3604206208430101 8/22/1993
3604201206950103 6/12/1995
3604206607980103 7/26/1998
3604200108000104 8/1/2000
3604200106030105 6/1/2003
3604204107050043 7/1/2005
3604200105630114 5/1/1963 BURUH
3604204101630115 1/1/1963
3604202306020118 6/23/2002
3604200101710119 1/1/1971 BURUH
3604204605820120 5/6/1982
3604204908970121 8/9/1997
3604201310050001 10/13/2005
3604201103670003 3/11/1987
36042047088700081 8/7/1987
3604206301110001 1/23/2011
360420305130003 5/3/2013

360420040440014 4/4/1940 BURUH

3604204505460142 5/5/1946
3604201608580144 8/16/1958 BURUH
3604204101650145 1/1/1965
3604204307940146 7/3/1994
3604200101670151 1/1/1967
3604204101690152 1/1/1969
3604200608850153 8/6/1985
3604200402920154 2/4/1992
3604204803990155 3/8/1999
3604200101690157 1/1/1969
3604204101700158 1/1/1970
3604204302050001 2/3/2005
3604200101630163 1/1/1963 BURUH
3604204306640164 6/3/1964
3604200602860165 2/6/1986
3604204802980166 2/8/1998
36042006090300167 9/6/2003
3604201011720168 11/10/1972 BURUH
3604205112770169 12/11/1977
36042043019701709 1/3/1997
3604205410990171 10/14/1999
3604205911060001 14/111/2006
3604200101690172 1/1/1969 √ BURUH
3604204101700281 1/1/1970 √
3604200504940175 4/5/1994 √
3604200103990176 3/1/1999 √
3604204101400177 1/1/2004 √
3604200203710179 3/2/1971 √ BURUH
3604204204720180 4/2/1972 √
3604204306920181 3-Jun √
3604200604960182 4/6/1996 √
3604206505000183 5/25/2000 √
3604201602030189 2/16/2003 √

3604204505710186 5/5/1971
3604200404860187 4/4/1986
3604200202000189 2/2/2000
3604205004060001 4/10/2006
3604204101600191 1/1/1960
3604200101820192 1/1/1982
3604200101900194 1/1/1990
3604200302540196 2/3/1950
3604200203820198 3/2/1982
3604204604920199 4/6/1992
3604200111700200 11/1/1970
3604206303720201 3/23/1972
3604200501940202 1/5/1994
3604204406980203 6/4/1998
3604204208000204 8/2/2000
3604201507030205 7/15/2003
3604202003050002 3/20/2005
3604204103700204 3/1/1970 √
3604200312990201 12/3/1999 √
3604200706020211 7-Jun √
3604204212750001 12/2/1975 BURUH
3604205505960219 5/15/1996
3604200903730223 3/9/1977 BURUH
3604204404840224 4/4/1978
3604201003950225 3/10/1998
3604202306970226 6/23/1967
36042001101680085 1/10/1968 √ BURUH
3604204101170405 1/1/1977 √
360420100511088 5/10/1991 √
36042050397019 3/3/1997 √
3604201212030189 12/12/2003 √
3604200107090202 1/1/1979 BURUH
3604204101760200 1/1/1976
3604200101000204 1/1/2000
36042010130205 1/1/2003
3604200810740001 10/8/1974 BURUH
360420081072000 1/1/1987
36042010173038 1/1/1973
36042011901600001 1/19/1999
3604202006069915 6/6/1999
3604200603800005 3/6/1980 BURUH
3604204102850004 2/1/1985
3604202604030001 4/26/2003
7/5/2010
7/5/2010
3604202204850001 4/22/1985 BURUH
3604205004880002 4/10/1988
3604200305080002 5/3/2008
3604208811870003 11/18/1987 √ BURUH
3604204404950003 4/4/1995 √
3604205311120001 11/13/2012 √
3604200702850004 2/7/1985 √ BURUH
3604204709860005 9/7/1986 √
3604202001100001 1/20/2010 √
3604200103770005 3/1/1977 BURUH
3604203505780003 5/5/1978
3604201300010002 8/13/2001
3604202212050001 12/22/2005
3604152511700002 11/25/1970 BURUH
3604164602790002 2/6/1979
3604151504970005 4/6/1997
 Umur Kehamilan Taksiran Peserta
Persalinan KB
2 3 4 5 6 7 8 9

17 18 19 20 21 22 23 24 25 26

PIL

SUNTIK

SUNTIK

2 BL May-16

SUNTIK

SUNTIK
SUNTIK

SUNTIK

SUNTIK

SUNTIK

SUNTIK

SUNTIK
SUNTIK

MOP

SUNTIK

SUNTIK

SUNTIK
SUNTIK

SUNTIK
PIL

SUNTIK

PIL

SUNTIK

SUNTIK

SUNTIK

SUNTIK

SUNTIK
 Status
Kemiskinan

27
KS III

KS III

KS III

PRA KS

PRA KS

PRA KS

PRA KS

PRA KS

KS III

KS III

PRA KS

KS III
KS III

KS III

KS III

PRA KS

PRA KS

PRA KS

PRA KS

PRA KS

KS III

KS III
PRA KS
PRA KS

PRA KS

PRA KS

PRA KS

PRA KS

KS II

KS II
PRA KS

PRA KS

PRA KS

PRA KS

KS II

PRA KS

KS III

KS III

PRA KS

KS III
KS II

KS II

KS II

KS III

KS II

KS II
NO NAMA Status Umur Nomor NIK Tanggal
Kepala Anggota KK Lahir
L P
Keluarga Keluarga
1 ENTAH K √ 360420110360420101 11/10/1942
MASITOH K √ 360420410 1/1/1960
JUENI BK √ 360420140 4/14/1987
2 √
AYISARIK √
A.RAFI BK √
3 HIDAYAT K √ 360420040360420220 5/22/1971
LISA KURNK √ 360420650 8/25/1975
BAYU KOMBK √ 360420300 8/30/1994
AGUNG P BK √ 360420261 10/26/2000
MEUTIA BK √ 360420640 1/24/2004
RAMADANBK √ 360420300 9/30/2007
4 KUSNI K √ 360420100360420002 2/10/1943
RUMI K √ 360420510 3/11/1949
5 DUDI K √ 360420170360420071 10/7/1989
KOMARIYAK √ 360420081 7/3/1989
M.RAMADA BK √ 360420550 8/13/2012
6 ISMA K √ 360420220360420100 10/6/1970
RUKIAH K √ 360420510 9/15/1979
ROHMANUBK √ 360420270 8/10/1998
DEALIS MABK √ 360420510 1/11/2013
7 MUHDIN K √ 360420110360420270 4/27/1973
SENA K √ 360420520 8/12/1975
M.YUSUF BK √ 360420230 2/23/1995
SAHRUDINBK √ 360420140 5/14/2001
ST.MAESA BK √ 360420630 3/23/2005
8 ENDANG K K √ 360420041360420080 8/8/1968
SUNTINI K √ 360420541 12/14/1967
NOVIA TRKBK √ 360420701 11/30/2000
9 ELI AMIN K √ 360420150360420050 8/5/1982
NOVITA E. K √ 360420691 11/29/1987
RAIYHAN ABK √ 360420220 1/22/2009
10 DIANA K √ 360420281360420220 12/29/1990
NAZRIEL I. K √ 3604206912900001
11 MEMED S K √ 360420110360420090 3/3/1953
HENI IRAWK √ 360420630 3/23/1957
NURIS SORBK √ 360420430 5/3/1957
12 THORIK F K √ 360420060 2/6/1990
WINDA A K √ 360420451 4/11/1989
13 MARTA K √ 360420051360420170 4/17/1937
 SUNDAWATK √ 360420650 3/25/1937
DAIL MA'RBK √ 360420280 3/28/1980
ST.MASITOBK √ 360420610 6/21/1992
ST.NURHA BK √ 360420630 7/23/1999
14 MUHANAN K √ 360420211360420180 8/18/1987
SUJINAH K √ 360420420 4/2/1970
MUNYATI BK √ 360420440 7/4/1998
SUHERI BK √ 360420150 7/15/2002
MULYATI BK √ 360420440 7/4/2005
15 SATIBI K √ 360420110360420010 1/1/1958
SAHATI K √ 360420450 7/5/1967
ST.NURYA BK √ 360420571 10/17/1998
16 RAHMAT B K 30 360420060360108150 4/15/1985
SUIRAT K 26 360420660 4/16/1989
ATIFAH B BK 2 360420880 2/26/2013
17 SUTA K 52 360420010 1/1/1963
UMI K 42 360420410 1/1/1973
SUYAMI BK 13
18 DEDI D K 41 360420290 4/29/1974
UMUN K 40 360420450 3/5/1975
DINA SAKI BK 2/10/2002
NAYLA BK 8/9/2012
19 MAHRUF K 360420241360420010 1/1/1967
SARWI K 360420410 1/1/1975
HARYANI BK 360420250 5/25/1992
ST.MAEMUBK 360420560 5/16/2000
R.RAMADABK 8/22/2009
20 HAERUDIN K 360420171360420231 12/23/1980
KOMARIYAK 360420610 7/21/1975
M.FATIH BK 360420231 4/17/2009
ZACFAU BK 360420610 11/30/2012
21 ADNAN K 360420216360420170 2/15/1984
ELAENI K 360420701 5/10/1969
IRAN BK 360420150 10/15/1997
KHAERUNIBK 360420500 5/30/1996
ST SHOLEHBK 360420151 10/3/2003
PAHMI BK 360420700 4/4/2008
22 SARJAYA K 360420110360420431 7/1/1967
ROHMIYATIK 360420040 7/1/1972
MAULUDINBK 360420010 7/1/1996
ST.NURMABK 360420410 7/1/1998
AGUS.M BK 360420010 8/19/2000
ST.NURJA BK 360420410 1/22/2003
ANDHIKA BK 360420230 5/23/2010
ALFIA BK 360420420 4/2/2013
23 MASRI K 7/1/1990
NIA K K 5/2/1994
NAJWA BK 5/25/2015
24 AGUS K 360420190360420060 8/6/1978
SUMIATI K 360420055 11/15/1982
MAHDI BK 360420270 7/27/2001
YUNITA BK 360420471 9/5/2003
25 MADHURI K 360420140360421815 10/15/1984
SUHARTINIK 360420470 2/7/1993
MEISYAH BK 360420550 5/15/2013
26 SA'ANAH K 360420211360420410 1/1/1980
ARIF K 360420240 4/24/2011
27 SARYONI K 360420220360420110 7/11/1987
SULIAWATIK 360420431 10/3/1995
M.FADIL BK 6/1/2015
28 PRIYANTO K 360420210360420110 7/11/1981
SUMALAH K 360420450 7/7/1987
FAREL BK 360420300 4/30/2007
FATONAH BK 360420690 6/18/2008
29 JAENUL K 360420021360420240 2/24/1963
SUHARTINK 360420410 1/1/1965
SRI LESTARBK 360420054 7/14/1993
EDAY BK 360420501 12/10/1995
MADRUS BK 360420100 3/10/2002
 FORMULIR PENDATAAN KESEHATAN IBU DAN BAYI
Kepemilikan BPJS / Asuransi Lainnya Pekerjaan Umur Kehamilan
BPJS Asuransi KK
1 2 3 4
PBI Mandiri Askes Lainnya Lainnya
PETANI
IRT
BURUH
BURUH √
IRT

BURUH
IRT
BURUH

√ PETANI
√
BURUH
IRT

√ BURUH
√ IRT
√
√
√ BURUH
√ IRT
√
√
√
√ BURUH
IRT

BURUH
IRT

√
√
√ PENSIUN
IRT
√ BURUH
√ BURUH
√ IRT √
√ PETANI
√ IRT
√
√
√
√ BURUH
√ IRT
√
√
√
BURUH
IRT

BURUH
IRT

BURUH
IRT

BURUH
IRT

√ BURUH
√ IRT
√
√
√
BURUH
IRT

BURUH
IRT

√ BURUH
√ IRT
√
√
√
√
√ BURUH
√ IRT
√
√ BURUH
√ IRT
√
√
BURUH
IRT

BURUH
IRT
BURUH
IRT

BURUH
IRT
Umur Kehamilan Taksiran Peserta Status
Persalinan KB Kemiskinan
5 6 7 8 9

KS

KS

KS

KS

KS

KS III
SUNTIK

KS III
SUNTIK

MOP KS

KS
PIL

SUNTIK

KS

KS
SUNTIK

KS

KS
MOW

KS
SUNTIK

KS
SUNTIK

KS IV
SUNTIK

KS
SUNTIK

KS
SUNTIK

KS
PIL

KS

KS
√ KS

KS

KS

KS
SUNTIK

KS

KS