Golongan Umur
Total Jumlah Kasus
≤ 1 thn 1 - 4 thn 5 - 9 thn 10 - 14 thn ≥ 15 thn
No Desa
Lk Pr Lk Pr Lk Pr Lk Pr Lk Pr Lk Pr
P M
P M P M P M P M P M P M P M P M P M P M P M P M
1
2
3
4
5
6
7
8
9
10
Total
..................................,.................................2014
Petugas Desa/Dusun
.........................................................................
NIP/NRPH/NRPTT