PMT2018

Provinsi : KALIMANTAN UTARA
Kabupaten/Kota : TARAKAN
Puskesmas/Kecamatan : JUATA LAUT
Desa/Kelurahan : JUATA LAUT
No Anak Tanggal Lahir Jenis No Kartu Keluarga NIK (Nomor Induk

Ke Kelamin Kependudukan)
(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001
2 2 7/28/2015 p
3 2 6/23/2013 P 6473041203090002 6473046306130001
4 4 11/27/2015 P 6473041612080086 6571046711160003
5 2 6/7/2016 L
6 5 4/24/2017 P 6473040906090003 6571046404170001
7 5 10/28/2013 L 6473042511080046 6571042810130001
8 2 7/19/2013 P
9 1 6/26/2017 L
10 5 2/18/2014 P 6571040202180002 6473045802140002
11 3 8/28/2016 L
12 1 1/9/2016 P 6571040205170005 6571044901160001
13 6 10/28/2014 P 6473041106100007 6571046810140001
14 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan
- Kolom 11 : Jika ayah tidak ada, maka diisikan nama ibu
- Kolom 12 : Jika ayah tidak ada, maka diisikan NIK ibu

Anak Jenis NIK (Nomor Induk

No Ke Tanggal Lahir Kelamin No Kartu Keluarga Kependudukan)
(1) (2) (3) (4) (5) (6)
1 2 11/11/2013 p 6473042704090020 6473045111130001
2 2 7/28/2015 p
3 2 6/23/2013 P 6473041203090002 6473046306130001
4 4 11/27/2015 P 6473041612080086 6571046711160003
5 2 6/7/2016 L
6 5 4/24/2017 P 6473040906090003 6571046404170001
7 5 10/28/2013 L 6473042511080046 6571042810130001
8 2 7/19/2013 P
9 1 6/26/2017 L
10 5 2/18/2014 P 6571040202180002 6473045802140002
11 3 8/28/2016 L
12 1 1/9/2016 P 6571040205170005 6571044901160001
13 6 10/28/2014 P 6473041106100007 6571046810140001
14 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan


(1) (2) (3) (4) (5) (6)
1 2 11/11/2013 p 6473042704090020 6473045111130001

2 2 7/28/2015 p
3 2 6/23/2013 P 6473041203090002 6473046306130001
4 4 11/27/2015 P 6473041612080086 6571046711160003
5 2 6/7/2016 L
6 5 4/24/2017 P 6473040906090003 6571046404170001
7 5 10/28/2013 L 6473042511080046 6571042810130001
8 1 6/26/2017 L
9 5 2/18/2014 P 6571040202180002 6473045802140002
10 3 8/28/2016 L
11 6 10/28/2014 P 6473041106100007 6571046810140001
12 7 3/12/2016 L 6473041106100007 6571042810160003
13 1 5/16/2017 L 6473042007100003 6571041505170003
Keterangan



(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001
2 2 7/28/2015 p
3 2 6/23/2013 P 6473041203090002 6473046306130001
4 4 11/27/2015 P 6473041612080086 6571046711160003
5 5 4/24/2017 P 6473040906090003 6571046404170001
6 5 10/28/2013 L 6473042511080046 6571042810130001
7 1 6/26/2017 L
8 5 2/18/2014 P 6571040202180002 6473045802140002
9 3 8/28/2016 L
10 1 5/16/2017 L 6473042007100003 6571041505170003
11 1 1/9/2016 P 6571040205170005 6571044901160001
12 6 10/28/2014 P 6473041106100007 6571046810140001
13 2 8/1/2013 L
14 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan


(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001
2 2 7/28/2015 p
3 2 6/23/2013 P 6473041203090002 6473046306130001
4 4 11/27/2015 P 6473041612080086 6571046711160003
5 5 4/24/2017 P 6473040906090003 6571046404170001
6 5 10/28/2013 L 6473042511080046 6571042810130001
7 1 6/26/2017 L
8 5 2/18/2014 P 6571040202180002 6473045802140002
9 3 8/28/2016 L
10 1 5/16/2017 L 6473042007100003 6571041505170003
11 1 1/9/2016 P 6571040205170005 6571044901160001
12 6 10/28/2014 P 6473041106100007 6571046810140001
13 2 8/1/2013 L
14 3 11/8/2016 P 6473041707090009 6571044811160001
15 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan



(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001
2 2 6/23/2013 P 6473041203090002 6473046306130001
3 4 11/27/2015 P 6473041612080086 6571046711160003
4 5 4/24/2017 P 6473040906090003 6571046404170001
5 5 10/28/2013 L 6473042511080046 6571042810130001
6 1 6/26/2017 L
7 5 2/18/2014 P 6571040202180002 6473045802140002
8 3 8/28/2016 L
9 1 5/16/2017 L 6473042007100003 6571041505170003
10 1 1/9/2016 P 6571040205170005 6571044901160001
11 6 10/28/2014 P 6473041106100007 6571046810140001
12 2 8/1/2013 L
13 3 11/8/2016 P 6473041707090009 6571044811160001
14 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan


(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001
2 4 11/27/2015 P 6473041612080086 6571046711160003
3 5 4/24/2017 P 6473040906090003 6571046404170001
4 1 6/26/2017 L
5 5 2/18/2014 P 6571040202180002 6473045802140002
6 5/16/2017 L 6473042007100003 6571041505170003
7 1 1/9/2016 P 6571040205170005 6571044901160001
8 6 10/28/2014 P 6473041106100007 6571046810140001
9 2 8/1/2013 L
10 3 11/8/2016 P 6473041707090009 6571044811160001
11 3 9/18/2017 L 6473040312080241 6571040809170001
12 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan


(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001
2 4 11/27/2015 P 6473041612080086 6571046711160003
3 5 4/24/2017 P 6473040906090003 6571046404170001
4 1 6/26/2017 L
5 5 2/18/2014 P 6571040202180002 6473045802140002
6 1 5/16/2017 L 6473042007100003 6571041505170003
7 1 1/9/2016 P 6571040205170005 6571044901160001
8 3 11/8/2016 P 6473041707090009 6571044811160001
9 3 9/18/2017 L 6473040312080241 6571040809170001
10 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan


(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001
2 4 11/27/2015 P 6473041612080086 6571046711160003
3 5 4/24/2017 P 6473040906090003 6571046404170001
4 1 6/26/2017 L
5 5 2/18/2014 P 6571040202180002 6473045802140002
6 1 5/16/2017 L 6473042007100003 6571041505170003
7 1 1/9/2016 P 6571040205170005 6571044901160001
8 3 9/18/2017 L 6473040312080241 6571040809170001
9 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan


(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001
2 4 11/27/2015 P 6473041612080086 6571046711160003
3 5 4/24/2017 P 6473040906090003 6571046404170001
4 1 6/26/2017 L
5 5 2/18/2014 P 6571040202180002 6473045802140002
6 1 5/16/2017 L 6473042007100003 6571041505170003
7 1 1/9/2016 P 6571040205170005 6571044901160001
8 3 9/18/2017 L 6473040312080241 6571040809170001
9 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan



(1) (2) (3) (4) (5) (6)

1 4 11/27/2015 P 6473041612080086 6571046711160003
2 5 4/24/2017 P 6473040906090003 6571046404170001
3 1 6/26/2017 L
4 5 2/18/2014 P 6571040202180002 6473045802140002
5 1 5/16/2017 L 6473042007100003 6571041505170003
6 1 1/9/2016 P 6571040205170005 6571044901160001
7 3 9/18/2017 L 6473040312080241 6571040809170001
8 2 8/9/2017 P
9 3 10/7/2017 P 6473041008090002 65710444710170002
10 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan


(1) (2) (3) (4) (5) (6)

1 4 11/27/2015 P 6473041612080086 6571046711160003
2 5 4/24/2017 P 6473040906090003 6571046404170001
3 1 6/26/2017 L
4 5 2/18/2014 P 6571040202180002 6473045802140002
5 1 5/16/2017 L 6473042007100003 6571041505170003
6 1 1/9/2016 P 6571040205170005 6571044901160001
7 3 9/18/2017 L 6473040312080241 6571040809170001
8 2 8/9/2017 P
9 3 10/7/2017 P 6473041008090002 65710444710170002
10 1 5/18/2018 L 6473040311090003 6571041805180001
11 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan




(1) (2) (3) (4) (5) (6)

1 4 11/27/2015 P 6473041612080086 6571046711160003
2 5 4/24/2017 P 6473040906090003 6571046404170001
3 1 6/26/2017 L
4 5 2/18/2014 P 6571040202180002 6473045802140002
5 1 5/16/2017 L 6473042007100003 6571041505170003
6 1 1/9/2016 P 6571040205170005 6571044901160001
7 3 9/18/2017 L 6473040312080241 6571040809170001
8 2 8/9/2017 P
9 3 10/7/2017 P 6473041008090002 65710444710170002
10 1 5/18/2018 L 6473040311090003 6571041805180001
11 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan


(1) (2) (3) (4) (5) (6)

1 4 11/27/2015 P 6473041612080086 6571046711160003
2 5 4/24/2017 P 6473040906090003 6571046404170001
3 1 6/26/2017 L
4 5 2/18/2014 P 6571040202180002 6473045802140002
5 1 5/16/2017 L 6473042007100003 6571041505170003
6 1 1/9/2016 P 6571040205170005 6571044901160001
7 3 9/18/2017 L 6473040312080241 6571040809170001
8 2 8/9/2017 P
9 3 10/7/2017 P 6473041008090002 65710444710170002
10 1 5/18/2018 L 6473040311090003 6571041805180001
11 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan

(1) (2) (3) (4) (5) (6)

1 4 11/27/2015 P 6473041612080086 6571046711160003
2 5 4/24/2017 P 6473040906090003 6571046404170001
3 1 6/26/2017 L
4 5 2/18/2014 P 6571040202180002 6473045802140002
5 1 5/16/2017 L 6473042007100003 6571041505170003
6 1 1/9/2016 P 6571040205170005 6571044901160001
7 3 9/18/2017 L 6473040312080241 6571040809170001
8 3 10/7/2017 P 6473041008090002 65710444710170002
9 1 5/18/2018 L 6473040311090003 6571041805180001
10 7 3/12/2016 L 6473041106100007 6571042810160003
Keterangan

FORMULIR PEMANTAUAN PERTUMBUHAN BALITA DI POSYANDU
Nama Posyandu :
Bulan : JANUARI
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Nama anak Nama Ayah
(BB)
Lahir 1=YA 1=YA,
2=Tidak 2=Tidak
(7) (8) (9) (10) (11)

ZARA AZIRA 2.8 1 1 HARI
FLORA 1 1 MUSA
YENI ANITA 2.7 1 1 YONATHAN
NUR HAJRAH 2.9 1 2 ABDUL KAMAR
PHILIP SENY 1 2 NACE
EFLIN 2.5 1 2 YOSEP RUAIN
ANDI TAUFIQ 2.8 1 1 ANDI SANDRIC
SHAKILA KANZA 2.9 1 1 AMRAN
M.ANDRIANSYAM 2.3 1 2 SYAMSUL BAHRI
IZATUL ULYA 1.5 1 1 DARMAN
M. ALIANSYAH 1 1 SALASIAH
CYNTIA 2.9 1 1 SANTI
NURMANIA 2.5 1 1 TASWIN
M.YUSRIL 1.9 1 2 TASWIN

Nama Posyandu :
Bulan : FEBRUARI
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Nama anak (BB) Nama Ayah
1=YA 1=YA,
Lahir 2=Tidak 2=Tidak
(7) (8) (9) (10) (11)
FLORA 1 1 MUSA
SHAKILA KANZA 2.9 1 1 AMRAN

Nama Posyandu :
Bulan : MARET
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
1=YA 1=YA,
(7) (8) (9) (10) (11)

FLORA 1 1 MUSA
M.FATIR 2.5 1 1 FRANIS
Nama Posyandu :
Bulan : APRIL
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Lahir 1=YA 1=YA,
2=Tidak 2=Tidak
(7) (8) (9) (10) (11)

FLORA 1 1 MUSA
REKY 3 1 2 YULIUS DOLLA
Nama Posyandu :
Bulan : MEI
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Lahir
Berat
Nama anak Badan Nama Ayah
(BB)
Lahir 1=YA 1=YA,
2=Tidak 2=Tidak
(7) (8) (9) (10) (11)

FLORA 1 1 MUSA
M. ALIANSYAH 2.7 1 1 SALASIAH
SHAFNA NUR ILMI 3.2 1 2 ANDI ARDI
Nama Posyandu :
Bulan : JUNI
Tahun :
Kepemilika
Berat n Buku IMD
Nama anak Badan KIA/KMS Nama Ayah
(BB)
Lahir 1=YA 1=YA,
2=Tidak 2=Tidak
(7) (8) (9) (10) (11)

M. ALIANSYAH 2.7 1 1 SALASIAH
Nama Posyandu :
Bulan : JULI
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Lahir 1=YA 1=YA,
2=Tidak 2=Tidak
(7) (8) (9) (10) (11)

JEWIS MINGKI 3 1 1 SAKUTA BOGA
Nama Posyandu :
Bulan : AGUSTUS
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Nama anak Nama Ayah
(BB)
Lahir 1=YA 1=YA,
2=Tidak 2=Tidak
(7) (8) (9) (10) (11)

Nama Posyandu :
Bulan : SEPTEMBER
Tahun :
Kepemilika
Berat n Buku IMD
(BB) 1=YA 1=YA,
(7) (8) (9) (10) (11)

Nama Posyandu :
Bulan : OKTOBER
Tahun :
Kepemilika
Berat n Buku IMD
(BB) 1=YA 1=YA,
(7) (8) (9) (10) (11)

Nama Posyandu :
Bulan : NOVEMBER
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
1=YA 1=YA,
(7) (8) (9) (10) (11)

FARISHA KHAIRIYAH 1 1 ABDUL KADIR
ASYIFA OKTAVIA 3.1 1 1 TRIO HANDOYO
Nama Posyandu :
Bulan : DESEMBER
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Lahir 1=YA 1=YA,
2=Tidak 2=Tidak
(7) (8) (9) (10) (11)

M.RIZKI 2.2 1 1 AGUS SEPTIAWAN
Nama Posyandu :
Bulan : JANUARI
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Lahir 1=YA 1=YA,
2=Tidak 2=Tidak
(7) (8) (9) (10) (11)

Nama Posyandu :
Bulan : FEBRUARI
Tahun :
Kepemilika
Berat n Buku IMD
(BB) 1=YA 1=YA,
(7) (8) (9) (10) (11)

Nama Posyandu :
Bulan : MARET
Tahun :
Kepemilika
Berat n Buku IMD
Badan KIA/KMS
Nama anak Nama Ayah
(BB) 1=YA 1=YA,
(7) (8) (9) (10) (11)

ERTUMBUHAN BALITA DI POSYANDU (PMT BALITA TAHUN 2018)
Panjang
BB Badan/
NIK Ayah No Tlp/ HP Ayah Alamat RT RW Tgl Pengukuran Tinggi
(kg) Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)

6473041208840005 08254517305 JL 10 1/3/2018 11.3 94
JL 9 1/3/2018 8.6 77.3
6473041212880001 JL 19 1/5/2018 10.6 93
6473041207830007 JL 12 1/10/2018 8 74.8
JL 13 1/12/2018 8.2 74.6
647304101180001 JL 14 1/12/2018 5.6 61
6473042707760003 082358856472 JL 3 1/15/2018 11.6 90
JL 18 1/19/2018 11.9 94
JL 7 1/20/2018 4.9 59.5
6473040505770002 085349320308 JL 17 1/22/2018 8.7 83.2
JL 16 1/25/2018 8.2 79.9
7326144608710001 08235300024692 JL 19 1/25/2018 7.3 75
6473043112780048 JL 17 1/27/2018 10.2 99.7
6473043112780048 JL 17 1/30/2018 5.7 73

Panjang
BB Badan/
NIK Ayah No Tlp/ HP Ayah Alamat RT RW Tgl Pengukuran (kg) Tinggi
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)
6473041208840005 08254517305 JL 10 2/4/2018 11.1 94
JL 9 2/4/2018 8.6 78
6473041212880001 JL 19 2/7/2018 10.7 93.5
6473041207830007 JL 12 2/8/2018 8.3 75.2
JL 13 2/8/2018 9 75
647304101180001 JL 14 2/14/2018 6 62
6473042707760003 082358856472 JL 3 2/16/2018 12 90.4
JL 18 2/16/2018 12.1 94.5
JL 7 2/20/2018 4.8 59.5
6473040505770002 085349320308 JL 17 2/22/2018 9.2 83.7
JL 16 2/25/2018 8.3 80
7326144608710001 08235300024692 JL 19 2/25/2018 7.3 75.2
6473043112780048 JL 17 2/27/2018 10.6 100
6473043112780048 JL 17 2/27/2018 5.5 66

Panjang
BB Badan/
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)
6473041208840005 08254517305 JL 10 3/4/2019 11.7 94.7

JL 9 3/5/2019 8.6 78
6473041212880001 JL 19 3/5/2019 10.9 95
6473041207830007 JL 12 3/7/2019 8.5 76
JL 13 3/8/2019 8.7 75.7
647304101180001 JL 14 3/10/2019 6 62
6473042707760003 082358856472 JL 3 3/10/2019 11.5 91
JL 7 3/12/2019 5.2 61
6473040505770002 085349320308 JL 17 3/16/2019 9.1 84
JL 16 3/16/2019 8.3 80.3
6473043112780048 JL 17 3/22/2019 10.4 100.3
6473043112780048 JL 17 3/25/2019 5 67.4
6473011209920005 085249396505 JL 14 3/25/2018 6.6 68

Panjang
BB Badan/
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)

6473041208840005 08254517305 JL 10 4/4/2018 11.5 95
JL 9 4/4/2018 8.7 78
6473041212880001 JL 19 4/6/2018 10.9 95.4
6473041207830007 JL 12 4/6/2018 8.6 76.4
647304101180001 JL 14 4/10/2018 6.1 62.7
6473042707760003 082358856472 JL 3 4/14/2018 11.6 91.5
JL 7 4/15/2018 5.3 61.3
6473040505770002 085349320308 JL 17 4/16/2018 9.2 84.3
JL 16 4/20/2018 8.8 80.5
6473011209920005 085249396505 JL 14 4/21/2018 6.6 68.3
7326144608710001 08235300024692 JL 19 2/25/2018 7.7 75.8
6473043112780048 JL 17 4/22/2018 11.7 92
JL 13 4/22/2018 11.6 95
6473043112780048 JL 17 4/22/2018 5.1 67.6
Panjang
BB Badan/
Badan
(cm)
Panjang
Badan/
NIK Ayah No Tlp/ HP Ayah Alamat RT RW Tgl Pengukuran BB Tinggi
(kg) Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)

6473041208840005 08254517305 JL 10 5/2/2018 11.6 95.3
JL 9 5/2/2018 8.8 78.7
6473041212880001 JL 19 5/4/2018 11 96
6473041207830007 JL 12 5/4/2018 8.6 77
647304101180001 JL 14 5/8/2018 6.4 63
6473042707760003 082358856472 JL 3 5/8/2018 12.1 93
JL 7 5/10/2018 6 63
6473040505770002 085349320308 JL 17 5/12/2018 9.4 85
JL 16 5/17/2018 9.2 81
6473011209920005 085249396505 JL 14 5/20/2018 6.9 69
7326144608710001 08235300024692 JL 19 5/20/2018 7.9 76
6473043112780048 JL 17 5/22/2018 11.1 92.2
JL 13 5/22/2018 12.6 96
6473042103840001 085345357303 JL 12 5/25/2018 7.3 75
6473043112780048 JL 17 5/28/2018 5.2 68.4
Panjang
BB Badan/
(kg) Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)

6473041208840005 08254517305 JL 10 6/2/2018 11.8 95.7
6473041212880001 JL 19 6/8/2018 11.1 96.6
6473041207830007 JL 12 6/10/2018 8.8 77.5
647304101180001 JL 14 6/10/2018 5.9 65
6473042707760003 082358856472 JL 3 6/12/2018 12.3 93.6
JL 7 6/13/2018 6.2 63.5
6473040505770002 085349320308 JL 17 6/19/2018 9.5 85.3
JL 16 6/19/2018 9 81.4
6473011209920005 085249396505 JL 14 6/22/2018 6.9 69.3
7326144608710001 08235300024692 JL 19 6/22/2018 8.2 76.4
6473043112780048 JL 17 6/22/2018 11.2 92.5
JL 13 6/26/2018 13.3 96.5
6473042103840001 085345357303 JL 12 6/27/2018 7.8 76
6473043112780048 JL 17 6/28/2018 5.5 68.7
Panjang
BB Badan/
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)

6473041208840005 08254517305 JL 10 7/3/2018 12.2 96
6473041207830007 JL 12 7/4/2018 8.8 78
647304101180001 JL 14 7/7/2018 6 65.6
JL 7 7/7/2018 6.4 64
6473040505770002 085349320308 JL 17 7/12/2018 10 85.3
6473011209920005 085249396505 JL 14 7/12/2018 7.8 70.9
7326144608710001 08235300024692 JL 19 7/17/2018 8.2 76.8
6473043112780048 JL 17 7/17/2018 11.3 93
JL 13 7/20/2018 13.4 97
6473042103840001 085345357303 JL 12 7/21/2018 8.3 77
6473041304760002 JL 13 7/26/2018 6.06 67
6473043112780048 JL 17 7/28/2018 5.3 69
Panjang
Badan/
(kg)
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)

6473041208840005 08254517305 JL 10 8/6/2018 12.5 97
6473041207830007 JL 12 8/6/2018 8.8 80
647304101180001 JL 14 7/7/2018 6.6 66.4
JL 7 8/10/2018 6.6 66.5
6473040505770002 085349320308 JL 17 8/12/2018 9.6 87.4
6473011209920005 085249396505 JL 14 8/12/2018 7.9 71.5
7326144608710001 08235300024692 JL 19 8/19/2018 8.3 77
6473042103840001 085345357303 JL 12 8/19/2019 8.8 79
6473041304760002 JL 13 8/28/2018 6.6 69
6473043112780048 JL 17 8/29/2018 5.5 71
Panjang
BB Badan/
(kg)
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)
6473041208840005 08254517305 JL 10 9/7/2018 12.2 97.3
6473041207830007 JL 12 9/10/2018 8.9 80.4
647304101180001 JL 14 9/10/2018 6.8 67
JL 7 9/12/2018 7.1 67
6473040505770002 085349320308 JL 17 9/12/2018 9.8 87.8
6473011209920005 085249396505 JL 14 9/15/2018 8.3 72
7326144608710001 08235300024692 JL 19 9/15/2018 8.3 77.4
6473041304760002 JL 13 9/22/2018 6.6 69
6473043112780048 JL 17 9/25/2018 5.2 71.6

Panjang
BB Badan/
(kg) Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)
6473041208840005 08254517305 JL 10 10/6/2018 12.2 97.6
6473041207830007 JL 12 10/8/2018 9.1 82
647304101180001 JL 14 10/10/2018 7.6 69
JL 7 10/10/2018 7.1 68
6473040505770002 085349320308 JL 17 10/14/2018 9.7 88
6473011209920005 085249396505 JL 14 10/14/2018 7.7 73
7326144608710001 08235300024692 JL 19 10/17/2018 8 78
6473041304760002 JL 13 10/26/2018 6.6 69
6473043112780048 JL 17 10/29/2018 5.3 71.6
Panjang
BB Badan/
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)
6473041207830007 JL 12 11/8/2018 9.4 83.5
647304101180001 JL 14 11/10/2018 7.4 69.4
JL 7 11/10/2018 8.2 69.1
6473040505770002 085349320308 JL 17 11/12/2018 9.8 88.7
6473011209920005 085249396505 JL 14 11/15/2018 8.3 74.5
7326144608710001 08235300024692 JL 19 11/17/2018 8.6 78.6
6473041304760002 JL 13 11/20/2018 6.6 70
JL 15 11/23/2018 6.2 68
6473041207800004 085247476446 JL 10 11/24/2018 6.3 69
6473043112780048 JL 17 11/29/2018 5.5 72.6
Panjang
Badan/
(kg)
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)

6473041207830007 JL 12 12/5/2018 9.5 84
647304101180001 JL 14 12/7/2018 7.6 70.3
JL 7 12/10/2018 8.2 69.5
6473040505770002 085349320308 JL 17 12/12/2018 10.1 90
6473011209920005 085249396505 JL 14 12/12/2018 7.8 74.6
7326144608710001 08235300024692 JL 19 12/18/2018 8 79
6473041304760002 JL 13 12/19/2018 7 71
JL 15 12/22/2018 7.4 69
6473041207800004 085247476446 JL 10 12/22/2018 7.1 70
6473040408880001 081220891595 JL 9 12/25/2018 4.6 59
6473043112780048 JL 17 12/28/2018 5.7 73

Panjang
BB Badan/
Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)

6473041207830007 JL 12 1/3/2019 9.7 85
647304101180001 JL 14 1/3/2019 7.7 71
JL 7 1/5/2019 8.8 70.9
6473040505770002 085349320308 JL 17 1/7/2019 10.2 91
6473011209920005 085249396505 JL 14 1/11/2019 8 75.4
7326144608710001 08235300024692 JL 19 1/11/2019 8.5 80
6473041304760002 JL 13 1/14/2019 7.6 72
JL 15 1/16/2019 7.6 70
6473041207800004 085247476446 JL 10 1/18/2019 7.2 70.5
6473040408880001 081220891595 JL 9 1/20/2019 5.4 61
6473043112780048 JL 17 1/25/2019 6 73.5
Panjang
Badan/
(kg) Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)
6473041207830007 JL 12 2/4/2019 9.8 86
647304101180001 JL 14 2/4/2019 7.9 72.1
JL 7 2/4/2019 8.9 71.5
6473040505770002 085349320308 JL 17 2/10/2019 10.2 91.4
6473011209920005 085249396505 JL 14 2/11/2019 8.2 76
7326144608710001 08235300024692 JL 19 2/14/2019 8.6 81
6473041304760002 JL 13 2/20/2019 7.8 72.8
JL 15 2/23/2019 7.8 71
6473041207800004 085247476446 JL 10 2/23/2019 7.4 71
6473040408880001 081220891595 JL 9 2/27/2019 5.6 62.7
6473043112780048 JL 17 2/27/2019 6.1 73.5
Panjang
BB Badan/
(kg) Badan
(cm)
(12) (13) (14) (15) (16) (17) (18) (19)
6473041207830007 JL 12 3/3/2019 9.9 87
647304101180001 JL 14 3/3/2019 8.3 73.2
JL 7 3/6/2019 9 72
6473040505770002 085349320308 JL 17 3/8/2019 10.2 92
6473011209920005 085249396505 JL 14 3/11/2019 9.1 79
7326144608710001 08235300024692 JL 19 3/11/2019 8.6 81.5
6473041304760002 JL 13 3/11/2019 8.3 74.6
6473041207800004 085247476446 JL 10 3/23/2019 7.6 72
6473040408880001 081220891595 JL 9 3/24/2019 5.8 64
6473043112780048 JL 17 3/23/2019 5.5 74
Vitamin A Vitamin A
Cara Ukur ASI EksklusifF1=YA, 2=Tidak Februari Agustus Prekembangan
1=Telenta 1=YA 1=YA KPSP

ng umur 0 bln umur 1 bln umur 2 bln umur 3 bln umur 4 bln umur5 bln
2=Berdiri 2=Tidak 2=Tidak Ds/Dm/Dp
(20) (21) (22) (23) (24) (25) (26) (27) (28) -29
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
1 1 1
2 1 1
2 1 1
1 1 1
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
Vitamin A Vitamin A
Cara Ukur ASI EksklusifF1=YA, 2=Tidak Februari Agustus
1=Telenta 1=YA 1=YA
ng umur 0 bln umur 1 bln umur 2 bln umur 3 bln umur 4 bln umur5 bln 2=Tidak 2=Tidak
2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
1 1 1
2 1 1
2 1 1
1 1 1
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
Vitamin A Vitamin A
1=Telenta
1=YA
umur 0 bln umur 1 bln umur 2 bln umur 3 bln umur 4 bln umur5 bln 2=Tidak 1=YA
ng 2=Tidak
2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
2 1 1
2 1 1
1 1 1
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
2 1 1
1 1 1
2 1 1
2 1 1
1 1 1
2 1 1
2 1 1
2 1 1
1 1 1
Vitamin A Vitamin A
1=Telenta
ng 1=YA
2=Tidak
2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
2 1 1
1 1 1
2 1 1
2 1 1
1 1 1
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
Vitamin A Vitamin A
1=Telenta
ng umur 0 bln umur 1 bln umur 2 bln umur 3 bln umur 4 bln umur5 bln 1=YA 1=YA
2=Berdiri 2=Tidak 2=Tidak
(20) (21) (22) (23) (24) (25) (26) (27) (28)

2 1 1
2 1 1
2 1 1
1 1 1
2 1 1
1 1 1
2 1 1
2 1 1
1 1 1
2 1 1
2 1 1
2 1 1
2 1 1
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

(20) (21) (22) (23) (24) (25) (26) (27) (28)

2 1 1
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
2 1 1
2 1 1
2 1 1
1 2 2
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
2 1 1
1 2 1
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
1 2 1
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
1 2 1
1 1 1
Vitamin A Vitamin A
1=Telenta
ng 1=YA
2=Tidak
2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
1 2 1
1 1 1
1 1
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

(20) (21) (22) (23) (24) (25) (26) (27) (28)

2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
1 2 1
1 1 1
1 1
1 2 2
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
1 2 1
1 1 1
1 1
1 2 2
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
1 2 1
1 1 1
1 1
1 2 2
1 1 1
Vitamin A Vitamin A
1=Telenta 1=YA 1=YA

2=Berdiri
(20) (21) (22) (23) (24) (25) (26) (27) (28)
2 1 1
1 1 1
1 1 1
2 1 1
1 1 1
2 1 1
1 2 1
1 1
1 2 2
1 1 1
Prekembangan
Buku KIA Tindak

Lanjut
S/TS SL/SU/R
(30 31
FORMULIR PEMANTAUAN IBU HAMIL (PMT 2018)
Provinsi : KALTARA Nama Posyandu :

Kabupaten/Kota : TARAKAN Bulan : JANUARI
Puskesmas/Kecamatan :JUATA LAUT Tahun : 2018 TTD
Desa/Kelurahan : JUATA LAUT Lingkar (Tablet Jika YA,
Kepemili Berat Tinggi
No Kehamila Tanggal Lahir No Kartu Keluarga NIK (Nomor Induk Nama Ibu Hamil Berat Badan awal kan Buku Nama Suami NIK Suami Alamat RT RW Tanggal Badan Badan Lengan Tambah brp butir
n ke Kependudukan) hamil/Trimester I pengukuran Atas darah) TTD
KIA (kg) (cm) (LiLA) 1=YA, diterima
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
2=Tidak
1 1 18 th YUNIARTI YA HARIS JL 15 1/5/2018 22 1 160
2 3 26TH SARAH YA RUBEN JL 19 1/5/2018 23 1 30
3 2 27TH AGUSTINA YA M. ALIANSYAH JL 12 1/10/2018 21 1 150
4 1 26TH SARTI YA SUKRI JL 7 1/12/2018 21 1 60
5 4 28TH ANASTASIA YA OKTAFIANUS JL 14 1/20/2018 22 1 90
Kabupaten/Kota : TARAKAN Bulan : FEBRUARI
Puskesmas/Kecamatan :JUATA LAUT Tahun : 2018

TTD
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
2=Tidak
1 1 18TH SALTIN YA ZEFRIL JL 9 2/10/2018 23 1 30
2 1 22TH PIESA YA ADI JL 18 2/10/2018 19.5 1 120
3 2 27TH AGUSTINA YA M. ALIANSYAH JL 12 2/15/2018 21 1 180
4 4 28TH ANASTASIA YA OKTAFIANUS JL 14 2/15/2018 22.5 1 120
Kabupaten/Kota : TARAKAN Bulan : MARET

TTD
No Kehamila Tanggal Lahir No Kartu Keluarga NIK (Nomor Induk Nama Ibu Hamil Berat Badan awal
kan Buku Nama Suami NIK Suami Alamat RT RW Tanggal
Badan Badan
Lengan Tambah brp butir
KIA (kg) (cm)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (LiLA)
(17) 1=YA,
(18) diterima
(19)
1 1 26TH SARTI YA SUKRI JL 7 3/3/2018 22 2=Tidak
1 90
2 1 22TH PIESA YA ADI JL 18 3/14/2018 20 1 120
3 1 16TH HUSPIANI YA MUDIN JL 12 3/15/2018 19.5 1 90
4 1 18TH MEGA NOVITA YA ISWAN JL 12 3/20/2018 21 1 30
5 2 26TH HARIATI YA ABDUL JL 1 3/22/2018 22 1 90
4 4 28TH ANASTASIA YA OKTAFIANUS JL 14 3/22/2018 22.5 1 150

Kabupaten/Kota : TARAKAN Bulan : APRIL
TTD
Lingkar (Tablet Jika YA,
Kehamila NIK (Nomor Induk Berat Badan awal Kepemili Tanggal Berat Tinggi Lengan Tambah brp butir
No Tanggal Lahir No Kartu Keluarga Nama Ibu Hamil kan Buku Nama Suami NIK Suami Alamat RT RW Badan Badan
n ke Kependudukan) hamil/Trimester I KIA pengukuran (kg) (cm) Atas darah) TTD
(LiLA) 1=YA, diterima
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
2 1 22TH PIESA YA ADI JL 18 4/15/2018 20 1 150
3 1 16TH HUSPIANI YA MUDIN JL 12 4/15/2018 20 1 120
5 2 26TH HARIATI YA ABDUL JL 1 4/17/2018 23.5 1 120
6 3 33TH FATIMAH YA ANDRIANTO JL 12 4/20/2018 22 1 60
7 1 24TH YUNI PUSPITA YA SUNARTO JL 5 4/20/2018 21 1 30
8 4 35TH ATIKA YA JUFRI JL 10 4/21/2018 22.5 1 30
9 1 17TH RISMA YA SAMSIBAR JL 12 4/22/2018 22.5 1 30
10 1 24TH SHERLY YA YULIUS JL 14 4/27/2018 21 1 30

Kabupaten/Kota : TARAKAN Bulan : MEI
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
2 1 22TH PIESA YA ADI JL 18 5/4/2018 22 1 180
6 1 24TH YUNI PUSPITA YA SUNARTO JL 5 5/23/2018 21.5 1 60
7 1 17TH RISMA YA SAMSIBAR JL 12 5/26/2018 24 1 60

9 1 19TH KIKI FITRIANI YA ASWAR JL 19 5/27/2018 22.5 1 30
10 1 22TH ANNARIA YA UDIN JL 12 5/29/2018 21 1 30
11 1 23TH RISKA YA JASMAN JL 12 5/29/2018 21 1 180
12 1 21TH JUMARNI YA JUMARNI JL 12 5/29/2018 22 1 60

Kabupaten/Kota : TARAKAN Bulan : JUNI
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
1 1 26TH SARTI YA SUKRI JL 7 6/1/2018 23.5 1 180
2 1 22TH PIESA YA ADI JL 18 6/1/2018 22 1 180
6 1 24TH YUNI PUSPITA YA SUNARTO JL 5 6/8/2018 24 1 90
7 1 17TH RISMA YA SAMSIBAR JL 12 6/9/2018 24 1 60
11 1 23TH RISKA YA JASMAN JL 12 6/20/2018 21 1 180
13 1 18TH MEGA NOVITA YA ISWAN JL 12 6/23/2018 21.5 1 90
14 1 21TH ADELIA YA CENLI JL 11 6/23/2018 21 1 120
15 2 25TH MARLINA YA AFIYANTO JL 13 6/27/2018 23 1 60
16 1 17TH IDA YA M.RIDWAN JL 15 6/27/2018 22 1 60

Kabupaten/Kota : TARAKAN Bulan : JULI
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
3 1 22TH ANNARIA YA UDIN JL 12 7/7/2018 22.5 1 60
5 1 17TH IDA YA M.RIDWAN JL 15 7/7/2018 23 1 90
6 1 22TH MEGAWATI YA BIMO WAHYU JL 9 7/7/2018 19.5 1 60
7 1 21TH YULIANTI YA YOSEP JL 18 7/7/2018 22.5 1 60
8 1 20TH RAHMAWATI YA HERMANSYAH JL 15 7/7/2018 22 1 60

Kabupaten/Kota : TARAKAN Bulan : AGUSTUS
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
4 1 21TH YULIANTI YA YOSEP JL 18 8/10/2018 22.5 1 60
5 1 20TH RAHMAWATI YA HERMANSYAH JL 15 8/15/2018 22 1 90
6 1 21TH JUMARNI YA JUMARNI JL 12 8/16/2018 22.5 1 90
8 1 18TH LINA YA HERMAN JL 14 8/26/2018 22 1 90
9 1 18TH HASRIAH YA SUKIANSYAH JL 18 8/27/2018 20 1 60

Kabupaten/Kota : TARAKAN Bulan : SEPTEMBER
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
2 1 21TH YULIANTI YA YOSEP JL 18 9/10/2018 23 1 90
3 1 21TH JUMARNI YA JUMARNI JL 12 9/10/2018 22.5 1 120
8 4 35TH ATIKA YA JUFRI JL 10 9/23/2018 22.5 1 60
9 3 30TH MARHAYA YA AMINULLAH JL 17 9/27/2018 23 1 90

Kabupaten/Kota : TARAKAN Bulan : OKTOBER
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
1 1 21TH YULIANTI YA YOSEP JL 18 10/10/2018 23 1 120
6 3 30TH MARHAYA YA AMINULLAH JL 17 10/17/2018 23 1 120
7 1 18TH HASRIAH YA SUKIANSYAH JL 18 10/20/2018 20 1 60
8 1 19TH SADIRA YA AMIN JL 19 10/20/2018 22 1 60
9 2 26TH RIANI YA BOLANG ROMBE JL 10 10/23/2018 20 1 30

Kabupaten/Kota : TARAKAN Bulan : NOVEMBER
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
1 2 25TH MARLINA YA AFIYANTO JL 13 11/11/2018 23.5 1 180
3 1 19TH SADIRA YA AMIN JL 19 11/15/2018 23 1 90
4 2 26TH RIANI YA BOLANG ROMBE JL 10 11/16/2018 21 1 60
6 1 20TH KURNIA YA SAMPE JL 15 11/20/2018 18 1 30
7 2 27TH NURLINA YA SYAMSUL JL 7 11/20/2018 22 1 60
8 3 27TH HASNI YA MARTEN JL 17 11/23/2018 21.5 1 60
9 1 21TH MITA YA ANDI SUHERMAN JL 17 11/25/2018 22.5 1 30

Kabupaten/Kota : TARAKAN Bulan : DESEMBER
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
1 2 25TH MARLINA YA AFIYANTO JL 13 12/11/2018 23.5 1 201
3 1 18TH LINA YA HERMAN JL 14 12/12/2018 23.5 1 180
4 2 27TH NURLINA YA SYAMSUL JL 7 12/16/2018 22.5 1 90
5 3 27TH HASNI YA MARTEN JL 17 12/16/2018 22 1 90
6 1 21TH MITA YA ANDI SUHERMAN JL 17 12/18/2018 23 1 60
7 1 19TH SARCE KENDEK YA BATTO JL 19 12/20/2018 22 1 30
8 1 17TH PRETY YA HALING JL 17 12/24/2018 23 2

Kabupaten/Kota : TARAKAN Bulan : JANUARI
TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
2 3 27TH HASNI YA MARTEN JL 17 1/3/2019 22 1 120
4 1 17TH PRETY YA HALING JL 17 1/10/2019 23 1 30
5 1 19TH HASLINDA YA SIRMAN JL 7 1/15/2019 22.5 1 30
6 2 25TH WAHYU UTAMI YA AHMAD YUDHA JL 8 1/20/2019 23 1 30
7 1 21TH ANGGUN YA RIFAI JL 10 1/22/2019 21 1 30
8 1 20TH RIZKIYANI YA ANDI JL 14 1/25/2019 21.5 1 30

TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
2 3 27TH HASNI YA MARTEN JL 17 2/5/2019 22.5 1 150
5 1 19TH HASLINDA YA SIRMAN JL 7 2/16/2019 23 1 60
6 2 25TH WAHYU UTAMI YA AHMAD YUDHA JL 8 2/20/2019 23 1 60
7 1 21TH ANGGUN YA RIFAI JL 10 2/20/2019 21 1 60
8 1 20TH RIZKIYANI YA ANDI JL 14 2/25/2019 21.5 1 60

TTD
2=Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)
5 1 19TH HASLINDA YA SIRMAN JL 7 3/16/2019 23 1 120
6 1 20TH LENA MARTEN YA ADHI JL 19 3/19/2019 22 1 30
7
8
Jika YA,
brp butir
TTD
diminum
(20)
148
20
140
60
85
Jika YA,
brp butir
TTD
diminum
(20)
20
100
160
100
Jika YA,
brp butir
TTD
diminum
(20)
90
100
90
25
70
120
Jika YA,
brp butir
TTD
diminum
(20)
120
130
120
50
100
40
30
30
2
20
Jika YA,
brp butir
TTD
diminum
(20)
150
150
150
100
60
60
30
50
30
25
100
60
Jika YA,
brp butir
TTD
diminum
(20)
180
150
180
100
90
90
30
80
60
25
100
60
90
90
50
60
Jika YA,
brp butir
TTD
diminum
(20)
120
90
60
120
90
60
60
50
Jika YA,
brp butir
TTD
diminum
(20)
150
90
150
60
90
90
90
90
60
Jika YA,
brp butir
TTD
diminum
(20)
180
90
120
120
100
120
120
60
90
Jika YA,
brp butir
TTD
diminum
(20)
120
150
130
150
150
120
60
60
30
Jika YA,
brp butir
TTD
diminum
(20)
180
180
90
60
140
30
30
60
30
Jika YA,
brp butir
TTD
diminum
(20)
210
200
180
60
90
60
30
Jika YA,
brp butir
TTD
diminum
(20)
90
80
60
30
30
30
30
30
Jika YA,
brp butir
TTD
diminum
(20)
120
90
90
60
60
60
60
60
Jika YA,
brp butir
TTD
diminum
(20)
120
120
30

PMT2018

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

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Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

PMT2018

Diunggah oleh

Hak Cipta:

Format Tersedia

Provinsi : KALIMANTAN UTARA

No Anak Tanggal Lahir Jenis No Kartu Keluarga NIK (Nomor Induk

(1) (2) (3) (4) (5) (6)

3 2 6/23/2013 P 6473041203090002 6473046306130001

4 4 11/27/2015 P 6473041612080086 6571046711160003

6 5 4/24/2017 P 6473040906090003 6571046404170001

7 5 10/28/2013 L 6473042511080046 6571042810130001

10 5 2/18/2014 P 6571040202180002 6473045802140002

12 1 1/9/2016 P 6571040205170005 6571044901160001

13 6 10/28/2014 P 6473041106100007 6571046810140001

14 7 3/12/2016 L 6473041106100007 6571042810160003

- Kolom 11 : Jika ayah tidak ada, maka diisikan nama ibu

- Kolom 12 : Jika ayah tidak ada, maka diisikan NIK ibu

Puskesmas/Kecamatan : JUATA LAUT

Desa/Kelurahan : JUATA LAUT

Anak Jenis NIK (Nomor Induk

(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001

3 2 6/23/2013 P 6473041203090002 6473046306130001

4 4 11/27/2015 P 6473041612080086 6571046711160003

6 5 4/24/2017 P 6473040906090003 6571046404170001

7 5 10/28/2013 L 6473042511080046 6571042810130001

10 5 2/18/2014 P 6571040202180002 6473045802140002

12 1 1/9/2016 P 6571040205170005 6571044901160001

13 6 10/28/2014 P 6473041106100007 6571046810140001

14 7 3/12/2016 L 6473041106100007 6571042810160003

- Kolom 11 : Jika ayah tidak ada, maka diisikan nama ibu

- Kolom 12 : Jika ayah tidak ada, maka diisikan NIK ibu

Puskesmas/Kecamatan : JUATA LAUT

Desa/Kelurahan : JUATA LAUT

Anak Jenis NIK (Nomor Induk

(1) (2) (3) (4) (5) (6)

1 2 11/11/2013 p 6473042704090020 6473045111130001

9 5 2/18/2014 P 6571040202180002 6473045802140002

11 6 10/28/2014 P 6473041106100007 6571046810140001

12 7 3/12/2016 L 6473041106100007 6571042810160003

13 1 5/16/2017 L 6473042007100003 6571041505170003

- Kolom 11 : Jika ayah tidak ada, maka diisikan nama ibu

Provinsi : KALIMANTAN UTARA

Anak Jenis NIK (Nomor Induk

(1) (2) (3) (4) (5) (6)

10 1 5/16/2017 L 6473042007100003 6571041505170003

11 1 1/9/2016 P 6571040205170005 6571044901160001

12 6 10/28/2014 P 6473041106100007 6571046810140001

14 7 3/12/2016 L 6473041106100007 6571042810160003

Provinsi : KALIMANTAN UTARA

Anak Jenis NIK (Nomor Induk

(1) (2) (3) (4) (5) (6)

10 1 5/16/2017 L 6473042007100003 6571041505170003

11 1 1/9/2016 P 6571040205170005 6571044901160001

12 6 10/28/2014 P 6473041106100007 6571046810140001

14 3 11/8/2016 P 6473041707090009 6571044811160001

15 7 3/12/2016 L 6473041106100007 6571042810160003

- Kolom 11 : Jika ayah tidak ada, maka diisikan nama ibu

Provinsi : KALIMANTAN UTARA

No Anak Tanggal Lahir Jenis No Kartu Keluarga NIK (Nomor Induk

(1) (2) (3) (4) (5) (6)

7 5 2/18/2014 P 6571040202180002 6473045802140002

9 1 5/16/2017 L 6473042007100003 6571041505170003

10 1 1/9/2016 P 6571040205170005 6571044901160001

11 6 10/28/2014 P 6473041106100007 6571046810140001

13 3 11/8/2016 P 6473041707090009 6571044811160001

14 7 3/12/2016 L 6473041106100007 6571042810160003