PEMERINTAH KOTA SAWAHLUNTO

DINAS KESEHATAN,PENGENDALIAN PENDUDUK

DAN KELUARGA BERENCANA
UPTD PUSKESMAS TALAWI
Jl. Prof. M. Yamin ,SH No.1- Kode Pos 27445
Telp (0754) 410444 Email : puskesmas.talawi@gmail.com

FORMULIR PEMANTAUAN HARIAN

(digunakan untuk orang dalam pemantauan, kontak erat)

Tempat pemantauan (Rumah/ KKP/ Fasyankes/ RS/ Lainnya : Puskesmas Talawi No.Lab :
Kabupaten/ Kota : Sawahlunto Nama Kasus :
Desa : Sijantang No.ID Petugas :
Bulan : April

Hasil Pemeriksaan
Penunjang (Jika Ket (diisi
Tgl Kontak Tanggal dan hasil pemantauan *) Jenis spesimen & Berubah Status) upaya yang
Terakhir tgl pengambilan dilakukan,
Nama JK Umur No. Telpon
(diisi untuk (jika berubah tempat
kontak erat) status) Lab rujukan
1 2 3 4 5 6 7 8 9 10 11 12 13 14 (darah, Ro' kasus, dll)
Sputum)

NURSYAKILA P 21 81363612788 3/23/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X

CINDY A P 20 81295523208 3/23/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X

INDRAJAYA L 40 85262472846 3/23/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X

ARIYANTO L 25 85379620352 3/24/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X

SYARIF A L 21 82288361636 3/26/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X 9/4.X

EDI USMANTO L 45 82337856184 3/25/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X

FEBIOLA P S P 19 81364423542 3/25/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X

AKBAL J P L 21 85282920324 3/26/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X 9/4.X

VIOLA W S P 24 81378097106 3/26/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X 9/4.X

ATIKA Y P 23 82283628361 3/20/2020 1/4.X 2/4.X 3/4.X

TOMI F K L 27 3/20/2020 1/4.X 2/4.X 3/4.X

RETI P 30 81276429209 3/29/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X 9/4.X 10/4.X 11/4.X 12/4.X

ILMI KHAIRI L 23 8126616354 3/31/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X 9/4.X 10/4.X 11/4.X 12/4.X 13/4.X 14/4.X

RIANTI A P 19 82386963522 3/31/2020 1/4.X 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X 9/4.X 10/4.X 11/4.X 12/4.X 13/4.X 14/4.X

ERNI W P 24 82324518886 4/1/2020 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X 9/4.X 10/4.X 11/4.X 12/4.X 13/4.X 14/4.X 15/4.X

SIGIT F P 24 82387733434 4/1/2020 2/4.X 3/4.X 4/4.X 5/4.X 6/4.X 7/4.X 8/4.X 9/4.X 10/4.X 11/4.X 12/4.X 13/4.X 14/4.X 15/4.X
ILVI YUHANA P 19 82261976721 4/4/2020 5/4.FLU 6/4.FLU 7/4.X 8/4.X 9/4.X 10/4.X 11/4.X 12/4.X 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X

DITO P R L 28 82170033293 4/5/2020 6/4.X 7/4.X 8/4.X 9/4.X 10/4.X 11/4.X 12/4.X 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X

DAVID O L 19 82372519507 4/10/2020 11/4.X 12/4.X 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X

DELLA N P 19 81268822365 4/10/2020 11/4.X 12/4.X 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X

FIODALA E P 21 82284022718 4/13/2020 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X

EVA SUSANTI P 40 82284221416 4/14/2020 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X

JEFINALDI L 25 81267162438 4/14/2020 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X

NOVRIZAL L 39 82173986318 4/12/2020 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X

SESPI N P 32 85263446436 4/12/2020 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X

RICOETLIAN L 21 81372119310 4/12/2020 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X

HANDOKO L 37 82311738091 4/12/2020 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X

HENDRA A L 26 82384813126 4/12/2020 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X

WENDRA L 29 82165791628 4/12/2020 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X

NOFRIADI Y L 24 8532774317 4/12/2020 13/4.X 14/4.X 15/4.X 16/4.X 17/4.X 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X

IPING O L 21 82390766752 4/18/2020 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

LASMANA P L 36 82386369212 4/18/2020 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

RESTI S P 32 82386369212 4/18/2020 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

YUSNI P 52 4/17/2020 18/4.X 19/4.X 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

ADITYA P C L 23 82214987301 4/22/2020 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

ZULKIFLI L 46 82384845816 4/19/2020 20/4.X 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

ADE S P L 33 81374916174 4/20/2020 21/4.X 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

FRENGKI L 19 4/21/2020 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

NADA G P 12 4/21/2020 22/4.X 23/4.X 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

YUFRIZAL L 46 81278331052 4/23/2020 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

DASMARYENTI P 42 85368888936 4/23/2020 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

JUFRI L 16 85368888936 4/23/2020 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

DELLA D P 22 82381674387 4/23/2020 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

DELLI N P 22 82381674387 4/23/2020 24/4.X 25/4.X 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

AIDIL FITRA L 26 81213631563 4/25/2020 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

ADE PUTRA L 39 4/25/2020 26/4.X 27/4.X 28/4.X 29/4.X 30/4.X

*) Isikan :mTgl dan hasil pemantauan

X = Sehat ; D = Demam ; B = Batuk ; S = Sesak Nafas ; L = Gejala lain, sebutkan………………………….
A = Aman (Selesai Dipantau) ; R = Rujuk RS
 PEMERINTAH KOTA SAWAHLUNTO
DINAS KESEHATAN,PENGENDALIAN PENDUDUK
DAN KELUARGA BERENCANA
PUSKESMAS KAMPUNG TELENG
Alamat : Jl.Stasiun Kereta Api Kel.Pasar Kecamatan Lembah Segar Kota Sawahlunto
Telp. (0754)62116 Email: puskesmaskampungteleng@gmail.com

FORMULIR PEMANTAUAN PETUGAS KESEHATAN

DIKANTOR KESEHATAN PELABUHAN/ FASYANKES (RS, PUSKESMAS, DLL)
TERHADAP KASUS ISPA, PNEUMONIA DAN PNEUMONIA BERAT

Tempat pemantauan :
Kabupaten/Kota
Provinsi

Diagnosa
Hari / Nama No.
No Umur JK Alamat Pengobatan Ket
Tanggal Lengkap Telpon Pneumonia Pneumonia
ISPA
Ringan Berat
 PEMERINTAH KOTA SAWAHLUNTO
DINAS KESEHATAN,PENGENDALIAN PENDUDUK
DAN KELUARGA BERENCANA
PUSKESMAS KAMPUNG TELENG
Alamat : Jl.Stasiun Kereta Api Kel.Pasar Kecamatan Lembah Segar Kota Sawahlunto
Telp. (0754)62116 Email: puskesmaskampungteleng@gmail.com

FORMULIR NOTIFIKASI KASUS DI WILAYAH

Fasyankes/ Dinkes
Tangga

Umur Riwayat Perjalanan Riwayat Sakit

Tatalaksana
Alamat di Kondisi Tgl Selesai
No Nama No.Hp Tanda/ Yang
Indonesia Negara/ Tgl Umum Pemantauan
L P Gejala Yang Tgl Awal Gejala dilakukan
Daerah Berangkat
Muncul
 PEMERINTAH KOTA SAWAHLUNTO
DINAS KESEHATAN,PENGENDALIAN PENDUDUK
DAN KELUARGA BERENCANA
PUSKESMAS KAMPUNG TELENG
Alamat : Jl.Stasiun Kereta Api Kel.Pasar Kecamatan Lembah Segar Kota Sawahlunto
Telp. (0754)62116 Email: puskesmaskampungteleng@gmail.com

FORMULIR IDENTIFIKASI KONTAK ERAT (CONTACT IDENTIFICATION)

TANGGAL

TEMPAT Rumah Sekolah Rumah Sakit Puskesmas

Informasi Lain

Kolom Diatas Diisi Nama Kontak

Formulir ini untuk memandu pasien/ kasus dalam mengingat waktu, tempat dan nama kontak erat terutama setelah muncul gejala
Pastikan untuk mendapatkan nomer telepon yang bisa dihubungi untuk mendapatkan informasi lengkap.
 PEMERINTAH KOTA SAWAHLUNTO
DINAS KESEHATAN,PENGENDALIAN PENDUDUK
DAN KELUARGA BERENCANA
PUSKESMAS KAMPUNG TELENG
Alamat : Jl.Stasiun Kereta Api Kel.Pasar Kecamatan Lembah Segar Kota Sawahlunto
Telp. (0754)62116 Email: puskesmaskampungteleng@gmail.com

FORMULIR NOTIFIKASI KASUS DI WILAYAH

Fasyankes/ Dinkes
Tanggal

Umur
TGL JARAK LAMA PAKAI
NAMA PEMILIK YG KELUHAN/
No NAMA TOKO No.Hp TERAKHIR KONTAK ≤ KONTAK MASKER YA/
KONTAK GEJALA
L P KONTAK 1,5 M (MENIT) TIDAK
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