FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Nama Puskesmas/Fasyankes/Po: RSUD BERKAH PANDEGLANG

Kabupaten/Kota : PANDEGLANG
Provinsi : BANTEN

Kepesertaan BPJS (tulis 'Ya' STATUS PENDAFTARAN

Dosis I
pada kolom yang sesuai) Keterangan APLIKASI PCARE
Umur (Ditunda/
No. Jenis Merek Tanggal
No NIK Nama Penerima Vaksin Pekerjaan* (18-59 Umur Tidak
Reg Kelamin Vaksin*** Screening
tahun) Tanggal Diberikan/
BPJS BPJS Non Lanjut)
Non Anggota Pemberian No. Batch MANUAL P CARE
PBI PBI
Vaksinasi

1 3601212111860000 ERNI NOVITASARI, Amd.G P A 35 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

2 3601214702660000 ELAH HAYATI P A 54 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

3 3604024705760440 HERIWATI, S.Kep P A 44 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

4 1871072606720000 dr. DODI KARDIA H., Sp.THT-KL,M.Kes L A 55 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

5 3601341101920003 IKMAL HARDIYATNA L A 29 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

6 3601201211840000 U. WACHEH L A 36 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

7 3601342703720000 ACHMAD HIDAYAT, SKM L A 48 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

8 3601136201000000 HARDIANTI P A 20 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

9 3601170206910001 HASAN BASRI L A 51 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

10 3601202109910000 GALIH REKASIWI L A 30 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

11 3601342501770002 ABDUL QUDDUS, A.Md L A 31 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

12 3601210704780001 TB. ANISUL FU'AD, S.AP L A 42 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

13 3602181012770001 ENCEP SAEPUL BACHRI, SST L A 43 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

14 3601160202850000 ROHMAN SYAFEI, Amd.Kep L A 35 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

15 3601340708710001 KARNO L A 49 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

16 3671076009860004 ETY WANINGSIH, S.Kep P A 34 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

17 3601234402800001 ANY KHANIFAH, SKM P A 40 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

18 3601214407790000 EMA MARDIAWATI, S.Sos P A 41 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

19 3601201211840000 UUS, S.Sos L A 43 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

20 3601170511830001 DIDI SUARDI HARJA L A 41 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

21 3601196102750003 dr. CEKLI WAHYU WIDOWATI, Sp.PD L A 45 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care
22 '3673065011740001 dr. TETI SRI GUNARTI, Sp. A p A 46 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

23 3215011504950000 dr. TITO SYAHJIHAD L A 25 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

24 3601180107920110 dr. IKHWANUL KAMIL L A 27 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

25 7271012706950000 dr. SUWANDI L A 25 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

26 3601124412780006 LENI MARLINA, Amd P A 42 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

27 3601215401760003 MULYANI P A 44 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

28 3601194810850001 DWI SARIPUJI ASTUTI, S.Kep, Ners P A 34 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

29 3601252005870002 A. MUHAELI L A 33 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

30 3601216311760001 ELIS HERYAWATI, S.Sos P A 44 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

31 3601250201720002 H. UNANG HAERANI, S.Sos L A 46 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

32 3601344904980002 NOVI APRIANI P A 22 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

33 3601215005800004 LUSI TRI KURNIASIH, Amd L A 40 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

34 '3601340701760002 H. MAMAT RAHMAT, S.Kep L A 44 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

35 3601192110860001 EKO HADI WIBOWO, S.Kep L A 34 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

36 3601256303690001 N. SURYATI, SST P A 51 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

37 3601251302920002 MUH. KIKI L A 25 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

38 3371025602850000 ERIKA DEWI SUKOTJO P A 35 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

39 3601210204720001 MAHMUDIN, SKM L A 45 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

40 3601212506880001 M AJI FAUZAN L A 32 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

41 3601331407970002 YOGI MAULANA Y L A 23 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

42 3673054505880005 DITA SURYA FIANA, Apt P A 32 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

43 '3601161602940002 M. ROMDHONI L A 26 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

44 3601201105670001 LATIP RULYADIN, S.Kep L A 53 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

45 3601152910850000 ROY BYAN, SKM P A 35 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

46 6307095710760000 dr. CAROLINA SIMAMORA P A 44 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

47 3601342406900006 AHMAD RI'FAI L A 30 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

48 '3601232310920002 SEHABUDIN L A 29 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

49 '3601212108940001 MUHAMAD YANA L A 26 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

50 3601150301700001 M.E. MIFTAHUDIN, SKM L A 50 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut P Care

51 360125122750001 dr. H. ACHMAD AFIF SAIFUDDIN, Sp. An L A 45 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual

52 3601255510770002 dr. YENI PURWATI P A 44 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual

53 3601181401740001 H. JENAL MUTAKIN, S.Kep.,M.Kes L A 46 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual

54 3601336010970002 GARNIS JAHRATUN NISA P A 24 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual

55 3601155106840001 TITA KHAERIAWATI P A 46 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual

56 3601345512800002 RINA ROSLINA P A 40 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual
57 3601342607794996 IMAT WIRAHMAT, S.S.T L A 41 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual

58 3604104407920574 INDRAWATIE P A 27 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual

59 3601341010590001 H. AHMAD SEFKUFFUWAN ALI L A 53 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Lanjut Manual

Tidak
60 3601255112800001 HERLIANA KUSUMA WIDHI, Amd.Kep p A 40 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 diberikan Pcare
vaksin

Tidak
61 3601144509860000 IDAH MUNDIAH, S.Sos P A 34 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 diberikan Pcare
vaksin

Tidak
62 3601340102640004 MARIAM , S.Sos P A 57 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 diberikan Pcare
vaksin

63 3602146409980001 LINA MARLINA P A 22 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

64 3602121301640001 H. BUDI IDWAN, SKM L A 56 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

65 3601346310860001 RAYNITA DEVANI P A 34 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

66 '3674026112810005 SITI NUR BAETI P A 39 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

67 3601251503830101 ADE KUSMANA L A 37 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

68 3601215808790001 LENI RAHMAWATI FITRI, S.S.T P A 41 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

69 3601254210650001 Hj. SITI ROHAYATI, AMGz p A 56 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

70 3601204812780001 AAT DESTIMULYANI, Amd. Kep P A 42 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

71 3273056208890002 SELVI AGUSTINA, AMKG P A 31 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

72 3601214507840001 EMAH P A 36 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

73 3601142505930001 M. RIDZAL FIRDAUS L A 27 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

74 3601212805860002 DEDE MUKHLIS, SKM P A 34 31-45 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

75 3601345901750001 SUTIARSIH p A 46 46-59 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare

76 3601040107980201 RESSI MASTERA P A 23 18-30 CoronaVac 28/01/2021 28/01/2021 202011042 Ditunda Pcare
Keterangan ***Merek Vaksin
* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di FasiB = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes)
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja

Kelompok Umur: Kepesertaan BPJS

18-30 3 BPJS PBI 0
31-45 12 BPJS Non PBI 0
46-59 5 Non Anggota 0
Total 20 Total 0
Pekerjaan: Pemberian Dosis
A 0 Dosis 1 20
B 0 Dosis 2 0
C 0 Total
D 0
E 0
Total 0