FORMAT REKAPITULASI PELA

TINGKAT PUSKESMAS/FA
Nama Puskesmas/Fasyankes/Pos : Puskesmas Sodonghilir
Kabupaten/Kota : Kabupaten Tasikmalaya
Provinsi : Jawa Barat

Sasaran
Tahap 1 Tahap 2
Tanggal/ Bulan
Pelaksanaan Total Sasaran
SDM Kesehatan Lansia Pelayan Publik

3/4/2021 7 0 0 7
3/6/2021 9 0 20 29
3/10/2021 0 0 77 77
0
0
0
0
0
0
0
TOTAL 16 0 97 113
ULASI PELAKSANAAN VAKSINASI COVID-19
SKESMAS/FASYANKES/POS VAKSINASI

Penerima Vaksin Dosis 1

Total Dosis I Tahap 1 Tahap 2
(Semua Tahapan)
SDM Kesehatan Lansia Pelayan Publik

# % # % # % # %

0 0 0 0 0 #DIV/0! 0 #DIV/0!
21 72.413793 1 11.1111111 0 #DIV/0! 20 100
72 93.506494 0 #DIV/0! 0 #DIV/0! 72 93.5064935
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
93 82.300885 1 6.25 0 #DIV/0! 92 94.8453608
 Tunda Vaksin Dosis 1
Total Tunda Dosis I Tahap 1 Tahap 2
(Semua Tahapan)
SDM Kesehatan Lansia Pelayan Publik

# % # % # % # %

0 0.0 0 0 0 #DIV/0! 0 #DIV/0!

0 0.0 0 0 0 #DIV/0! 0 0
5 6.5 0 #DIV/0! 0 #DIV/0! 5 6.49350649
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
5 4.4 0 0 0 #DIV/0! 5 5.15463918
 Batal Vaksin Dosis 1
Total Batal Dosis I Tahap 1 Tahap 2
(Semua Tahapan)
SDM Kesehatan Lansia Pelayan Publik

# % # % # % # %

0 0.0 0 0 0 #DIV/0! 0 #DIV/0!

0 #DIV/0! 0 0 0 #DIV/0! 0 0
0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 0
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 #DIV/0! 0 0 0 #DIV/0! 0 0
 Penerima Vaksin Dosis 2
Total Tunda Dosis
Total Dosis 2 Tahap 1 Tahap 2 2
(Semua Tahapan)
(Semua Tahapan)
SDM Kesehatan Lansia Pelayan Publik

# % # % # % # % #

7 100 7 100 0 #DIV/0! 0 #DIV/0! 0

8 27.5862069 8 88.8888889 0 #DIV/0! 0 0 0
0 0 0 #DIV/0! 0 #DIV/0! 0 0 0
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0
0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0
15 13.2743363 15 93.75 0 #DIV/0! 0 0 0
 Tunda Vaksin Dosis 2 B
Total Tunda Dosis
Tahap 1 Tahap 2 Total Batal Dosis 2 Tahap 1
2
(Semua Tahapan)
(Semua Tahapan)
SDM Kesehatan Lansia Pelayan Publik SDM Kesehatan

% # % # % # % # % #

0.0 0 0 0 #DIV/0! 0 #DIV/0! 0 0.0 0

0.0 0 0 0 #DIV/0! 0 0 0 0.0 0
0.0 0 #DIV/0! 0 #DIV/0! 0 0 0 0.0 0
#DIV/0! #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
0.0 0 0 0 #DIV/0! 0 0 0 0.0 0
 Batal Vaksin Dosis 2 Indeks Pemakaian Vaksin Berdasarkan Merek
Tahap 1 Tahap 2
Coronavac Vaksin Covid-19 B
SDM Kesehatan Lansia Pelayan Publik (Single Dose Vial) (Multi Dose Vial

Jmlh Vial Jmlh Jmlh Vial

% # % # % IP
Terpakai Diimunisasi Terpakai
0 0 #DIV/0! 0 #DIV/0! 7 7 1.0 0
0 0 #DIV/0! 0 0 9 9 1.0 2
#DIV/0! 0 #DIV/0! 0 0 0 0 #DIV/0! 7
#DIV/0! #DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0!
#DIV/0! #DIV/0! #DIV/0! #DIV/0!
0 0 #DIV/0! 0 0 16 108 6.8 9
n Berdasarkan Merek

Vaksin Covid-19 BF
(Multi Dose Vial)

Jmlh
IP
Diimunisasi
0 #DIV/0!
20 10.0
72 10.3
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
108 12.0
Nama Puskesmas/Fasyankes/Pos
Kabupaten/Kota
Provinsi
Hari, Tanggal

No No. Tiket

1 N-8E6893BA

2 N-89D8F37E

3 N-580B3008

4 N-7CB97E7D

5 N-72697BE8

6 N-35A4A4D5

7 P-25TBNRTT
 8 N-7FA20847

9 N-1637B310

10 N-3902D1FA

11 P-25I9GNVP

12 Q-FBC4FC06

13 N-2DC0EA83

14 N-7D22EB1E

15 N-F107A17C

16 N-07938E25

17 N-C1E17DFF

18

19

Keterangan
* Pekerjaan dikelompokkan menjadi:
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
 NIK

3206340411650001

3206141406860003

3278081202850013

3206120210820006

3206124103920001

3206125407940001

3206122601970001
 3206131702830001

3206126009940001

3206121509720002

3206074910890001

3206120320700001

3206074112800004

3206125305860001

3206124305950010

3206126301910001

3206122805850001

litas Pelayanan Kesehatan

dapan langsung dengan masyarakat
 Kelompok Umur:
18-30
31-45
46-59
≥ 60 tahun
Total
Pekerjaan:
A
B
C
D
E
Total
: Puskesmas Sodonghilir
:
:
:

Jenis
Nama Penerima Vaksin Pekerjaan*
Kelamin

Ugan Suganda L A

Deden Riki Wardeni, A.Md.AK. L A

dr. Febriyansyah Adi Sastra L A

Eko, S.Kep. L A

Rida Qori, Amd.Keb L A

Ghina Nur Ilmiyati R, Amd.Keb. P A

Moh Peri Iyasa L A

 Rano Nurcipta, A,Md.Kep. L A

Haryanti, S.Tr.Keb P A

Tatang Sutiawan L A

Sri Rani Maulani, A.Md.Keb. P A

Cecep Sutarman L A

Heti Herlinawati, A.Md.KG. P A

Arien Fuji Rahayu, A.Md.Keb. P A

Epa Hermawati, S.Tr.Keb P A

Efy Listiawati, AM.Keb. P A

Irpani,Amd.Kep L A

***Merek Vaksin
A = Sinovac
B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes)
elompok Umur: Kepesertaan BPJS
6 BPJS PBI
8 BPJS Non PBI
3 Non Anggota
0
17 Total
Pekerjaan: Pemberian Dosis
0 Dosis 1
0 Dosis 2
0 Total
0
0
0
 FORMAT PENCATAT
TINGKAT PUSK

Umur
Tanggal Lahir Kelompok Umur
(18 sd ≥ 60 tahun)

56 46-59

35 31-45

36 31-45

39 31-45

29 18-30

27 18-30

24 18-30
 38 31-45

27 18-30

15/09/1972 49 46-59

09/10/1989 32 31-45

01/12/1980 51 46-59

01/12/1980 41 31-45

13/05/1986 35 31-45

03/05/1995 26 18-30

30 18-30

36 31-45
0
17
0

17

17
15
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Alamat

Perum Griya Permata Ds. Mangunjaya Rajapolah

Kp. Cibuluh Ds. Sukarasa Salawu

Lewo babakan Linggajaya Mangkubumi

Parumasan Sodonghilir

Cukangkawung Sodonghilir

Sepatnunggal Sodonghilir

Kp. Sepatnunggal
 Ds. Raksasari Kec. Taraju

Kp. Narawita Ds. Sodong Kec. Sodonghilir

Kp. Ciroda Ds. Sodong Kec.Sodonghilir

Kp. Sirahsawah

Kp Ciroda Rt.04 Rw.08

Kp. Derah Ds. Karya bakti Parungponteng

Raksajaya Sodonghilir

Kp. Sodong Ds. Sodong Kec. Sodonghilir

Kp. Pencut Ds. Sodong Kec. Sodonghilir

Raksajaya Sodonghilir
 Pekerjaan
A
B
C

D
E
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp

BPJS PBI BPJS Non PBI

081222807212 Ya

085314649991 Ya

081282858123 Ya

085223041471 Ya

085280391170 Ya

082115306025 Ya

081248898770 Ya
085223840334 Ya

082321705929 Ya

085220503910 Ya

085294912223 Ya

085223812530 Ya

085223906089 Ya

085294441119 Ya

082120102732 Ya

082117555005 Ya

081222977286 Ya
aan
0
0
0

0
0
0
a' pada kolom yang sesuai)

Tanggal Screening Nama/Jenis/Merek Vaksin***

Non Anggota

2/18/2021 A

2/18/2021 A

2/18/2021 A

2/18/2021 A

2/18/2021 A

2/18/2021 A

2/16/2021 A
2/20/2021 A

2/20/2021 A

2/20/2021 A

2/20/2021 A

2/20/2021 A

2/18/2021 A

2/18/2021 A

2/18/2021 A

3/6/2021 A

2/20/2021 A
 Dosis I

Tanggal Pemberian
No. Batch No. Serial
Vaksinasi

2/18/2021 202011044 16098303475627

2/18/2021 202011044 16098303475627

2/18/2021 202011044 16098303475627

2/18/2021 202011044 16098303475627

2/18/2021 202011044 16098303475627

2/18/2021 202011044 16098303475627

2/16/2021 202011044 16098303475627

2/20/2021 202011044 16098303499841

2/20/2021 202011044 16098303499841

2/20/2021 202011044 16098303499841

2/20/2021 202011044 16098303499841

2/20/2021 202011044 16098303499841

2/18/2021 202011044 16098303499841

2/18/2021 202011044 16098303499841

2/18/2021 202011044 16098303499841

3/6/2021 202011044 16098310783396

2/20/2021 202011044 16098303499841

 Dosis 2

Tanggal Pemberian
No. Batch No. Serial
Vaksinasi

3/4/2021 202011044 16098310783396

3/4/2021 202011044 16098310783396

3/4/2021 202011044 16098310783396

3/4/2021 202011044 16098310783396

3/4/2021 202011044 16098310783396

3/4/2021 202011044 16098310783396

3/4/2021 202011044 16098310783396

3/6/2021 202011044 16098310783396

3/6/2021 202011044 16098310783396

3/6/2021 202011044 16098310783396

3/6/2021 202011044 16098310783396

3/6/2021 202011044 16098310783396

3/6/2021 202011044 16098310783396

3/6/2021 202011044 16098310783396

3/6/2021 202011044 16098310783396

 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)

Selesai

Selesai

Selesai

Selesai

Selesai

Selesai

Selesai
Selesai

Selesai

Selesai

Selesai

Selesai

Selesai

Selesai

Selesai

KIPI
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Nama Puskesmas/Fasyankes/Pos : Puskesmas Sodonghilir

Kabupaten/Kota : TASIKMALAYA
Provinsi : JAWA BARAT

Hari, Tanggal :SABTU, 6 MARET 2021

20
Kepesertaan BPJS (tulis 'Y
Umur pada kolom yang sesuai)
Jenis Tanggal Kelompok
No No. Tiket NIK Nama Penerima Vaksin Pekerjaan* (18 sd ≥ 60 Alamat No. Hp
Kelamin Lahir Umur BPJS Non
tahun) BPJS PBI
PBI

1 2 3 4 5 6 7 8 9 10 11 12 13

GRIYA MUNCANG ASRI F.25 RT. 001, RW. 015 DS/KEL.

1 S-7AC4BD0C 3278050505650016 ATANG L B 5/5/1965 56 46-59 081290042273 YA
GUNUNG GEDE KEC. KAWALU KOTA TASIKMALAYA

KP. NARAWITA RT. 003, RW. 001 DESA SODONGHILIR

2 S-F49EB788 3206121011640002 SUGIYATUN L B 10/11/1964 57 46-59 085223305696 YA
KEC. SODONGHILIR KAB. TASIKMALAYA

DUSUN NAMAS RT. 003, RW. 011 KEL/DS. BUNISEURI

3 N-756DBC2B 3207112403840002 DAVIT ANDRIAWAN L B 4/24/1984 37 31-45 085231784196 YA
KEC. CIPAKU CIAMAIS

KP. CIDUNGUS RT 001 RW 004 DS/KEC MALANGBONG

4 S-2E612331 3205141806860005 AANG AHMAD MUBARAK SYARIPUDIN L B 6/18/1986 35 31-45 085348870887 YA
KAB GARUT

KP. CIRODA RT.004, RW. 008 DESA SODONGHILIR KEC.

5 S-E7DED41F 3206121502840001 RUKMANA L B 2/15/1984 37 31-45 081313060529 YA
SODONGHILIR KAB. TASIKMALAYA

KP. CIBENGANG RT. 008, RW. 002 DS/KEL.

6 S-220147FB 3206160603830007 DIAN MARDIANA, S.H L B 3/6/1983 38 31-45 TANJUNGJAYA KEC. TANJUNG JAYA KAB. 082115912283 YA
TASIKMALAYA
PONDOK KARISMA RESIDENCE JL. RAFLESIA V D. 118
7 S-17243FE8 3278021112860002 ADE IRAWAN L B 22/10/1982 39 31-45 RT. 003, RW. 021 KEL/DS. PANGLAYUNGAN KEC. 081290589321 YA
CIPEDES KOTA TASIKMALAYA

KP. TAMIANG KUNING RT. 001, RW. 004 KEL/DS.

8 P-4TH0KSOB 3205272303840001 ARIN ARIANTO L B 3/23/1984 37 31-45 081395708400 YA
KANDANGMUKTI KEC. LELES KAB. GARUT

KP. PARIGI RT.001, RW. 009 DESA LEUWIDULANG

9 S-63039963 3206121409780001 DENIH DERMAWAN L B 9/14/1978 43 31-45 085254491888 YA
KEC. SODONGHILIR KAB. TASIKMALAYA

KP. CIKOLE RT. 003, RW. 005 DS/KEL. MARGAMULYA

10 N-DBD16212 3206381703930003 FIRDAUS FATAH RAMADHAN L B 3/17/1993 38 31-45 085298252456 YA
KEC. SUKARESIK KAB. TASIKMALAYA

DUSUN CIBOBOKO RT. 005 RW. 003 KEL/DS.

11 P-4TRA3T24 3211012901940008 RICKY OKIYANA L B 1/29/1994 27 18-30 085213355697 YA
MEKARSARI KEC. JATIGEDE SUMEDANG

KP. BABAKAN RT. 009, RW, 002 DESA SODONGHILIR

12 P-4TW2W2W807 3206121708580000 SURYANA FATAH L B 8/17/1958 61 ≥60 082216807757
KEC. SODONGHILIR TASIKMALAYA

KP. NARAWITA RT. 003, RW. 001 DESA SODONGHILIR

13 P-4UKDXMLL 3206122710820000 YUYU SUANDI L B 10/27/1982 39 31-45 085215353864
KEC. SODONGHILIR KAB. TASIKMALAYA

14 P-4UOGW1IC 3206122003600004 SUDENG L B 7/1/1966 55 46-59 CIPENDE MUNCANG 085318737137

Kp. Gunung Subang Rt. 01/02 Kel. Cilamajang Kec. Kawalu

15 P-4MFD67QL 3278051005700001 Hadi Hardiyana L B 10-05-1970 50 46-59 085284073047 YA
Kota Tasikmalaya

Blok Babakan Sari No. 12 Rt. 02 Rw. 05 Batujajar Barat Kab.

16 P-4MJGOWML 3217090310730005 Istiklal L B 16-10-1973 47 46-59 082253540200 YA
Bandung

Kp. Manjah Beureum Ds. Cileunyi Kulon Kec. Cileunyi Kab.

17 P-4MMNKYLK 3204050204730006 Dedi Aziz. M L B 02-04-1973 48 46-59 081214606260 YA
Bandung

Jl. Banjaran Kp. Sukameulang Rt. 04 Rw. 12 Kel. Andir Kec.

18 P-4MSN1QY4 3204320108740038 Agus L B 01-08-1974 46 46-59 081214616094 YA
Baleendah Kab. Bandung

Kp. Cikijing Ds. Mangu Arga Kec. Cimanggung Kab.

19 P-4SHEBG8Z 3211142707760000 Aminludin L B 27-07-1976 44 31-45 085294886910 YA
Sumedang

Kp. Cikalendong Rt. 2/5 Ds. Ciherang Kec. Nagrek Kab.

20 P-4T4ITMNF 3204260101790063 Yayan Kardian L B 01-01-1979 42 31-45 085385501929 YA
Bandung Jawa Barat

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes)
anan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja

Kelompok Umur: Kepesertaan BPJS

18-30 1 BPJS PBI 0

31-45 11 BPJS Non PBI 17

46-59 7 Non Anggota 3

≥ 60 tahun 1 Total 20

Total 20 Pemberian Dosis

Pekerjaan: Dosis 1 20
A 0 Dosis 2 0
B 20 Total 20
C 0
D 0
E 0
Total 20
 20
BPJS (tulis 'Ya' Keterangan
Dosis I Dosis 2
yang sesuai) (Ditunda/
Tanggal Nama/Jenis/Mere
Tanggal Tanggal Tidak
Non Screening k Vaksin***
Pemberian No. Batch No. Serial Pemberian No. Batch No. Serial Diberikan/
Anggota Lanjut)
Vaksinasi Vaksinasi
14 15 16 17 18 19 20 21 22 23

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

YA 3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

YA 3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

YA 3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

3/6/2021 Vaksin Covid-19 3/6/2021 24000521 16123399459765 Lanjut

Nama Puskesmas/Fasyankes/Pos : Puskesmas Sodonghilir
Kabupaten/Kota : TASIKMALAYA
Provinsi : JAWA BARAT

Hari, Tanggal : RABU, 10/03/2021

77
Nama Penerima Jenis
No No. Tiket NIK Pekerjaan*
Vaksin Kelamin

1 2 3 4 5 6

1 P-8S1HQVU2 3206132206790000 Erwin Surahman L B

2 P-8PVU3188 3278080608860009 Rian Fardiansyah L B

3 P-8RWJL33Y 3261215018800002 Taupik Rahmayadi L B

4 P-8QZYWI3Y 3206020802790002 Koko Kowiyanto L B

5 P-8PZ4QYAH 3206120709890003 Aris Winaldi L B

6 P-8S4EF4LI 3206134107940109 Dian Triwianti P B

Alief Raka Afrizal

7 P-8T0XFZ5A 3206130404970004 L B
Sutiana
8 P-8SAU96J0 3206061108870001 AGUS CAHYANA L B

RINTO AULIA
9 P-8MO8LAPM 3206122612790003 L B
CANDRA

10 S-339C97BC 3207022010680001 Ir. Amin Mu'min L B

11 S-CC560455 3205022203800002 Taofiq Hidayat L B

12 S-06264193 3278051208820005 Dienul Permana L B

13 S-83534326 3278060305850004 Fajar Dwi Purnama L B

14 S-5069E9BE 3206321202900006 Rian Riana L B

15 S-2C9807A0 3206120407880007 Dede Zenal Mutaqin L B

16 S-5E56AE2F 1810011008920003 Milaviandy Pranata L B

Alvina Agnest
17 S-E61CFB50 3278060303920003 L B
Agromarthin

18 S-F1E8653C 3206332105940002 Aji Bastaman L B

19 S-04FF1AAD 3278061903960003 Deris Margana L B

Muhammad Rafi
20 S-BC1AE05C 3206161803960003 L B
Permana

21 P-8SLHSIMP 3206110207830003 Nono Sumarno L B

22 P-8DFEPADI 3206121307920001 Maris Al-hadi L B

23 P-8MTWCOPS 3278074302930002 TIKA KARTIKA P B

 YOGA
24 P-8N2UJKZE 3206012705930001 L B
SUANDANA

ASEP IRFAN
25 P-8MXDNP3H 3206120512940007 L B
FAUZI

Aan
26 S-8F3C2DFE 3206071010720001 Budiman,AM,Kg.,S. L B
Sos
H.Wawan
27 S-57DF2010 3278081706640000 Setiawan,S.IP.,M.Si L B

Yaya Taryana
28 S-00812DAC 3206132707730005 L B

Wawan,S.Pd
29 P-8EBJ0NHO 3206120107530195 L B

Enop Akhmad Jenal

30 S-C5164E3A 3206040711640001 Musarop,S.IP L B

Maman,S.Sos,
31 S-F706043E 3206120701670005 L B

Kartiwa, S.IP.
32 S-20D14647 3206122403760001 L B

33 S-3DDF6D64 3206120503780012 Kanda Suganda L B

YOSEP
34 P-7VRLYDJJ 3206122208800003 L B
SUPRIATNA

35 P-80LFYFB4 3206121301700001 Syaeful Hidayat L B

36 P-814TQ4JY 3206082909780002 Solahudin L B

37 P-7W70COQX 3206120701830001 Aa Gaosul Adim,SH L B

38 P-7YFW57UF 3206120203840003 Ridwanul Hakim L B

39 S-790774C3 3206252111820001 Ayi Saepuloh L B

 Bangbang
40 P-7X1KQO08 3206120306940002 Irawan,S.Pd L B

41 P-8D3BY54L 3206154410010001 Reikeu Noerismiraz P B

H. SARIP
42 S-33807CE7 3206301003690002 HIDAYAT, S.Ag L B
MH

ASEP MIFTAH
43 S-16040CF1 3206122008800002 L B
HOLIK, S.Sos.I

ELIN AMALIANI,
44 S-B2B26920 P B
S.Ag

SRI
45 P-83M60MMW 3206126311900001 P B
MUSTIKAWATI

46 P-7WHN7CEZ 3206122309650002 NANA SUMARNA L B

47 P-850G4FPS 3206122103760002 AJAT SUDRAJAT L B

48 P-81U6S9SY 3206120306670009 FALAH L B

49 S-A90972A4 3206121111600001 TATANG NASIR L B

50 S-BAE4B7AF 3206120101750015 ARIPIN,S.Ag L B

51 P-7Z4JI3TP 3206122111780001 Dayat Nurhidayat L B

52 P-7XZC6LTW 3206122111790001 Azis Muslim L B

53 P-7YWGX5MR 3206121502630001 Pakih L B

Rais Yatim
54 P-7ZKHI3TA 3206091204870004 L B
Almudaris

55 P-7YPN6CAX 3206012411910002 Ali Imron L B

56 P-7ZUWF9RV 3206123001670001 Nana Supriatna L B

57 P-7XNDJM7D 3206120405720002 Dede Rohman L B

58 S-3587EB70 3206126712850004 Desi Arisandi P B

59 S-DC8642EF 3206120303830004 Roni Rahmat L B

60 P-7XBZHOQ1 3206120801670002 Muslih Hidayat L B

61 S-12B83EAA 3206120101790009 DIDIN L B

TATANG
62 S-A698B057 3206240504710002 L B
SURYANA

DEDE HIDAYAT,
63 S-9729A08D 3206121611650000 L B
S.Ag

64 S-9E2BDFE0 3206120609630004 SAEPULOH, S.Sos L B

65 P-8RAOQE01 3206121911930001 Asep Rahmat L B

SRI RISMAYANTI,
66 P-8O5F0KMP 3206124310930002 L B
S.Sos

67 S-E50F20FA 3206121708880001 Jiji Gustaman L B

68 S-620340C6 3206123009880004 Z Aripin Aa Lk L B

69 P-82QCLYRJ 3206122208810001 Iwan Kurniawan L B

Mohamad Yogi
70 S-DB81523D 3206120810930003 L B
Sampurna

71 S-8598CCAF 3206124204650004 N yayat Juhayati P B

 72 S-785D47A8 3206120505910004 Anggi Nurachman L B

73 P-8NGSKCEV 3206124505820004 Ii Sobariah P B

74 P-8OICYRBV 3206122603870001 Opik Hidayat L B

75 P-8NBCM76Y 3206125207900001 Irma nurasiani P B

76 P-5BXQANS2 3206120909630002 Selamet Riadi L B

77 P-7VRLYDJJ 3206121107570001 Wagimun L B

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
gas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima P
pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja

Kelompok Umur: Kepesertaan BPJS

18-30 16 BPJS PBI

BPJS Non
31-45 12
PBI
Non
46-59 1
Anggota
≥ 60 tahun 1 Total

Total 29 Pemberian Dosis

Pekerjaan: Dosis 1
A 0 Dosis 2
B 77 Total
C 0
D 0
E 0
Total 77
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis

Umur 'Ya' pada kolom yang
Tanggal (18 sd ≥ Kelompok sesuai)
Alamat No. Hp
Lahir 60 Umur
tahun) BPJS BPJS Non
PBI Non PBI Anggota

7 8 9 10 11 12 13 14
Jl. Raya Taraju RT 003
RW 004 Desa Taraju
6/22/1979 41 31-45 081312585586
Kec. Taraju Kab.
Tasikmalaya
Maniis RT 002 RW
005 Kel. Linggajaya
8/6/1986 34 31-45 085223936886
Kec. Mangkubumi
Kampung
Kota Tasikmalaya
Datar Jeruk
RT 021 RW 007 Desa
1/15/1988 33 31-45 Sodonghilir Kec. 081312850003
Sodonghilir Kab.
Kampung Tenjosari RT
Tasikmalaya
005 RW 007 Desa
2/8/1979 42 31-45 Cikukulu Kec. 085217747485
Karangnunggal Kab.
Kampung Legokpicung
Tasikmalaya
RT 037 RW 008 Desa
8/10/1989 31 31-45 Cikalong Kec. 085289374929
Sodonghilir Kab.
Kampung
Tasikmalaya
Sembahpanjang RT
3/11/1992 29 18-30 037 RW 008 Desa 085353254700
Cikubang Kec. Taraju
Kampung Cijalu
Kab. Tasikmalaya
Tengah RT 014 RW
4/4/1997 24 18-30 004 Desa Banyuasih 082317446364
Kec. Taraju Kab.
Tasikmalaya
 Kampung Kertawana
RT 001 RW 006 Desa
8/11/1987 33 31-45 Setiawaras Kec. 085353527800
Cibalong Kab.
Tasikmalaya
Kp. Sinarkencana
12/26/1979 41 31-45 081321661363
Sodonghilir

Dusun Desa Kulon

10/20/1968 52 46-59 081323175191
Rt/Rw. 10/03

3/22/1980 41 31-45 Ciparay RT/RW. 01/01 081395046556

Perum Cisalak GG
8/12/1982 38 31-45 08112110777
Mawar VII No-97

Perum Bumi Citra

5/3/1985 35 31-45 081312850003
Pagaden Rt/Rw. 01/13

Cigorowong Rt/Rw.
2/12/1990 31 31-45 082121136055
05/01

7/4/1988 32 31-45 Pencut Rt/Rw. 29/06 082319829292

Perum Asri Residance

3/11/1992 29 18-30 082317030225
Cintaraja

3/3/1992 29 18-30 Awipari Rt/Rw. 06/02 082316527554

Sarimukti Rt/Rw.
5/21/1994 26 18-30 085863880326
01/07

Perum Kotabaru
3/19/1996 25 18-30 082126068010
Kencana No. 123

Pakemitan II Rt/Rw.
8/18/1996 24 18-30 082318636596
04/06

7/2/1983 37 31-45 Ciawi Rt/Rw. 04/15 085222540660

Sawahbaru Rt/Rw.
1/13/1992 29 18-30 082126827960
09/05
BABAKANJATI
003/002 DESA
2/3/1993 28 18-30 085314720282
MULYASASI KEC
TAMANSARI
 PANTILAKSANA
004/006 DESA
5/27/1993 27 18-30 085314334373
CIKAWUNGGADING
KEC CIPATUJAH
KUBANG 020.007
DESA
12/5/1994 26 18-30 081224079061
SODONGHILIR KEC
Kp.SODONGHILIR
Parungponteng Rt.
001 Rw. 001 Desa
10/10/1972 49 46-59 Parungponteng 085213738330
Kecamatan
Parungponteng
Perum Baitul
Marhamah
17-06-1964 ### #VALUE! 085221614460
Sambongjaya
Mangkubumi
Kp. Cipicung Koneng
Rt. 021 Rw. 005 Desa
27-07-1973 ### #VALUE! 085318806280
Singasari Kecamatan
Taraju
Kp. Cipaseh Rt. 013
Rw. 002 Desa
08-07-1967 54 46-59 082319193048
Raksajaya Kecamatan
Sodonghilir
Kp. Cibongas Rt. 001
Rw. 001 Desa
07-11-1964 ### #VALUE! 081223085175
Cibongas Kecamatan
Pancatengah
Kp. Neglasari Rt. 021
Rw. 003 Desa
07-01-1967 ### #VALUE! 082321012043
Parumasan Kecamatan
Sodonghilir
Kp. Burujul Rt. 010
Rw. 003 Desa
24-03-1976 45 31-45 085302650567
Raksajaya Kecamatan
Sodonghilir
Kp. Babakanjoho Rt.
003 Rw. 001 Desa
05-03-1978 ### #VALUE! 085317642643
Cukangkawung
Kecamatan Sodonghilir
Kp. Sodong Rt. 002
Rw. 001 Desa
22-08-1980 ### #VALUE! 082126577206
Sodongghilir
Kecamatan Sodonghilir
Kp.Narawita Rt. 003
Rw. 001 Desa
1/13/1970 51 46-59 085314789593
Sodongghilir
Kecamatan Sodonghilir

9/29/1978 42 31-45 085315864367

07-01-1983 ### #VALUE! 085221631613

Kp. Muncang Rt.04

082218592527
Rw. 01 Muncang

Kp. Satron Rt 28 Rw
081321459276
05 Parumasan
 Kp. Lembur Gede Rt.
001 Rw. 008 Desa
6/3/1994 26 18-30 082317348060
Sukabakti Kecamatan
Sodonghilir
Kp. Citapen Rt. 003
Rw. 001 Desa
14-10-2001 ### #VALUE! 085526237384
Pusparahayu
Kecamatan Puspahiang
Kp. Mageung Rt. 003
Rw. 003 Desa Sirnasari
3/10/1969 52 46-59 085318151965
Kecamatan Sariwangi
Tasikmalaya
Kp. Sirnagalih Rt.005
Rw.008 Desa/Kec.
20/08/1980 ### #VALUE! 081222900123
Sodonghilir
Tasikmalaya
Kp. Sodong Rt.001
23/03/1972 ### #VALUE! Rw.001 Desa/Kec. 08523506654
Sodonghilir
Kp. Datar Jeruk Rt.021
23/11/1990 ### #VALUE! Rw.007 Desa/Kec. 083826029630
Sodonghilir
Kp. Sirnagalih Rt.
9/23/1965 55 46-59 005/008 Desa/Kec. 085352242385
Sodonghilir
Kp. Bendungan Desa
21/03/1976 ### #VALUE! Sepatnunggal Kec. 081232585445
Sodonghilir
Kp. Babakan Joho
03/06/1965 56 46-59 Desa Cukangkawung 085323225680
Kec. Sodonghilir
Kp. Kebonjeruk Desa
17/11/1960 ### #VALUE! Sodonghilir Kec. 082318234475
Sodonghilir
Kp. Sirah Sawah
Rt.005 Rw. 001 Desa
01/01/1975 46 46-59 081222997397
Cikalong Kecamatan
Sodonghilir
Kp. Mulyasari Rt/Rw
10/15/1977 43 31-45 004/012 Desa 085223451426
Sukabakti
Kp. Balangendong
11/21/1979 41 31-45 Rt/Rw 004/013 Desa 085223616310
Sukabakti
Kp. Lemah Berem
2/15/1963 58 46-59 Rt/Rw 003/012 Desa 085353421595
Sepatnunggal
Kp. Madur Rt/Rw
001/003 Desa
4/12/1987 34 31-45 082115792136
Bojongasih Kec.
Bojongasih
Kp. Margasari Rt/Rw
002/001 Desa
11/24/1991 29 18-30 085317195230
Margalaksana Kec.
Salawu
 Kp. Leugokmuncang
1/30/1967 54 46-59 Rt/Rw 012/002 Desa 082317726048
Cikalong
Kp. Babakanjoho
5/4/1972 48 46-59 Rt/Rw 003/001 Desa 085223021543
Cukangkawung
Kp.wargijaya Rt/Rw
12/7/1985 35 31-45 016/004 Desa 085292272233
Raksajaya
Kp. Cintapada Rt/Rw
3/3/1983 38 31-45 012/006 Desa 082217312182
Pakalongan
Kp. Sodong Rt/Rw
1/8/1967 54 46-59 002/001 Desa 082214591741
Sodonghilir
KP. SODONGHILIR
RT/RW: 40/01 DESA
1/1/1979 42 31-45 081323677697
SODONGHILIR KEC.
SODONGHILIR
KP. MARGAMULYA
RT/RW: 02/04 DESA
5/4/1971 49 46-59 085223827975
CIKUNIR KEC.
SINGAPARNA
Kp.CIHANGGOR
RT/RW 004/006
16-11-1965 ### #VALUE! 082318662866
DS.CIPAINGEUN
KEC.SODONGHILIR
Kp.BONGAS RT/RW
002/001
06-09-1963 ### #VALUE! DES.WANGUNSARI 082119296514
KEC.BANTARKALO
NG
Kp. Sodong RT/RW
19-11-1992 ### #VALUE! 082218957759
01/01 Sodonghilir
Kp.MEKARWANGI
RT/RW 040/001
03-09-1993 ### #VALUE! 082364006087
DS/KEC.SODONGHI
LIR
Kp. Wakap RT/RW
8/17/1988 32 31-45 03/01 Ds. Wakap Kec. 085321938434
Bantarkalong
Kp. Cibokor Ds.
9/30/1988 32 31-45 Parumasan Kec. 085320824177
Sodonghilir

Jl. Padasuka Nagrak

8/22/1981 39 31-45 085281642744
Kota Tasikmalaya

Kp. Legoktangkalak
10/8/1993 27 18-30 Ds. Cukangjayaguna 081221395725
Kec. Sodonghilir
Kp. Panglayungan Ds.
4/2/1965 56 46-59 Cipaingeun Kec. 085323295558
Sodonghilir
 Kp. Lembur Gede Ds.
5/5/1991 29 18-30 Sukabakti Kec. 081221650690
Sodonghilir
Kp. Mekarsari Ds.
5/7/1982 38 31-45 Cukangjayaguna Kec. 085321472707
Sodonghilir
Kp. Banyuwaras Ds.
3/26/1987 34 31-45 Raksajaya Kec. 082118782235
Sodonghilir
Kp. Panglayungan Ds.
7/12/1990 30 18-30 Cipaingeun Kec. 085320644449
Sodonghilir

Kp. Cacaban Rt.03/

9/9/1963 57 46-59 082180799663
Rw.013 sepatnunggal

Kp. Mekarwangi
7/11/1957 63 ≥60 Rt.040 Rw.001 085292873108
Sodonghilir

n jenis vaksin yang diterima Puskesmas/Faskes)

Kepesertaan BPJS

Pemberian Dosis

72
0
72
 Dosis I Dosis 2
Tanggal Nama/Jenis/Me Tanggal
Screening rek Vaksin*** Tanggal Pemberi
No. No. No.
Pemberian No. Serial an
Batch Batch Serial
Vaksinasi Vaksina
15 16 17 18 19 si
20 21 22

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021

3/10/2021

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021 Vaksin Covid-19 3/10/2021 24000521 16123399459765

3/10/2021
 77
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gan
(Ditunda
/ Tidak
Diberika
n/
Lanjut)
23

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Lanjut

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(HT)

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Lanjut

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Ditunda
(Ginjal)

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Lanjut

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 Lanjut

Lanjut

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Lanjut

Ditunda
(Ginjal +
HT)

Ditunda
(Hamil)

Lanjut

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Lanjut

Lanjut

Lanjut

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Lanjut

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Lanjut

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Lanjut

Ditunda
(HT)
Nama Puskesmas/Fasyankes/Pos : Puskesmas Sodonghilir
Kabupaten/Kota : TASIKMALAYA
Provinsi : JAWA BARAT

Hari, Tanggal : SELASA, 16/03/2021

5
Nama Penerima Jenis
No No. Tiket NIK Pekerjaan*
Vaksin Kelamin

1 2 3 4 5 6

CKK P-BHVWLRQC 3206120808620002 DAMAN L B

S-05DBAD9F 3206120308810001 YAYAN SULISTIAWAN L B

S-28980AEC 3206122809870005 ABDUL HAKIM S.Pd.I L B

P-BK37NS9W 3206121404830001 YOHANDI PERMANA L B

YAYAN SURYANA
P-BIRMPFHN 3206120409820005
S.Pd.I
L B

P-BID8L2NJ 3206120901840001 MAHMUD NURDIN L B

P-BI3KHHIK 3206122303780001 UUS NURHUSAENI L B

 P-BGVTA5U7 3206120510670002 UYENG L B

P-BJX5J81Z 3206120703630003 UJER GUNAWAN L B

P-BJTDOWKY 3206120110820002 DEDE SURYADI S.Pd.I L B

P-BK9ZYV9E 3206121808810002 ADIH PRIANA L B

P-BIWD3MU9 3206120107650109 AEN L B

P-BJ1710PO 3206121109720001 EYEN L B

P-BJ8AERO1 3206121102870002 ADE ISHAK SOLIH L B

SODONG 3206121006760004 JAJANG, SH L B

HILIR
P-BL0L30SS

3206122705680003 ASEP SAEPUDIN L B

P-BL6HIKWE

3205122507870002 ADE SUTANTO L B

P-BLBEDWR4

3206121109880002 ALFIN RIKSA NURZEHA L B

P-BLFI8TVN

3206121712840001 M. DARUSMAN L B
P-BN3WQVIR

3206122711800001 A. FATHURAHMAN L B

3206123010650001 TATANG SUTISNA L B

P-BMUPP8RY

3206121408800002 E. SAEPUL WARDIN L B

P-BMZEOAK7
CIKALO 3206121507680001 TATANG SONTANI L B
NG
P-BZPWUC3F

3206120505790007 AGUS, S.Pd.I L B

P-C01HHVKD

3206121206910001 AYI KOSASIH L B

P-BZM2QKUF

3206127009820001 ADE NURHAYATI P B

P-BXSU6ADL

3206120407950002 LUTFI SAEPUL QISTI L B

P-BY0ZXN51

3206120612910001 ABDUL LATIF, S.Pd.I L B

S-4281C0E3

3206121608680001  ADE RAHMAT L B

P-BOJAWLTX

3206120807810001 YANTO L B
P-BZJFT3ZY

3206122404710002 ADE SUHANDI L B

P-C04DFHKH

3206125010830004 LILIS SITI KURAESIN P B

S-F6D94A5F

3206120308650014 ARIFIN NOOR L B

P-BZ730CJM

MUNCA
NG
P-BYH7CDP0 3208050605690003 Drs.Heryanto

P-BZRN2V13 3206121701790000 Cuncun Riswanto

P-BYY5GN4X 3206125708940005 Dini Agustina

P-BYSK2YRT 3171071603991001 Asep Kurniawan

P-BZ02CA4G 3206120104990004 Pajar Aprian

 P-BYNTR0PV 3206122704820003 Andri Andiansah, S.Kom

P-BZC8E9MS 3206122204640001 Heryanto

P-BXO22MJ3 3206120405780001 Kusnadi

P-BZGZS25W 3206121203900002 Davi Jangga Mario

P-BXIVCIIW 3206124303870009 Reni Lestari

P-BXEVLWO6 3206120204620005 Jajang Sutisna

P-BYRMD8GD 3206120110940003 Wisnu Gunawan

P-BYL6DYOF 3206120605780007 Doni

P-BYTYA85W 3206124908900004 Lia Nurlianti

PKLONG
P-BXHEUGNU 3206120606790005 NUNUNG SURYANA

P-BZICLLW6 3206120203920005 HENDRA PERMANA

P-BZWDAY0C 3206120708680001 HARYONO

P-BZY5RDYR 3206120202770003 SURYAMAN

P-BZUI1OIQ 3206121509880005 ERWIN KURNIA

P-BXPNAOV7 3206124702900003 IKA TRISNAWATI

P-BYDFOE7V 3206121007170007 AYI ABDUL RASYID S.Pd

 P-BXW8XYOS 3206126301960001 RAHMAWATI HIDAYAH

P-BXVA2UXE 3273120611980002 EGI SETIAWAN

P-BZEME46C 3206120603630006 DAUD

P-BY2YOEYJ 3206121011830002 NURDANI

P-BZAJ9WWD 3206121204850001 APIP HANAPI

P-BXXIJ3QZ 3206121003740001 ENTING

RAKSAJ
AYA 320602131066000CECEP DARMAWAN
P-BZ4F0AU7

320612030175000UUY
P-BXD0U7TN

320612200690000RUDI HARTONO
P-BZOKHKZT

320612680980000RANI
P-BZVKAUCR

320612470794000SANTIKA
P-BYMRS6MI

320612051189000HABIB MUTAKIN,S.Pd.I
P-BYEY5H8T

320612050194000WAWAN HERMAWAN
P-C02DKZ5Y

320612260391000PEPEN EPENDI
P-BZMVB4OO

320612150780000BUDI SUDARSONO
P-BYJJFFRM

320612110300001ABDUL PATAH
 320612213274000ADAR
P-BZ1UFSIG

327505050584001RAHMAT DARMAWAN
P-BZTFOQYD

CIPAING 3206122303760001
EUN
P-C0CBUVAB JENI JAELANI

3206121707750004
S-D0CDC524 DADANG SAEPUL MIFTAH, S.IP

3206120401920001
P-BY7MCJFM EPUL SAEPULOH, S.T

3206125001920003
P-C0BGFKJC RINA ROSMAWATI, S.PD.I

3206125212970011
P-C05WATH7 NIDAWATI

3206121504710003
P-BY5TX5BK NANA RUSMANA

3206120107820136
S-081D0A4F UUS HUSAENI, S.P

3206120107590069
P-BYA078I8 SURYAMAN

3206123107890002
S-5062078A DANI RAHMATIKA
P-BYV64KIQ 3206121506890001 SUTISNA
P-C07VIDKY 3206122411940001 AYI ZAINATUL FAIZAH
SEPATNUNGAL
P-BOSI26NF 3206121907730001 YUDI PERMANA
P-BP9W11PH 3206126907930001 PUPUT PURWASIH

P-BOX6IG13 3206124101810022 HAERANI

P-BROYZ7AY 3206121111970007 NUNUR NURJANAH
P-BOONZB2R 3206124306800001 ENTIN ROSTINI
S-AEDABA40 3206120306960003 PAHMI HUSAENI
P-BP1E2USD 3206126410960004 NANI SUMARNI

P-BNNJH94G 3206121906760005 TATANG SUHERLAN

P-BNC6NUKK 3206120805730001 YUYU ABDUL ROHMAN
P-BNUTZXHX 3206121704820004 JAJANG SANUSI
 P-BNR8UE7Y 3206120402730005 AJID
P-BN9QCF61 3206122707690003 AGUSTIN
P-BLU2K3SA 3206120407680007 SOBIRIN
P-BQNOTRR2 3273240203770001 BANGBANG
SUKABAKTI
P-BSJGOMT9 3206121706830003 NANDANG SURYANA, S. Sos.I
P-BJGA644B 3206122104850003 DEDING
P-BPH9TDGY 3206120107850247 UJANG SUPRIATNA
P-BKGFBNO2 3206120401830005 JEMI ZENAL MUTAQIN, SH
P-BMJU0LBM 3206121003940002 ROHMAT SAPA'AT
P-BQ12KSLB 3206120107800322 DEDE ALAMSYAH
P-BPDRGWDL 3206120306800008 RUHIMAT, S. Sos
3206120107700598 NAJMUDIN
P-BKTW4NM6 3206120101900024 HENDI DIANA
P-BKL4VGLS 3206120510890001 HENDI NURYAMIN
P-BKQ9NQR2 3206121410710001 AHID
JYGUNA S-96F928B8 3206121210870001 YOPI INDRA KELANA
P-BGLXARN4 3206121108950002 RAMDANI
P-BJKKSNIA 3206121704920003 YANDI KASMAN
S-BA5E7D8E 3206121208700003 ISMAIL YOGASWARA
S-42D7E02D 3206124407840005 SUMIATI
P-BHOZRYOF 3206121508760002 ADE KARTIWA
S-FB4F7CB6 3206125106910006 IIP NURUL MUSLIM
P-BIL9TCI7 3206121702940007 DIKI PAHRUDIN
P-BH1CWG47 3206121505600003 TATA
P-BH7K66TB 3206120107740236 SUPRIATNA
3206120705820004 TUDIN
P-BGRZI0MN 3206122906820001 IBAH MISBAH
P-BJODQQUK 3206121709620001 NUDIN
P-BGF5Q4UO 3206121011620005 ABAS
3206141903810002 TAOPIK LUBIS
PARUMAS S-1316C362 3278051707570002 IIP KOSWARA
P-BRRJD21Z 3206120109860001 UMAR HADIYAT
P-BRW3AKWO 3206121004890001 SYEH MUDAKIR
P-BQKHUM0M 3206121510900002 ASEP SULAEMAN
P-BREOJ5J1 3206120804910001 RUSLAN ALIP MUJAKIR
P-BR3LRISA 3206122012860003 ADE FAHRUL Q
P-BQNOTRR2 3206122701860001 BANGBANG NURHIDAYAT
P-BPV00BNO 3206120406800003 WAWAN RUHIMAT
P-BQSLF2CV 3206122906920002 ASEP PITRA NUGRAHA
P-BQCU2E1N 3206121910640001 MIMIN
P-BQVN8NIE 3206120909780002 KOMADIN ALI NASIR
P-BRK6YIPB 3206120111840003 DEDI SALEH
P-BQZ1Y9GM 3206122707640001 MA'MUN
P-BQ70ODJ9 3206126908890001 AYI AGUSTINA
P-BM4PEAT2 3206162012640901 RUSTAMAN, S.Pd
 S-46A38EC8 3206161203700007 WARYONO, M.Pd
S-FC15F8E4 3206124607770013 YANTI RESTIANI
S-B5A152F1 3206120606930000 AGUNG PATURAHMAN
P-BOJAWLTX 3206121001991006 ADE RAHMAT HIDAYAT
S-41BF69DD 3206367110890001 POPONG NURAISAH
BJB P-BO2W74LU 3278056810840007 Farah Fatia Nur Dinny s.pd
P-BOAN6PXM 3206246205910000 Ulfah Nadiah
P-BMOM2FPO 3206012711980004 Ulfah Nadiah
P-BFZUAU3D 3206120309920001 Jujun
P-BG7GLDY5 3206131701880002 NANANG
 FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis

Umur 'Ya' pada kolom yang
(18 sd ≥ Kelompok sesuai)
Tanggal Lahir Alamat No. Hp
60 Umur
tahun) BPJS BPJS
PBI Non PBI

7 8 9 10 11 12 13

kp. Desa Rt 002 Rw

59 001 082317724841

kp. Desa Rt 002 Rw

40 001 082214314510

Kp. Babakanjoho Rt
33 003 Rw 001 082216501213

Kp. Gununganten Rt
38 003 Rw 005 081321451129

Kp. Cipurut Rt 001 Rw

39 011 082260001393

kp. Desa Rt 002 Rw

37 001 085320126998

Kp. Babakangirang Rt
43 001 Rw 001 085223266188
 Kp. Cilogata Rt 002 Rw
54 003 085353731367

Kp. Gununganten Rt
58 003 Rw 005 085321514543

Kp. Candraniti Rt 001

38 Rw 008 085215212501

Kp. Babakanpalah Rt
33 004 Rw 009 085223352488

Kp. Cirukem Rt 002 Rw

56 011 085321349169

Kp. Bangbayang Rt 002

49 Rw 014 082310462059

kp. Desa Rt 002 Rw

34 001 081212668563

KP. CIBODAS II RT:028

6/10/1976 45 RW:006 DESA 085223510600
SODONGHILIR
KP. CILEUTIK RT:007
5/27/1968 53 RW:002 DESA 085323900211
SODONGHILIR
KP. PENCUT BITUNG
7/25/1987 34 RT:022 RW:007 DESA 082116096941
SODONGHILIR
KP. NARAWITA RT:003
9/11/1988 33 RW:007 DESA 081313669472
SODONGHILIR
KP. LEMBURSAWAH
12/17/1984 37 RT:011 RW:008 DESA 082219144733
SODONGHILIR
KP. BABAKAN RT:10
11/27/1980 41 RW:002 DESA 081312964241
SODONGHILIR
KP. NARAWITA RT:003
10/30/1965 56 RW:001 DESA 085256068010
SODONGHILIR
KP. PANI'IS RT:015
8/14/1980 41 RW:003 DESA 085295376619
SODONGHILIR
 Kp. Muara RT. 008/002
Dusun Muara Desa
Cikalong Kec.
15-07-1968 52 Thn Sodonghlir 082318311975
Kp. Cikerta Rt. 023/005
Dusun Sukaparan Desa
Cikalong Kec.
5/5/1979 41 Thn Kp. Galumpit RT.
Sodonghilir 085352244811
007/001 Dusun
Galumpit Desa
Cikalong Kec.
12/6/1991 29 Thn Sodonghilir 082320613209
Kp. Muara RT. 008/002
Dusun Muara Desa
Cikalong Kec.
30/09/1982 38 Thn Sodonghlir 085323887929
Kp. Padasuka RT.
009/002 Dusun Muara
Desa Cikalong Kec.
4/7/1995 25 Thn Sodonghilir 081220564733
Kp. Muara RT. 008/002
Dusun Muara Desa
Cikalong Kec.
6/12/1991 29 Thn Sodonghlir 082317544761
Kp. Kadubongkok RT.
013/002 Dusun Muara
Desa Cikalong Kec.
16-08-1968 52 Thn Sodonghilir 08815228009
Kp. Bujalsari RT.
021/004 Dusun
Bujalsari Desa Cikalong
8/7/1981 39 Thn Kec. Sodonghilir 085294645680
Kp. Cikerta Rt. 023/005
Dusun Sukaparan Desa
Cikalong Kec.
24-04-1971 49 Thn Sodonghilir 082318091883
Kp. Lengkongsari RT.
002/008 Dusun Giripati
Desa Cikalong Kec.
10/10/1983 37 Thn Sodonghilir 085214982373
Kp. Cikedok RT.
015/003 Dusun
Cikalong Desa Cikalong
3/8/1965 55 Thn Kec. Sodonghilir 085321396665

06/05/1968
53

17/01/1979
42

17/08/1994
27

26/09/1999
22

01/04/1999
22
27/04/1982
39

15/02/1965
56

04/05/1978
43

12/03/1992
29

03/03/1987
34

02/04/1962
59

01/10/1994
27

01/07/1976
45

09/08/1990
31
 OVID-19

NASI

ertaan BPJS (tulis

ada kolom yang Dosis I Dosis 2
sesuai) Tanggal Nama/Jenis/Me Tanggal
Screening rek Vaksin*** Tanggal Pemberi
Non No. No.
Pemberian No. Serial an
Anggota Batch Batch
Vaksinasi Vaksina
14 15 16 17 18 19 si
20 21

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

3/16/2021 Vaksin Covid-19

 0
Keteran
Dosis 2 gan
(Ditunda
/ Tidak
No. Diberika
Serial n/
Lanjut)
22 23