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NAMA ISTRI :.............................................................................................................................................

NAMA SUAMI :.............................................................................................................................................
ALAMAT :
DUSUN.................................................................RT......................../RW........................
DESA :...............................................................................................................................
KECAMATAN :...............................................................................................................

KABUPATEN :.................................................................................................................

STATUS INTERVAL
MASA
IMUNISASI MINIMAL TGL/BLN/TH PARAF
PERLINDUNGAN
PEMBERIAN

T1 - -

T2 4 Minggu T1 3 Thn

T3 6 Bulan  T2 5 Thn

T4 1 Thn  T3 10 Thn

T5 1 Thn  T4 >25 Thn

 Kepada orang tua agar membawa bayinya ke Puskesmas / poyandu untuk diimunisasi
supaya terhindar dari penyakit berbahaya : Hepatitis, TBC, Difteri, Tetanus,
Meningitis, Polio, Campak.