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KITIR VAKSINASI COVID-19

VAKSINASI SERENTAK KOTA SURABAYA Akun Puskesmas :


TANGGAL : 2021 .............................

Nama : ............................................................
Alamat : ..........................................................
NIK : .........................................................
No. E Ticket : ..........................................................

Hasil skrining : Dilakukan vaksinasi ( ) Petugas Meja 2 :


Ditunda ( )
Tidak bisa dilakukan vaksinasi ( )
( Nama dokter )
Nama Vaksin : ........................................................
No. Batch : ........................................................
Tanggal pemberian : ........................................................
Jam perberian : Pk. ...................................................
Jam lepas observasi : Pk. ...................................................

Nama vaksinator : ........................................................ Vaksinator :


Puskesmas : ........................................................
No. HP : ........................................................

(Nama terang)

KITIR VAKSINASI COVID-19


VAKSINASI SERENTAK KOTA SURABAYA Akun Puskesmas :
TANGGAL : 2021 .............................

Nama : ............................................................
Alamat : ..........................................................
NIK : .........................................................
No. E Ticket : ..........................................................

Hasil skrining : Dilakukan vaksinasi ( ) Petugas Meja 2 :


Ditunda ( )
Tidak bisa dilakukan vaksinasi ( )
( Nama dokter )
Nama Vaksin : ........................................................
No. Batch : ........................................................
Tanggal pemberian : ........................................................
Jam perberian : Pk. ...................................................
Jam lepas observasi : Pk. ...................................................

Nama vaksinator : ........................................................ Vaksinator :


Puskesmas : ........................................................
No. HP : ........................................................

(Nama terang)

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