FORMULIR PENDATAAN STUNTING TAHUN 2021

Provinsi : Lampung Nama Posyandu :

Kabupaten/Kota : Tanggamus Bulan :
Puskesmas/Kecamatan : Pasar Simpang Tahun :
Desa/Kelurahan :
Panjang Vitamin
Berat Panjang Badan/ Cara Ukur ASI IMD A Vitamin A Kepemilik
No No Kartu Keluarga NIK (Nomor Induk Anak Nama anak Tanggal Lahir JK Badan Badan Nama Ortu (Ayah&IBU) NIK Ayah No Tlp/ HP Ortu Alamat RT RW Tgl BB (kg) Tinggi 1=Telentang EksklusifF1 1=YA, Februari Agustus an Buku
Kependudukan) Ke (BB) (PB) Lahir Pengukuran Badan 2=Berdiri =YA, 2=Tidak 1=YA 1=YA KIA
Lahir (cm) 2=Tidak 2=Tidak 2=Tidak

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23)
1 1806191806090004 1806195905190001 2 ADZKIA ZOYA 2019-05-19  P 2.8 41 OMBI DENIAL 1806191906880002 085366618884 TEBA 2 1 25/02/2021 9.4 79 Terlentang
2 3671061912140008 3671063006190006 4 AHMAD RAMA 2019-08-29  L 3.4 49 MARISA 3671061204800001 082371382723 TEBA 1 1 25/02/2021 9.5 79 Terlentang
3 1806192709130001  1806195698150002  2 AIRIN AGUSTINA 2016-08-16  P 2.8 38 HENDRI 1806190202860003  082260228403 TEBA 1 1 25/02/2021 Berdiri
4 1806190501110002  1806196006170001  2 AISYAH AYUDIA INARA 2017-06-20  P 3 48 ZAIPI 1806191206820006  082182821012  TEBA 1 2 25/02/2021 15 105 Berdiri
5 1806191902180001  1806191812170002  2 AL FATAN 2017-12-18  L 3.2 49 JUNED 1806190503890002  TEBA 1 2 25/02/2021 13.1 92 Berdiri
6 1806191908100003  1802224712187843  4 alicia 2018-12-07  P 2.8 47 dewi pursita 1806195212840003  085365305707 TEBA 1 1 25/02/2021 13.5 87 Berdiri
7 1806192601150002  1806196501140003  1 anisa maulida 2018-01-25  P 3.2 48 indarsyah 1806180607930005  TEBA 1 2 25/02/2021 16 101 Berdiri
8 1806191412160002  1806196708170001  2 anisa salsabila 2017-09-27  P 3.2 46 aminulloh 180601053890001  085368514517  TEBA 1 1 25/02/2021 13 91 Berdiri
9 1806192911160002  1806196512160002  1 AQILLA MAICHA 2017-12-25  P 2.8 47 MAT NURI 1806190710870001  085273416094  TEBA 2 1 25/02/2021 16.1 101 Berdiri
10 1806190701110015  1806192409160002  2 ARCHA ADITYA 2016-09-24  L 3 48 MARHANDI 1806190211740000  085788818316 TEBA 1 1 25/02/2021 15 99 Berdiri
11 1806192709130001  1806190904190001  4 ARKA FERDIANSYAH 2019-04-09  L 3.1 49 YUNI ARLIZA 1806194706910003  TEBA 1 1 25/02/2021 Terlentang
12 1806191806090001 1806190303200001 2 ARZANKA 2020-03-03  L 3.2 48 Radi hartono 1806192002850003 082282368630 TEBA 1 1 25/02/2021 8.4 84 Terlentang
13 1806192303100021  1806196011170001  3 ASYIFA RAUDATUL JANNAH 2017-11-20  P 3.5 48 SRI MEGAWATI 180619510580002  085218545845  TEBA 1 2 25/02/2021 14.2 93 Berdiri
14 1806190807150003  1806194311180001  3 AURA MAULIDA 2018-11-03  P 3.2 48 KISMA WENTI 1301084605850005  085273088284 TEBA 2 2 25/02/2021 9.7 81 Berdiri
15 1806191806090001 1806196005190001 3 AZKAYRA RAESHA 2019-05-20  P 3.2 46 zulhan efendi 1806192401800001 TEBA 1 2 25/02/2021 11.5 82 Berdiri
16 1806192303100022  1802224709189267  3 azzahra tri 2018-09-07  P 2.8 47 Edison 1806197012900002  085273348154 TEBA 1 1 25/02/2021 13.2 90 Berdiri
17 1806192312160001  1802226010196704  1 DELICIA KIRANA 2019-10-20  P 3 48 desi armiyani 1806192108950001 TEBA 1 2 25/02/2021 7.8 73 Terlentang
18 180619080710003  1806195404160001  2 DEVINA AFRILIA 2016-04-14  P 3.6 50 MUSALIM 1301080803810003  085273088284 TEBA 2 2 25/02/2021 15 98 Berdiri
19 1806191010160002 1806190612200001 3 FARIS SAPUTRA 2020-12-06  L 1.7 46 SUHAIMI 1806192901750002 082235739393 TEBA 1 1 25/02/2021 4.8 57 Terlentang
20 1806190909190002  1806195005200001  1 FAZIA SINTIA 2020-05-10  P 3.2 47 AINA DAHLIA 1806194201960002  082119539780  TEBA 1 2 25/02/2021 7.6 66 Terlentang
21 1806191202180006  1806196701000001  1 FEBI YUNATA 2018-02-17  L 3.8 50 BUYUNG 1806191808940001  081280338148 TEBA 1 1 25/02/2021 14 96 Berdiri
22 1806190204083514  1806191411150004  4 FERDI SEBASTIAN 2016-11-14  L 3.6 50 JONI AZHAN 180619702790004  TEBA 1 1 25/02/2021 16.5 108 Berdiri
23 1806181212170001  1802222805203379  2 GIANDRA ALI 2020-05-28  L 3.4 48 TOBRONI 1806190904900001 TEBA 1 2 25/02/2021 7.4 69 Terlentang
24 1806191706090002  1806192502180002  4 IMAM 2018-02-28  L 2.6 47 NAZARUDIN 1806192705790002  081277216336 TEBA 1 2 25/02/2021 11.8 90 Berdiri
25 1806190710090004  1806195004170004  6 KENISHA PRILI 2017-04-11  L 3.5 48 ZAINADI 1806191509730002  085383907333  TEBA 1 1 25/02/2021 17 Berdiri
26 1806192303150002  1806190801190002  2 KEVIN ALFARO 2019-01-08  L 3.3 48 ERMAYANI 1806035605920006  082182997227 TEBA 0 0 25/02/2021 11.5 88 Terlentang
27 1806192004150001  1806190301190002  2 KEYZAM DWI PUTRA 2019-01-03  L 4.2 49 SAHRONI 1806010805890001  085279381407  TEBA 1 2 25/02/2021 8.7 78 Terlentang
28 1806191506090004  1806191207140001  2 KHAIRUL NIZAM 2018-07-21  L 3.2 48 RIKA WANSAH 1806190107820019  TEBA 1 1 25/02/2021 7.2 86 Berdiri
29 1806193009130001 1806194304170001 2 LESTI APRILIA 2018-04-18  P 2.8 46 ROSIDI 1806190304790001 TEBA 1 1 25/02/2021 14.5 89 Berdiri
30 1806191612110004  1806191306170004  2 M JUNISEL 2017-06-13  L 3.4 49 KUSAL 1806190407850003  TEBA 1 2 25/02/2021 13.2 94 Berdiri
31 1806193010150001 1806191309190002 2 M. ALFATIH 2019-09-13  L 3.4 47 SAFARUDDIN 1806192506850002  TEBA 1 1 25/02/2021 9.5 78 Terlentang
32 1806191104170001 1806190211200001 3 M. QAILAN 2020-11-02  L 3.8 50 HENDRI 1806190306810002 085251457363 TEBA 1 2 25/02/2021 7.8 66 Terlentang
33 1806181212170001  1802222204208496  1 M. RAIHAN 2020-04-22  L 3.2 48 MERIYA 1806165303980001  TEBA 1 1 25/02/2021 8.1 74 Terlentang
34 1806191105180001  1802222104202183  2 M. ZAIDAN 2020-04-21  L 3.4 50 hernida 1806190201900003 TEBA 1 1 25/02/2021 8.8 77 Terlentang
35 1806192603100016  1806191203160001  4 MAHESA 2016-12-03  L 4 51 BUYUNG 1806190710780002  082283302614  TEBA 1 1 26/02/2021 17 109 Berdiri
36 1806191406160001  1806192405180001  2 MAIZA RAMADHAN 2018-05-24  L 3.1 49 SLAMET 1806190307890001  TEBA 1 1 26/02/2021 11.8 92 Berdiri
37 1806192209890002 1806196605190002 1 MALIKA SUCI 2019-05-26  P 2.6 41 IRZANDI 1806192209890002 082235739393 TEBA 1 1 26/02/2021 10 79 Terlentang
38 1806191102190001  1806192412190001  1 MAULANA YUSUF HABIBI 2019-12-24  L 3.5 48 habib bunazar 1806150901920002  082281184440  TEBA 1 1 26/02/2021 8.3 82 Terlentang
39 1806191809180003  1806193007180002  1 MUHAMMAT FADIL ALFARIZI 2018-07-30  L 2.8 47 MARLINA 1806165408980002  082210748328 TEBA 1 1 26/02/2021 6.1 85 Berdiri
40 1806190111170002  1806194812180001  1 NAFISHA HANINDYA 2018-12-08  P 3.2 48 AGUS TIANI 1806185708920004  TEBA 1 2 26/02/2021 Berdiri
41 1806190809160001  1806192111180002  2 NAZIKA NAFENDRA 2018-11-21  L 3.1 47 SAKIDAH 1806197006800001  082210748328 TEBA 1 1 26/02/2021 12 89 Berdiri
42 1806190107130001  1806194309170001  1 NAZWA PUTRI 2017-09-03  P 3 48 NIRWANTO 1806010511940002  085267313021 TEBA 2 1 26/02/2021 16.5 95 Berdiri
43 1806190902150001  1802226904196604  2 neza afrienzha 2019-04-29  P 3.6 50 nur hidayati 1806195202860004  081379193049 TEBA 1 1 26/02/2021 14 97 Terlentang
44 1806181212170001  1806196107200001  2 NOUREEN RIFKATUL 2020-07-21  P 3.5 48 SARIYANI 1806197006910002  082278910997  TEBA 1 2 26/02/2021 7.2 64 Terlentang
45 1806192509150004  4 NURFAZIRA 2020-03-15  P 3.2 48 hasaroh 1806190207750002 08530514243 TEBA 2 2 26/02/2021 7.8 69 Terlentang
46 1806191612110001  1806194302160001  2 NURUL FEBRIANI NAZWA 2018-03-02  P 3.5 48 EDI SURYADI 1806012905850003  TEBA 1 2 26/02/2021 14.5 100 Berdiri
47 1806192504130002 1806194817170001 2 NURUL OKTAVIA 2017-11-06  P 3.4 50 IRHAM 1806190707870002 082179146289 TEBA 1 1 26/02/2021 12.4 99 Berdiri
48 1806190201140001  1806194404160001  4 PUTRI VIOLA 2018-04-04  P 3.5 49 MASNAN 1806191302730001  TEBA 1 1 26/02/2021 15 100 Berdiri
49 1806191806200001  1802224710192285  2 QALISIYA ALYA 2019-10-07  P 2.4 47 ELIYANA 1806191306790003 TEBA 1 1 26/02/2021 8.3 74 Terlentang
50 1806190201140001 1806192805170001 3 RAYHAN RAMADHAN 2017-05-28  L 3.6 49 ROHANA 1806011206840000  082371141948  TEBA 1 1 26/02/2021 13.5 94 Berdiri
51 1806191010090006  1806196606200001  1 RAYZA RAVANIA 2020-06-26  P 2.9 47 LIS TOUYAH 1806092412000001  TEBA 2 1 26/02/2021 7.1 68 Terlentang
52 1806190512110003  1802220701196984  1 RENALDI SAPUTRA 2019-01-07  L 2.5 46 herna diana 1806190511000001 082324862405 TEBA 1 1 26/02/2021 7.8 76 Berdiri
53 1806190203120002  1806197701180005  3 RIZKA NURMA 2018-01-27  P 3.2 48 EDIYANTO 1806190312830001  085269393623 TEBA 1 2 26/02/2021 11.9 92 Berdiri
54 1806192908170001  1806190607160001  6 RIZKY FITRIA 2016-07-06  L 3.2 46 BASRI 1806190306740002  TEBA 2 2 26/02/2021 17 100 Berdiri
55 1806192004150001  1802224304180000  2 SAFIRA DWI 2018-04-03  P 2.8 47 SAHRANI 180619101880004  085216367757  TEBA 1 2 26/02/2021 13 89 Berdiri
56 1806190605140001  1806191902200001  3 SAHREZA ALIMUN HANIF 2020-02-19  L 3 48 aminulloh 1805080505850022  081373394093  TEBA 1 1 26/02/2021 10 77.5 Terlentang
57 1806193007120001  1806191511200001  3 SATRIYO WIJAYA 2020-11-15  L 4 50 SAHRONI 1806010805890001  085279381407  TEBA 1 2 26/02/2021 4.5 59 Terlentang
58 1806193007120001 1806196009180001  2 SEPTIRA AZZAHRA 2018-09-20  P 3.1 46 ZIRMA 1806194302920003  TEBA 1 1 26/02/2021 10 82.5 Berdiri
59 1806190509120002  1806190710190001  1 SHERLY INTAN NURHAFEEZA 2019-10-07  P 3 47 suherli 1806191703920001  085312857072  TEBA 2 1 26/02/2021 9 79 Berdiri
60 1806190601200001  1806194301180001  2 SINTIA DWINA 2018-01-03  L 2.9 47 SERUWAN AZAN 1806190808880002  TEBA 1 1 26/02/2021 15.6 98 Berdiri
61 1806193008170001  1806196802180001  3 SITI NURFADILA 2018-02-28  P 2.5 46 SAHIDIN 1806190509120002  TEBA 2 2 26/02/2021 11 90 Berdiri
62 1806193008170001  1802221907207378  1 TAMA 2020-07-19  L 3.1 45 HERNITA 1806184502030004  TEBA 1 1 26/02/2021 8 70 Terlentang
63 1806193008170001 1806190503180001  2 VINO RIANSYAH 2018-03-05  L 3.2 46 REVIANSYAH 1806180607930003  08234862405  TEBA 1 2 26/02/2021 13 91 Berdiri
64 1806191810190002  1806194210170002  4 WIRDA AZZAHRA 2017-10-02  P 2.8 47 ZULYADI 1806192511740002  081358380001  TEBA 1 1 26/02/2021 15 98 Berdiri
65 1806190106120002  1802220508193696  1 ZABDAN 2019-08-05  L 3 48 IQBAL 1806191004920004 085383351887  TEBA 1 2 26/02/2021 11.7 80 Terlentang
66 1806191810190003 1806194104200001  1 ZAIRA FADHILA 2020-04-01  P 3 47 RISKA RIA 1806195112990001  081298931425  TEBA 2 2 26/02/2021 8.6 72 Terlentang
67 1806190106120002 1806190104190001  3 ZIDHAN RAFA ALHAFIZ 2019-04-01  L 3.2 48 LITA ZAHARA 1806194209870001  085383351887  TEBA 1 1 26/02/2021 9.7 84.5 Terlentang
68 1806192102190001 1906195502190001 2 DISTA ANNISA 2/15/2019 P 3.2 48 WAWAN 1806190207900003 0852799994974 TEBA 1 1 26/02/2021 11 83 Berdiri
69 1806192102190001 1806196510190001 1 KHAULA ARUNA 10/25/2018 P 3.2 49 JANSEN 3671070302890006 082297969090 TEBA 2 1 26/02/2021 11.9 87 Berdiri
70 3671061912140008 3671080104170001 3 M. REZA NANDA 4/1/2017 L 3.5 50 SOLIHIN 3671061204800001 082371382723 TEBA 2 1 26/02/2021 15 97 Berdiri
71 2 ASILA KHUMAIRA 9/28/2018 P 2.7 46 UMAR TEBA 2 1 26/02/2021 12.4 90 Berdiri
 FORMULIR PEMANTAUAN IBU HAMIL

Provinsi : Nama Posyandu :

Kabupaten/Kota : Bulan :
Puskesmas/Kecamatan : Tahun :
Desa/Kelurahan :
TTD
Berat Tinggi (Tablet
Lingkar Kehamilan Tambah Jika YA, brp
NIK (Nomor Induk Badan Tanggal Berat Badan
No No Kartu Keluarga Kependudukan) Nama Ibu Hamil sebelum Alamat RT RW Tanggal Lahir pengukuran (kg) Badan Lengan ke darah) butir TTD
hamil (cm) Atas (LiLA) 1=YA, didapat
2=Tidak

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16)
1 1806190106110008 ERVIANI KAGUNGAN 001 001 4/10/2001 10/15/2018 48 153.7 22.5 1
2 180619020520008 1806190204081838 SITI ARSIH KAGUNGAN 001 004 5/6/1983 10/15/2018 48 145.9 25.5 3
3 EMILIA KAGUNGAN 001 002 4/7/1980 10/15/2018 48 157 25.5 2
4 1806192201130001 1806196907900001 DEWI YANTI 7/29/1990
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