FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Nama Puskesmas/Fasyankes/Pos : UPTD Puskesmas Langsa Timur

Kabupaten/Kota : Kota Langsa
Provinsi : Aceh

Kepesertaan BPJS (tulis 'Ya' pada kolom

Dosis I Dosis 2
yang sesuai) Keterangan
Jenis Umur Kelompok Merek Tanggal (Ditunda/Tidak
No No. Registrasi NIK Nama Penerima Vaksin Pekerjaan* Alamat No. Hp
Kelamin (18-59 tahun) Umur Vaksin*** Screening Tanggal Tanggal Diberikan/Lanjut
Non
BPJS PBI BPJS Non PBI Pemberian No. Batch Pemberian No. Batch )
Anggota
Vaksinasi Vaksinasi

1 P-HRDWK3D3 1174014505760005 SALAWATI P B 43 31-45 BUKET MEUTUAH 085270727625 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

2 P-HYZBIB3S 1174012103640002 sujarwo L B 57 46-59 GP BAR0 085261965104 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

3 P-IATD2U1G 1174012812990002 EDI RAHMANA L B 22 18-30 ALUE MERBAU 081262042255 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

4 P-ILAB342W 1174016308990001 TRI AMBARWATI P B 33 31-45 ALUE MERBAU 085260620990 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

5 P-ISHPVVLT 1174015503670002 ratna nurlela P B 54 46-59 GP BARO 082277717134 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

6 P-IZRRCG5M 1205130811900005 M SYAHPUTRA L B 31 31-45 GP BARO 0895326227471 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

7 P-LNOPV5VB 1174016805790001 JULAILA P B 42 31-45 ALUE PINEUNG 082292820395 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

8 P-MGPS1GXP 1174014706770002 ROSNILAINI P B 44 31-45 ALUE PINEUNG 082219110732 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

9 P-NVISPU3S 1174012607640002 BUDIONO L B 0 SEULALAH BARU 082366997066 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

10 P-OVW0EWDK 1174020606950006 YANDA ARISTA L B 26 18-30 PAYA BUJOK TUNONG 082218468840 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

11 P-QAG6AT67 1174015301810001 FARIDAH P B 40 31-45 BUKIT PULO 082365908360 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

12 P-QANIZQPN 1174016610000003 POPPY INTAN PAULINA P B 21 18-30 PONDOK PABRIK 082276912747 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

13 P-QBVECODY 1174045403960001 ESTER ANDREESY PANGABEAN P B 25 18-30 PONDOK PABRIK 085361604490 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

14 P-QDELU52L 1174015804720001 SITI JAMALINDA P B 49 46-59 SIDODADI 085358421276 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

15 P-QH37QO5W 1174014107790033 MISRIANI P B 42 31-45 BUKIT MEDANG ARA 082274350265 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

16 P-QIUWNQUH 1174011504000003 RISKI SYUHADA L B 21 18-30 ALUE PINEUNG TIMUE 082269879788 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

17 P-QIZDWT0J 1174056206840001 NOVA PUSPITA P B 37 31-45 MEURANDEH TEUNGOH 085296764068 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

18 P-QJ857LIT 1174015907970001 NURUL AZMI P B 24 18-30 BUKIT MEUTUAH 082267047103 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

19 P-QJYUNBDE 1174010612630001 ZULKIFLI L B 58 46-59 ALUE PINEUNG TIMUE 082272439937 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

20 P-QLJ312IS 1174011503640001 USMAN L B 0 SIMPANG WIE 082129982470 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

21 P-QO0FGYDU 1174010802980003 SYAWALUDDIN L B 23 18-30 SIMPANG WIE 082129982470 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

22 P-QO92ZF4O 1174014812860001 BADRIAH P B 35 31-45 082368920435 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

23 P-QOLRV11B 1174032005640006 EMY SUMARNO P B 57 46-59 PONDOK KEMUNING 0852966982212 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

24 P-QPGHWO4M 1174032911910001 M FAWZI SETIAWAN L B 30 18-30 GP TEUNGOH 081378873447 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

25 P-QQHANZ3N 1174011503630001 LASMAN L B 58 46-59 PONDOK PABRIK 085260303963 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

26 P-QRNG07XY 1174015009850001 FITRIANI P B 36 31-45 SIMPANG WIE 085372936533 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

27 P-QS5GRKZF 1174014901750002 LILI SUHERI L B 46 46-59 BUKET MEUTUAH 085243138181 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

28 P-QSBT7D66 1174010106800001 DEDI INDRA PRADESA L B 41 31-45 BUKET MEUTUAH 085371156455 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

29 P-QSJEIVJC 1174010602900003 YUSBA ALHAMDASYARI P B 31 31-45 ASAM PEUTEK 085270274541 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

30 P-QSZM2A2T 1174045806990002 AYU ANGGRAINI PUTRI P B 22 18-30 MEURANDEH DAYAH 082219907934 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

31 P-QVRTXU2V 1174010909610001 JAMILUN LUBIS L B 60 0 ALUE MERBAU 082267018258 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

32 P-QZK9VQZH 1174011603970003 ENDAH FAJAR LESTARI P B 24 18-30 BUKIT MEDANG ARA 085261369618 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

33 S-022AA9BB 1174014107400021 BONIYEM P B 88 0 ALUE PINEUNG 082224070849 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

34 S-252AEBC1 1174010109880003 AULIA RAHMAN L B 33 31-45 ALUE PINEUNG 082273728883 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

35 S-429EA084 1174044606560001 SAMSIDAR P B 63 0 GP BARO 085267715267 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

36 S-C1AC7949 1174010107520047 INDRA SURYA L B 69 0 ALUE PINEUNG 085270880787 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut
37 S-C6346A5A 1103041308820002 SURIANTO L B 39 31-45 SUKAREJO 082362054456 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

38 S-C9C12B1D 117401100850002 MOH JAMIL IKRAL L B 91 0 BUKET PULO 082282718232 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

39 S-E6088034 1174015908990002 HULWA LUTHFIYAH P B 22 18-30 SEULALAH BARU 082363850783 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

40 P-DTR826E2 : 1174036707940005 SRI RATNA RIZKY P B 0 JL PANGLIMA POLEM/AMALIA 082276402274 Ya CoronaVac 6/8/2021 6/8/2021 24003621 Lanjut

Langsa, 09 Juni 2021

Kepala UPTD Puskesmas Langsa Timur

Vivi Handayani, SKM, M.Kes

Pembina / Nip. 19810820 200604 2 010