KARTU KENDALI VAKSINASI COVID-19 KARTU KENDALI VAKSINASI COVID-19

UPTD PUSKESMAS KEDUNGWUNGU UPTD PUSKESMAS KEDUNGWUNGU

NAMA PENERIMA :__________________________________________ L / P NAMA PENERIMA :__________________________________________ L / P

NIK :__________________________________________ NIK :__________________________________________
TGL. LAHIR :_____________________________ USIA :_________ TGL. LAHIR :_____________________________ USIA :_________
NO. HP :_____________________________ DOSIS KE :_________ NO. HP :_____________________________ DOSIS KE :_________
ALAMAT :__________________________________________ ALAMAT :__________________________________________
KELOMPOK : O Lansia O Masy. Rentan O Masy. Umum O Remaja KELOMPOK : O Lansia O Masy. Rentan O Masy. Umum O Remaja
O Bumil O Disabilitas O Anak O Bumil O Disabilitas O Anak
SKRINING SKRINING
SUHU TUBUH :_________ oC T/D : _________ mm/Hg SUHU TUBUH :_________ oC T/D : _________ mm/Hg
HASIL SKRINING : O Lanjut Vaksin O Tunda Vaksin O Batal Vaksin HASIL SKRINING : O Lanjut Vaksin O Tunda Vaksin O Batal Vaksin
CATATAN : CATATAN :

VAKSINASI VAKSINASI
VAKSIN :_______________ BATCH:____________________JAM :__________________ VAKSIN :_______________ BATCH:____________________JAM :__________________

KARTU KENDALI VAKSINASI COVID-19 KARTU KENDALI VAKSINASI COVID-19

UPTD PUSKESMAS KEDUNGWUNGU UPTD PUSKESMAS KEDUNGWUNGU

NAMA PENERIMA :__________________________________________ L / P NAMA PENERIMA :__________________________________________ L / P

NIK :__________________________________________ NIK :__________________________________________
TGL. LAHIR :_____________________________ USIA :_________ TGL. LAHIR :_____________________________ USIA :_________
NO. HP :_____________________________ DOSIS KE :_________ NO. HP :_____________________________ DOSIS KE :_________
ALAMAT :__________________________________________ ALAMAT :__________________________________________
KELOMPOK : O Lansia O Masy. Rentan O Masy. Umum O Remaja KELOMPOK : O Lansia O Masy. Rentan O Masy. Umum O Remaja
O Bumil O Disabilitas O Anak O Bumil O Disabilitas O Anak
SKRINING SKRINING
SUHU TUBUH :_________ oC T/D : _________ mm/Hg SUHU TUBUH :_________ oC T/D : _________ mm/Hg
HASIL SKRINING : O Lanjut Vaksin O Tunda Vaksin O Batal Vaksin HASIL SKRINING : O Lanjut Vaksin O Tunda Vaksin O Batal Vaksin
CATATAN : CATATAN :

VAKSINASI VAKSINASI
VAKSIN :_______________ BATCH:____________________JAM :__________________ VAKSIN :_______________ BATCH:____________________JAM :__________________