PKO
DESA KARANGWANGI Bulan : Agustus
Konfirmasi
Perdarahan Abortus Prekeklamsia/ Infeksi Tuberculosis Malaria Jantung DM Positif Covid Lain-lain
Eklamsia
19
18 19 20 21 22 23 24 25 26 27
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 3
0 0 3 2 0 0 2 0 0 12
0 0 12 8 0 0 8 0 0 48
LAPORAN PWS KIA (PROGRAM KESEHATAN IBU)
DESA : KARANGWANGI Bulan : Agustus TAHUN :2021
Sasaran
No NAMA POSYANDU Bumil K1 K1 K2 Bumil Amanat
Akses Murni Buku KIA Notifikasi Tabulin Persalinan
TT1 Fe1 K4 TT2 Fe3
Bulin Buteki
Proyeksi Risk
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 ANGGREK 17 1 17 17 2 2 2 2 2 3 2 1 2 2 1 2
2 SINARJAYA 15 1 15 15 2 1 1 2 2 0 2 1 2 2 1 2
3 KARANGSETRA 18 2 18 18 1 1 1 1 1 0 1 1 1 1 2 1
4 MAWAR 11 2 11 11 2 2 2 2 2 0 2 0 2 1 1 1
5 MELATI 16 2 16 16 2 2 2 2 2 0 2 0 2 2 1 2
6 SINAR LAUT 1 20 1 19 19 1 1 1 1 1 0 1 1 1 1 1 1
7 SINAR LAUT 2 13 2 13 13 1 1 1 1 1 0 1 1 1 2 1 2
8 TERATAI 15 1 13 13 1 1 1 1 1 6 1 0 1 1 1 1
Jml Bln ini 125 12 122 122 12 11 11 12 12 9 12 5 12 12 9 12
% Bln ini 9.60 8.80 8.80 9.60 9.60 7.20 9.60 4.00 9.60 9.60 7.20 9.60
Jumlah bulan lalu 14 11 11 11 11 11 11 14 14 14 11 11
Kum s/d bln ini 88 77 77 69 69 77 66 77 77 74 71 61
% Kumulatif 70.4 61.6 44.8 55.2 55.2 61.6 52.8 61.6 61.6 59.2 56.8 48.8
KESEHATAN IBU)
Agustus TAHUN :2021
Bulin Nakes Tempat Pers
K6 TT3 TT4 TT5 Anemia Bumil DT/DTT JML
Bumil Hyp-t BDD Nakes Kemitraan Jumlah Kelahiran Sarkes Non
Lain Linakes Sarkes
19 20 21 22 23 24 25 26 27 28 29 30 31 32
2 1 0 0 0 0 2 0 0 2 0 2 1 1
2 1 0 0 0 0 1 0 1 2 0 2 2 0
1 0 0 0 0 0 0 0 0 0 1 1 1 0
2 0 0 0 0 0 1 0 0 0 1 2 1 1
2 0 0 0 0 0 2 0 0 2 0 2 2 0
1 0 0 0 0 0 0 0 1 1 0 1 1 0
1 0 0 0 0 0 2 0 0 2 0 2 2 0
1 0 0 0 0 0 1 0 0 1 0 1 1 0
12 2 - - - - 9 - 2 10 2 13 11 2
100.00 1.60 0.00 0.00 0.00 0.00 7.38 0.00 1.64 8.20 1.64 10.66 9.02 1.64
11 1 2 - - - 9 5 5 14 6 14 14 -
74 4 4 6 - 1 43 26 9 71 10 76 60 16
616.7 3.2 3.2 4.8 0.0 0.8 35.2 21.3 7.4 58.2 8.2 62.3 49.2 13.1
LAPORAN PWS KIA (PROGRAM KESEHATAN IBU) 2
DESA : KARANGWANGI Bulan : Agustus TAHUN : 2021
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 ANGGREK 18 18 18 1 0 0 2 2 2 2 2 2
2 SINARJAYA 13 13 13 1 0 0 2 2 2 2 2 2
3 KARANGSETRA 11 11 11 2 0 0 1 1 1 1 1 1
4 MAWAR 14 14 13 0 1 0 2 2 2 2 2 2
5 MELATI 16 16 14 0 0 0 2 2 2 2 2 2
6 SINAR LAUT 1 18 18 18 0 1 0 1 1 1 1 1 1
7 SINAR LAUT 2 14 14 14 0 0 0 2 2 2 2 2 2
8 TERATAI 18 18 17 0 0 0 1 1 1 1 1 1
Jml Bln ini 122 122 118 4 2 0 13 13 13 13 13 13
% Bln ini 10.66 10.66 10.66 10.66 10.66 11.02
Jumlah bulan lalu 14 14 14 14 14 14
Ibu Hamil
Anemia Ibu Hamil Ibu Hamil
Diperiksa Anemia Diperiksa KEK (LiLA Diperiksa Positif (+) Diperiksa GD >140 Datang Ibu Hamil
Hb (8-11 (<8 mg/dl) LiLA < 23,5 cm) g/dl dengan ditawarkan dites HIV Hasil Tes
mg/dl) Tes HIV HIV (+)
HIV(+)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 ANGGREK 17 2 0 0 2 0 2 0 0 0 0 2 2 0
2 SINARJAYA 15 2 0 0 2 0 2 0 0 0 0 2 2 0
3 KARANGSETRA 18 1 0 0 1 1 1 0 0 0 0 1 1 0
4 MAWAR 11 2 0 0 2 0 2 0 0 0 0 2 2 0
5 MELATI 16 2 0 0 2 0 2 0 0 0 0 2 2 0
6 SINAR LAUT 1 20 1 0 0 1 0 1 0 0 0 0 1 1 0
7 SINAR LAUT 2 13 1 0 0 1 0 1 0 0 0 0 1 1 0
8 TERATAI 15 1 0 0 1 1 1 0 0 0 0 1 1 0
Jml Bln ini 125 12 - - 12 2 12 - - - - 12 12 -
% Bln ini 10 0 0 10 2 10 0 0 0 0 10 10 0
Jumlah bulan lalu 15 0 0 15 0 0 0 0 0 0 15 15 0
Kum s/d bln ini 50 0 0 36 2 12 0 0 0 0 50 27 0
% Kumulatif
ANTE NATAL TERPADU
Integrasi Program
Penularan HIV dari Ibu ke Anak (PPIA) Pencegahan Malaria Dalam Kehamilan TB dalam Kehamilan Kecacingan dalam Kehamilan Pencegahan IMS dalam Kehamilan
(PMDK)
- - - - - - - - - - - - - - -
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pelaksanaan kelas ibu hamil
32 33 34 35 36 37 38 39 40
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
- - - - - - - - -
0 0 0 0 0 10 10 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
BULAN : Agustus TAHUN : 2021
1 2 3 4 5 6 7
1 ANGGREK 124 3 0 0 0
2 SINARJAYA 128 2 0 0 0
3 KARANGSETRA 200 1 0 0 0
4 MAWAR 132 1 0 0 0
5 MELATI 161 0 0 0 0
6 SINAR LAUT 1 109 0 0 0 0
7 SINAR LAUT 2 113 0 0 0 0
8 TERATAI 106 0 0 0 0
Jumlah 1,073 7 - - -
% Cakupan
CAKUPAN KB AKTIF DAN KB PASCA SALIN
8 9 10 15 12 13 14 15
0 0 2 10 0 0 0 0
0 0 4 7 0 0 0 0
0 0 1 15 0 0 0 0
0 0 2 8 0 0 0 0
0 0 1 11 0 0 0 0
0 0 2 15 0 0 0 0
0 0 5 10 0 0 0 0
0 0 4 11 0 0 0 0
- - 21 87 - - - -
PASCA SALIN
%
MAL Jml Peserta Kondom Pil Suntik AKDR Pasca AKDR
KB Aktif Plasenta
16 17 18 19 20 21 22 23
0 12 9.677419355 0 1 0 0 0
0 11 8.59375 0 0 1 0 0
0 16 8 0 0 1 0 0
0 10 7.575757576 0 1 2 0 0
0 12 7.453416149 0 0 0 0 0
0 17 15.59633028 0 0 0 0 0
0 15 13.27433628 0 0 2 0 0
0 15 14.1509434 0 2 1 0 0
- 108 10 - 4 7 - -
erta KB Paska Persalinan (0-42 hari) Jumlah Peserta KB Pasca Kegug
24 25 26 27 28 0 30 31
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
- - - - - - - 1
Jumlah Peserta KB Pasca Keguguran
Jml Peserta
AKDR Implan MOW MOP KB Pasca
Keguguran
32 33 34 35 36
0 0 0 0 -
0 0 0 0 1
0 0 0 0 -
0 0 0 0 -
0 0 0 0 -
0 0 0 0 -
0 0 0 0 -
0 0 0 0 -
- - - - 1
LAPORAN PWS BAYI (PROGRAM KESEHATAN ANAK)
TATALAKSANA KOMPLIKASI NEONATUS
DESA : KARANGWANGI TAHUN : 2021
Bulan : Agustus
SASARAN Neonatal Risiko Tinggi PKN Distribusi Komplikasi pada Neonatus yang ditangani (rujukan + tertangani di Puskesmas) BBL yang dilakukan SHK
No NAMA POSYANDU
Konfirmasi
Lahir Tertangani di Tetanus Kelainan Komplikasi
Bayi 15% risk Rujukan L P BBLR ( < 2500 gr) Asfiksia Infeksi
Neonatorum Kongenital
Positif Covid
Lainnya
Abs %
Hidup Puskesmas 19
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 ANGGREK 18 16 2 1 - 1 0 1 1 0 0 0 0 0 0 0
2 SINARJAYA 15 12 2 - - 0 0 0 0 0 0 0 0 0 0
3 KARANGSETRA 12 11 2 1 - - 1 0 0 0 0 0 0 1 0 0
4 MAWAR 14 12 2 - - 0 0 0 0 0 0 0 0 0 0
5 MELATI 16 14 2 - - 0 0 0 0 0 0 0 0 0 0
6 SINAR LAUT 1 13 16 2 - - - 0 0 0 0 0 0 0 0 0 0
7 SINAR LAUT 2 13 13 2 - - - 0 0 0 0 0 0 0 0 0 0
8 TERATAI 14 15 1 - - - 0 0 0 0 0 0 0 0 0 0
0
Jml sd. Bulan ini 115 109 15 2 - 1 1 1 1 - - - - 1 - -
% BLn ini 13.3333333333 0 6.666667 6.67 6.67 6.67 0.00 0.00 0.00 0.00 6.67 0.00 0.00
Jumlah bulan lalu 4 0 3 1 0 2 0 0 0 0 2 0 0
Kum s/d bln ini 7 1 6 8 4 6 2 - - - 4 - 7
% Kumulatif 46.66666666667 6.6666666667 40 53.3 26.7 40.0 13.3 0.0 0.0 0.0 26.7 0.0 46.7
Bayi
SASARAN Kunj. Saat Lahir mendapatkan
IMD
Bayi di ukur Bayi di ukur
No NAMA POSYANDU panjang badan≤ 48 panjang badan> 48 KN1 KN2 KN-3
Anak Balita cm (BBL stunting)) cm
Lahir Bayi 15% risk (1-5 Th L P
Hidup kurang 1 hari)
L P L P L P L P L P
1 2 3 4 5 6 7 8 9 10 9 10 11 12 13 14 15 16
1 ANGGREK 18 16 2 70 1 0 0 1 0 1 1 1 1 1 1 1
2 SINARJAYA 15 12 2 50 - 0 2 0 0 0 2 0 2 0 2 0
3 KARANGSETRA 12 11 2 47 - 0 0 1 0 0 0 1 0 1 0 1
4 MAWAR 14 12 2 55 - 0 1 1 1 1 1 1 1 1 1 1
5 MELATI 16 14 2 65 - 0 1 1 0 1 1 1 1 1 1 1
6 SINAR LAUT 1 13 16 2 70 - 0 0 1 1 0 0 1 0 1 0 1
7 SINAR LAUT 2 13 13 2 55 - 0 1 1 0 0 1 1 1 1 1 1
8 TERATAI 14 15 1 69 - 0 0 1 2 1 0 1 0 1 0 1
Jml sd. Bulan ini 115 109 15 481 1 - 5 7 4 4 6 7 6 7 6 7
% BLn ini 0.86957 0 4.58716 46.66667 3.47826 3.478261 5.22 6.086957 5.22 6.08695652 5.22 6.08695652
Jumlah bulan lalu 0 0 0 0 4 6 6 3 6 3 6 3
Kum s/d bln ini 1 1 5 5 15 18 18 - 30 30 30 30
% Kumulatif 0.869565 0.9 4.6 33.3 13.04348 15.7 15.65217 0.0 26.0869565 26.1 26.0869565 26.1
LAPORAN PWS BAYI (PROGRAM KESEHATAN ANAK)
DESA: KARANGWANGI Bulan : Agustus
KNL BBL mdpt Salep Mata BBL mdpt Injeksi Vit K BBL mdpt Imunisasi TN Hidup Mati
HB 0
Normal BBLR
L P L P L P L P L P L P
L P L P
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
1 1 1 1 1 1 1 1 0 0 0 1 1 0 0 0
2 0 2 0 2 0 2 0 0 0 2 0 0 0 0 0
0 1 0 1 0 1 0 1 0 0 0 1 0 0 0 0
1 1 1 1 1 1 1 1 0 0 1 1 0 0 0 0
1 1 1 1 1 1 1 1 0 0 1 1 0 0 0 0
0 1 0 1 0 1 0 1 0 0 0 1 0 0 0 0
1 1 1 1 1 1 1 1 0 0 1 1 0 0 0 0
0 1 0 1 0 1 0 1 0 0 0 1 0 0 0 0
6 7 6 7 6 7 6 7 - - 5 7 1 - - -
5.22 6.08695652 5.22 6.08695652 5.22 6.08695652 5.22 6.08695652 0.00 0 4.35 6.08695652 0.87 0 0.00 0
6 3 6 3 6 3 6 3 0 0 6 3 0 0 0 0
30 30 30 30 30 30 30 30 - - 30 30 2 4 - -
26.0869565 26.1 26.0869565 26.1 26.08695652 26.08695652 26.1 26.0869565 0.0 0 26.1 26.0869565 1.7 3.47826087 0.0 0
Tatalaksana BBLR Kunjungan Bayi
BBLR Hidup BBLR Tertangani BBLR dirujuk B-3 B-6 B-9 B-12 Kunjungan bayi
Paripurna
L P L P L P L P L P L P L P L P
33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
1 0 1 0 0 0 1 0 1 1 3 1 1 1 1 1
0 0 0 0 0 0 0 1 1 1 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1
0 0 0 0 0 0 0 1 1 2 0 0 0 0 0 0
0 0 0 0 0 0 0 0 2 0 1 0 0 0 0 0
0 0 0 0 0 0 1 0 0 0 0 0 1 0 1 1
0 0 0 0 0 0 0 0 1 2 1 1 1 0 1 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 - 1 - - - 2 2 6 6 6 3 5 2 5 4
6.67 0 15 #DIV/0! 0 #DIV/0! 1.83 1.83 5.50 5.50 5.50 2.75 4.59 1.83 4.59 3.67
0 0 0 0 0 0 7 3 4 3 5 4 6 4 4 4
2 7 2 4 - - 28 10 27 14 25 12 32 20 25 22
1.7 6.08695652 1.7 3.4782608696 0 0.0 25.7 9.2 24.8 12.8 22.9 11.0 29.4 18.3 22.9 20.2
Balita memiliki Buku
Bayi memiliki Buku KIA Kunj. Balita KIA
L P L P L P
49 50 51 52 53 54
1 1 1 2 1 2
1 0 2 4 2 4
1 1 1 3 1 3
0 0 1 2 1 2
0 0 5 4 5 4
1 1 1 4 1 4
1 1 7 2 7 2
0 0 4 2 4 2
5 4 22 23 22 23
4.59 3.67 4.57 4.78 4.57 4.78
24 35 4 35 24 35
109 99 89 81 109 99
100.0 90.8 18.5 16.8 22.7 20.6
CAKUPAN KB AKTIF DAN KB PASCA SALIN
BULAN : Agustus
Jumlah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
REKAPITULASI DETEKSI DINI TUMBUH KEMBANG ANAK DI KABUPATEN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 ANGGREK 16 70 1 1 0 0 0 0 0 0 0 0
2 SINARJAYA 12 50 1 2 1 1 0 1 0 0 0 0
3 KARANGSETRA 11 47 2 2 0 0 0 0 0 0 0 0
4 MAWAR 12 55 1 1 0 0 0 0 0 0 0 0
5 MELATI 14 65 1 1 0 0 0 0 0 0 0 0
6 SINAR LAUT 1 16 70 1 2 1 1 0 0 0 0 0 0
7 SINAR LAUT 2 13 55 0 1 0 0 0 0 0 0 0 0
8 TERATAI 15 69 1 1 0 0 0 0 0 0 0 0
JUMLAH 109 481 8 11 2 2 0 1 0 0 0 0
UPATEN
TINDAK LANJUT
15 16 17 18 19 20
0 0 0 0 0 0
0 1 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 0 0 0 0
REKA
Jumlah Kunjungan Umur Jumlah Kunjungan Umur di MTBS Jenis Kelamin Jenis Kunjungan
12 Bln - 5 12 Bln - 5
2-12 Bln Jumlah 2-12 Bln Jumlah L P Jumlah Pertama Ulang Jumlah Pneumonia
Th Th Berat / Peny Pneumonia
Batuk Bukan
Pneumonia
Diare Dehidrasi
Berat
Sangat Berat
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 ANGGREK 1 1 2 1 1 2 1 1 2 2 1 3 0 0 1 0
2 SINARJAYA 1 0 1 1 0 1 1 0 1 1 0 1 0 0 1 0
3 KARANGSETRA 2 0 2 2 0 2 2 0 2 2 0 2 0 0 1 0
4 MAWAR 1 0 2 1 0 2 1 0 2 2 1 3 0 0 1 0
5 MELATI 1 1 2 1 1 2 1 1 2 2 0 2 0 0 0 1
6 SINAR LAUT 1 1 0 1 1 0 1 1 0 1 1 1 2 0 0 0 1
7 SINAR LAUT 2 0 1 1 0 1 1 0 1 1 1 0 1 0 0 0 1
8 TERATAI 0 1 1 0 1 1 0 1 1 1 0 1 0 0 0 1
JUMLAH 7 4 12 7 4 12 7 4 12 12 3 15 0 0 4 4
REKAPITULASI LAPORAN KEGIATAN MTBS
Klasifikasi
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 6 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Status Gizi HIV
Anemia HIV
Kemungkinan
Kurus Diduga HIV Terpajan HIV Bukan Infeksi
Terkonfirmasi
HIV
38 39 40 41 42 43
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
REKAPITULASI LAPORAN KEGIATAN MTBM
Jumlah Kunjungan Umur Jumlah Kunjungan Umur di MTBM Jenis Kelamin Jenis Kunjungan
NO NAMA POSYANDU
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 ANGGREK 2 2 2 2 8 2 2 2 2 8 1 1 2 0 1 1
2 SINARJAYA 2 2 2 2 8 2 2 2 2 8 2 0 2 1 1 2
3 KARANGSETRA 1 1 1 1 4 1 1 1 1 4 0 1 1 0 1 1
4 MAWAR 2 2 2 2 8 2 2 2 2 8 1 1 2 1 1 3
5 MELATI 2 2 2 2 8 2 2 2 2 8 1 1 2 1 1 2
6 SINAR LAUT 1 1 1 1 1 4 1 1 1 1 4 0 1 1 1 0 1
7 SINAR LAUT 2 2 2 2 2 8 2 2 2 2 8 1 1 2 1 1 1
8 TERATAI 1 1 1 1 4 1 1 1 1 4 0 1 1 1 1 3
JUMLAH 13 13 13 13 52 13 13 13 13 52 6 7 13 6 7 14
Klasifikasi
Masalah Pemberian
Infeksi Bakteri Ikterus Diare HIV Masalah Pemberian ASI Minum pada Bayi PASI
Kemungkinan BB Rendah BB Rendah BB Rendah BB Rendah
Infeksi Bakteri Infeksi Bakteri Mungkin Bukan Tidak Ada Diare Dehidrasi Diare Dehidrasi Diare Tanpa HIV Menurut Umur - Menurut Umur -
Berat Lokal Infeksi Ikterus Berat Ikterus Sedang Ikterus Berat Ring-Sed Dehidrasi Terkonfirmasi Diduga HIV Terpajan HIV Bukan Infeksi Menurut Umur - Tidak Ada Menurut Umur - Tidak Ada
HIV Masalah Masalah Masalah Masalah
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
- - - - 1 - - - - - - - - - - - -
Bulan Puskesmas No Nama Ibu / Usia Nama Suami/Usia
REKAPITULASI KEMATIAAN IBU BY NAME BY ADDRESS
TAHUN 2021
Penyebab Status
TANGGAL Kematian PEKERJAAN
ALAMAT (desa)* Kematian KEMATIAN (Bumil-Bulin- SUAMI*
(Diagnosa)
Bufas)
NAME BY ADDRESS
L U
P U
L U
P U
L U
P U
L U
P U
L U
R
Jumlah
B
P U
Keterangan:
Formulir I ini diisi oleh petugas di unit pelayanan terpadu (UPT); dan direkap setiap bulan.
Formulir I ini disimpan di UPT yang bersangkutan.
Jenis Kasus adalah:
B = baru
U = berulang
R = rujukan
FORMULIR I
MULIR REGISTER PELAYANAN BAGI KORBAN KEKERASAN
P
-CIRI PELAKU
Kebang-
Pekerjaan Hubungan dgn korban
saan
Keterangan
Oran Sua Indo
Beke Kelu Lain Asin
g mi/ nesi
rja arga nya g
Tua Istri a
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16)
L
Baru
P
Jumlah (L+P)
Tabel 2: Bentuk Kekerasan, Tempat Kejadian dan Jenis Pelayanan Yang Diberikan
L
Baru P
L+P
L
Berulang P
L+P
L
Rujukan P
L+P
Cianjur, 2021
Penanggung Jawab (Unit Pelayanan
_________________
Nip:
FORMULIR II
ASIL KEGIATAN PELAYANAN BAGI KORBAN KEKERASAN
Ciri-Ciri Pelaku
(17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35)
L+P
Cianjur, 2021
nggung Jawab (Unit Pelayanan),
_________________
Kebangsaan
Indone
Asing
sia
(36) (37)
wab unit
y dikirimkan ke
LAPORAN PELAYANAN KESEHATAN REPRODUKSI CALON PENGANTIN
Bulan: Tahun :
PUSKESMAS :
Hasil Pemeriksaan
No DATA
Dalam Gedung Luar gedung
Jumlah Catin yang dilayani
1 Laki-laki
Perempuan
Jumlah Hasil Pemeriksaan Fisik Sehat
2 Laki-laki
Perempuan
Jumlah Hasil Pemeriksaan Fisik Tidak Sehat
3 Laki-laki
Perempuan
Jumlah Hasil Pemeriksaan Status Gizi
Laki-laki Status Gizi Normal
Laki-laki Status Gizi Kurus
4 Laki-laki Status Gizi Obesitas
Perempuan Status Gizi Normal
Perempuan Status Gizi Kurus
Perempuan Status Gizi Obesitas
Jumlah Catin Anemia
5 Laki-laki (Hb < 13 g%)
Perempuan (Hb < 12 g%)
Jumlah Pemeriksaan HIV Positif (+)
6 Laki-laki
Perempuan
Jumlah Pemeriksaan IMS Positif (+)
7 Laki-laki
Perempuan
Jumlah Pemeriksaan Hepatitis Positif (+)
8 Laki-laki
Perempuan
9 Jumlah Calon Pengantin Wanita mendapatkan imunisasi TT
Jumlah Catin yang mendapatkan KIE Kesehatan Reproduksi
10 laki-laki
Perempuan
11 Jumlah Catin yang dirujuk
Mengetahui,
Kepala Puskesmas Bidan Koordinator
___________________ ___________________
Nip: Nip:
Jumlah
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
rdinator
_________
:
PUSKESMAS
KABUPATEN / KOTA CIANJUR
PROVINSI JAWA BARAT
BULAN / TAHUN :
LAPORAN HAS
Pkm Non
Dtg Sndr
NO JENIS KASUS
Jumlah
Jumlah
Dukun
0-7 hr 8-14 hr 15-28
Kader
Bidan
Prwt
hr
1 ASFIKSIA 0 0 0 0 0 0 0 0 0 0
2 BBLR 0 0 0 0 0 0 0 0 0 0
3 CAPUT SUCC/ CEPHAL HEMATOM 0 0 0 0 0 0 0 0 0 0
4 DEMAM 0 0 0 0 0 0 0 0 0 0
5 DIARE 0 0 0 0 0 0 0 0 0 0
6 HIPOTERMIA 0 0 0 0 0 0 0 0 0 0
7 IKTERUS NEONATORUM 0 0 0 0 0 0 0 0 0 0
8 IUFD 0 0 0 0 0 0 0 0 0 0
9 FEBRIS/ INFEKSI LAINNYA 0 0 0 0 0 0 0 0 0 0
10 KEJANG 0 0 0 0 0 0 0 0 0 0
11 KELAINAN KONGENITAL 0 0 0 0 0 0 0 0 0 0
12 PNEUMONIA 0 0 0 0 0 0 0 0 0 0
13 PREMATUR 0 0 0 0 0 0 0 0 0 0
14 PERDARAHAN TALI PUSAT 0 0 0 0 0 0 0 0 0 0
15 TETANUS NEONATORUM 0 0 0 0 0 0 0 0 0 0
16 LAIN-LAIN 0 0 0 0 0 0 0 0 0 0
17 PARTUS NORMAL 0 0 0 0 0 0 0 0 0 0
19 SEPSIS 0 0 0 0 0 0 0 0 0 0
Jumlah 0 0 0 0 0 0 0 0 0 0
LAPORAN HAS
Pkm Non
Dtg Sndr
NO JENIS KASUS
Jumlah
Jumlah
Dukun
15-28
Kader
Bidan
Prwt
0-7 hr 8-14 hr hr
1 ASFIKSIA 0 0 0 0 0 0 0 0 0 0
2 BBLR 0 0 0 0 0 0 0 0 0 0
3 CAPUT SUCC/ CEPHAL HEMATOM 0 0 0 0 0 0 0 0 0 0
4 DEMAM 0 0 0 0 0 0 0 0 0 0
5 DIARE 0 0 0 0 0 0 0 0 0 0
6 HIPOTERMIA 0 0 0 0 0 0 0 0 0 0
7 IKTERUS NEONATORUM 0 0 0 0 0 0 0 0 0 0
8 IUFD 0 0 0 0 0 0 0 0 0 0
9 FEBRIS/ INFEKSI LAINNYA 0 0 0 0 0 0 0 0 0 0
10 KEJANG 0 0 0 0 0 0 0 0 0 0
11 KELAINAN KONGENITAL 0 0 0 0 0 0 0 0 0 0
12 PNEUMONIA 0 0 0 0 0 0 0 0 0 0
13 PREMATUR 0 0 0 0 0 0 0 0 0 0
14 PERDARAHAN TALI PUSAT 0 0 0 0 0 0 0 0 0 0
15 TETANUS NEONATORUM 0 0 0 0 0 0 0 0 0 0
16 LAIN-LAIN 0 0 0 0 0 0 0 0 0 0
17 PARTUS NORMAL 0 0 0 0 0 0 0 0 0 0
19 SEPSIS 0 0 0 0 0 0 0 0 0 0
Jumlah 0 0 0 0 0 0 0 0 0 0
LAPORAN HASIL PELAYANAN KESEHATAN BAYI DI PUSKESMAS PONED
Dirujuk ke Kehamilan ke Keadaan Bayi Waktu Lahir Cara Persalinan Berat Lahir
RSU Swasta
(sebutkan)
< 2500 gr
Tindakan
Normal /
Spontan
Jumlah
Jumlah
Jumlah
Jumlah
RSKIA
Sehat
RSUD
Cacat
Sakit
1 2-3 >3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
LAPORAN HASIL PELAYANAN KESEHATAN BAYI DI PUSKESMAS PONED
Dirujuk ke Kehamilan ke Keadaan Bayi Waktu Lahir Cara Persalinan Berat Lahir
RSU Swasta
(sebutkan)
< 2500 gr
Tindakan
Normal /
Spontan
Jumlah
Jumlah
Jumlah
Jumlah
RSKIA
Sehat
RSUD
Cacat
Sakit
1 2-3 >3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Berat Lahir Penolong Persalinan Tindakan
Non Nakes
Resusitasi
> 2500 gr
Jumlah
Jumlah
Jumlah
Rawat
Nakes
LL
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
Berat Lahir Penolong Persalinan Tindakan
Non Nakes
Resusitasi
> 2500 gr
Jumlah
Jumlah
Jumlah
Rawat
Nakes
LL
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
PUSKESMAS :
KABUPATEN / KOTA : CIANJUR
PROVINSI : JAWA BARAT
BULAN :
TAHUN :
LAPORAN HASIL P
Dtg Sndr
Jumlah
Dukun
Kader
Bidan
<20 21-35 >35
1 Persalinan Normal 0 0 0 0 0 0 0 0 0
2 Kelainan Lamanya Kehamilan 0 0 0 0 0 0 0 0 0
1. Abortus 0 0 0 0 0 0 0 0 0
2. Partus Imaturus 0 0 0 0 0 0 0 0 0
3. Partus Prematurus 0 0 0 0 0 0 0 0 0
4. Partus Serotinus 0 0 0 0 0 0 0 0 0
5 Partus Lama/tdk maju/ macet 0 0 0 0 0 0 0 0 0
6 Ab incomplit 0 0 0 0 0 0 0 0 0
3 Kelainan Tempat Kehamilan 0 0 0 0 0 0 0 0 0
1. Kehamilan Ektopik 0 0 0 0 0 0 0 0 0
4 Kelainan Telur 0 0 0 0 0 0 0 0 0
1 Blighted ovum 0 0 0 0 0 0 0 0 0
2 Mola Hidatidosa 0 0 0 0 0 0 0 0 0
5 Kelainan Plasenta 0 0 0 0 0 0 0 0 0
1. Plasenta Previa 0 0 0 0 0 0 0 0 0
2. Placenta Acreta 0 0 0 0 0 0 0 0 0
3. Retensio Plasenta 0 0 0 0 0 0 0 0 0
4. Sisa Plasenta 0 0 0 0 0 0 0 0 0
5. Solutio Placenta 0 0 0 0 0 0 0 0 0
7 Kelainan Ketuban 0 0 0 0 0 0 0 0 0
1. Polyhidramnion 0 0 0 0 0 0 0 0 0
2. Oligohidramnion 0 0 0 0 0 0 0 0 0
9 Gestose 0 0 0 0 0 0 0 0 0
1. Hyperemesis Gravidarum 0 0 0 0 0 0 0 0 0
2. Preeklamsi 0 0 0 0 0 0 0 0 0
3. Eklampsi 0 0 0 0 0 0 0 0 0
10 Perdarahan 0 0 0 0 0 0 0 0 0
1 Perdarahan di awal kehamilan 0 0 0 0 0 0 0 0 0
2 Perdarahan antepartum 0 0 0 0 0 0 0 0 0
3 Perdarahan Postpartum 0 0 0 0 0 0 0 0 0
11 Penyulit Kehamilan 0 0 0 0 0 0 0 0 0
1. Karena penyakit 0 0 0 0 0 0 0 0 0
12 Malpresentasi 0 0 0 0 0 0 0 0 0
1. Letak sungsang 0 0 0 0 0 0 0 0 0
2. Letak lintang 0 0 0 0 0 0 0 0 0
3. Letak Muka 0 0 0 0 0 0 0 0 0
4. Distosia Bahu 0 0 0 0 0 0 0 0 0
5. CPD 0 0 0 0 0 0 0 0 0
22 LAIN-LAIN 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
JUMLAH 0 0 0 0 0 0 0 0 0
LAPORAN HASIL PELAYANAN KESEHATAN IBU HAMIL, IBU BERSALIN DAN IBU NIFAS DI PUSKESMAS PONED
RSU Swasta
Jumlah
Jumlah
Jumlah
Jumlah
Sehat
Sehat
RSUD
Sakit
Sakit
Mati
1 2-3 >3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Keadaan Bayi Tindakan
Vakum Extraksi
partus normal
Pit Drip / Drip
Curetase
Placenta
Di rawat
Manual
Jumlah
Jumlah
MgSo4
Digital
Mati
dll
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0