I.

pengenalan tempat

4. nama puskesmas
2. kabupaten/kota

5. desa/kelurahan
3. kecamatan
1. provinsi

6. RT/RW
NO

1 jambi jambi Kota Baru Kenali Asam Bawah RT 16

2 jambi Jambi Kota Baru Kenali Asam Bawah RT 16

3 jambi jambi kota baru Kenali asam bawah rt16

4 jambi jambi kota baru Kenali Asam Bawah RT 16

5 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

6 jambi jambi kota baru Kenali Asam Bawah RT 16

7 jambi Jambi Kota Baru Kenali Asam Bawah RT 16

8 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

9 jambi jambi kota baru kenali asam bawah rt 16

10 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

11 jambi jambi kota baru kenali asam bawah RT 16

12 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

13 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

14 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

15 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

16 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

17 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

18 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

19 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

20 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

21 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

22 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

23 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

24 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

25 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

26 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

27 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

28 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

29 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

30 jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

31 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

32 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

33 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

34 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

35 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

36 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

37 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

38 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

39 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

40 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

41 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

42 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

43 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

44 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

45 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

46 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

47 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

48 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

49 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

50 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

51 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

52 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

53 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

54 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT 16

55 Jambi Kota Jambi Kota Baru Kenali Asam Bawah RT16

56 jambi Jambi Kota Baru Kenali Asam Bawah RT 16

57 jambi jambi Kota Baru Kenali Asam Bawah RT 16

58 jambi jambi Kota Baru Kenali Asam Bawah RT 16

59 jambi jambi Kota Baru Kenali Asam Bawah RT 16

60 jambi jambi Kota Baru Kenali Asam Bawah RT 16

61 jambi jambi Kota Baru Kenali Asam Bawah RT 16

62 jambi jambi Kota Baru Kenali Asam Bawah RT 16

63 jambi jambi Kota Baru Kenali Asam Bawah RT 16

64 jambi jambi Kota Baru Kenali Asam Bawah RT 16

65 jambi jambi Kota Baru Kenali Asam Bawah RT 16

66 jambi jambi Kota Baru Kenali Asam Bawah RT 16

67 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

68 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

69 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

70 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

71 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

72 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

73 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

74 Jambi Jambi Kota baru kenali asam bawah RT 16

75 Jambi Jambi kota baru kenali asam bawah RT 16

76 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

77 Jambi Jambi kota baru kenali asam bawah RT 16

78 Jambi Jambi Kota Baru Kenali Asam Bawah RT16

79 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

80 Jambi Jambi KotaBaru Kenali Asam Bawah RT 16

81 Jambi Jambi Kota baru kenali asam bawah RT 16

82 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

83 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

84 Jambi Jambi Kota Baru Kenali Asam bawah RT 16

85 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

86 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

87 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

88 Jambi Jambi Kota Baru KenalI Asam Bawah RT 16

89 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

90 Jambi Jmabi Kota Baru Kenali Asam Bawah RT 16

91 Jmabi Jambi Kota Baru Kenali Asam Bawah RT 16

92 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

93 Jambi Jambi Kota Jambi Kenali Asam Bawah RT 16

94 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

95 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

96 Jambi Jambi Kota Baru Kenali Asam Bawah RT.16

97 Jambi Jambi Kota Baru Kenali Asam Bawah RT 16

 1. Nama KK

Jasri
Sadi

Ramto
Mukmin

Mustopa

Jumianto
T.Nababan

Riklas Medi

2
5
6
3
2
4
5
9
a. jumlah ART

3
5
6
2
2
4
4
7
b. jumlah ART dewasa (> 15)

-
-
-
-
-
-

1
1
c. jumlah ART usia 12-59 bulan

1
1
1
1
1
1
1
1
d. jumlah ART diwawancara

4
4
5
2
3
4
4
7
e. jumlah ART usia 10 - 54 tahun
2. Jumlah anggota rumah tangga

-
-
-
-
-
-
-

1
f. jumlah ART usia 0-11 bulan
II. Keterangan rumah tangga

1
1
1
1
1
1
1
1

3. sarana air besih

1
1
1
1
1
1
1
1

4. jenis sumber air

1
1
1
1
1
1
1
1

5. jamban

1
1
1
1
1
1
1
1

6. jenis jamban

-
-
-
-
-
-
-
-

7. diagnosis sakit jiwa

-
-
-
-
-
-
-
-

8. minum obat secara teratur (jika ia)

-
-
-
-
-
-
-
-

9. ada ART dipasung

Ridho Pandapo
Indra Pardame

Rm.Rahmat Bu
 Rasikin 5 3 1 1 4 1 1 1 1 - - -

Koma Siburian 3 2 1 3 1 1 1 1 - - -

Kasirun 2 - - 2 2 - 1 1 1 1 - - -

Sudiono 3 3 - 1 3 - 1 1 1 1 - - -

Rusdi 4 3 - 1 3 - 1 1 1 1 - - -

Darka 4 3 - 1 4 - 1 1 1 1 - - -

Lie Fui Thong 3 3 - 2 3 - 1 1 1 1 - - -

J. Sihombing 6 5 - 1 6 - 1 1 1 1 - - -

Lidia Feranita
Sahat Maranat
Karwi 2 2 - 1 0 - 1 1 1 1 - - -

Hari Susilo 1 1 - 1 1 - 1 1 1 1 2 - 2
Masiran 2 2 - 2 - 1 1 1 1 2 - 2

Ahmad Sarnubi 2 2 - 1 2 - 1 2 1 1 2 - 2

Saryono 3 2 - 1 2 - 1 2 1 1 2 - 2

Muroso 3 2 - 1 3 - 1 1 1 1 2 - 2

Salamun 3 2 - 2 2 - 1 1 1 1 2 - 2

Rafik Hadi 3 2 1 1 2 - 1 1 1 1 2 - 2
 Jurijan 3 3 - 1 3 - 1 1 1 1 2 - 2

Karno 2 2 - 2 - - 1 1 1 1 2 - 2

Nurdjali 4 2 - 1 2 - 1 1 1 1 2 - 2

Parijan 4 2 - 1 3 1 1 1 1 1 2 - 2

Muhammad M
Sudardi 4 3 - 1 3 - 1 1 1 1 2 - 2

Karwito 4 2 - 1 3 1 1 1 1 1 2 - 2

Muhammad B
Nali Harimurti 4 2 1 1 2 - 1 1 1 1 2 - 2

Nastusha quee
Muslim 4 3 - 1 2 - 1 1 1 1 2 - 2

Wardoyo 5 3 1 1 3 - 1 1 1 1 2 - 2

Jaman 6 5 - 2 6 - 1 1 1 1 2 - 2

Kusno 6 6 - 1 6 - 1 1 1 1 2 - 2

Sholihin 3 2 - 1 3 - 1 1 1 1 2 - 2

Mulyono S. 6 4 - 1 5 - 1 1 1 1 2 - 2
 Suroto 5 2 2 1 2 - 1 2 1 1 2 - 2

Wagino 3 3 - 1 1 - 1 1 1 1 2 - 2

Huminsa Marhehe Lumbantoruan 4 2 - 1 2 - 1 2 1 1 2 - 2

Tiurma Dumaria
David Parluhutan
Evangelia Lum
Joko Sutrisno 5 3 - 1 3 - 1 2 1 1 2 - 2

Yaman 5 2 1 1 3 - 1 2 1 1 2 - 2

Zulkarnain 3 2 - 1 2 - 1 1 1 1 2 - 2

Muhammad Ib
Ngarbianto 2 2 - 1 1 - 1 1 1 1 2 - 2

Sumini 1 1 - 1 1 - 1 2 1 1 2 - 2
Adi Kurniawan 2 2 - 1 2 - 1 1 1 1 2 - 2

Samiun 2 2 - 1 - - 1 1 1 1 2 - 2

Irman 2 2 - 1 2 - 1 1 1 1 2 - 2

Supardi 2 2 - 1 2 - 1 1 1 1 2 - 2

Sukijan 5 4 - 1 4 - 1 1 1 1 2 - 2

Sarjono 4 2 - 1 3 - 1 2 1 1 2 - 2
 Subronto 3 2 1 1 2 - 1 2 1 1 2 - 2

Kasiono 4 3 - 1 4 - 1 1 1 1 2 - 2

Gimin 2 2 - 1 - - 1 2 1 1 2 - 2

Sarijah 1 1 - 1 - - 1 2 1 1 2 - 2
Sudadi 4 3 - 2 3 - 1 2 1 1 2 2 2

Supardi 2 2 - 1 - - 1 2 1 1 2 2 2

Suwoto 4 2 - 1 3 - 1 2 1 1 2 2 2

Iswanto 3 3 - 1 3 - 1 2 1 1 2 2 2

Kastari S 4 4 - 1 2 - 1 2 1 1 2 2 2

Kaelan 4 4 1 4 - 1 2 2 1 2 2 2

Eko Sunarjo 4 2 - 1 2 1 1 2 1 1 2 2 2

Yoso 3 3 1 1 2 - 1 1 1 1 2 2 2

M Suhardi 4 3 - 1 3 - 1 1 1 1 2 2 2

Sulastri 1 1 - 1 1 - 1 2 1 1 2 2 2
Ambok Dalek 4 2 1 1 3 - 1 2 1 1 2 2 2

Muhtar 2 2 - 1 - - 1 1 1 1 2 - 2

Kutono 2 2 - 1 1 - 1 1 1 1 2 - 2
 Ahmad Efendi 3 2 1 1 2 - 1 1 1 1 2 - 2

Ahmad Muslihun 3 2 1 1 2 - 1 2 1 1 2 - 2

Kartono 4 2 1 1 2 - 1 1 1 1 2 - 2

Alwin Sembiring 4 3 - 1 4 - 1 1 1 1 2 - 2

Sabar 4 3 - 1 4 - 1 1 1 1 2 - 2

Sutikno 4 2 0 1 3 - 1 1 1 1 2 - 2

Ahmad Safudin 4 2 1 1 3 - 1 1 1 1 2 - 2

Herman Sujarwo 4 3 - 1 4 - 2 2 1 1 2 - 2

Suyoto 5 5 - 1 3 - 1 1 1 1 2 - 2

Isrowiyah 5 4 - 1 5 - 1 1 1 1 2 - 2

Saipullah 6 4 1 1 5 - 1 1 1 1 2 - 2

Sumarno 5 3 - 1 4 - 1 1 1 1 2 - 2
Ahmad Solikhun 8 8 - 1 8 - 1 1 1 1 2 - 2

Musnadi 6 5 1 1 4 - 1 1 1 1 2 - 2

Sugianto 5 2 1 1 2 - 1 1 1 1 2 - 2

Saiful Bahri 5 5 - 1 5 - 2 2 1 1 2 - 2

Samijan 5 4 - 1 5 - 1 2 1 1 2 - 2

Sumardi. S 4 4 - 1 4 - 1 1 1 1 2 - 2

Sukarno 4 4 - 1 3 - 1 1 1 1 2 - 2

Ambok Upek 4 2 - 1 3 1 2 2 1 1 2 - 2

Tukimin 4 3 - 1 3 - 1 1 1 1 2 - 2

Supawi. S 4 4 - 1 4 - 1 2 1 1 2 - 2
Supriyanto 4 4 - 1 3 - 1 1 1 1 2 - 2

Muhammad Z
Syafril 4 4 - 1 4 - 1 1 1 1 2 - 2

Sutaji 3 3 - 1 3 - 1 1 1 1 2 - 2

Sarno 3 2 - 1 2 - 1 1 1 1 2 - 2

Sidik Tantawi 3 2 - 1 2 - 1 1 1 1 2 - 2

Syahilla Thalita
Abdul Fitri 3 2 - 1 2 - 1 1 1 1 2 - 2

M. Arsyad 2 2 - 1 2 - 1 1 1 1 2 - 2
 IV. Keterangan anggota rumah tangga

7. status perkawinan
3. hubungan ART

5. umur (tahun)

8. sedang hamil
6. jenis kelamin

10. pendidikan

11. pekerjaan
Umur (Bulan)

9. agama
2. Nama

4. TGL

T.Nababan 1 12/8/1969 49 595 1 1 - 2 4 5

L.Sihombing 2 10/3/1970 49 588 2 1 2 2 4 1
Indra Pardamean Nababan 3 12/7/1992 26 320 1 2 - 2 5 1
Daniel Nababan 3 3/7/1994 24 296 1 2 - 2 5 1
Andi Saputra Nababan 3 30/04/1996 22 275 1 2 - 2 5 1
Dewi Lastiar 3 25/03/2000 19 228 2 2 2 2 4 2
Ridho Pandapotan Nababan 3 6/6/2002 16 201 1 2 - 2 4 2
Jelita Lestari Nababan 3 10/5/2009 9 118 2 2 2 2 2 1
Rifayaloina Nababan 3 28/02/2008 8 97 1 2 - 2 2 1
Mukmin 1 9/7/1972 46 552 1 1 - 1 5 5
Jamitun 2 1/4/1980 38 456 2 1 2 1 3 1
Muhaimin Suryono 3 10/5/2000 18 216 1 2 - 1 4 4
Muhaimin Irawan 3 20/3/2002 17 204 1 2 - 1 4 4
Afitun Kholifah 3 3/10/2013 5 60 2 2 - 1 1 2
Sadi 1 10/1/1965 53 636 1 1 - 1 4 1
Sumirah 2 3/2/1970 49 588 2 1 2 1 4 1
Rohana 3 4/19/1998 20 240 2 2 2 1 5 1
Muklas Saputra 3 6/19/2000 18 216 1 2 - 1 5 1
Ramto 1 7/4/1990 28 336 1 1 - 1 4 8
Sulasmi 2 20/10/1988 30 360 2 1 2 1 3 8
Jasri 1 3/19/1986 33 396 1 1 - 1 5 5
Alvi Hidayatul Ma'va 2 5/16/1988 30 368 2 1 2 1 6 1
Qiola Al-Fathinah 3 4/9/2017 1 23 2 2 - 1 1 1
Mustopa 1 9/8/1976 42 504 1 1 - 1 3 5
Janu Warti 2 21/11/1977 41 492 2 1 2 1 3 1
Nursoviyanti 3 10/3/1995 24 288 2 2 2 1 4 2
Nova Mudrika 3 12/11/1999 19 228 2 2 2 1 2 2
Rm.Rahmat Burya Kusuma 3 20/1/2008 10 120 1 2 - 1 1 1
Patimah 6 7/5/1945 73 876 2 4 - 1 3 1
Riklas Medi 1 7/16/1962 56 672 1 1 - 1 4 9
Eti Susanti 2 11/10/1967 51 612 2 1 2 1 4 9
Indra rio Bionika 3 10/11/1985 33 396 1 2 - 1 5 5
Riki Evan 3 8/4/1992 26 312 1 2 - 1 5 5
Ririn Amedia Santika 3 12/30/2002 16 192 2 2 - 1 4 1
Jumianto 1 15/1/1965 54 648 1 1 - 1 5 5
 Meri Tukinah 2 10/8/1970 48 576 2 1 2 1 5 5
Rasikin 1 4/9/1978 40 480 1 1 - 1 5 1
Sriyati 2 8/17/1978 40 480 2 1 2 1 5 1
Angga Wahyu Pratama 3 9/4/1999 19 228 1 2 - 1 3 1
Wanda Nurul Hikmah 3 5/26/2003 15 180 1 2 - 1 2 1
Ahmad Zainal Aqzia 3 2/21/2012 7 84 1 2 - 1 1 1
Koma Siburian 1 3/3/1967 52 624 1 1 - 2 5 8
Rosdiana Br Nainggolan 2 30/5/1967 51 612 2 1 2 2 5 8
Abet Nego Siburian 3 13/6/2005 13 156 1 2 - 2 2 2
Kasirun 1 19/06/1966 52 633 1 1 - 1 4 8
Puatin 2 29/03/1977 41 503 2 1 2 1 4 8
Sudiono 1 31/12/1969 49 591 1 1 - 1 3 9
Suriati 2 13/07/1992 46 560 2 1 2 1 3 9
Sutiono 3 11/9/1992 26 318 1 2 - 1 5 5
Rusdi 1 1/3/1977 42 504 1 1 - 1 4 5
Kaswati 2 28/12/1979 40 483 2 1 2 1 4 2
Lilis Adriani 3 15/6/2001 17 213 2 2 - 1 3 1
Nuri Neng Setyani 3 29/12/2009 9 111 2 2 - 1 3 1
Darka 1 7/3/1979 39 476 1 1 - 1 3 8
Siti Awaliyah 2 8/4/1983 35 427 2 1 2 1 3 8
Wisnu Saputra 3 9/1/2001 17 210 1 2 - 1 3 1
Vika Sari 3 4/19/2006 12 155 2 2 2 1 3 1
Lie Fui Thang 1 6/5/1955 63 765 1 1 - 5 5 5
Sri Rahayu 2 1/1/1979 40 482 2 1 2 5 3 9
Lie Siawan 2 10/29/2003 16 197 1 2 - 5 5 1
J. Sihombing 1 7/3/1975 43 524 1 1 - 2 5 5
T. Simamora 2 5/12/1977 41 502 2 1 2 2 5 8
Mega R. Sihombing 3 7/2/1997 21 260 2 2 - 2 5 1
Hendri J. Sihombing 3 3/18/2002 17 204 1 2 - 2 4 1
Lidia Feranita Sihombing 3 1/1/2004 15 182 2 2 2 2 3 1
Sahat Maranata Sihombing 3 6/25/2006 12 153 1 2 - 2 3 1
Karwi 1 3/19/1959 60 720 1 1 - 1 3 8
Jamiatun 2 3/12/1962 57 684 2 1 - 1 3 8
Hari susilo 1 18/06/1985 33 405 1 2 - 1 3 5
Masiran 1 11/11/1952 66 796 1 1 - 1 4 6
Warinah 2 2/5/1960 58 706 2 1 - 1 3 1
Ahmad Sarnubi 1 3/1/1987 32 386 1 1 - 1 5 8
Sri Muryati 2 15/05/1991 27 334 2 1 2 1 6 1
Saryono 1 11/7/1964 54 656 1 1 - 1 3 6
Kewat 2 28/11/1969 49 592 2 1 2 1 3 1
dwi ulfana 3 22/06/2012 6 81 2 2 - 1 - -
Muroso 1 8/5/1975 43 526 1 1 - 1 4 6
Nur hayati 2 17/05/1986 32 394 2 1 2 1 3 1
Ni'matus sa'idah 3 14/12/2007 11 135 2 2 - 1 2
Salamun 1 23/07/1984 34 416 1 1 - 1 5 6
Purwati 2 10/2/1991 28 337 2 1 2 1 5 1
Alfin Hayatul Husnah 3 3/8/2012 6 79 2 2 - 1 - -
Rafik Hadi 1 15/4/1993 25 311 1 1 - 1 5 5
Tika Oktariansari 2 8/10/1993 25 305 2 1 2 1 5 5
Azizah Syazwani 3 18/3/2018 1 12 2 2 - 1 - -
 Jurijan 1 14/10/1960 58 701 1 1 - 1 4 3
Nur Aida 2 27/12/1977 41 495 2 1 2 1 5 1
Kartika Dewi Wulandari 3 6/10/2001 17 209 2 2 - 1 4 2
Karno 1 2/8/1954 64 775 1 1 - 1 3 6
Karmini 2 15/7/1957 61 740 2 1 - 1 3 1
Nurdjali 1 12/10/1990 27 329 1 1 - 1 5 5
Fitra Dewi 2 10/11/1990 27 328 2 1 2 1 5 1
Kafi Al Azam 3 25/04/2014 3 47 1 2 - 1 - -
Syafi Assyauqi 3 25/04/2014 3 47 1 2 - 1 - -
Parijan 1 5/2/1980 39 469 1 1 - 1 3 6
Jumrotun 2 18/06/1986 32 393 2 1 2 1 3 6
Nadia Riyal Jannah 3 29/08/2009 9 115 2 2 - 1 - -
Muhammad Mafatih Niam 3 24/10/2018 5 1 2 - 1 - -
Sudardi G 1 2/2/1977 42 505 1 1 - 1 3 6
Sularsi 2 11/11/1978 40 484 2 1 2 1 5 1
Rafi Arme Gustari 3 17/08/1999 18 223 2 2 - 1 2 2
Reyhan Pebriansyah 3 12/2/2008 11 133 1 2 - 1 - 1
Karwito 1 27/7/1979 39 476 1 1 - 1 5 8
Sri Handayani 2 25/7/1985 33 404 2 1 2 1 4 1
Anisa Salsabila 3 25/3/2007 12 144 2 2 - 1 - 2
Muhammad Bagas Alfariq 3 9/8/2018 7 1 2 - 1 - -
Nali Harimurti 1 2/6/1987 31 381 1 1 - 1 7 5
Novita indah sar 2 16/11/1988 30 424 2 1 2 1 6 5
Talitha kirana harimurti 3 22/07/2013 5 68 2 2 - 1 - -
Nastusha queena harimurti 3 9/1/2018 1 14 2 2 - 1 - -
Muslim 1 23/07/1960 58 704 1 1 - 1 3 6
Asmi julaeha 2 17/06/1967 51 621 2 1 2 1 3 1
Ali hairul 3 8/5/1999 19 238 1 2 - 1 3 2
Rahma Tusalimah 3 3/11/2008 10 124 2 2 - 1 - 1
Wardoyo 1 11/12/1971 47 567 1 1 - 1 4 5
Dini Parlina 2 30/09/1978 41 498 2 1 2 1 5 1
Gani nasafi 3 24/07/2002 16 200 1 2 - 1 - 1
talita Fara 3 10/6/2009 8 105 2 2 - 1 - -
Yuda Lingga 3 15/01/2016 3 38 1 2 - 1 - -
Jaman 1 23/04/1958 61 743 1 1 - 1 3 8
Minah 2 20/11/1965 53 640 2 1 2 1 3 8
Gupron 3 12/3/1985 34 408 1 2 - 1 3 8
Solikhatun 3 11/6/1993 24 297 2 2 - 1 3 2
Muslika 3 25/08/1996 21 259 1 2 - 1 3 2
Salakul Nurrahman 3 30/09/2007 10 126 1 2 - 1 - 1
Kusno 1 4/5/1955 63 766 1 1 - 1 3 6
Karsini 2 12/7/1965 53 644 2 1 2 1 2 1
Jumiyati 3 12/8/1987 31 379 2 2 - 1 3 1
Sarminah 3 18/07/1990 28 344 2 2 - 1 3 1
Sueb Wijaya 3 22/02/2000 19 229 2 2 - 1 2 2
Parti 6 15/04/1935 83 1007 2 4 - 1 1 1
Sholihin 1 6/17/1965 53 645 1 1 - 1 5 8
Sukijah 2 6/15/1976 42 513 2 1 2 1 5 1
Bima Maarif 3 2/28/2005 14 169 1 2 - 1 2 2
Mulyono S. 1 28/05/1969 49 598 1 1 - 1 5 5
 Andi Besek Asirah 2 4/4/1977 41 503 2 1 2 1 5 5
Melisah Alrasiyida 3 5/5/1998 20 250 2 2 - 1 4 1
M. Mursid Al Fahri 3 6/4/2001 17 213 1 2 - 1 3 2
Aulliyu Martaria 3 28/03/2005 14 168 2 2 - 1 2 2
Azilla Ramadhani 3 8/12/2010 8 103 2 2 - 1 1 -
Suroto 1 21/12/1983 35 423 1 1 - 1 5 5
Melati 2 19/10/1987 31 377 2 1 2 1 5 5
Naysah Yuri 3 26/07/2009 9 116 2 2 - 1 1 -
Akhtar Akbar 3 7/3/2015 3 44 1 2 - 1 - -
Amar Akbar 3 7/3/2015 3 44 1 2 - 1 - -
Wagino 1 12/30/1956 62 747 1 1 - 1 2 6
Parni 2 12/31/1959 59 711 2 1 - 1 2 1
Rohadi 3 12/21/1994 24 291 1 2 - 1 5 1
Huminsa Marhehe Lumbantoruan 1 15/04/1976 42 515 1 1 - 2 5 5
Tiurma Dumaria Simorangkir2 21/08/1980 38 463 2 1 2 2 5 1
David Parluhutan Lumbantoruan3 14/04/2011 7 95 1 2 - 2 1 -
Evangelia Lumbantoruan 3 10/5/2014 4 53 2 2 - 2 - -
Joko Sutrisno 1 1/5/1979 40 482 1 1 - 1 5 5
Hilianita 2 24/12/1983 35 423 2 1 2 1 5 5
Aditya Putra Pratama 3 5/9/2009 9 118 1 2 - 1 1 -
Nazilla Kaylin Azzahra 3 24/09/2013 5 66 2 2 - 1 1 -
Mohardi 7 24/08/1989 29 355 1 2 - 1 5 1
Yaman 1 9/5/1980 38 462 1 1 - 1 5 8
Supangati Sartika 2 15/10/1976 42 509 2 1 2 1 7 1
Jihan Anika Zahrah 3 4/3/2004 14 154 2 2 - 1 4 2
M. Almer Abiyu 3 15/05/2014 4 58 1 2 - 1 - -
M. Sakha Raffasya 3 15/10/2017 1 17 1 2 - 1 - -
Zulkarnain 1 2/10/1993 26 313 1 1 - 1 5 5
Windi Windayani 2 21/02/1995 24 289 2 1 2 1 5 1
Muhammad Ibni Muazzam 3 16/12/2013 5 63 1 2 - 1 1 -
Ngarbianto 1 3/28/1962 56 672 1 1 - 1 2 6
Sumiati 2 8/25/1972 46 559 2 1 - 1 3 1
Sumini 1 5/18/1977 41 502 2 4 2 1 2 1
Adi Kurniawan 1 9/6/1994 24 294 1 1 - 1 5 5
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Samiun 1 3/3/1957 62 744 1 1 - 1 3 9
Ramisah 2 1/9/1960 59 710 2 1 - 1 3 9
Irman 1 14/07/1964 54 656 1 1 - 1 4 5
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Zaskya Al Hidayah 3 12/3/2010 8 99 2 2 - 1 1 2
Wagini 6 12/31/1960 58 699 2 1 - 1 1 1
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Siti Rohani 2 15/08/1987 31 379 2 1 2 1 3 1
Robiyanto 3 30/01/2008 11 134 1 2 - 1 1 2
Rafi Ardianto 3 21/02/2013 6 73 1 2 - 1 1 -
 Subronto 1 9/7/1981 37 450 1 1 - 1 5 5
Desiyana 2 12/2/1984 34 411 2 1 2 1 5 1
Adzra Ranaa Thurayya 3 21/07/2016 2 32 2 2 - 1 - -
Kasiono 1 11/8/1972 46 556 1 1 - 1 2 6
Nuhkise 2 7/15/1980 38 464 2 1 2 1 2 1
Edi Kurniawan 3 8/10/2001 17 211 1 2 - 1 4 2
Ainun Munawaroh 3 8/28/2008 10 127 2 2 - 1 2 2
Gimin 1 12/10/1944 74 891 1 1 - 1 2 6
Paerah 2 9/12/1955 63 762 2 1 - 1 2 1
Sarijah 1 4/3/1956 62 755 2 3 - 1 2 1
Sudadi 1 3/14/1973 46 553 1 1 - 1 3 6
Sudarti 2 3/16/1975 44 529 2 1 2 1 3 1
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Septiani Rodiyah 3 9/2/2009 9 114 2 2 - 1 2 -
Supardi 1 12/31/1952 66 795 1 1 - 1 3 6
Yateni 2 12/31/1962 56 675 2 1 - 1 3 1
Suwoto 1 6/23/1980 38 465 1 1 - 1 3 6
Indrawati 2 6/12/1986 32 393 2 1 2 1 3 1
Rifan Ardiansyah Putra 3 6/6/2005 13 165 1 2 - 1 3 2
Rivaldi Hidayatul Akbar 3 4/4/2013 6 72 1 2 - 1 2 -
Iswanto 1 5/16/1972 46 563 1 1 - 1 4 6
Suciami 2 12/12/1982 36 435 2 1 2 1 4 1
Eva Selvianita 3 1/6/2001 18 218 2 2 2 1 4 1
Kastari S 1 11/13/1956 62 748 1 1 - 1 4 6
Rusmiati 2 9/21/1963 55 666 2 1 - 1 3 1
Sri Hastuti 3 6/8/1980 38 465 2 2 2 1 5 1
Yogo Prayitno 3 11/11/1987 31 376 1 2 - 1 5 1
Kaelan 1 7/5/1950 68 823 1 1 - 1 4 6
Sukartini 2 12/3/1960 58 699 2 1 - 1 4 1
Setia Ningrum 3 12/17/1997 22 265 2 2 2 1 4 2
Tohasan 7 9/7/1986 32 390 1 2 - 1 3 5
Eko Sunarjo 1 12/27/1977 41 495 1 1 - 1 5 6
Yulianti 2 7/10/1989 29 356 2 1 2 1 3 1
Haizatul Qoyum Al-Jawa 3 4/17/2010 8 907 2 2 - 1 2 -
Fathan Shariq 3 4/29/2018 0 11 1 2 - 1 - -
Yoso 1 4/1/1968 51 613 1 1 - 1 5 5
Ani Kusrini 2 3/24/1975 44 528 2 1 2 1 5 1
Asmiawati 6 10/19/1938 80 965 2 4 - 1 2 1
M Suhardi 1 7/15/1980 38 464 1 1 - 1 5 6
Andi Rahima 2 7/1/1979 39 476 2 1 2 1 5 1
Andi Tentri Wulan 3 1/14/2002 17 206 2 2 2 1 5 2
Andi Adam Rahadi 3 8/8/2013 5 67 1 2 - 1 1 -
Sulastri 1 4/20/1967 51 623 2 1 2 1 3 6
Ambok Dalek 1 5/16/1984 35 430 1 1 - 1 2 9
Hasna 2 4/7/1983 36 443 2 1 2 1 2 1
Andi Kurniawan 3 8/1/2006 13 163 1 2 - 1 3 2
M Arfan 3 12/22/2015 4 51 1 2 - 1 - -
Muhtar 1 1/7/1956 63 764 1 1 - 1 3 6
Murni 2 1/7/1946 73 884 2 1 - 1 3 1
Kutono 1 25/8/1959 60 151 1 1 - 1 3 5
 Siti Yuliana 2 30/5/1970 49 596 2 1 - 1 4 1
Ahmad efendi 1 24/01/1995 24 291 1 1 - 1 5 8
Siti Yuliana 2 25/10/1999 19 233 2 1 2 1 5 1
Noerdyyah 3 1/10/2018 1 14 2 2 - 1 - -
Ahmad Muslihun 1 25/12/1989 30 363 1 1 - 1 4 8
Irma Ramadhani 2 1/5/1987 32 392 2 1 2 1 5 1
Sofia Humaira. A 3 21/12/2016 2 27 2 2 - 1 - -
Kartono 1 17/5/1984 35 430 1 1 - 1 5 9
Suwarti 2 12/3/1986 33 397 2 1 2 1 4 1
Alif Nur F. 3 7/5/2011 8 106 1 2 - 1 1 -
Afifa Nahda R. 3 3/12/2016 3 37 2 2 - 1 - -
Alwin Sembiring 1 19/10/1986 33 401 1 1 - 1 5 8
Yuli Asih 2 24/9/1978 31 378 2 1 2 1 5 1
Sigit Willy P. 3 15/11/1999 19 232 1 2 - 1 5 2
Irghi Willy A. 3 15/10/2007 12 147 1 2 - 1 3 2
Sabar 1 31/12/1971 48 579 1 1 - 1 3 6
Nur Utami 2 12/12/1975 44 531 2 1 2 1 3 1
Sugiarto 3 3/10/1997 22 269 1 2 - 1 2 1
Mohammad Abdul 3 19/7/2007 12 152 1 2 - 1 2 2
Sutikno 1 13/03/1973 46 Pas 1 1 - 1 4 3
Karmawati 2 19/12/1986 33 399 2 1 2 1 4 1
Puji lestari 3 9/2/2006 13 558 2 2 - 1 3 1
Agung pratama 3 8/1/2012 7 86 1 2 - 1 - -
Ahmad Safudin 1 24/11/1984 35 424 1 1 - 1 3 9
Rosmala Dewi 2 21/04/1984 35 431 2 1 2 1 1 4
Muhamad Irfan A 3 23/10/2009 10 125 1 2 - 1 1 1
Arsyla Romesa F 3 25/01/2017 3 38 2 2 - 1 - -
Herman Sujarwo 1 10/2/1968 51 613 1 1 - 1 3 9
Binah 2 12/10/1973 46 557 2 1 2 1 3 1
Wahyu Sodikin 3 24/12/2006 13 159 1 2 - 1 1 1
Suryatno 7 11/11/1972 47 568 1 2 - 1 3 9
Suyoto 1 7/1/1958 61 734 1 1 - 2 2 6
sumarni 2 12/11/1965 54 652 2 1 - 2 2 1
Teguh Utomo 3 11/2/1984 35 421 1 2 - 2 2 2
Nanik Endang L 3 22/11/1985 34 412 2 2 - 2 5 1
Rami 6 7/1/1921 92 1106 2 4 - 2 1 1
Isrowiyah 2 3/4/1965 54 659 2 1 2 1 3 6
Siti Handayani 3 20/6/1993 26 321 2 2 - 1 5 5
Siti Rodiah 3 26/11/1995 24 291 2 2 - 1 5 5
Siti Mardiah 3 26/11/19995 24 292 2 2 - 1 5 5
Alya Khairunisa 9 22/1/2006 13 158 2 2 - 1 1 2
Saipullah 1 31/12/1975 44 531 1 1 - 1 3 5
Kartini 2 31/12/1979 40 483 2 1 2 1 4 1
Maulana Saputra 3 18/6/1998 21 261 1 2 - 1 5 2
Shela Apriliani 3 8/4/2002 17 215 2 2 - 1 1 1
Siti Aisah 3 21/1/2008 11 134 2 2 - 1 1 2
Karla Rafania 3 1/4/2018 1 23 2 2 - 2 - -
Sumarno 1 4/4/1979 39 469 1 1 - 1 2 5
Jumiati 2 25/2/1983 36 433 2 1 2 1 2 1
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 Aji Naufal K 2 12/10/2008 10 125 1 2 - 1 2 1
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Naryati 8/11/1971 48 580 2 1 2 1 3 1
Indah Lestari 29/01/1983 26 314 2 2 - 1 4 5
Dinda Anggun E 30/11/1999 19 232 2 2 - 1 2 9
Muhamad asnawi M 11/1/1992 28 338 1 2 - 1 4 5
Hera Setiawan 4/10/1983 26 323 1 2 - 1 4 9
Sriyatun 6/12/1971 48 585 2 2 - 1 3 1
Poniman 22/04/1982 37 455 1 1 - 1 5 5
Musnadi 1 12/3/1979 40 480 1 1 - 1 5 8
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Dian Anggraeni 3 1/3/2010 9 108 2 2 - 1 2 -
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Sugianto 1 8/11/1982 40 484 1 1 - 1 5 8
Melliyanti 3 5/1/1982 37 446 2 1 2 1 4 1
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Kyaisha Amanda Saputri 3 18/01/2010 9 110 2 2 - 1 2 -
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Enny 2 20/11/1974 45 544 2 1 2 1 4 1
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Tarbiyatul Muhdalifa 3 26/11/2009 9 112 2 2 - 1 1 -
Sumardi. S 1 10/10/1965 53 641 1 1 - 1 4 6
Siti Harminah 2 15/06/1976 42 513 2 1 2 1 4 6
Nur Aini Yuni Saputri 3 29/06/1994 25 309 2 2 2 1 7 5
Dia Setia Ramadhani 3 20/09/2007 11 138 2 2 2 1 3 2
Sukaryo 1 7/6/1967 51 621 1 1 - 1 4 8
Puryanti 2 24/04/1972 46 563 2 1 2 1 1 1
Fitria Amalia Khusna 3 18/12/2001 17 207 2 2 2 1 5 2
Kamsinah 6 15/11/1935 83 1000 2 1 2 1 1 1
Ambok Upek 1 16/06/1981 37 453 1 1 - 1 5 5
Musdalipah 2 1/12/1986 32 387 2 1 2 1 5 1
Alia Kasida 3 14/07/2006 12 152 2 2 2 1 2 2
Siti Nurjanah Khalifah 3 21/04/2018 11 2 2 - 1 - -
Tukimin 1 7/12/1977 41 495 1 1 - 1 5 8
Sulistiorini 2 15/05/1984 34 418 1 1 2 1 4 1
Viona Umi Azizah 3 31/07/2004 14 176 2 2 2 1 3 2
Vania Kanaya Lasyifa 3 12/1/2014 5 62 2 2 - 1 2 -
Supawi. S 1 4/5/1963 55 670 1 1 - 1 3 9
Karsi 2 7/2/1963 56 673 2 1 2 1 3 1
Muhammad Athif 3 9/2/2002 17 205 1 2 - 1 4 2
 Purwanto 7 11/12/1977 41 495 1 2 - 1 4 5
Supriyanto 1 17/08/1978 40 487 1 1 - 1 5 5
Melliyarni 2 30/03/1987 36 432 1 1 2 1 4 9
Zaskia Meiya Azzahra 3 16/12/2009 9 111 2 2 - 1 2 -
Muhammad Zharif Mu'afi 3 16/10/2011 7 89 1 2 - 1 2 -
Syafril 1 20/031971 48 576 1 1 - 1 3 5
Aminah 2 23/05/1975 44 538 2 1 2 1 3 5
Windi Wulandari 3 6/6/1995 24 297 2 1 2 1 5 1
Rizki Ananda 3 27/06/2003 17 213 1 2 1 1 4 1
Sutaji 1 21/11/1988 30 364 1 1 - 1 2 8
Asrifah 2 17/04/1979 39 479 2 1 2 1 2 1
Lutfiyah unni'mah 3 13/11/1998 20 244 2 2 2 1 5 2
Sarno 1 8/11/1984 34 412 1 1 - 1 5 4
Semiyati 2 9/10/1989 29 353 2 1 2 1 5 1
Shakila Azzahra 3 14/10/2013 5 65 2 2 - 1 2 -
Sidik Tantawi 1 25/05/1986 32 394 1 1 - 1 3 5
Silvia Kartika Sari 2 13/10/1989 29 353 2 1 2 1 7 4
Syahilla Thalita Ash-Siddiq 3 15/07/2015 3 44 2 2 - 1 - -
Abdul Fitri 1 21/04/1994 24 299 1 1 - 1 4 5
Siti Wadianti 2 21/12/1997 22 267 2 1 2 1 3 1
Aisyah Ayudia Inara 3 29/07/2016 3 44 2 2 - 1 - -
M. Arsyad 1 16/07/1964 54 656 1 1 - 1 3 5
Karmini 2 8/5/1967 51 622 2 1 2 1 1 3
 V. Keterangan individu (anggota ART )
A. Identitas anggota rumah tangga B. Gangguan Kesehatan

6. batuk > 2 minggu, darah, BB turun, dll

5. minum obat secara teratus (jika ia)
2. BAB di jamban
1. no urut ART

3. TGL puldat

3. merokok

4. TBC
1. JKN
2. NIK

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4 1571076808080021 30/03/2019 1 - - - - -
1 1571071012440001 30/03/2019 1 1 2 1 1 1
2 1571075209550001 30/03/2019 1 1 2 2 - 2
1 1571074304560001 30/03/2019 2 1 2 2 - 2
1 1571071403730021' 3/24/2019 1 1 1 2 - 2
2 1571075603750021' 3/24/2019 1 1 2 2 - 2
3 1571074303030121' 3/24/2019 1 1 2 2 - 2
4 1571074209090041' 3/24/2019 1 - - - - -
1 1571073112520261' 3/24/2019 1 1 2 2 - 2
2 1571077112620402' 3/24/2019 1 1 2 2 - 2
1 1571072306800201' 3/24/2019 1 1 1 2 - 2
2 1571076206860081' 3/24/2019 1 1 2 2 - 2
3 1571070606060101' 3/24/2019 1 - - - - -
4 1571070404130002' 3/24/2019 2 - - - - -
1 1571071605720101' 3/24/2019 1 1 1 2 - 2
2 1571075212820101' 3/24/2019 1 1 2 2 - 2
3 1571074601010041' 3/24/2019 1 1 2 2 - 2
1 1571071311560001' 3/24/2019 1 1 1 2 - 2
2 1571076109630021' 3/24/2019 1 1 2 2 - 2
3 1571074806800061' 3/24/2019 1 1 2 2 - 2
4 1571071111870121' 3/24/2019 1 1 1 2 - 2
1 1571070507500061' 3/24/2019 1 1 1 2 - 2
2 1571074312600001' 3/24/2019 1 1 2 2 - 2
3 1571075212970041' 3/24/2019 1 1 2 2 - 2
4 1571070709860021' 3/24/2019 1 1 2 2 - 2
1 1571072712770041' 3/24/2019 1 1 2 2 - 2
2 1571075007890082' 3/24/2019 1 1 2 2 - 2
3 1571075704100041' 3/24/2019 1 - - - - -
4 1571072904180001' 3/24/2019 1 - - - - -
1 1571070104680121' 3/24/2019 1 1 1 2 - 2
2 1571076403750021' 3/24/2019 1 1 2 2 - 2
3 1571074910380021' 3/24/2019 1 1 2 2 - 2
1 1507031507800091' 3/24/2019 1 1 2 2 - 2
2 1571074107790121' 3/24/2019 1 1 2 2 - 2
3 1571074401020041' 3/24/2019 1 1 2 2 - 2
4 1571070808130003' 3/24/2019 1 - - - - -
1 1571076004670001' 3/24/2019 2 1 2 2 - 2
1 1505081605840001' 3/24/2019 1 1 1 2 - 2
2 1505084704820001' 3/24/2019 1 1 2 2 - 2
3 1505080108060001' 3/24/2019 1 - - - - -
4 1571072212150008. 3/24/2019 1 - - - - -
1 1571070107560202 3/24/2019 2 1 2 2 - 2
2 1571074107460320 3/24/2019 2 1 2 2 - 2
1 1571072508590040 3/30/2019 1 1 2 2 - 2
2 1571077005700021 3/30/2019 1 1 2 2 - 2
1 3318092801960000 3/24/2019 1 1 1 2 - 2
2 ,1571076510990040 3/24/2019 1 1 2 2 - 2
3 ,1571075001180005 3/24/2019 1 - - - - -
1 1505082512890001 3/30/2019 1 1 1 2 - 2
2 1209144105870007 3/30/2019 1 1 2 2 - 2
3 1571076112160002 3/30/2019 1 - - - - -
1 1571071705840061 3/24/2019 1 1 1 2 - 2
2 1571075203860190 3/24/2019 1 1 2 2 - 2
3 1571070705110000 3/24/2019 1 - - - - -
4 1571074312160000 3/24/2019 1 - - - - -
1 1505081910860003 3/24/2019 1 1 1 2 - 2
2 1505086409780002 3/24/2019 1 1 2 2 - 2
3 1505081611990001 3/24/2019 1 1 1 2 - 2
4 1505081510070002 3/24/2019 1 - - - - -
1 1571073112710000 3/24/2019 1 1 2 2 - 2
2 1571075212750020 3/24/2019 1 1 2 2 - 2
3 1571070910970000 3/24/2019 1 1 2 2 - 2
4 1571071910070100 3/24/2019 1 - - - - -
1 ,1571073037300440 3/30/2019 1 1 2 2 - 2
2 ,1571075128660021 3/30/2019 1 1 2 2 - 2
3 ,15710746090660041 3/30/2019 1 - - - - -
4 ,1571070108120002 3/30/2019 1 - - - - -
1 ,1571022111840181 3/24/2019 2 1 1 2 - 2
2 ,1571026104840201 3/24/2019 2 1 2 2 - 2
3 ,1571022310090001 3/24/2019 2 - - - - -
4 1571076501170001 24/03/2019 2 - - - - -
1 157107100268061 3/24/2019 1 1 1 2 - 2
2 1571075210730041 3/24/2019 1 1 2 2 - 2
3 1571072412060021 3/24/2019 1 - - - - -
4 1571071111720081 3/24/2019 1 1 2 2 - 2
1 ,1571070175580021 3/24/2019 1 1 2 2 - 2
2 ,15710751112650021 3/24/2019 1 1 2 2 - 2
3 ,1571071102840001 3/24/2019 1 1 1 2 - 2
4 ,1571076211850021 3/24/2019 1 1 2 2 - 2
5 ,1571074107210001 3/24/2019 1 1 2 2 - 2
2 1505084304650001 3/24/2019 2 1 2 2 - 2
3 1505086006930001 3/24/2019 2 1 2 2 - 2
4 1505086811950002 3/24/2019 2 1 2 2 - 2
5 1505086811950001 3/24/2019 2 1 2 2 - 2
6 1571078201060141 3/24/2019 2 - - - - -
1 1571083112750141 3/24/2019 1 1 1 2 - 2
2 1571087112790181 3/24/2019 1 1 2 2 - 2
3 1571081806980021 3/24/2019 1 1 2 2 - 2
4 1571084804020081 3/24/2019 1 1 2 2 - 2
5 1571076101080062 3/24/2019 1 - - - - -
6 ,1571074401180003 3/24/2018 1 - - - - -
1 1571080404790121 3/24/2019 2 1 1 2 - 2
2 1571082505830021 3/24/2019 2 1 2 2 - 2
3 1571082701030021 3/24/2019 2 1 2 2 - 2
4 1571081012080021 3/24/2019 2 - - - - -
5 1571085212110001 3/24/2019 2 - - - - -
1 ,1571971804700001 3/24/2019 1 1 2 2 - 2
2 ,1571015106710061 3/24/2019 1 1 2 2 - 2
3 ,1571016901930001 3/24/2019 1 1 2 2 - 2
4 ,1571017011980021 3/24/2019 1 1 2 2 - 2
5 ,1571070711920102 3/24/2019 1 1 2 2 - 2
6 ,1571075206710122 3/24/2019 1 1 2 2 - 2
7 ,1571011004930061 3/24/2019 1 1 2 2 - 2
8 ,1571012204820081 3/24/2019 1 1 2 2 - 2
1 1571071203790181' 24/03/2019 2 2 1 2 - 2
2 1571075507850142' 24/03/2019 2 2 2 2 - 2
3 1571072911040061' 24/03/2019 2 - - - - -
4 1571074103100041' 24/03/2019 2 - - - - -
5 1571072802180003' 24/03/2019 2 - - - - -
6 1571074102620122' 24/03/2019 1 1 2 2 - 2
1 1505080811780001' 24/03/2019 1 1 1 2 - 2
2 1505084501820001' 24/03/2019 1 1 2 2 - 2
3 1505084701030001' 24/03/2019 1 1 2 2 - 2
4 1505085801100003' 24/03/2019 1 - - - - -
5 1571070601180005' 24/03/2019 1 - - - - -
1 1571071012700081' 24/03/2019 1 1 1 2 - 2
2 1571074406890021' 24/03/2019 1 1 2 2 - 2
3 1571075006020121' 24/03/2019 1 1 2 2 - 2
4 1571076408040081' 24/03/2019 1 1 2 2 - 2
5 1571076010070021' 24/03/2019 1 - - - - -
1 1571071210680041' 24/03/2019 1 1 1 1 1 2
2 1571076311740021' 24/03/2019 1 1 2 2 - 2
3 1571076212940041' 24/03/2019 1 1 2 2 - 2
4 1571073010970121' 24/03/2019 1 1 2 2 - 2
5 1571076611090043' 24/03/2019 1 - - - - -
1 1571071010650201' 24/03/2019 1 1 2 2 - 2
2 1571075506760041' 24/03/2019 1 1 2 2 - 2
3 1571076906940001' 24/03/2019 1 1 2 2 - 2
4 1571076009070001' 24/03/2019 1 - - - - -
1 1571070706670061' 24/03/2019 1 1 1 2 - 2
2 1571076304720181' 24/03/2019 1 1 2 2 - 2
3 1571076712010121' 24/03/2019 1 1 2 2 - 2
4 1571076611360021' 24/03/2019 1 1 2 2 - 2
1 1571071606810102' 24/03/2019 1 1 2 2 - 2
2 1571074112066122' 24/03/2019 1 1 2 2 - 2
3 1571075407060082' 24/03/2019 1 - - - - -
4 1571076104180003' 24/03/2019 1 - - - - -
1 1571070712770061' 24/03/2019 1 1 2 2 - 2
2 1571075505840241' 24/03/2019 1 1 2 2 - 2
3 1571077107040021' 24/03/2019 1 - - - - -
4 1571075201140001' 24/03/2019 1 - - - - -
1 1571030405630041' 24/03/2019 1 1 2 2 - 2
2 1571034702630041' 24/03/2019 1 1 2 2 - 2
3 1571070902020162' 24/03/2019 1 1 2 2 - 2
4 1571071112770083' 24/03/2019 2 1 1 2 - 2
1 1571071709760241' 30/03/2019 1 1 2 2 - 2
2 1571077003630061' 30/03/2019 1 1 2 2 - 2
3 1571075612090021' 30/03/2019 1 - - - - -
4 1571071610110042' 30/03/2019 1 - - - - -
1 1571072003710042' 30/03/2019 1 1 1 2 - 2
2 1571076306750062' 30/03/2019 1 1 2 2 - 2
3 1571074606960162' 30/03/2019 1 1 2 2 - 2
4 1571072706020062' 30/03/2019 1 1 1 2 - 2
1 1571072122680041' 24/03/2019 1 1 1 2 - 2
2 1571076704790021' 24/03/2019 1 1 2 2 - 2
3 1571076311980021' 24/03/2019 1 1 2 2 - 2
1 1571070811840051' 24/03/2019 1 1 2 2 - 2
2 1571024910890121' 24/03/2019 1 1 2 2 - 2
3 1571075410130002' 24/03/2019 1 - - - - -
1 1571072505880283' 24/03/2019 1 1 1 2 - 2
2 1571025310890121' 24/03/2019 1 1 2 2 - 2
3 1571075307130002' 24/03/2019 1 - - - - -
1 1571071404940102' 24/03/2019 2 1 1 2 - 2
2 1571026112970001' 24/03/2019 2 1 1 2 - 2
3 1571076907160003' 24/03/2019 2 - - - - -
1 1571071607640002' 24/03/2019 1 1 2 2 - 2
2 1571074805670043' 24/03/2019 1 1 2 2 - 2
B. Gangguan Kesehatan Indikator Pola Hidup Bersih dan Sehat dalam tatanan Rumah tangga

2. Cuci tangan dengan sabun dan air bersih

11. imunisasi lengkap ART 12-13 Bulan
9.bersalin di faskes ART < 12 Bulan

10. ASI eksklusif ART 7-23 Bulan

Minum obat secara teratur

12. pemantauan balita

1. Persalinan Faskes
8. penggunaan KB

4. Makan Buah
7. Hipertensi

3. PSN 3 M
KK ke-
No
2 - 2 - - - - 1 1 1 1 1
2 - 2 - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
- - - - - - -
2 - 1 - - - - 2 1 1 1 2
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
2 - 1 - - - - 3 - 2 1 1
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
2 - 2 - - - - 4 1 2 1 2
2 - 2 - - - -
2 - 2 - - - - 5 - 1 1 2
2 - 2 - - - -
- - - - 1 - 1
2 - 2 - - - - 6 1 1 1 2
2 - 2 - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
2 - - - - - -
2 - - - - - - 7 1 1 1 1
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
1 1 2 - - - - 8 1 1 1 1
1 1 2 - - - -
2 - 1 - - - - 9 1 1 1 1
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
2 - 2 - - - - 10 1 1 1 1
1 1 2 - - - -
- - - - - - -
2 - 2 - - - - 11 - 1 1 2
2 - 2 - - - -
2 - 1 - - - - 12 1 1 1 1
2 - 1 - - - -
2 - - - - - -
2 - 2 - - - - 13 2 1 1 1
2 - 2 - - - -
2 - - - - - -
- - - - - - -
2 - 2 - - - - 14 1 1 1 2
2 - 1 - - - -
2 - - - - - -
- - - - - - -
2 - - - - - - 15 1 1 2 1
2 - 1 - - - -
2 - - - - - -
2 - 2 - - - - 16 1 1 2 1
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - - 17 2 1 2 2
2 - - - - - -
2 - - - - - - 18 - 1 1 2
1 1 - - - - - 19 2 1 1 2
2 - - - - - -
2 - 1 - - - - 20 2 1 1 2
1 2 1 - - - -
1 1 1 - - - - 21 1 1 2 2
2 - 1 - - - -
- - - - - - -
2 - 2 - - - - 22 1 1 1 1
2 - 2 - - - -
- - - - - - -
2 - 1 - - - - 23 1 1 1 2
2 - 1 - - - -
- - - - - - -
2 - 1 - - - - 24 1 1 1 2
2 - 1 - - - -
- - - 1 1 1 1
2 - 1 - - - - 25 1 1 1 2
1 1 1 - - - -
2 - - - - - -
2 - - - - - - 26 1 1 1 2
1 2 - - - - -
2 - 1 - - - - 27 1 1 2 1
2 - 1 - - - -
- - - - - - 2
- - - - - - 2
2 - 1 - - - - 28 2 1 1 1
2 - 1 - - - -
- - - - - - -
- - - 1- - 2
2 - 2 - - - - 29 1 1 1 1
2 - 2 - - - -
2 - - - - - -
- - - - - - -
2 - 2 - - - - 30 1 1 1 2
2 - 2 - - - -
- - - - - - -
- - - 1 2- 2
2 - 2 - - - - 31 1 1 1 2
2 - 2 - - - -
- - - - - - -
- - - - 2- 1
2 - - - - - - 32 1 1 1 2
1 1 1 - - - -
2 - - - - - -
- - - - - - -
2 - 2 - - - - 33 1 1 1 1
1 1 2 - - - -
2 - - - - - -
- - - - - - -
- - - - - - 2
2 - - - - - - 34 1 1 2 2
1 2 2 - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
2 - - - - - - 35 1 1 1 1
2 - 2 - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - 1 - - - - 36 2 1 1 1
2 - 1 - - - -
- - - - - - -
2 - 1 - - - - 37 1 2 1 1
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
- - - - - - -
2 - 1 - - - - 38 1 2 2 2
2 - 1 - - - -
- - - - - - -
- - - - - - 1
- - - - - - 1
2 - - - - - - 39 2 2 1 2
2 - - - - - -
2 - - - - - -
1 2 1 - - - - 40 1 1 1 2
2 - 1 - - - -
- - - - - - -
- - - - - - 1
2 - 1 - - - - 41 1 1 1 2
2 - 1 - - - -
- - - - - - -
- - - - - - -
2 - - - - - -
2 - 1 - - - - 42 1 1 1 1
2 - 1 - - - -
- - - - - - -
- - - - - - 1
- - - - 1 2 1
2 - 2 - - - - 43 1 1 1 2
2 - 2 - - - -
- - - - - - -
2 - - - - - - 44 1 1 1 2
1 2 2 - - - -
2 - 2 - - - - 45 2 1 2 2
2 - 2 - - - - 46 1 1 1 2
2 - 2 - - - -
1 2 - - - - - 47 2 1 1 2
2 - - - - - -
2 - 2 - - - - 48 1 1 2 2
2 - 2 - - - -
1 2 - - - - - 49 2 1 1 2
2 - - - - - -
2 - 1 - - - - 50 1 2 2 2
2 - 1 - - - -
2 - - - - - -
- - - - - - -
1 2 - - - - -
2 - 1 - - - - 51 1 1 1 2
2 - 1 - - - -
- - - - - - -
- - - - - - -
2 - 2 - - - - 52 1 2 2 2
2 - 2 - - - -
- - - - - - 1
2 - 1 - - - - 53 1 1 1 2
2 - 1 - - - -
2 - - - - - -
- - - - - - -
2 - - - - - - 54 2 2 1 2
2 - - - - - -
2 - - - - - - 55 2 2 2 2
2 - 1 - - - - 56 1 1 2 2
2 - 1 - - - -
2 - - - - - -
- - - - - - -
2 - - - - - - 57 2 2 1 2
2 - - - - - -
2 - 1 - - - - 58 1 1 1 2
2 - 1 - - - -
- - - - - - -
- - - - - - -
2 - 2 - - - - 59 1 1 1 2
2 - 2 - - - -
2 - - - - - -
2 - - - - - - 60 2 1 2 2
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - - 61 2 1 1 2
1 1 - - - - -
2 - - - - - -
2 - - - - - -
2 - 1 - - - - 62 1 1 1 2
2 - 1 - - - -
- - - - - - -
- - - 1 1 1 1
2 - 2 - - - - 63 2 1 2 2
2 - 2 - - - -
2 - - - - - -
2 - 1 - - - - 64 1 1 1 1
2 - 1 - - - -
2 - - - - - -
- - - - - - -
2 - - - - - - 65 - 1 1 2
2 - 1 - - - - 66 1 1 1 2
2 - 1 - - - -
- - - - - - -
- - - - - - 2
2 - 2 - - - - 67 2 2 1 2
2 - 2 - - - -
1 2 2 - - - - 68 1 1 1 1
1 2 2 - - - -
2 - 2 - - - - 69 1 1 2 1
2 - 1 - - - -
- - - - 1 - 2
2 - 1 - - - - 70 1 2 1 2
2 - 1 - - - -
- - - - - - 2
2 - 2 - - - - 71 1 1 1 2
2 - 1 - - - -
- - - - - - -
- - - - - - 2
2 - 2 - - - - 72 1 1 1 2
2 - 2 - - - -
2 - - - - - -
- - - - - - -
2 - 2 - - - - 73 1 1 1 2
2 - 1 - - - -
2 - - - - - -
- - - - - - -
2 - 2 - - - - 74 1 2 1 2
2 - 2 - - - -
- - - - - - -
- - - - - - -
2 - 2 - - - - 75 1 1 1 2
2 - 2 - - - -
- - - - - - -
- - - - 1- -
2 - 2 - - - - 76 1 1 1 2
2 - 2 - - - -
- - - - - - -
2 - - - - - -
2 - - - - - - 77 2 1 1 2
2 - 2 - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - 2 - - - - 78 2 1 1 2
2 - 2 - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
2 - 1 - - - - 79 1 1 1 2
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
- - - - 2- 2
2 - 2 - - - - 80 1 1 1 2
2 - 1 - - - -
2 - - - - - -
- - - - - - -
- - - - - - -
2 - 2 - - - - 81 2 1 1 2
2 - 2 - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - - - - - -
2 - 2 - - - -
2 - 1 - - - - 82 1 1 1 2
2 - 1 - - - -
- - - - - - -
- - - - - - -
- - - - 1 1 1
2 - - - - - -
2 - 2 - - - - 83 1 1 1 1
2 - 2 - - - -
2 - - - - - -
- - - - 1 1 1
- - - - - - 1
2 - 1 - - - - 84 1 1 1 2
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
2 - 1 - - - - 85 1 1 1 2
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
- - - - - - -
1 1 1 - - - - 86 1 1 1 2
2 - 1 - - - -
2 - - - - - -
- - - - - - -
2 - 1 - - - - 87 1 1 1 2
2 - 1 - - - -
2 - - - - - -
1 1 - - - - -
2 - 1 - - - - 88 1 1 2 2
2 - 1 - - - -
- - - - - - -
- - - 1 2 - 1
1 1 1 - - - - 89 1 1 1 1
2 - 1 - - - -
- - - - - - -
- - - - - - -
2 - 1 - - - - 90 1 1 2 1
2 - 1 - - - -
2 - - - - - -
2 - - - - - -
2 - 1 - - - - 91 1 1 1 1
2 - 1 - - - -
- - - - - - -
- - - - - - -
2 - 1 - - - - 92 1 1 1 1
2 - 1 - - - -
2 - 2 - - - -
2 - - - - -
2 - 2 - - - - 93 1 1 2 2
2 - 2 - - - -
2 - - - - - -
2 - 1 - - - - 94 1 1 1 1
2 - 1 - - - -
- - - - - - -
2 - 1 - - - - 95 1 1 2 1
2 - 1 - - - -
- - - - - - 2
2 - 1 - - - - 96 1 1 1 2
2 - 1 - - - -
- - - - - - 2
2 - - - - - - 97 1 1 2 1
1 1 2 - - - -
tatanan Rumah tangga

7. Merokok di rumah
6. Aktivitas fisik
5. Makan sayur

1 1 1

1 1 2
Catt:
1. P : Sumur gali terlindung
1. R : kloset (jongkok)

1 2 1

2 2 2

2 2 1

1 1 2

1 2 2

1 1 2
2 2 2

1 1 2

1 1 1

1 1 2

1 1 2

1 1 2

1 2 1

1 2 2

1 2 2

2 1 1
1 1 1

1 1 2

1 2 1

1 1 2

1 1 2

1 1 2
1 1 1

1 1 1

1 2 2

1 1 2

1 1 1

1 1 1

1 1 2

1 1 1

1 1 2

1 2 2

2 2 2

1 1 2

1 1 2
1 1 2

1 1 2

1 2 2

2 1 2

1 1 2

1 1 2

1 1 2

2 1 2
1 1 2

1 1 2

1 2 2

1 1 1

1 1 2

2 1 2
2 2 2

1 1 1

1 2 2

2 1 2
1 1 1

1 1 2

1 1 2

1 1 2

1 1 2

1 1 2

1 1 2

1 1 2

1 1 2

2 2 2
1 1 2

1 1 2

1 1 2
1 1 2

1 1 2

1
1 1 2

1 1 2

1 1 2

1 1 2

1 1 2

1 1 2

1 1 2

1 1 1

1 1 2

1 2 2
1 1 1

1 1 1

1 1 2

1 1 2

1 1 1

1 1 2

1 1 2

2 1 2

1 1 2

1 1 2
1 1 2

1 1 1

1 1 2

1 1 2

1 1 1

1 1 2

1 1 2
 PROGRAM PIS-PK

5.Bayi dan balita dilakukan pemantauan tumbuh kembang

2. Ibu bersalin di fasilitas pelayanan kesehatan
1. Pasangan suami istri mengikuti program KB

3. Bayi memperoleh imunisasi lengkap

4. Bayi memperoleh ASI eklusif

KK Ke-
No

1 KK Ke-1 2 - - - -
2 kk Ke-2 1 - - - -
3 KK Ke-3 1 - - - -
4 KK Ke-4 2 - - - -
5 KK Ke-5 2 - - 1 1
6 KK Ke-6 1 - - - -
7 KK Ke-7 2 - - - -
8 KK Ke-8 2 - - - -
9 KK Ke-9 1 - - - -
10 KK Ke-10 2 - - - -
11 KK Ke-11 2 - - - -
12 KK Ke-12 1 - - - -
13 KK Ke-13 2 - - - -
14 KK Ke-14 1 - - - -
15 KK Ke-15 1 - - - -
16 KK Ke-16 1 - - - -
17 KK Ke-17 - - - - -
18 KK Ke-18 - - - - -
19 KK Ke-19 - - - - -
20 KK Ke-20 1 - - - -
21 KK Ke-21 1 - - - -
22 KK Ke-22 2 - - - -
23 KK Ke-23 1 - - - -
24 KK Ke-24 1 - 1 1 1
25 KK Ke-25 1 - - - -
26 KK Ke-26 - - - - -
27 KK Ke-27 1 - - - 2
28 KK Ke-28 1 1 - - 2
29 KK Ke-29 2 - - - -
30 KK Ke-30 2 1 - 2 2
31 KK Ke-31 2 - - 2 1
32 KK Ke-32 1 - - - -
33 KK Ke-33 2 - - - 1
34 KK Ke-34 2 - - - -
35 KK Ke-35 2 - - - -
36 KK Ke-36 1 - - - -
37 KK Ke-37 1 - - - -
38 KK Ke-38 1 - - - 1
39 KK Ke-39 - - - - -
40 KK Ke-40 1 - - - 1
41 KK Ke-41 1 - - - -
42 KK Ke-42 1 - 2 1 1
43 KK Ke-43 2 - - - -
44 KK Ke-44 2 - - - -
45 KK Ke-45 2 - - - -
46 KK Ke-46 - - - - -
47 KK Ke-47 - - - - -
48 KK Ke-48 2 - - - -
49 KK Ke-49 - - - - -
50 KK Ke-50 1 - - - -
51 KK Ke-51 1 - - - -
52 KK Ke-52 2 - - - 1
53 KK Ke-53 1 - - - -
54 KK Ke-54 - - - - -
55 KK Ke-55 - - - - -
56 KK Ke-56 1 - - - -
57 KK Ke-57 - - - - -
58 KK Ke-58 1 - - - -
59 KK Ke-59 2 - - - -
60 KK Ke-60 - - - - -
61 KK Ke-61 - - - - -
62 KK Ke-62 1 1 1 1 1
63 KK Ke-63 2 - - - -
64 KK Ke-64 1 - - - -
65 KK Ke-65 - - - - -
66 KK Ke-66 1 - - - -
67 KK Ke-67 2 - - - -
68 KK Ke-68 2 - - - -
69 KK Ke-69 1 - - 1 2
70 KK Ke-70 1 - - - 2
71 KK Ke-71 1 - - - 2
72 KK Ke-72 2 - - - -
73 KK Ke-73 1 - - - -
74 KK Ke-74 2 - - - -
75 KK Ke-75 1 - - 1 -
76 KK Ke-76 2 - - - -
77 KK Ke-77 2 - - - -
78 KK Ke-78 2 - - - -
79 KK Ke-79 1 - - 1 2
80 KK Ke-80 1 - - - -
81 KK Ke-81 2 - - - -
82 KK Ke-82 1 - 1 1 1
83 KK Ke-83 2 - 1 1 1
84 KK Ke-84 1 - - - -
85 KK Ke-85 1 - - - -
86 KK Ke-86 1 - - - -
87 KK Ke-87 1 - - - -
88 KK Ke-88 1 1 - 2 1
89 KK Ke-89 1 - - - -
90 KK Ke-90 1 - - - -
91 KK Ke-91 1 - - - -
92 KK Ke-92 1 - - - -
93 KK Ke-93 2 - - - -
94 KK Ke-94 1 - - - -
95 KK Ke-95 1 - - - 2
96 KK Ke-96 1 - - - 2
97 KK Ke-97 2 - - - -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-

1
1

-
6. TB Paru berobat sesuai standar
PROGRAM PIS-PK

-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-

2
1
1
2
1
1
1

-
7. Tekanan darah tinggi berobat sesuai standar

-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-

2
2
2
2
2
2
2
2
2
2
2
2
2
2
8.Gangguan Jiwa

1
2
2
1
1
2
2
1
1
1
2
1
2
2
1
2
2
2
1
1
2
1
2
2
2
2
2
2
2
2
2
9.Anggota rumah tangga yang tidak merokok

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
10. Keluarga menggunakan air bersih

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
11. Keluarga memiliki jamban sehat

1
1
2
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

12. Anggota rumah tangga memiliki JKN

- 1 2 2 1 1 1
- 1 2 2 1 1 1
- 2 2 2 1 1 1
- - 2 1 1 1 1
- - 2 1 1 1 1
- - 2 1 1 1 2
- - 2 2 1 1 1
- - 2 2 1 1 2
- 2 2 2 1 1 1
- - 2 2 1 1 1
- - 2 2 1 1 1
- - 2 1 1 1 1
- 2 2 2 1 1 1
- - 2 1 1 1 1
- - 2 2 1 1 1
- 2 2 2 1 1 1
- - 2 2 1 1 2
- 2 2 1 1 1 1
- 2 2 1 1 1 1
- - 2 1 1 1 1
- - 2 2 1 1 1
- - 2 2 1 1 1
1 - 2 1 1 1 1
- - 2 1 1 1 2
- - 2 2 1 1 1
- - 2 2 1 1 1
- - 2 2 1 1 2
- - 2 2 1 1 1
- - 2 2 1 1 1
- 1 2 2 1 1 1
- - 2 2 1 1 1
- - 2 2 1 1 1
- - 2 2 1 1 1
- - 2 2 1 1 2
- - 2 2 1 1 1
- - - 1 1 1 2
- 2 - 1 1 1 1
- - - 2 1 1 1
- - - 2 1 1 1
- - - 2 1 1 1
- - - 2 1 1 1
- - - 1 1 1 1
- - - 1 1 1 1
- - - 2 1 1 2
- - - 2 1 1 1
- - - 2 1 1 1
- - - 1 1 1 2
- - - 2 1 1 1
- - - 2 1 1 2
- - - 1 1 1 1
2 - 2 2 1 1 2
2 - 2 2 1 1 1
2 - 2 2 1 1 1
2 - 2 2 1 1 1
2 1 2 1 1 1 1
2 1 2 2 1 1 1
2 - 2 1 1 1 1
2 1 2 1 1 1 1
2 - 2 2 1 1 1
2 - 2 1 1 1 1
2 - 2 2 1 1 1
2 - 2 2 1 1 1
2 - 2 1 1 1 1
2 - 2 2 1 1 1
2 - 2 2 1 1 2
2 1 2 1 1 1 1