LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : JANUARI 2022

IDENTITAS GEJALA YANG DIALAMI

JK No. Batch/ TEMPAT DEMAM BENGKAK MERAH MUNTAH
No. Batch/ JENIS VAKSIN TANGGAL
NO UMUR JENIS VAKSIN 1 Exp.Date Vaksin PEMBERI IMUNISASI PELAYANAN LAIN-LAIN
NAMA ANAK TGL LAHIR NAMA ORTU ALAMAT Exp.Date Vaksin 1 2 IMUNISASI
(bln) 2 IMUNISASI (SEBUTKAN)
L/P Jika ya ditandai P

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Fahra P 10/05/2020 20 Ana / Syaiful Bandengan DPT/Hb/Hib 1 Polio 2 Amalia K, A.Md.Keb Posyandu 24/01/2022 √

2 Jihan P 09/07/2021 6 Ike / Dwi Paowan DPT/Hb/Hib 1 Polio 2 Sofi A, A.Md.Keb Ponkesdes 28/01/2022 √

3 Zahra P 30/10/2021 3 Khoiotin Blikeran 1/1 DPT/Hb/Hib 1 Polio 2 Diana B, A.Md.Keb Posyandu 18/01/2022 √

4 Zafran L 25/07/2021 6 Desi Blikeran 3/1 DPT/Hb/Hib 1 Polio 2 Diana B, A.Md.Keb Posyandu 18/01/2022 √

5 Nur Siena P 26/07/2021 6 Riska A Blikeran 2/1 DPT/Hb/Hib 2 Polio 3 Diana B, A.Md.Keb Posyandu 18/01/2022 √

6 Wildan Aff L 01/10/2021 3 Nurul Randu 4/1 DPT/Hb/Hib 1 Polio 2 Istiqomah, A.Md.Keb Pustu 09/01/2022 √

7 Zahrul P 22/06/2021 8 Ulfah Langai 4/1 DPT/Hb/Hib 2 Polio 3 Istiqomah, A.Md.Keb Pustu 09/01/2022 √

8 Talita P 10/10/2020 3 Mikyal Krj. Timur DPT/Hb/Hib 1 Polio 2 Darwati, S.Tr.Keb Ponkesdes 20/01/2022 √

9 Fania P 11/04/2021 2 Wasita Krj. Timur DPT/Hb/Hib 1 Polio 2 Darwati, S.Tr.Keb Ponkesdes 18/01/2022 √

10 Bisma L 21/09/2021 4 Rindi Krj. Timur DPT/Hb/Hib 2 Polio 3 Darwati, S.Tr.Keb Ponkesdes 08/01/2022 √

11 Kenzo L 28/09/2021 4 Tri Angraini Krj. Barat DPT/Hb/Hib 2 Polio 3 Darwati, S.Tr.Keb Ponkesdes 08/01/2022 √

12 Abil L 07/02/2021 6 Anik Krj. Timur DPT/Hb/Hib 3 Polio 4 Darwati, S.Tr.Keb Ponkesdes 20/01/2022 √

13 Clarinfa P 20/02/2021 23 Fitriyatul Parut 2/1 DPT/Hb/Hib 4 - Sulistina, A.Md.Keb Ponkesdes 20/01/2022 √

14 Ranarya L 26/04/2021 9 Ulfah Parut 1/2 DPT/Hb/Hib 2 Polio 3 Sulistina, A.Md.Keb Ponkesdes 20/01/2022 √

15 Kaira P 17/08/2021 5 Yeni Panorama DPT/Hb/Hib 3 Polio 2 Sulistina, A.Md.Keb Ponkesdes 20/01/2022 √

16 Viko L 30/10/2021 3 Nurvia R Villa Bukit DPT/Hb/Hib 1 Polio 2 Sulistina, A.Md.Keb Ponkesdes 20/01/2022 √

17 Syakila P 22/11/2021 2 Putri Devi Parsel 1/4 DPT/Hb/Hib1 Polio 2 Sulistina, A.Md.Keb Ponkesdes 20/01/2022 √

18 Tirta Malik Neyhan L 27/09/2021 4 Ayu / Agus Krajan 12/5 DPT/Hb/Hib 1 Polio 2 Maknunah, A.Md.Keb Posyandu 25/01/2022 √
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 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : FEBRUARI 2022

IDENTITAS GEJALA YANG DIALAMI

JK No. Batch/ TEMPAT DEMAM BENGKAK MERAH MUNTAH
No. Batch/ JENIS VAKSIN TANGGAL
NO UMUR JENIS VAKSIN 1 Exp.Date Vaksin 1 2 Exp.Date Vaksin PEMBERI IMUNISASI PELAYANAN IMUNISASI LAIN-LAIN
NAMA ANAK TGL LAHIR (bln) NAMA ORTU ALAMAT 2 IMUNISASI (SEBUTKAN)
L/P Jika ya ditandai P

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Ponkesdes
1 M. Azka L 18/03/2021 11 Dewi Karangsari DPT/Hb/Hib 3 5010120 / 12.22 Polio 4 2053121 / 4.23 Amalia K, A.Md.Keb Kilensari 1 8/2/2022 √

Ponkesdes
2 Aretha P 13/11/2021 3 Nur Latifa Karangsari 3/4 DPT/Hb/Hib 1 5010120 / 12.22 Polio 2 2053121 / 4.23 Amalia K, A.Md.Keb Kilensari 2 8/2/2022 √

3 Vania P 3 Wasita Krajan Timur 1/3 DPT/Hb/Hib 1 5010120 / 12.22 Polio 2 2053121 / 4.23 Darwatiningsih, S.ST Ponkesdes 10/2/2022 √

4 Holifatus Zahro P 23/3/2021 11 Khofifah Sabrang 1/1 DPT/Hb/Hib 3 5010120 / 12.22 Polio 4 2053121 / 4.23 Diana B, A.Md.Keb Posyandu 14/2/2022 √

Ponkesdes
5 Nofisa P 30/5/2021 9 Isnaini / Juhri Tokengan DPT/Hb/Hib 2 5010120 / 12.22 Polio 3 2053121 / 4.23 Ika Sahadatina, A.Md.Keb Peleyan 25/2/2022 √

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 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : MARET 2022

IDENTITAS GEJALA YANG DIALAMI

JK No. Batch/ TEMPAT DEMAM BENGKAK MERAH MUNTAH
No. Batch/ JENIS VAKSIN TANGGAL
NO UMUR JENIS VAKSIN 1 Exp.Date Vaksin 1 2 Exp.Date Vaksin PEMBERI IMUNISASI PELAYANAN IMUNISASI LAIN-LAIN
NAMA ANAK TGL LAHIR (bln) NAMA ORTU ALAMAT 2 IMUNISASI (SEBUTKAN)
L/P Jika ya ditandai P

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Oktaviani / Ponkesdes
1 M. Daviansyah L 19/8/2021 7 Ahmad Kilensari 2/1 DPT/Hb/Hib 3 5040221 / 4.23 Polio 4 2051821 / 2.23 Amalia K, A.Md.Keb Kilensari 1 11/3/2022 √

2 Fahmi L 12/12/2021 3 Kiki Krajan Timur DPT/Hb/Hib 1 5040221 / 4.23 Polio 2 2051821 / 2.23 Darwatiningsih, S.ST Ponkesdes 21/3/2022 √

3 Tiwi P 25/5/2021 10 Siti Holfia Sabrang 1/1 DPT/Hb/Hib 3 5040221 / 4.23 Polio 4 2051821 / 2.23 Diana B, A.Md.Keb Posyandu 10/3/2022 √

Ponkesdes
4 Tazkiyah P 17/8/2021 7 Rohmi Kota Beddah DPT/Hb/Hib 2 5040221 / 4.23 Polio 3 2053121 / 2.23 Ika Sahadatina, A.Md.Keb Peleyan 25/3/2022 √

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 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : APRIL 2022

IDENTITAS GEJALA YANG DIALAMI

JK No. Batch/ TEMPAT DEMAM BENGKAK MERAH MUNTAH
No. Batch/ JENIS VAKSIN TANGGAL
NO UMUR JENIS VAKSIN 1 Exp.Date Vaksin 1 2 Exp.Date Vaksin PEMBERI IMUNISASI PELAYANAN IMUNISASI LAIN-LAIN
NAMA ANAK TGL LAHIR (bln) NAMA ORTU ALAMAT 2 IMUNISASI (SEBUTKAN)
L/P Jika ya ditandai P

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 Al Maira P 9/1/2022 3 Anggi Krajan Barat DPT/Hb/Hib 1 5041021 / 6.23 Polio 2 2051821 / 2.23 Darwatiningsih, S.ST Ponkesdes 11/04/2022 √

Ponkesdes
2 Arjuanata L 12/1/2021 3 Lia Sabrang 1/2 DPT/Hb/Hib 1 5041021 / 6.23 Polio 2 2051821 / 2.23 Diana B, A.Md.Keb 18/4/2022 √
Wr. Anom

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 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : MEI 2020

IDENTITAS GEJALA YANG DIALAMI

JK No. Batch/ TEMPAT DEMAM BENGKAK MERAH MUNTAH
No. Batch/ JENIS VAKSIN TANGGAL
NO UMUR JENIS VAKSIN 1 Exp.Date Vaksin 1 2 Exp.Date Vaksin PEMBERI IMUNISASI PELAYANAN IMUNISASI LAIN-LAIN
NAMA ANAK TGL LAHIR (bln) NAMA ORTU ALAMAT 2 IMUNISASI (SEBUTKAN)
L/P Jika ya ditandai P

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Wulandari/ Gumuk Selatan

1 Maulana Kenzi L 18/3/2022 2 Supriyadi 1/1 DPT/Hb/Hib 1 5041021 / 6.23 Polio 2 2051821 / 2.23 Maknunah, A.Md.Keb Posyandu 24/5/2022 √

2 Faiz Alfarisqi L 18/2/2022 3 Suci/Ari Pathek Barat DPT/Hb/Hib 1 5041021 / 6.23 Polio 2 2051821 / 2.23 Hadiyanti W, A.Md.Keb Posyandu 24/5/2022 √

Pustu
3 Abizar L 28/1/2022 5 Anis Fitria Tanah Anyar 3/6 DPT/Hb/Hib 3 5041021 / 6.23 Polio 4 2051821 / 2.23 Dian B, A.Md.Keb 3/5/2022 √
Alasmalang

Ponkesdes
4 Deswa L 15/12/2021 5 Yeni / Ilham Blikeran DPT/Hb/Hib 3 5041021 / 6.23 Polio 4 2051821 / 2.23 Diana B, A.Md.Keb 25/5/2022 √
Wr. Anom

5 Alesha P 19/11/2021 15 Yuan Sabrang DPT/Hb/Hib 3 5041021 / 6.23 Polio 4 2051821 / 2.23 Diana B, A.Md.Keb Posyandu 12/5/2022 √

6 Daffa P 12/1/2021 6 Qurotin Sabrang DPT/Hb/Hib 3 5041021 / 6.23 Polio 4 2051821 / 2.23 Diana B, A.Md.Keb Posyandu 12/5/2022 √

Ponkesdes
7 Kahfi L 4/1/2022 4 Liska Tribungan DPT/Hb/Hib 3 5041021 / 6.23 Polio 4 2051821 / 2.23 Darwatiningsih, S.ST Sbkolak 2 10/5/2022 √

Ponkesdes
8 Febi P 7/2/2022 3 Meli Krajan Barat DPT/Hb/Hib 1 5041021 / 6.23 Polio 2 2051821 / 2.23 Darwatiningsih, S.ST Sbkolak 2 21/5/2022 √

Ponkesdes
9 Haikal P 31/1/2022 4 Harisa Tribungan DPT/Hb/Hib 2 5041021 / 6.23 Polio 3 2051821 / 2.23 Darwatiningsih, S.ST Sbkolak 2 21/5/2022 √

Ponkesdes
10 Shaka L 10/3/2023 2 Eli Agustin Krajan Timur DPT/Hb/Hib 1 5041021 / 6.23 Polio 2 2051821 / 2.23 Darwatiningsih, S.ST Sbkolak 2 21/5/2022 √

Pustu Sbkolak
11 M. Raizan P 25/21/2022 6 Lina Langai 3/2 DPT/Hb/Hib 3 5041021 / 6.23 Polio 4 2051821 / 2.23 Istiqomah, A.Md.Keb 1 27/5/2022 √

Pustu Sbkolak
12 M. Zafran L 16/11/2021 6 Dwi / Adi Randu 1/2 DPT/Hb/Hib 3 5041021 / 6.23 Polio 4 2051821 / 2.23 Istiqomah, A.Md.Keb 2 27/5/2022 √

Pitri Dewi / Pustu Sbkolak

13 Putri Anisa L 22/12/2022 5 Kevin Langai 1/2 DPT/Hb/Hib 1 5041021 / 6.23 Polio 2 2051821 / 2.23 Istiqomah, A.Md.Keb 3 27/5/2022 √

14 M. Haidar L 10/1/2022 4 Herliana Ardiwilis DPT/Hb/Hib 1 5041021 / 6.23 Polio 2 2051821 / 2.23 Sofi A, A.Md.Keb Posyandu 14/5/2022 √
 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : JUNI 2019
IDENTITAS GEJALA YANG DIALAMI
JENIS VAKSIN No. Batch/ JENIS No. Batch/ TEMPAT TANGGAL
NO JK Exp.Date Exp.Date PEMBERI IMUNISASI PELAYANAN DEMAM BENGKAK MERAH MUNTAH
UMUR 1 VAKSIN 2 IMUNISASI LAIN-LAIN
NAMA ANAK TGL LAHIR (bln) NAMA ORTU ALAMAT Vaksin 1 Vaksin 2 IMUNISASI (SEBUTKAN)
L/P Jika ya ditandai P
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Raisya P 08/04/2019 4 Wilda Kil. Selatan DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Sri Wahyuni, Amd.Keb Posyandu 05/08/2019 √
2 Nafisa P 08/05/2019 3 Siska Bataan DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Sri Wahyuni, Amd.Keb Posyandu 13/08/2019 √
3 Hanif L 03/05/2019 3 Nonik Karangsari DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Amalia KP, Amd.Keb Posyandu 08/08/2019 √
4 Almira P 13/06/2019 2 Firsya Karangsari DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Amalia KP, Amd.Keb Ponkesdes 16/08/2019 √
5 Sindi P 18/06/2019 2 Sukarsih Pss. Utara DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Endah S, Amd.Keb Ponkesdes 27/08/2019 √
6 Raisa P 13/04/2019 4 Sintani P. Tanah Anyar DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Endah S, Amd.Keb Posyandu 8/28/2019 √
7 Zaki Ahmad L 29/04/2019 4 Hani Paowan DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Sofi Angelina, Amd.Keb Posyandu 28/08/209 √
8 Shaquenena P 03/04/2019 4 Ratna Dewi Greenhill DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Istiqomah, A.Md.Keb Pustu 8/14/2019 √
9 Ibrahim L 08/04/2019 4 Wulandari Grennhill C4-7 DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Istiqomah, A.Md.Keb Pustu 8/14/2019 √
MaklumRandu
10 Adzriel L 23/04/2019 4 Ike Triyuni 1/1 DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Istiqomah, A.Md.Keb Pustu 8/20/2019 √
11 Diandra L 13/06/2019 2 Nofi Randu 1/1 DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Istiqomah, A.Md.Keb Pustu 8/19/2019 √
12 Felisa P 14/06/2019 2 Didin Diana Krajan Barat DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Darwati, A.Md.Keb Ponkesdes 8/10/2019 √
13 Raska L 18/05/2019 3 Ruli Krajan Barat DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Darwati, A.Md.Keb Ponkesdes 8/26/2019 √
14 Faris L 11/04/2019 4 Nita Krajan Timur DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Darwati, A.Md.Keb Ponkesdes 20/08/1019 √
15 Aldiko L 11/04/2019 4 Dewi Krajan Timur DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Darwati, A.Md.Keb Posyandu 8/6/2019 √
16 Arini P 28/02/109 7 Nurul Krajan Timur DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Darwati, A.Md.Keb Posyandu 8/6/2019 √
17 Hafiz Ramadhan L 11/06/2019 2 Komariiya Villa DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Winda Tri, A.Md.Keb Posyandu 8/10/2019 √
18 Hana P 08/04/2019 4 Naila Perum Baiti Jannati DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Winda Tri, A.Md.Keb Posyandu 8/10/2019 √
19 Razka L 25/02/2019 6 Anita Banjiran DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Winda Tri, A.Md.Keb Posyandu 8/21/2019 √
20 Albiano L 09/07/2019 1 Siti Nuraini Banjiran BCG 5042918/07.20 Polio 1 2050219/01.21 Winda Tri, A.Md.Keb Posyandu 8/10/2019 √
21 Khayla Salsabila P 19/03/2019 5 Siti Hawani Blikeran DPT/Hb/Hib 2 5042918/07.20 Polio 4 2050219/01.21 Petugas Poli KIA Puskesmas 7/30/2019 √
22 Maima P 10/04/2019 4 Enka Blikeran DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Petugas Poli KIA Puskesmas 7/30/2019 √
23 Jelita P 28/05/2019 3 Sri Blikeran DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Petugas Poli KIA Puskesmas 8/27/2019 √
24 Abibah A P 18/04/2019 4 Minil HK Sabrang DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Petugas Poli KIA Puskesmas 8/27/2019 √
25 Aura P 01/06/2019 2 Tias Wringin Anom DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Anny Sylvia, A.Md.Keb Posyandu 8/28/2019 √
26 Rasya L 13/03/2019 5 Novi Wringin Anom DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Anny Sylvia, A.Md.Keb BPM 8/5/2019 √
27 Deby P 28/03/2019 5 Nurul Krajan DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 dr. Frida (Inship) Posyandu 8/8/2019 √
28 Nayla P 11/04/2019 4 Lia Krajan DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 dr. Frida (Inship) Posyandu 25/08/2018 √
29 Nabila P 21/05/2019 3 Erlinda Krg.Polo 2/5 DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Winda Yulia, A.Md.Keb Posyandu 8/24/2019 √
30 Makin Mardani L 18/06/2019 2 Lutfiyatus Pathek Timur 1/2 DPT/Hb/Hib 1 5041318/04.20 Polio 2 2050219/01.21 Novita Eka, A.Md.Keb Posyandu 8/26/2019 √
31 Rohmatika Fitriatul P 18/05/2019 3 Ulfatul H Gel. Selatan RT 14 DPT/Hb/Hib 1 5041318/04.20 Polio 2 2050219/01.21 Laiyatul, S.Kep, Ns Posyandu 8/19/2019 √
32 Moh. Farga L 21/01/2019 7 Quratul Aini Gel. Krajan RT 11 DPT/Hb/Hib 2 5041318/04.20 Polio 3 2050219/01.21 Maknunah, A.Md.Keb Posyandu 8/8/2019 √
 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : JULI 2019
IDENTITAS GEJALA YANG DIALAMI
JENIS VAKSIN No. Batch/ JENIS No. Batch/ TEMPAT TANGGAL
NO JK Exp.Date Exp.Date PEMBERI IMUNISASI PELAYANAN DEMAM BENGKAK MERAH MUNTAH
UMUR 1 VAKSIN 2 IMUNISASI LAIN-LAIN
NAMA ANAK TGL LAHIR (bln) NAMA ORTU ALAMAT Vaksin 1 Vaksin 2 IMUNISASI (SEBUTKAN)
L/P Jika ya ditandai P
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Sheren P 04/05/2019 2 Holila Karang sari DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Sri Wahyuni, Amd.Keb Posyandu 13/07/2019 √
2 Hafidzah P 22/01/2019 6 Tolak Ina Karang sari DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 Amalia KP, Amd.Keb Ponkesdes 12/07/2019 √
3 Moh. Dije L 08/02/2019 5 Rika Karang sari DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 Amalia KP, Amd.Keb Posyandu 24/07/2019 √
4 Naratama L 20/03/2019 4 Hosnia Tanah Anyar DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Endah S, Amd.Keb Posyandu 18/07/2019 √
5 Ayesa P 08/04/2018 3 Nahdiara Tanah Anyar DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Endah S, Amd.Keb Posyandu 13/07/2019 √
6 Moh. Maulana L 18/04/2019 3 Andriani Nangkaan DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Sofi Angelina, Amd.Keb Posyandu 22/07/2019 √
7 Moh. Aliwafa L 05/04/2019 3 Sri Inayah Maklum DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Istiqomah, Amd.Keb Pustu 18/07/2019 √
8 Zafran L 28/02/2019 5 Wirda Maklum DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Istiqomah, Amd.Keb Pustu 18/07/2019 √
9 Azriel L 23/04/2019 2 Ike Maklum DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Istiqomah, Amd.Keb Pustu 18/07/2019 √
10 Hana P 28/01/2019 6 Siti Fatimah Langai 1 DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 Istiqomah, Amd.Keb Pustu 22/07/2019 √
11 Amira P 04/05/2019 2 Titin Trib. Timur DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Darwati, Amd.Keb Posyandu 05/07/2019 √
12 Calista P 09/05/2019 2 Rike Dam DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Darwati, Amd.Keb Posyandu 10/07/2019 √
13 M. Arfan L 19/05/2019 2 Narulita Dam DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Darwati, Amd.Keb Ponkesdes 21/07/2019 √
14 Kheza P 21/01/2019 7 Yunita Trib. Barat DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Anisia, Amd.Keb Posyandu 11/07/2019 √
15 Antar Rama L 11/04/2019 4 Nita Krj. Timur DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Darwati, Amd.Keb Ponkesdes 19/07/2019 √
16 Raska L 08/05/2019 3 Ruli Krj. Barat DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Darwati, Amd.Keb Ponkesdes 21/07/2019 √
17 Zinan L 05/03/2019 4 Riski Parut 3/1 DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 Winda Tri, A.Md.Keb Posyandu 22/07/2019 √
18 Keenan L 07/03/2019 4 Riris Parut 2/1 DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 Winda Tri, A.Md.Keb Posyandu 10/07/2019 √
19 Ragna P 11/06/2019 1 Mega Parut 1/2 BCG 03757131/12.19 Polio 1 2050219/1.21 Winda Tri, A.Md.Keb Posyandu 11/07/2019 √
20 Almira L 15/02/2019 5 Ika Panorama DPT/Hb/Hib 2 5041318/4.20 Polio 2 2050219/1.21 Winda Tri, A.Md.Keb Posyandu 18/07/2019 √ √
21 Adel P 25/03/2019 4 Maya Kom DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Diana, Amd.Keb Posyandu 11/07/2019 √
22 Arka P 27/12/2017 19 Rahma Kom 1/1 DPT/Hb/Hib 4 5041318/4.20 - - Diana, Amd.Keb Posyandu 10/07/2019 √
23 Balqis P 08/11/2018 8 Kukuk Kom DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 Diana, Amd.Keb Posyandu 10/07/2019 √
24 Farah P 07/02/2019 5 Apin Wringin 1 DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 Anny Silvia, A.Md.Keb Posyandu 12/07/2019 √
25 Adelia P 25/05/2019 2 Bunila Pasarean DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Ika S, Amd.Keb Posyandu 05/07/2019 √
26 Feliya P 25/01/2019 6 Yulia Pasarean DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 Ika S, Amd.Keb Posyandu 20/07/2019 √
27 Inayatul P 15/03/2019 3 Suhartini Pasarean DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Ika S, Amd.Keb Posyandu 20/07/2019 √
28 Aidil L 16/03/2019 3 Herlina Pasarean DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Ika S, Amd.Keb Posyandu 20/07/2019 √
29 Abil Sidqi L 12/02/2019 5 Vita Dwi Krg. Rejo 1/3 DPT/Hb/Hib 3 5041318/4.20 Polio 4 2050219/1.21 WindaYulia, A.Md.Keb Posyandu 15/07/2019 √
30 Nur Maqbullah L 09/04/2019 3 Titin Ptk. Barat 1/1 DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Novita Eka, A.Md.Keb Posyandu 12/07/2020 √
31 Naswa P 16/03/2019 4 Febriana Gmk. Barat RT 10 DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Laiyatul, S.Kep, Ns Posyandu 18/07/2019 √
32 Solehatun P 03/04/1019 3 Nurfadila Gmk. Barat RT 10 DPT/Hb/Hib 1 5041318/4.20 Polio 2 2050219/1.21 Maknunah, A.Md.Keb Posyandu 10/07/2020 √
33 Haisha P 06/04/2029 3 Devi Andriani Gmk. Barat RT 4 DPT/Hb/Hib 2 5041318/4.20 Polio 3 2050219/1.21 Maknunah, A.Md.Keb Posyandu 17/07/2021 √
 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : AGUSTUS 2019
IDENTITAS GEJALA YANG DIALAMI
JENIS VAKSIN No. Batch/ JENIS No. Batch/ TEMPAT TANGGAL
NO JK Exp.Date Exp.Date PEMBERI IMUNISASI PELAYANAN DEMAM BENGKAK MERAH MUNTAH
UMUR 1 VAKSIN 2 IMUNISASI LAIN-LAIN
NAMA ANAK TGL LAHIR (bln) NAMA ORTU ALAMAT Vaksin 1 Vaksin 2 IMUNISASI (SEBUTKAN)
L/P Jika ya ditandai P
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Raisya P 08/04/2019 4 Wilda Kil. Selatan DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Sri Wahyuni, Amd.Keb Posyandu 05/08/2019 √
2 Nafisa P 08/05/2019 3 Siska Bataan DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Sri Wahyuni, Amd.Keb Posyandu 13/08/2019 √
3 Hanif L 03/05/2019 3 Nonik Karangsari DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Amalia KP, Amd.Keb Posyandu 08/08/2019 √
4 Almira P 13/06/2019 2 Firsya Karangsari DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Amalia KP, Amd.Keb Ponkesdes 16/08/2019 √
5 Sindi P 18/06/2019 2 Sukarsih Pss. Utara DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Endah S, Amd.Keb Ponkesdes 27/08/2019 √
6 Raisa P 13/04/2019 4 Sintani P. Tanah Anyar DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Endah S, Amd.Keb Posyandu 8/28/2019 √
7 Zaki Ahmad L 29/04/2019 4 Hani Paowan DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Sofi Angelina, Amd.Keb Posyandu 28/08/209 √
8 Shaquenena P 03/04/2019 4 Ratna Dewi Greenhill DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Istiqomah, A.Md.Keb Pustu 8/14/2019 √
9 Ibrahim L 08/04/2019 4 Wulandari Grennhill C4-7 DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Istiqomah, A.Md.Keb Pustu 8/14/2019 √
MaklumRandu
10 Adzriel L 23/04/2019 4 Ike Triyuni 1/1 DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Istiqomah, A.Md.Keb Pustu 8/20/2019 √
11 Diandra L 13/06/2019 2 Nofi Randu 1/1 DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Istiqomah, A.Md.Keb Pustu 8/19/2019 √
12 Felisa P 14/06/2019 2 Didin Diana Krajan Barat DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Darwati, A.Md.Keb Ponkesdes 8/10/2019 √
13 Raska L 18/05/2019 3 Ruli Krajan Barat DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Darwati, A.Md.Keb Ponkesdes 8/26/2019 √
14 Faris L 11/04/2019 4 Nita Krajan Timur DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Darwati, A.Md.Keb Ponkesdes 20/08/1019 √
15 Aldiko L 11/04/2019 4 Dewi Krajan Timur DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Darwati, A.Md.Keb Posyandu 8/6/2019 √
16 Arini P 28/02/109 7 Nurul Krajan Timur DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Darwati, A.Md.Keb Posyandu 8/6/2019 √
17 Hafiz Ramadhan L 11/06/2019 2 Komariiya Villa DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Winda Tri, A.Md.Keb Posyandu 8/10/2019 √
18 Hana P 08/04/2019 4 Naila Perum Baiti Jannati DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Winda Tri, A.Md.Keb Posyandu 8/10/2019 √
19 Razka L 25/02/2019 6 Anita Banjiran DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Winda Tri, A.Md.Keb Posyandu 8/21/2019 √
20 Albiano L 09/07/2019 1 Siti Nuraini Banjiran BCG 5042918/07.20 Polio 1 2050219/01.21 Winda Tri, A.Md.Keb Posyandu 8/10/2019 √
21 Khayla Salsabila P 19/03/2019 5 Siti Hawani Blikeran DPT/Hb/Hib 2 5042918/07.20 Polio 4 2050219/01.21 Petugas Poli KIA Puskesmas 7/30/2019 √
22 Maima P 10/04/2019 4 Enka Blikeran DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Petugas Poli KIA Puskesmas 7/30/2019 √
23 Jelita P 28/05/2019 3 Sri Blikeran DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Petugas Poli KIA Puskesmas 8/27/2019 √
24 Abibah A P 18/04/2019 4 Minil HK Sabrang DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Petugas Poli KIA Puskesmas 8/27/2019 √
25 Aura P 01/06/2019 2 Tias Wringin Anom DPT/Hb/Hib 1 5042918/07.20 Polio 2 2050219/01.21 Anny Sylvia, A.Md.Keb Posyandu 8/28/2019 √
26 Rasya L 13/03/2019 5 Novi Wringin Anom DPT/Hb/Hib 3 5042918/07.20 Polio 4 2050219/01.21 Anny Sylvia, A.Md.Keb BPM 8/5/2019 √
27 Deby P 28/03/2019 5 Nurul Krajan DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 dr. Frida (Inship) Posyandu 8/8/2019 √
28 Nayla P 11/04/2019 4 Lia Krajan DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 dr. Frida (Inship) Posyandu 25/08/2018 √
29 Nabila P 21/05/2019 3 Erlinda Krg.Polo 2/5 DPT/Hb/Hib 2 5042918/07.20 Polio 3 2050219/01.21 Winda Yulia, A.Md.Keb Posyandu 8/24/2019 √
30 Makin Mardani L 18/06/2019 2 Lutfiyatus Pathek Timur 1/2 DPT/Hb/Hib 1 5041318/04.20 Polio 2 2050219/01.21 Novita Eka, A.Md.Keb Posyandu 8/26/2019 √
31 Rohmatika Fitriatul P 18/05/2019 3 Ulfatul H Gel. Selatan RT 14 DPT/Hb/Hib 1 5041318/04.20 Polio 2 2050219/01.21 Laiyatul, S.Kep, Ns Posyandu 8/19/2019 √
32 Moh. Farga L 21/01/2019 7 Quratul Aini Gel. Krajan RT 11 DPT/Hb/Hib 2 5041318/04.20 Polio 3 2050219/01.21 Maknunah, A.Md.Keb Posyandu 8/8/2019 √
 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : SEPTEMBER 2019
IDENTITAS GEJALA YANG DIALAMI
JK JENIS VAKSIN No. Batch/ JENIS No. Batch/ TEMPAT TANGGAL DEMAM BENGKAK MERAH MUNTAH
NO UMUR Exp.Date Exp.Date PEMBERI IMUNISASI PELAYANAN LAIN-LAIN
NAMA ANAK TGL LAHIR 1 VAKSIN 2 IMUNISASI
L/P (bln) NAMA ORTU ALAMAT Vaksin 1 Vaksin 2 IMUNISASI Jika ya ditandai P (SEBUTKAN)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Nurul P 18/05/2019 4 Fitria Kilen Selatan DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Sri Wahyuni, Amd.Keb Posyandu 23/09/2019 √
2 Nuril L 28/05/2019 4 Ita Bataan DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Amalia KP, Amd.Keb Ponkesdes 13/09/2019 √
3 Sharen P 04/05/2019 4 Holila Karangsari DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Amalia KP, Amd.Keb Posyandu 13/09/2019 √
4 Wildan L 30/05/2019 4 Ika Fitriyah Pss. Selatan DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Endah S, Amd.Keb Posyandu 14/09/2019 √
5 Keisya P 13/06/2019 3 Weni Pss. Utara DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Endah S, Amd.Keb Posyandu 24/09/2019 √
6 M. Fadil L 16/06/2019 3 Seniawati Pss. Utara DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Endah S, Amd.Keb Ponkesdes 24/09/2019 √
7 Firli P 02/04/2019 5 Faridatul Locancang 3/1 DPT/Hb/Hib 2 5042918/07.20 Polio 2 2051019/06.21 Sofi Angelina, Amd.Keb Posyandu 16/09/2019 √
8 Nur Afni P 23/05/2019 4 Nur Jamila Randu 2/2 DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Istiqomah, A.Md.Keb Pustu 17/09/2019 √
9 Anggun p 17/07/2019 2 Cicip/ Niden Langai 2 DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Istiqomah, A.Md.Keb Pustu 19/09/2019 √
10 Adzriel L 23/04/2019 5 Ike Triyuni Maklum DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Istiqomah, A.Md.Keb Pustu 23/09/2019 √
11 Aldiko L 11/04/2019 5 Dewi Krajan Timur DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Darwati, A.Md.Keb Posyandu 10/09/2019 √
12 Alfin L 08/02/2019 7 Ita Purnama Krajan Timur DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Darwati, A.Md.Keb Posyandu 10/09/2019 √
13 Bilqis P 30/06/2019 3 Siti Nurhasana Krajan Timur DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Darwati, A.Md.Keb Posyandu 10/09/2019 √
14 Azriel L 27/02/2019 7 Sri Rahaya Dam DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Darwati, A.Md.Keb Posyandu 14/09/2019 √
15 M. Arifan L 19/05/2019 4 Narulita Dam DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Darwati, A.Md.Keb Ponkesdes 24/09/2019 √
16 Aisyah Syatriaroh P 02/05/2019 4 Nilam Parut DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Winda Tri, A.Md.Keb KR 16/09/2019 √
17 Adum Al Fatih L 26/06/2019 3 Ayu K Parut 1/1 DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Winda Tri, A.Md.Keb KR 16/09/2019 √
18 Fraya P 05/08/2019 1 Oktaviana Villa Bukit BCG 03757131/12.19 Polio 1 2051019/06.21 Winda Tri, A.Md.Keb Posyandu 10/09/2019 √
19 Bima Aditya L 10/04/2018 7 Oktavia Blikeran DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Diana, Amd.Keb Posyandu 10/09/2019 √
20 Milka Nasya P 21/06/2018 6 Evi Mei Sabrang DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Diana, Amd.Keb Posyandu 10/09/2019 √
21 Gibran Fatih L 24/07/2018 5 Susmiyati Sabrang DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Diana, Amd.Keb Posyandu 10/09/2019 √
22 Huzdaifa L 26/03/2018 2 Fatmawiyati Sabrang DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Petugas Poli KIA Puskesmas 13/09/2019 √
23 Azam L 28/02/2019 7 Turyatun Krajan DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Ika Sahadatina, Amd.Keb Posyandu 09/09/2019 √
24 Naila P 11/04/2019 5 Lia Krajan DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Ika Sahadatina, Amd.Keb Posyandu 09/09/2019 √
25 Haydar L 12/04/2019 5 Halimatus Krajan DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Ika Sahadatina, Amd.Keb Posyandu 09/09/2019 √
26 Deby P 28/03/2019 6 Nuril Krajan DPT/Hb/Hib 3 5042918/07.20 Polio 4 2051019/06.21 Ika Sahadatina, Amd.Keb Posyandu 09/09/2019 √
27 Viandra Kaffi R L 27/05/2019 3 Dian Krg. Polo 4/5 DPT/Hb/Hib 2 5042918/07.20 Polio 3 2051019/06.21 Dian Barirah, Amd.Keb KR 20/09/2019 √
28 Fahri L 28/04/2019 5 Nurjannah Duwet Sel 3/1 DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Novita Eka, A.Md.Keb Posyandu 16/09/2019 √
29 Almera Azzaroh P 19/06/2019 4 Kustini Gumuk Barat 9 DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Laiyatul, S.Kep, Ns Posyandu 9/12/2019 √

Lailatun Awalia P 20/05/2019 5 Yuliana Gumuk Sel 3 DPT/Hb/Hib 1 5042918/07.20 Polio 2 2051019/06.21 Laiyatul, S.Kep, Ns Posyandu 9/13/2019 √
 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : OKTOBER 2019
IDENTITAS GEJALA YANG DIALAMI
JK JENIS VAKSIN No. Batch/ JENIS No. Batch/ TEMPAT TANGGAL DEMAM BENGKAK MERAH MUNTAH
NO UMUR Exp.Date Exp.Date PEMBERI IMUNISASI PELAYANAN LAIN-LAIN
NAMA ANAK TGL LAHIR 1 VAKSIN 2 IMUNISASI
L/P (bln) NAMA ORTU ALAMAT Vaksin 1 Vaksin 2 IMUNISASI Jika ya ditandai P (SEBUTKAN)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Afgan L 30/07/2019 2 Fitria Gudang Seng DPT/Hb/Hib 1 50403318/7.20 Polio 1 2052019/7.21 Amalia, Amd.Keb Ponkesdes 10/1/2019 √
2 Akhtar L 31/07/2019 2 Winda Karangsari DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Amalia, Amd.Keb Ponkesdes 10/10/2019 √
3 Maulana L 30/03/2019 7 Fitriya Karangsari DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Sri Wahyuni, Amd.Keb Posyandu 26/10/2019 √
4 Rohimi P 11/02/2019 8 Anis Puji Pss. Utara DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Endah S, Amd.Keb Posyandu 08/10/2019 √
5 Aditya L 24/02/2019 8 Irawati Pss. Utara DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Endah S, Amd.Keb Ponkesdes 15/10/2019 √
6 Aulia Muntaz L 24/06/2019 3 Ika W Paowan DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Sofi Angelina, Amd.Keb Posyandu 16/10/2019 √
7 Anggun P 17/07/2019 3 Cicip Langai 1 DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Istiqomah, Amd.Keb Pustu 24/10/2019 √
8 Dirga L 19/08/2019 2 Ika Langai 2/2 DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Istiqomah, Amd.Keb Pustu 24/10/2019 √
9 Alyanesha P 15/07/2019 3 Risya Bukit Asri C33 DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Istiqomah, Amd.Keb Pustu 17/10/2019 √
10 Jibrane L 06/04/2019 6 Indah Bukit Asri DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Istiqomah, Amd.Keb Pustu 17/10/2019 √
11 Amira P 04/05/2019 5 Agustin Tribungan 3/1 DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Darwati, Amd.Keb Ponkesdes 08/10/2019 √
12 Firza P 23/03/2019 7 Faiza Krajan Barat DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Darwati, Amd.Keb Ponkesdes 11/10/2019 √
13 Felisa P 14/06/2019 4 Didin Diana Krajan Barat DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Darwati, Amd.Keb Posyandu 21/10/2019 √
14 Anggi P 24/06/2019 4 Niana Krajan Barat DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Anisia, Amd.Keb Posyandu 14/10/2019 √
15 Ghivar L 20/05/2019 5 Dini Krajan Barat DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Darwati, Amd.Keb Posyandu 16/10/2019 √
16 Alvino Bima L 28/04/2019 6 Burati Parut 1/1 DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Winda Tri, Amd. Keb Posyandu 16/10/2019 √
17 Adam Al Fatih L 26/06/2019 4 Ayu F Parut 1/1 DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Winda Tri, Amd. Keb Posyandu 16/10/2019 √
18 Rafisha Ahmad L 16/09/2019 1 Herawati Parut 3/2 BCG 03757131/12.19 Polio 1 2052019/7.21 Winda Tri, Amd. Keb KR 31/10/2019 √
19 M. Riski Darmawan L 21/09/2019 1 Humairoh Parut BCG 03757131/12.19 Polio 1 2052019/7.21 Winda Tri, Amd. Keb KR 31/10/2019 √
20 Alamsyah Risky L 20/06/2019 4 Rully Kelana Panorama DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Winda Tri, Amd. Keb Posyandu 22/10/2019 √
21 Milka Nasya P 19/03/2019 6 Evi Mei Sabrang DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Diana, Amd.Keb Posyandu 11/10/2019 √
22 Aisyah P 22/07/2019 3 Altur Sabrang DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Diana, Amd.Keb Posyandu 11/10/2019 √
23 Gafi L 28/07/2019 3 Dewi Sabrang DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Petugas Poli KIA Puskesmas 22/10/2019 √
24 Qurota Ayuna P 08/05/2019 5 Gita Diana Krg. Polo 4/5 DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Dian Barirah, Amd.Keb Posyandu 02/10/2019 √
Duwet Krajan
25 Moh. Roy Sihaluatin L 21/04/2019 6 Yuni DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Novita Eka, A.Md.Keb Posyandu 08/10/2019 √
2/1
Gelung Krajan RT
26 Moh. Azka L 01/07/2019 3 Evi Susiana DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Maknunah, A.Md.Keb Posyandu 12/10/2019 √
11
Gumuk Selatan
27 Syarifatul Azizah P 29/07/2019 3 Noer Atika RT 2 DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Maknunah, A.Md.Keb Pustu 17/10/2019 √
 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : NOPEMBER 2019
IDENTITAS GEJALA YANG DIALAMI
JK JENIS VAKSIN No. Batch/ JENIS No. Batch/ TEMPAT TANGGAL DEMAM BENGKAK MERAH MUNTAH
NO UMUR Exp.Date Exp.Date PEMBERI IMUNISASI PELAYANAN LAIN-LAIN
NAMA ANAK TGL LAHIR 1 VAKSIN 2 IMUNISASI
L/P (bln) NAMA ORTU ALAMAT Vaksin 1 Vaksin 2 IMUNISASI Jika ya ditandai P (SEBUTKAN)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Adila P 30/07/2019 4 Unzila Kilen Selatan DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Amalia, A.Md.Keb Ponkesdes 11/14/2019 √
2 Akhtar L 31/07/2019 4 Winda Karangsari DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Amalia, A.Md.Keb Ponkesdes 11/11/2019 √
3 Nurul L 22/08/2019 3 Sri W Karangsari DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Sri Wahyuni, A.Md.Keb Ponkesdes 05/11/2019 √
4 Sindi P 17/06/2019 5 Sukarsih Pss. Utara DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Endah S, A.Md.Keb Ponkesdes 06/11/2019 √
5 Rivaldi L 21/04/2019 7 Ririn Pss. Utara DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Endah S, A.Md.Keb Ponkesdes 12/11/2019 √
6 Briliant L 13/04/2019 5 Novelia Perumnas DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Sofi Angelina, A.Md.Keb Posyandu 14/11/2019 √
7 Alienka Qiana P 13/06/2019 5 Kismafil Langai 1/2 DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Istiqomah, A.Md.Keb Pustu 05/11/2019 √
8 Ach. Shaka Arka L 03/04/2019 7 Nismawati Maklum DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Istiqomah, A.Md.Keb Pustu 13/11/2019 √
9 Alisha Al Rahmania P 29/05/2019 6 Laily Afisah Greenhill DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Istiqomah, A.Md.Keb Pustu 13/11/2019 √
10 Fahri L 13/07/2019 4 Eni Tribungan DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Anisia, A.Md.Keb Posyandu 13/11/2019 √
11 Salsabila P 10/09/2019 2 Ila Tribungan DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Darwati, S.Tr.Keb Posyandu 15/11/2019 √
12 Revalina P 26/07/2019 4 Dewi Tribungan DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Darwati, S.Tr.Keb Posyandu 15/11/2019 √
13 Bilqis P 20/06/2019 5 Siti Nurhasanah Krajan Timur DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Darwati, S.Tr.Keb Posyandu 12/11/2019 √
14 Raska L 02/09/2019 2 Anik Krajan Timur DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Darwati, S.Tr.Keb Posyandu 12/11/2019 √
15 Zean L 04/09/2019 2 Ayu Krajan Timur DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Darwati, S.Tr.Keb Posyandu 12/11/2019 √
16 Runa P 04/09/2019 2 Ayu Krajan Timur DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Darwati, S.Tr.Keb Posyandu 12/11/2019 √
17 Roy L 02/07/2019 4 Antika Parut DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Winda Tri, A.Md. Keb Posyandu 10/11/2019 √
18 Khanza P 29/08/2019 3 Randita Parut DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Winda Tri, A.Md. Keb Posyandu 18/11/2019 √
19 kKania P 11/08/2019 4 Lusia Puri Indah DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Winda Tri, A.Md. Keb Posyandu 10/11/2019 √
20 Rasya L 29/08/2019 3 Desi Villa S DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Winda Tri, A.Md. Keb Posyandu 26/11/2019 √
21 Aisyah P 06/09/2019 2 Fasil Blikeran DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Dwi Prastiwi, A.Md.Keb Posyandu 11/11/2019 √
22 Radilyah P 28/05/2019 6 Sri Y Sabrang DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Dwi Prastiwi, A.Md.Keb Posyandu 11/11/2019 √
23 Kenet L 18/08/2019 3 Jesika Sabrang DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Petugas Poli KIA Puskesmas 26/11/2019 √
24 Azzarah P 12/07/2019 4 Erika Sabrang DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Petugas Poli KIA Puskesmas 26/11/2019 √
25 Aisyah P 16/07/2019 5 Nurfadila Mumbul DPT/Hb/Hib 2 50403318/7.20 Polio 3 2052019/7.21 Ika Sahadatina, A.Md.Keb Posyandu 09/11/2019 √
26 Umi P 24/04/2019 6 Holifah Mumbul DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Ika Sahadatina, A.Md.Keb Ponkesdes 02/11/2019 √
27 Viandra Kaffa L 27/05/2019 6 Dian B Karang Polo DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Dian Barirah, A.Md.Keb KR 02/11/2019 √
28 M. Makin Mardani L 18/06/2019 5 Lutfiatus Pathek Timur DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 BPM BPM 14/11/2019 √
29 Ahmad Arvio L 21/02/2019 9 Fatimatus Gumuk Barat DPT/Hb/Hib 3 50403318/7.20 Polio 4 2052019/7.21 Lailyatul M, S.Kep, Ns Posyandu 15/11/2019 √
30 Fatimatus Zahra P 31/07/2019 4 Uswatul Gumuk Utara DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Lailyatul M, S.Kep, Ns Posyandu 11/11/2019 √
31 Alivia P 24/07/2019 4 Sinta Gumuk Utara DPT/Hb/Hib 1 50403318/7.20 Polio 2 2052019/7.21 Lailyatul M, S.Kep, Ns Posyandu 11/11/2019 √
 LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

PUSKESMAS : PANARUKAN
BULAN/TAHUN : DESEMBER 2019
IDENTITAS GEJALA YANG DIALAMI
JK JENIS VAKSIN No. Batch/ JENIS No. Batch/ TEMPAT TANGGAL DEMAM BENGKAK MERAH MUNTAH
NO UMUR Exp.Date Exp.Date PEMBERI IMUNISASI PELAYANAN LAIN-LAIN
NAMA ANAK TGL LAHIR 1 VAKSIN 2 IMUNISASI
L/P (bln) NAMA ORTU ALAMAT Vaksin 1 Vaksin 2 IMUNISASI Jika ya ditandai P (SEBUTKAN)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Kayla P 09/09/2019 3 Anggun Kilen Selatan DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Sri Wahyuni, Amd.Keb Ponkesdes 09/12/2019 √
2 Maulana L 08/10/2019 2 Maysaroh Kilen Selatan DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Sri Wahyuni, Amd.Keb Ponkesdes 12/12/2019 √
3 Syauqi L 24/09/2019 3 Mita Kilen Selatan DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Amalia, Amd.Keb Ponkesdes 21/12/2019 √
4 Akhtar L 31/07/2019 5 Winda Karangsari DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Amalia, Amd.Keb Posyandu 12/12/2019 √
5 Naila P 13/01/2019 11 Yuliana Pss. Utara DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Petugas Poli KIA Puskesmas 17/12/2019 √
6 Maira P 29/09/2019 3 Mayang Pss. Selatan DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Endah S, Amd.Keb Ponkesdes 16/12/2019 √
7 Keyza P 13/06/2019 6 Weni Pss. Utara DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Endah S, Amd.Keb Posyandu 19/12/2019 √
8 Shaquita Alfariski L 21/09/2018 2 Nur Lailatul Perumnas DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Sofi Angelina, A.Md.Keb Posyandu 14/12/2019 √
9 Halba Zain Al L 18/09/2019 3 Erna Tri Langai 1/2 DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Istiqomah, Amd.Keb Pustu 05/12/2019 √
10 Zaini L 25/08/2019 4 Alif Langai 2/1 DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Istiqomah, Amd.Keb Posyandu 13/12/2019 √
11 Ifta P 09/08/2019 4 Maya Langai 2/1 DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Istiqomah, Amd.Keb Posyandu 13/12/2019 √
12 Moh. Rifki L 16/09/2019 3 Ubay Tribungan DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Anisia, Amd.Keb Posyandu 06/12/2019 √
13 Anggi P 24/06/2019 6 Niama Krajan Barat DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Darwati, S.Tr.Keb Ponkesdes 10/12/2019 √
14 Talitha P 20/09/2019 3 Winda Krajan Barat DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Darwati, S.Tr.Keb Ponkesdes 10/12/2019 √
15 Zeam L 04/09/2019 3 Ayu Krajan Timur DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Anisia, Amd.Keb Ponkesdes 18/12/2019 √
16 Runa P 04/09/2019 3 Ayu Krajan Timur DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Anisia, Amd.Keb Ponkesdes 18/12/2019 √
17 Azam L 17/09/2019 3 Wulan Krajan Timur DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Darwati, S.Tr.Keb Ponkesdes 10/12/2019 √
18 Aiyal P 26/09/2019 3 Erlina Krajan Timur DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Darwati, S.Tr.Keb Ponkesdes 10/12/2019 √
19 Adam L 23/06/2019 6 Ayu Parut 1/1 DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Winda Tri, A.Md. Keb Posyandu 17/12/2019 √
20 Khanza P 24/08/2019 4 Renata Parut 1/2 DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Winda Tri, A.Md. Keb Posyandu 18/19/2018 √
21 Naura P 01/10/2019 2 Handini Parut 3/1 DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Winda Tri, A.Md. Keb Posyandu 11/12/2019 √
22 Nanda L 21/08/2019 4 Sri W Sabrang DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Dwi Prastiwi, A.Md.Keb KR 12/12/2019 √
23 Aisyah P 22/07/2019 5 Altur R Sabrang DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Petugas Poli KIA Puskesmas 12/12/2019 √
24 Erdogen P 25/07/2019 5 Sari A Sabrang DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Petugas Poli KIA Puskesmas 10/12/2019 √
25 Sufarah Maulida P 27/10/2019 2 Sulaika Sabrang DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Anny Sylvia, A.Md.Keb Posyandu 16/12/2019 √
26 Rosi L 15/06/2019 6 Fatimah Dj. Gudang DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Ika Sahadatina, A.Md.Keb Posyandu 03/12/2019 √
27 Nela P 28/06/2019 6 Yana Sabrang DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Ika Sahadatina, A.Md.Keb Posyandu 12/12/2019 √
28 Muhammad Abizar P 29/08/2019 4 Bayuh Krg Polo 4/5 DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Dian Barirah, Amd.Keb KR 10/12/2019 √
29 Bugur 1/2 DPT/Hb/Hib 3 5043318/07.20 Polio 4 2052719/07.21 Hadiyati W, A.Md.Keb Posyandu 15/12/2019 √
30 Razeg Seftiayah L 19/09/2019 3 Yulis Glg Sel RT 14 DPT/Hb/Hib 1 5043318/07.20 Polio 2 2052719/07.21 Maknunah, A.Md.Keb Posyandu 07/12/2019 √
31 Moh. Alga L 22/07/2019 5 Jannatul Gumuk Ut RT 8 DPT/Hb/Hib 2 5043318/07.20 Polio 3 2052719/07.21 Lailyatul M, S.Kep, Ns Posyandu 11/12/2019 √