FORMAT PENCATATAN HASIL PELAYANAN

Posyandu/Pos ayanan BIAN lainnya : Nama petugas :

Desa/kelurahan : Puskesmas : Ranah Ampek Hulu
Tanggal : 11/06/2022 Kabupaten : Pesisir Selatan

Imunisasi Kejar
(Ya = 1, Tidak=0)

Campak
Jenis Kelamin Rubela
No. Nama Anak Tgl lahir Umur (L/P) Nama orang tua Alamat No.Hp NIK (Ya=1,
Tidak=0)
OPV IPV DPT-HB-Hib

SD 04 Sako a b c d e f g h i j k l m
Kelas 1 1 Adel Lita 7/31/2014 Sako 1301147107140001 1
2 Affan Nurfallah 6/13/2015 Sako 1301141306150001 1
3 Angga Saputra 12/20/2014 Sako 1301142012140001 1
4 Annisa Alaini Jannah 9/10/2015 Sako 1301145009150001 1
5 Febri Arjuna 2/4/2015 Sako 1301030402150002 1
6 Muhammad Fadel Al Fikri 9/16/2014 Sako 1301141609140001 1
7 Nada Salsabila 2/13/2015 Sako 1871065302150002 1
8 Nia Rahmadani 7/1/2014 Sako 1301144107140001 1
9 Nufikha Hayumi. A 8/21/2015 Sako 1301146108150002 1
10 Qavka Albuqhory 9/16/2015 Sako 1301141609150001 1
11 Muhammad Akbal Khairi 2/24/2015 Sako 1301142402150001 1
Kelas 2 12 Alpan Azzaki 6/24/2014 Sako 1301142406140001 1
13 Daffano Destan 12/8/2014 Sako 1301140812140001 1
14 M.Alfarizi 1/12/2014 Sako 1301141201140002 1
15 Wahyu Muhammad.A 8/31/2014 1301143108140001 1
Kelas 3 16
17
18
19
20
21
22
23
24
25
26
Kelas 4 27
28
29
30
31
32
33
34
35
36
37
Kelas 5 38
39
40
41
42
43
44
45
46
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135
136
137
138
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144
145
146
147
Jumlah vaksin (vial) dan logistik yang digunakan

Jenis logistik OPV IPV DPT-HB-HIB CAMPAK RUBELA Pelarut Campak Rubela Dropper ADS 0,5 ML ADS 5 ML Safety Box Pen Marker

Jumlah 2 2 20 2 1
Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Ket** (bila anak mendapatkan
dosis kedua/keetiga/keempat
OPV/Penta saat BIAN, maka
tetap dicatat namun tidak
dimasukkan sebagai cakupan
BIAN)

n
 FORMAT REKAPITULASI HASIL PELAYANAN BULAN IMUNISASI ANAK NASIONAL TINGKAT PUSKESMAS
Desa/kelurahan : Tanggal : 07/06/2022 s/d tgl 13 Juni 2022
Puskesmas : Ranah Ampek Hulu Nama petugas :
Isilah pada kolom yang berwarna

Sasaran dan Cakupan Imunisasi Kejar Sasaran dan cakupan imunisasi campak rubela
Usia 12 -<15 thn
Usia 12 - 59 bulan Usia 9-59 bulan Usia 5 - <7 thn Usia 7-<12 thn
(bagi 5 Prov.) Total Total
TANGGAL No Posyandu/Pos layanan BIAN
lainnya OPV IPV DPT-HB-Hib Campak Rubella Campak Rubela Campak Rubela Campak Rubela Sasaran dimunisasi
Jumlah Campak Campak
Jumlah Jumlah Jumlah Jumlah Jumlah diimuni Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah Jumlah Rubella Rubella
sasaran diimunisasi % sasaran diimunisasi % sasaran % sasaran diimunisasi % sasaran diimunisasi % sasaran diimunisasi % sasaran diimunisasi %
sasi
a b c d e f g h i j k l m n o p q r s t u v w x y
7 Juni 2022 1 Posyandu Karang Gizi Tebing
Tinggi 0.0% 0.0% 0.0% 41 20 48.8% 0.0% 0.0% 0.0% 41 20
8 Juni 2022 1 SD 01 Sungai Gambir 0.0% 0.0% 0.0% 0.0% 8 17 212.5% 114 63 55.3% 28 5 17.9% 150 85
2 SD 07 Padang Leban 0.0% 0.0% 0.0% 0.0% 33 7 21.2% 183 167 91.3% 40 3 7.5% 256 177
3 SD 03 Koto Pulai 0.0% 0.0% 0.0% 0.0% 20 18 90.0% 211 180 85.3% 35 3 8.6% 266 201
4 Posyandu Kemajuan 0.0% 0.0% 5 2 40.0% 51 11 21.6% 0.0% 0.0% 0.0% 51 11
5 SMP 2 KP.Tengah 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 135 50 37.0% 135 50
6 Posyandu Belimbing 0.0% 0.0% 0.0% 29 25 86.2% 0.0% 0.0% 0.0% 29 25
7 Posyandu Gaya Baru 0.0% 0.0% 0.0% 98 34 34.7% 0.0% 0.0% 0.0% 98 34
8 Posyandu Anggrek IV 10 5 50.0% 2 2 100.0% 0.0% 50 30 60.0% 0.0% 0.0% 0.0% 50 30
9 Posyandu Pinang Wangi 1 0.0% 0.0% 0.0% 46 35 76.1% 40 10 25.0% 0.0% 0.0% 86 45
10 Posyandu Durian 2 0.0% 0.0% 0.0% 15 2 13.3% 0.0% 0.0% 0.0% 15 2
11 Posyandu Durian 3 0.0% 0.0% 0.0% 9 3 33.3% 0.0% 0.0% 0.0% 9 3
12 Posyandu Mawar Indah 30 15 50.0% 0.0% 0.0% 89 67 75.3% 0.0% 0.0% 0.0% 89 67
13 Posyandu Lima Sempurna 0.0% 0.0% 0.0% 55 47 85.5% 0.0% 0.0% 0.0% 55 47
9 Juni 2022 1 SD 09 Sungai Gambir 0.0% 0.0% 0.0% 0.0% 13 13 100.0% 85 80 94.1% 3 3 100.0% 101 96
2 SD 06 Talang 0.0% 0.0% 0.0% 0.0% 16 16 100.0% 102 88 86.3% 11 1 9.1% 129 105
3 SMP 1 Kubu 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 121 113 93.4% 121 113
4 MTSN 1 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 414 175 42.3% 414 175
5 Posyandu Aur Duri 0.0% 0.0% 0.0% 38 17 44.7% 0.0% 0.0% 0.0% 38 17
6 Posyandu Harapan Indah 0.0% 0.0% 0.0% 33 7 21.2% 0.0% 0.0% 0.0% 33 7
7 Posyandu Pinang Wangi 2 1 1 100.0% 0.0% 1 1 100.0% 47 26 55.3% 22 21 95.5% 0.0% 0.0% 69 47
8 Posyandu Raflesia 0.0% 2 2 100.0% 0.0% 49 37 75.5% 3 3 100.0% 0.0% 0.0% 52 40
9 Posyandu Anggrek 3 0.0% 0.0% 0.0% 58 48 82.8% 0.0% 0.0% 0.0% 58 48
10 Juni 2022 1 SD 08 Binjai 0.0% 0.0% 0.0% 0.0% 8 8 100.0% 41 39 95.1% 0.0% 49 47
2 SD 02 Padang Kejai 0.0% 0.0% 0.0% 0.0% 1 1 100.0% 53 44 83.0% 0.0% 54 45
3 SD 10 Pasar Melintang 0.0% 0.0% 0.0% 0.0% 5 5 100.0% 119 110 92.4% 0.0% 124 115
4 SMP 3 Talang Balarik 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 80 65 81.3% 80 65
5 Posyandu Durian 1 0.0% 0.0% 0.0% 11 5 45.5% 0.0% 0.0% 0.0% 11 5
6 Posyandu Sinar Harapan 1 1 100.0% 1 1 100.0% 1 1 100.0% 82 44 53.7% 0.0% 0.0% 0.0% 82 44
7 Posyandu Wijaya Kusuma 0.0% 0.0% 0.0% 60 56 93.3% 0.0% 0.0% 0.0% 60 56
8 Tambahan Posyandu Durian 2 0.0% 0.0% 0.0% 13 3 23.1% 0.0% 0.0% 0.0% 13 3
9 Tambahan Posyandu Durian 3 0.0% 0.0% 0.0% 6 1 16.7% 0.0% 0.0% 0.0% 6 1
10 Posyandu Pinang Wangi 3 1 1 100.0% 0.0% 0.0% 75 65 86.7% 12 9 75.0% 0.0% 0.0% 87 74
11 Posyandu Anggrek 2 0.0% 0.0% 0.0% 62 50 80.6% 0.0% 0.0% 0.0% 62 50
12 Posyandu Anggrek 1 1 1 100.0% 0.0% 0.0% 51 45 88.2% 0.0% 0.0% 0.0% 51 45
11 Juni 2022 1 SDN 11 Kubu 0.0% 0.0% 0.0% 0.0% 7 6 85.7% 83 72 86.7% 8 7 87.5% 98 85
2 SDN 04 Sako 0.0% 0.0% 0.0% 0.0% 3 3 100.0% 40 25 62.5% 2 1 50.0% 45 29
3 SDN 05 Kubu 0.0% 0.0% 0.0% 0.0% 14 10 71.4% 184 158 85.9% 7 7 100.0% 205 175
4 MTSN 1 Rahul 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 239 130 54.4% 239 130
5 Posyandu Durian 3 Sako 0.0% 0.0% 0.0% 5 1 20.0% 0.0% 0.0% 0.0% 5 1
6 Posyandu Empat Sehat 0.0% 0.0% 0.0% 43 39 90.7% 0.0% 0.0% 0.0% 43 39
13 Juni 2022 1 Paud Bunda Sungai Pinang 0.0% 0.0% 0.0% 0.0% 20 13 65.0% 0.0% 0.0% 20 13
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0 0
Total 44 24 54.5% 5 5 100.0% 7 4 57.1% 1116 718 64.3% 225 160 71.1% 1215 1026 84.4% 1123 563 50.1% 3679 2467
 Total
Cakupan

48.8%
56.7%
69.1%
75.6%
21.6%
37.0%
86.2%
34.7%
60.0%
52.3%
13.3%
33.3%
75.3%
85.5%
95.0%
81.4%
93.4%
42.3%
44.7%
21.2%
68.1%
76.9%
82.8%
95.9%
83.3%
92.7%
81.3%
45.5%
53.7%
93.3%
23.1%
16.7%
85.1%
80.6%
88.2%
86.7%
64.4%
85.4%
54.4%
20.0%
90.7%
65.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
 0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
67.1%
 FORMAT REKAPITULASI LOGISTIK PUSKESMAS
Provinsi : Sumatera Barat Tanggal : 07/06/2022 s/d 13 Juni 2022
Kabupaten/Kota :
Pesisir Selatan
Puskesmas : Ranah Ampek Hulu Tapan

Isilah Kolom yang berwarna kuning!

OPV IPV DPT-HB-Hib Campak Rubela Jumlah Logistik yang digunakan

No. Posyandu/Pos Imunisasi lainnya

Jumlah Jumlah Vial IP Jumlah Jumlah Vial IP Jumlah Jumlah Vial IP Jumlah Jumlah Vial IP Pelarut Dropper ADS 0,5 ADS 5 Safety
diimunisasi digunakan diimunisasi digunakan diimunisasi digunakan diimunisasi digunakan ML ML Box

a b c d e f g h i j k l m n o p q r s

07 Juni 2022 1 Posyandu Karang Gizi Tebing 20 2 2 20 2 1

Tinggi #DIV/0! #DIV/0! #DIV/0! 10
08 Juni 2022 1 SD 01 Sungai Gambir #DIV/0! #DIV/0! #DIV/0! 85 9 9.4444444 9 85 9 1
2 SD 07 Padang Leban #DIV/0! #DIV/0! #DIV/0! 177 18 9.8333333 18 177 18 1
3 SD 03 Koto Pulai #DIV/0! #DIV/0! #DIV/0! 201 20 10.05 20 201 20 1
4 SMP 2 KP.Tengah #DIV/0! #DIV/0! #DIV/0! 50 5 10 5 50 5 1
5 Posyandu Kemajuan #DIV/0! #DIV/0! 2 1 2 11 1 11 1 13 1 1
6 Posyandu Belimbing #DIV/0! #DIV/0! #DIV/0! 25 3 8.3333333 3 25 3 1
7 Posyandu Gaya Baru #DIV/0! #DIV/0! #DIV/0! 34 4 8.5 4 34 4 1
8 Posyandu Pinang Wangi 1 #DIV/0! #DIV/0! #DIV/0! 45 5 9 5 45 5 1
9 Posyandu Anggrek IV 5 1 5 2 1 2 #DIV/0! 30 3 10 3 32 3 1
10 Posyandu Durian 2 #DIV/0! #DIV/0! #DIV/0! 2 1 2 1 2 1 1
11 Posyandu Durian 3 #DIV/0! #DIV/0! #DIV/0! 3 1 3 1 3 1 1
12 Posyandu Mawar Indah 15 2 7.5 #DIV/0! #DIV/0! 67 7 9.5714286 7 67 7 1
13 Posyandu Lima Sempurna #DIV/0! #DIV/0! #DIV/0! 47 5 9.4 5 47 5 1
09 Juni 2022 1 SD 09 Sungai Gambir #DIV/0! #DIV/0! #DIV/0! 96 10 9.6 10 96 10 1
2 SD 06 Talang #DIV/0! #DIV/0! #DIV/0! 105 11 9.5454545 11 105 11 1
3 SMP 1 Kubu #DIV/0! #DIV/0! #DIV/0! 113 12 9.4166667 12 113 12 1
4 MTSN 1 #DIV/0! #DIV/0! #DIV/0! 175 17 10.294118 17 175 17 1
5 Posyandu Aur Duri #DIV/0! #DIV/0! #DIV/0! 17 2 8.5 2 17 2 1
6 Posyandu Harapan Indah #DIV/0! #DIV/0! #DIV/0! 7 1 7 1 7 1 1
7 Posyandu Pinang Wangi 2 1 1 1 #DIV/0! 1 1 1 47 5 9.4 5 48 5 1
8 Posyandu Raflesia #DIV/0! 2 2 1 #DIV/0! 40 4 10 4 42 4 1
9 Posyandu Anggrek 3 #DIV/0! #DIV/0! #DIV/0! 48 5 9.6 5 48 5 1
10 Juni 2022 1 SD 08 Binjai #DIV/0! #DIV/0! #DIV/0! 47 5 9.4 5 47 5 1
2 SD 02 Padang Kejai #DIV/0! #DIV/0! #DIV/0! 45 5 9 5 45 5 1
3 SD 10 Pasar Melintang #DIV/0! #DIV/0! #DIV/0! 115 11 10.454545 11 115 11 1
4 SMP 3 Talang Balarik #DIV/0! #DIV/0! #DIV/0! 65 7 9.2857143 7 65 7 1
5 Posyandu Durian 1 #DIV/0! #DIV/0! #DIV/0! 5 1 5 1 5 1 1
6 Posyandu Sinar Harapan 1 1 1 1 1 1 1 1 1 44 5 8.8 5 46 5 1
7 Posyandu Wijaya Kusuma #DIV/0! #DIV/0! #DIV/0! 56 6 9.3333333 6 56 6 1
8 Tambahan Posyandu Durian 2 #DIV/0! #DIV/0! #DIV/0! 3 1 3 1 3 1 1
9 Tambahan Posyandu Durian 3 #DIV/0! #DIV/0! #DIV/0! 1 0 #DIV/0! 0 1 0 0
10 Posyandu Pinang Wangi 3 1 1 1 #DIV/0! #DIV/0! 74 7 10.571429 7 74 7 1
11 Posyandu Anggrek 2 #DIV/0! #DIV/0! #DIV/0! 50 5 10 5 50 5 1
12 Posyandu Anggrek 1 1 1 1 #DIV/0! #DIV/0! 45 5 9 5 45 5 1
11 Juni 2022 1 SDN 11 Kubu #DIV/0! #DIV/0! #DIV/0! 85 9 9.4444444 9 85 9 1
2 SDN 04 Sako #DIV/0! #DIV/0! #DIV/0! 29 3 9.6666667 3 29 3 1
3 SDN 05 Kubu #DIV/0! #DIV/0! #DIV/0! 175 18 9.7222222 18 175 18 1
4 MTSN 1 Rahul #DIV/0! #DIV/0! #DIV/0! 130 13 10 13 130 13 1
5 Posyandu Durian 3 Sako #DIV/0! #DIV/0! #DIV/0! 1 0 #DIV/0! 0 1 0 0
6 Posyandu Empat Sehat #DIV/0! #DIV/0! #DIV/0! 39 4 9.75 4 39 4 1
13 Juni 2022 1 Paud Bunda Sungai Pinang #DIV/0! #DIV/0! #DIV/0! 13 2 6.5 2 13 2 1

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

#DIV/0! #DIV/0! #DIV/0! #DIV/0!
TOTAL 24 7 3.428571 5 4 1.25 4 3 1.33333 2467 258 9.5620155 258 0 2476 258 40

Catatan :
IP = Jumlah yang diimunisasi/jumlah vial vaksin yang digunakan
ang digunakan

Pen
Marker

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