FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Nama Puskesmas/Fasyankes/Pos : Puskesmas KERANGGAN

Kabupaten/Kota : Tangerang Selatan
Provinsi : Banten

Kepesertaan BPJS (tulis 'Ya' pada

Dosis I Dosis 2
kolom yang sesuai)
Keterangan
Jenis Umur
No No. Registrasi NIK Nama Penerima Vaksin Pekerjaan* Kelompok Umur Alamat No. Hp Merek Vaksin*** Tanggal Screening (Ditunda/Tidak
Kelamin (18-59 tahun)
Diberikan/Lanjut)
BPJS Non Non Tanggal Pemberian Tanggal Pemberian
BPJS PBI No. Batch No. Batch
PBI Anggota Vaksinasi Vaksinasi

1 1 3674026401630002 NUNUNG KURNIASIH P GURU 57 SERPONG UTARA 087776138176 v CORONAVAC 3/5/2021 3/5/2021 24000121

2 2 3674014805770001 HAMIDAH P GURU 43 KP MARUGA 081314326933 v CORONAVAC 3/5/2021 3/5/2021 24000121

3 3 3674024710650008 TITING SULASTRI P GURU 55 PRIYANG SERUT 081284665013 v CORONAVAC 3/5/2021 3/5/2021 24000121

4 4 3674025209870004 DEDE MULYADI P GURU 33 ASRAMA YONKAV 9 081281962942 v CORONAVAC 3/5/2021 3/5/2021 24000121

5 5 3674025507690001 SITI KHODIJAH P GURU 51 BUARAN 081806733359 v CORONAVAC 3/5/2021 3/5/2021 24000121

6 6 3671127103810001 TITIN NURBAITI P GURU 39 KP PONDOK BAHARI 081399919933 v CORONAVAC 3/5/2021 3/5/2021 24000121

7 7 3674025708680008 MURIAH P GURU 52 KP KAYU GEDE 081316551308 v CORONAVAC 3/5/2021 3/5/2021 24000121

8 8 3671114512720001 HAMIDAH P GURU 48 PINANG 087879585063 v CORONAVAC 3/5/2021 3/5/2021 24000121

9 9 3671115910770002 SRI MULYANAH P GURU 43 JL. KH HASYIM ASHARI GG. AMBON 087879449686 v CORONAVAC 3/5/2021 3/5/2021 24000121

10 10 3603205009750003 YULVA ARMADANI P GURU 44 GRIYA ASTER 081368097378 v CORONAVAC 3/5/2021 3/5/2021 24000121

11 11 3674025003660002 FITRIATI P GURU 54 KOMP. YON ARHANUDRI I KONSTRAD SERPONG 081388074667 v CORONAVAC 3/5/2021 3/5/2021 24000121

12 12 3674016007710001 TETI PUSPASARI P GURU 49 KP SERPONG 085286637172 v CORONAVAC 3/5/2021 3/5/2021 24000121

13 13 3674075711660001 MAMI ROSINAH P GURU 53 KADEMANGAN 081283041232 v CORONAVAC 3/5/2021 3/5/2021 24000121

14 14 3674016510650002 SUANAH P GURU 55 KP SERPONG 081310373599 v CORONAVAC 3/5/2021 3/5/2021 24000121

15 15 3603234705780003 MUNAWAROH P GURU 42 GRAND SERPONG 085282537999 v CORONAVAC 3/5/2021 3/5/2021 24000121

16 16 3674026007720003 SUWARTI P GURU 48 KP JELUPANG 081311563551 v CORONAVAC 3/5/2021 3/5/2021 24000121

17 17 3674076611670001 TRIANA DAHLIANTI P GURU 53 KP MUNCUL 082122236873 v CORONAVAC 3/5/2021 3/5/2021 24000121

18 18 3674014706810003 YUNITA NUNUNG P GURU 39 KP CILENGGANG 08128256840 v CORONAVAC 3/5/2021 3/5/2021 24000121

19 19 3674075809730004 MURTAPIAH P GURU 47 JL. PUSPIPTEK 087809302697 v CORONAVAC 3/5/2021 3/5/2021 24000121

20 20 3674016803650003 RAHAYU MIARSIH P GURU 55 KAVLING SERPONG 089698345452 v CORONAVAC 3/5/2021 3/5/2021 24000121

21 21 3671115010790002 TITIN SUMARTINI P GURU 41 PINANG KOTA TANGERANG 081289785631 v CORONAVAC 3/5/2021 3/5/2021 24000121

22 22 3674025609690001 RATIH RAHAYU P GURU 51 KP CIATER 081398246890 v CORONAVAC 3/5/2021 3/5/2021 24000121

23 23 3674024014660001 TUNAH P GURU 54 JL KAYU GEDE 1 087808733448 v CORONAVAC 3/5/2021 3/5/2021 24000121

24 24 3674025603720005 MARJAENAH P GURU 49 PAKU JAYA 089533309396 V CORONAVAC 3/5/2021 DITUNDA covid, kontak erat

covid, obat pengencer darah,

25 25 3674014204660001 HAERIYAH P GURU 54 SERPONG 081383311624 V CORONAVAC 3/5/2021 DITUNDA
RA, DM

26 26 3674075708680003 SURTINI P GURU 54 KADEMANGAN 081310016674 V CORONAVAC 3/5/2021 DITUNDA ispa

27 27 3674024303680004 NURYATI P GURU 53 PAKU JAYA 08811451124 V CORONAVAC 3/5/2021 DITUNDA dm

28 28 3671055006720011 RATU YULIANA P GURU 49 CIPONDOH 085959721514 V CORONAVAC 3/5/2021 DITUNDA covid

29 29 3674075308660001 NANI SUMARNI P GURU 54 KADEMANGAN 081381925471 V CORONAVAC 3/5/2021 DITUNDA dm

30 30 3671127005800007 HERLINA P GURU 40 KARANG TENGAH 081314339413 V CORONAVAC 3/5/2021 DITUNDA ht

31 31 3671056711760003 ROAINI P GURU 43 CIPONDOH 081381406613 V CORONAVAC 3/5/2021 DITUNDA ht

32 32 3674076403960002 ARTIAH P GURU 51 KP BARU ASIH 082112898617 V CORONAVAC 3/5/2021

33 33 3674076403690002 YOEALIS WIJIYANTI P GURU 52 BULU II 08563221122 V CORONAVAC 3/5/2021

34 34 3201215806910003 SUMIATI P GURU 29 JL ASIA AFRIKA 085777242405 V CORONAVAC 3/5/2021

35 35 3674066305850010 INDRIYANI P GURU 35 JL DEPAG 08988937921 V CORONAVAC 3/5/2021

36 36 3674046012930009 DESYANA FIRMANTI P GURU 27 JL DEWI SARTIKA 087885468361 V CORONAVAC 3/5/2021

37 37 1809044408940004 SITI MARYATUL QIBTIA'H P GURU 26 CIPAYUNG 089699918005 V CORONAVAC 3/5/2021

38 38 3211034716890011 YENI OKTAVIANY P GURU 31 KP PAYUNG BENING 081931713635 V CORONAVAC 3/5/2021

39 39 3674064805820005 EUIS MEILASARI P GURU 38 JL MUSHOLA ANNUR 085718636193 V CORONAVAC 3/5/2021

40 40 3674045211790001 RADEN NOVI NOVITA DEWI P GURU 41 BUKIT INDAH 085215191111 V CORONAVAC 3/5/2021

41 41 3674046104880006 LUCYKA YANWARY DEWI P GURU 32 SERUA MAKMUR 087721888789 V CORONAVAC 3/5/2021

42 42 3674066602790009 SYARKIYAH HAIRUMI P GURU 44 JL MASJID DARISSALAM 081388273825 V CORONAVAC 3/5/2021

43 43 3674050504810008 ASRUL HAFIIZH L GURU 39 JL CIREUNDEU INDAH III 081380642045 V CORONAVAC 3/5/2021

44 44 3674052207920003 BILAL ARADEA M L GURU 28 JL MEKAR RANU 1 0877025189914 V CORONAVAC 3/5/2021

45 45 3674055004710007 HENI RAKHMAWATI P GURU 39 JL NURUL HUDA 081318739791 V CORONAVAC 3/5/2021

46 46 3674054111780008 ENDANG SRI NOVIANTI P GURU 42 PINANG BARAT 085892463076 V CORONAVAC 3/5/2021

47 47 3674041408970006 ABDUL ROHMAN L GURU 23 KP RAWA LELE 085891022844 V CORONAVAC 3/5/2021

48 48 3674041209320002 AHMAD SAMNURANTO L GURU 28 KP RAWA LELE 0856716763246 V CORONAVAC 3/5/2021

49 49 3674065302630001 TRI SUKAPTI P GURU 57 PAMULANG PERMAI 085883325215 V CORONAVAC 3/5/2021

50 50 3212262807870001 KHOIRUL ARAM L GURU 33 DESA PLOSOKEREP 081210997265 V CORONAVAC 3/5/2021

51 51 3674054208810010 RIKA PERMANAWATI P GURU 39 JL CIRENDEU INDAH 1 081389890610 V CORONAVAC 3/5/2021

52 52 3674076102880002 PARIDA P GURU 32 JL MERPATI RAYA 085692554676 V CORONAVAC 3/5/2021

53 53 3603234607940003 HERLIN LISA ALFRIANA P GURU 26 BSD SEKTOR 1.1 081280805066 V CORONAVAC 3/5/2021

54 54 3674056402730005 MULYANIH P GURU 47 CIPUTAT TIMUR 085773448796 V CORONAVAC 3/5/2021 DITUNDA HT

55 55 3674055903790003 SUPRIATIN P GURU 42 V CORONAVAC 3/5/2021 DITUNDA HAMIL

56 56 3674045703750003 ATAOLAH P GURU 45 CIPUTAT 085782547613 V CORONAVAC 3/5/2021 DITUNDA HT

PELAYANAN
57 57 367111181183002 Fachrul Azizi L 37 DUTA BINTARO 085719484083 V CORONAVAC 3/5/2021
UMUM

PELAYANAN
58 58 3671124210960001 EMERALDA TRIA KARTIKA P 24 BANGUN REKSA INDAH 081807999682 V CORONAVAC 3/5/2021
UMUM

PELAYANAN
59 59 3671122209830003 RIKY ANDRIANSYAH L 37 BANGUN REKSA INDAH 085718360554 V CORONAVAC 3/5/2021
UMUM

PELAYANAN
60 60 3304126801000001 ISTIFAIJAH P 21 DUSUN RIBUG 085798547384 V CORONAVAC 3/5/2021
UMUM

PELAYANAN
61 61 3674015405860002 MEITY RAMADANIA L 34 PUSPITA LOKA BSD 085711176357 V CORONAVAC 3/5/2021
UMUM

PELAYANAN
62 62 3674012107740001 RIZAL YOHAN PERMANA L 46 PUSPITA LOKA BSD 085648895836 V CORONAVAC 3/5/2021
UMUM

PELAYANAN
63 63 3202050107930059 DEDE S L 27 CIGENTENG 085286781334 V CORONAVAC 3/5/2021
UMUM

PELAYANAN
64 64 3201110704860001 MUHAMMAD IRSAD L 34 CIBINONG 0895360849663 V CORONAVAC 3/5/2021
UMUM

65 3674025302670005 SUMINAH P GURU 53 SERPONG UTARA V CORONAVAC

66 3674065212850004 TRI BUDIARTI L GURU 35 PAMULANG 081212186606 CORONAVAC DITUNDA ISPA

PELAYANAN
65 67 5205085206900001 NURWAHIDAH P 29 CIGENTENG '087771448953 V CORONAVAC 3/5/2021
UMUM

Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes)
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja

Kelompok Umur: Kepesertaan BPJS Pekerjaan

18-30 0 BPJS PBI 0 A 0
31-45 0 BPJS Non PBI 0 B 0
46-59 0 Non Anggota 0 C 0
Total 0 Total 0 D 0
Pekerjaan: Pemberian Dosis E 0
A 0 Dosis 1 67 Total 0
B 0 Dosis 2 23
C 0 Total
D 0
E 0
Total 0

Petugas
dr. M. Ali Hasymi
Bd. Nurlaela Sari
Nurma Sintia Julaila
Anggiat Paima T.M