FORMAT PENCATATAN PELAKSANAAN VAKSINAS

TINGKAT PUSKESMAS/FASYANKES/POS VAKS

Nama
Puske
smas/F :
asyank
es/Pos
Kabup
aten/ :
Kota
Provin
:
si

Kepesertaan BPJS (tulis 'Ya

Umur
No. Jenis Kelompok
No NIK Nama Penerima Vaksin Pekerjaan* (18-59 Alamat No. Hp
Registrasi Kelamin Umur
tahun)
BPJS PBI

1 P 33 31-45 Puskesmas Tegalsiwalan

N-9A66F134 "3209085702880004" Riawati Sundara, A.Md.Keb Bidan Klinis 6285212127188

2 L 35 31-45 Puskesmas Tegalsiwalan

N-4E84D1FB "3508192305860009" M. Hoirul Mustain, S.Kep.Ners Ners 6281290203110

3 P 29 18-30 Puskesmas Tegalsiwalan

N-A1614F38 "3509085608920003" Reni Fidiawati, A.Md.Kep Perawat (Non Ners) 6281230417284

4 P 30 18-30 Puskesmas Tegalsiwalan

N-EBDE7B3D "3513057012910002" Yuliatin, S.Kep.Ners Ners 628990389656
5 L 30 18-30 Puskesmas Tegalsiwalan
N-B0C13E1C "3513060503910001" Aji Tri Utomo, A.Md.Kep Perawat (Non Ners) 6285895962031

6 P 37 31-45 Puskesmas Tegalsiwalan

N-78C1E4CF "3513067008840001" Primanti Zia Nurrakhmi, A.Md.Kep Perawat (Non Ners) 6281358712333

7 L 29 18-30 Puskesmas Tegalsiwalan

N-9FB39ABD "3513070404920003" Zainal abidin Keamanan 6285331837995

8 L 29 18-30 Puskesmas Tegalsiwalan

N-487AA88D "3513082502920003" Muzammil, S.Kep.Ners Ners 6281217696100

9 P 32 31-45 Puskesmas Tegalsiwalan

N-4C91A0AF "3513094605890002" MUARIFAH Dokter Gigi 628113501455

10 P 29 18-30 Puskesmas Tegalsiwalan

N-7AEC4056 "3513096510920001" Karimatul Hasanah, A.Md.Keb Bidan Desa 6285321596587

11 L 38 31-45 Puskesmas Tegalsiwalan

N-C829839B "3513100310830004" ARIF EKO TRILIANTO, S.KM Kepala Puskesmas 6281333317203
Tenaga Umum
12 L Lainnya Yang Belum 48 46-59 Puskesmas Tegalsiwalan
N-ABC41A0E "3513122711730002" Syaiful Anshori Tercantum 6282317673272
Ahli Teknologi
13 P Laboratorium Medik 50 46-59 Puskesmas Tegalsiwalan
N-7CCEEA26 "3513195807710002" Karsiti, A.Md.AK (Analis Kesehatan) 6282330244840

14 P 59 46-59 Puskesmas Tegalsiwalan

N-31812165 "3513196208620001" Kustiyani, SST Bidan Desa 6285234530423
Tenaga Umum
15 L Lainnya Yang Belum 27 18-30 Puskesmas Tegalsiwalan
N-CAA07354 "3513200505940003" SAIFUL CHAK Tercantum 6282217844454
Tenaga Umum
16 L Lainnya Yang Belum 30 18-30 Puskesmas Tegalsiwalan
N-8A935D52 "3513202710910001" Yofy Dimas Puja Purnama Tercantum 6285333773262

17 L 49 46-59 Puskesmas Tegalsiwalan

N-8EE41AE8 "3513202806720001" Moch. Bahri, S.Kep.Ners Ners 6282281824166

18 P 27 18-30 Puskesmas Tegalsiwalan

N-70ADA811 "3513204207940001" Tutik Nur Islakh, A.Md.Kep Perawat (Non Ners) 6282257867931

19 P 27 18-30 Puskesmas Tegalsiwalan

N-2F8ADF57 "3513204503940001" Siti Prafuriantini Bidan Klinis 6285204619885

20 P 27 18-30 Puskesmas Tegalsiwalan

N-1EE27A68 "3513204610940002" Iin sugianto Bidan Klinis 6285335203816
Tenaga Umum
21 P Lainnya Yang Belum 42 31-45 Puskesmas Tegalsiwalan
N-2050EEEB "3513205101790002" Getreda Jeni Sulfasinasili Tercantum 6281235043007
 Tenaga Umum
22 P Lainnya Yang Belum 28 18-30 Puskesmas Tegalsiwalan
N-BD4AE79D "3513205204930001" Vivin Sugiarti Tercantum 6282331147170

23 P 27 18-30 Puskesmas Tegalsiwalan

N-55CDB75A "3513205605940002" Vivi Wulandari, A.Md.Keb Bidan Klinis 6285236509508

L 31 31-45 Puskesmas Tegalsiwalan

24 N-3FF1D765 "3513210612900001" Dedy Krista Dinata, S.Kep.Ners Ners 628563280794

P 37 31-45 Puskesmas Tegalsiwalan

25 N-8F1B9830 "3513236706840002" Nur Azizah Kurnia DH, A.Md.Keb Bidan Klinis 6285330724612

P 37 31-45 Puskesmas Tegalsiwalan

26 N-6A1E9973 "3574014905840004" Wiwin Sulistyorini, SKM Promosi Kesehatan 6285233238713

P 47 46-59 Puskesmas Tegalsiwalan

27 N-BD48E9D8 "3574015009740004" CHOIRUL NISA,S.S.T.,MM Bidan Klinis 6281332118625

P 56 46-59 Puskesmas Tegalsiwalan

28 N-929B3A77 "3574024608650002" Sestu Wiludjeng, SGz Nutrisionis 6282131347202

P 34 31-45 Puskesmas Tegalsiwalan

29 N-43CB8ABD "3574025212860001" Dwi Jayanti Prawitasari, A.Md.Keb Bidan Klinis 6281336653950

P 32 31-45 Puskesmas Tegalsiwalan

30 N-D0B3B10B "3574025410890002" Vrisca Aninta Nisawati, A.Md.Keb Bidan Desa 6282245710890

"3574055407850003" P 0 Puskesmas Tegalsiwalan 081333334507

31 N-39E0A7DA Eka Jarmiati, A.Md.Keb Bidan Klinis

"3513206604910003" P 30 18-30 Puskesmas Tegalsiwalan 085204903386

32 N-EEC2A305 Faridatul Mardiyah, A.Md.Keb Bidan Klinis

"3515015311820001" P 39 31-45 Puskesmas Tegalsiwalan 082232255599

33 N-3A16657E Ika Setiawati, A.Md.Keb Bidan Klinis

"3513205105740002" P 47 46-59 Puskesmas Tegalsiwalan 085232115684

34 N-00665020 Maya Fardhilla Indraswari, SST Bidan Klinis

"3513207003700001" P 51 46-59 Puskesmas Tegalsiwalan 081217329469

35 N-D4337780 Siti Chusniyah Bidan Klinis

"3513145906880002" P 33 31-45 Puskesmas Tegalsiwalan 082247517180

36 N-D95E1F5D Siti Mutmainah, A.Md.Keb Bidan Klinis

"3513205303790001" P 42 31-45 Puskesmas Tegalsiwalan 083846546952

37 N-AFECA807 Uul Kholifah SST Bidan Klinis

"3513224405860003" P 35 31-45 Puskesmas Tegalsiwalan 085336125021

38 N-66E56852 Wieke Widiyarti, A.Md.Keb Bidan Klinis
 "3513204904860002" P 35 31-45 Puskesmas Tegalsiwalan 085330228729
39 N-DA95D554 Effi Dwi Pramadya P, A.Md.Kep Perawat (Non Ners)

"3513206510620002" P 59 46-59 Puskesmas Tegalsiwalan 081252606089

40 N-077EAEE3 Endang Sri Puji Andayani, A.Md.Kep Perawat (Non Ners)

"3513205311720001" P 49 46-59 Puskesmas Tegalsiwalan 085233372066

41 N-9A4C74F1 Junaedah, A.Md.Kep Perawat (Non Ners)

"3513202809650001' L 56 46-59 Puskesmas Tegalsiwalan 085236902799

42 N-862D4CA3 K a b u l, A.Md.Kep Perawat (Non Ners)

"3513200204720002" L 49 46-59 Puskesmas Tegalsiwalan 082337595077

43 N-F74CD6B1 Muttaqin, S.Kep.Ners Ners

"3508046310860001" P 34 31-45 Puskesmas Tegalsiwalan 085330903025

44 N-D08C04CA Reni Karyawati, A.Md.Kep Perawat (Non Ners)

"3513054409910001" P 29 18-30 Puskesmas Tegalsiwalan 085258785690

45 N-F2D0484B Rizky Amelia, A.Md.Kep Perawat (Non Ners)

"3513205505700002" P 51 46-59 Puskesmas Tegalsiwalan 082333105797

46 N-8E75C235 Ketut Sri Dyah Asriani, S.Kep.Ners Perawat (Non Ners)

47 "3513202911910003" Abdul Gofur L Perawat 30 18-30 Puskesmas Tegalsiwalan 085859775903

48 "3513195102880004" Nurhayati P Bidan Klinis 33 31-45 Puskesmas Tegalsiwalan 082244617858

49 "3513055606650001" Erni Yulaningsih P Perawat gigi 56 46-59 Puskesmas Tegalsiwalan 08123467662

A
B =
*Keteran
Petugas
Pekerja ***Merek Vaksin
gan
Medis
pelayan
an
dan
an Non A = Sinovac
dikelom B = Lainnya (Mohon disebutkan
Medis
pokkandi
publik jenis vaksin yang diterima
Fasilitas
yang
menjadi:
C = Puskesmas/Faskes)
Pelayan
berhada
Adminis
an
pan
trator
Kesehat
langsun
Pemerin
D
an=
g
tahan
Lainnya
E =
dengan
Tidak
masyar
Bekerja
akat

Kelompok Umur: Kepesertaan BPJS Pekerjaan

18-30 16 BPJS PBI A 0
31-45 17 BPJS Non PBI 0 B 0
46-59 13 Non Anggota 46 C 0
Total 46 Total 0 D 0
Pekerjaan: Pemberian Dosis 46 E 0
A 0 Dosis 1 Total 0
B 0 Dosis 2 44
C 0 Total 0
D 0
E 0
Total 0
AKSINASI COVID-19
POS VAKSINASI

n BPJS (tulis 'Ya' pada kolom yang sesuai) Dosis I Dosis 2

Merek Vaksin*** Tanggal Screening

Tanggal Pemberian Tanggal Pemberian
BPJS Non PBI Non Anggota No. Batch No. Batch
Vaksinasi Vaksinasi

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 29-01-21 3/2/2021 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 6/2/2021 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 4/2/2021 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 30-01-21 30-01-21 202011043

Ya Coronavac 29-01-21 29-01-21 202011043

Ya Coronavac 6/2/2021 6/2/2021 202011043

Ya Coronavac 6/2/2021 6/2/2021 202011043

Ya Coronavac 6/2/2021 6/2/2021 202011043

 Alasan Tidak diberikan
Keterangan
Vaksinasi (isi jika sasaran
(Ditunda/Tidak Diberikan/Lanjut)
tidak divaksin)
Tidak di vaksin DM,Jantung
Ditunda batuk pilek
Di tunda Riwayat jantung