Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO

Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 31 MEI 2021
Kategori : UMUM

Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin
Umur

1 P-LD0SFAEN : 3575036704840003 APRILIA 4/27/1984 UMUM PERUM KARYA BHAKTI BLOK G - 06 : 085806426262 CoronaVac
2 P-KXPBIXAR : 3575030107750057 WAHYO PRIHONO 4/11/1983 UMUM JL. ANJASMORO GG XIV : 08813321264 CoronaVac
3 P-KHPQE3KP : 3575025308790002 SANTI EKO DEWI 8/13/1979 UMUM PERUM TAMBAK YUDAN MAKMUR F9 : 081233577818 CoronaVac
4 P-AGDN0RQ2 : 3575034407010001 SANIY RACHARDIANINGTYAS 7/4/2001 UMUM JI VETERAN 9F BUGUL LOR : 081353160214 CoronaVac
5 P-AUJMSB7I : 3575030805980001 SETIAWAN HARISH PRADANA 5/8/1998 UMUM JI VETERAN 9F BUGUL LOR : 085782162426 CoronaVac
6 P-JUAEUPST : 3575025707750003 NUR FADIAH RUSVIANA 7/17/1975 UMUM JL ERLANGGA 7 : 085755459101 CoronaVac
7 P-720JFH6J : 3575016906830002 KHANIFAH 6/29/1983 UMUM JL SLAMET RIYADI : 0895395353333 CoronaVac
8 P-6DUHXSKH : 3575014707770001 SULAMI 7/7/1977 UMUM JL SLAMET RIYADI : 089516531362 CoronaVac
9 P-JNTGC9GT : 3575015907000004 SHINTA AMELIA 7/19/2000 UMUM JL URIP SUMOHARJO : 083833967165 CoronaVac
10 P-JXAWTSUR : 3575016601990002 NIKMATUL FITRIYAH 1/26/1999 UMUM JL HANGTUAH GG 2 RT 2 RW 3 : 085816182983 CoronaVac
11 P-JSCQ3JJH : 3575032810940002 ari ardiansyah 28/10/1994 UMUM jl durian raya no. 16 : 081217107754 CoronaVac
12 P-JI96TAAQ : 3514202705920003 NANANG YUSRON 5/27/1992 UMUM JL HALMAHERA 13 / 53 : 085755563584 CoronaVac
13 S-0908FC54 : 3575022009890002 MOHAMMAD CATUR INDARMAWAN 9/20/1989 UMUM JL. URIP SUMOHARJO : 082230301385 CoronaVac
14 S-2DFEBF75 : 3575011609890002 TRI MULYONO 9/16/1989 UMUM JL.GATOT SUBROTO : 0881036754584 CoronaVac
15 P-FFGF2HWM : 7404305205860002 SUNARLIN 5/12/1986 UMUM ASRAMA YON ZIPUR 10 : 082264593526 CoronaVac
16 P-F6672IHQ : 3515024901860002 yeni puspitasari 1/9/1986 UMUM JL. SUKARNO HATTA ZIPUR 10, : 081216138193 CoronaVac
17 P-IYA70FZJ : 3575015303810003 ROBIATUL ADAWIYAH 3/13/1981 UMUM JL BANDA RT 04 RW 02 : 083848421180 CoronaVac
18 P-JOPVNUED : 3575034612780003 nugraheni rachmika sapti 6/12/1978 UMUM jln veteran 9f : 082140810747 CoronaVac
19 P-1A4GWKAK : 3575015707880001 DIAH KRISTANTI 7/17/1988 UMUM JL URIP SUMOHARJO : 082141443874 CoronaVac
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 31 MEI 2021
Kategori : UMUM

Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tangg
Umur Pembe
Vaksin

1 P-LD0SFAEN : 3575036704840003 APRILIA 4/27/1984 UMUM PERUM KARYA BHAKTI BLOK G - 06 : 085806426262 CoronaVac 5/31/2021
2 P-KXPBIXAR : 3575030107750057 WAHYO PRIHONO 4/11/1983 UMUM JL. ANJASMORO GG XIV : 08813321264 CoronaVac 5/31/2021
3 P-KHPQE3KP : 3575025308790002 SANTI EKO DEWI 8/13/1979 UMUM PERUM TAMBAK YUDAN MAKMUR F9 : 081233577818 CoronaVac 5/31/2021
4 P-AGDN0RQ2 : 3575034407010001 SANIY RACHARDIANINGTYAS 7/4/2001 UMUM JI VETERAN 9F BUGUL LOR : 081353160214 CoronaVac 5/29/2021
5 P-AUJMSB7I : 3575030805980001 SETIAWAN HARISH PRADANA 5/8/1998 UMUM JI VETERAN 9F BUGUL LOR : 085782162426 CoronaVac 5/29/2021
6 P-JUAEUPST : 3575025707750003 NUR FADIAH RUSVIANA 7/17/1975 UMUM JL ERLANGGA 7 : 085755459101 CoronaVac 5/29/2021
7 P-720JFH6J : 3575016906830002 KHANIFAH 6/29/1983 UMUM JL SLAMET RIYADI : 0895395353333 CoronaVac 5/28/2021
8 P-6DUHXSKH : 3575014707770001 SULAMI 7/7/1977 UMUM JL SLAMET RIYADI : 089516531362 CoronaVac 5/28/2021
9 P-JNTGC9GT : 3575015907000004 SHINTA AMELIA 7/19/2000 UMUM JL URIP SUMOHARJO : 083833967165 CoronaVac 5/27/2021
10 P-JXAWTSUR : 3575016601990002 NIKMATUL FITRIYAH 1/26/1999 UMUM JL HANGTUAH GG 2 RT 2 RW 3 : 085816182983 CoronaVac 5/27/2021
11 P-JSCQ3JJH : 3575032810940002 ari ardiansyah 28/10/1994 UMUM jl durian raya no. 16 : 081217107754 CoronaVac 5/27/2021
12 P-JI96TAAQ : 3514202705920003 NANANG YUSRON 5/27/1992 UMUM JL HALMAHERA 13 / 53 : 085755563584 CoronaVac 5/27/2021
13 S-0908FC54 : 3575022009890002 MOHAMMAD CATUR INDARMAWAN 9/20/1989 UMUM JL. URIP SUMOHARJO : 082230301385 CoronaVac 5/27/2021
14 S-2DFEBF75 : 3575011609890002 TRI MULYONO 9/16/1989 UMUM JL.GATOT SUBROTO : 0881036754584 CoronaVac 5/27/2021
15 P-FFGF2HWM : 7404305205860002 SUNARLIN 5/12/1986 UMUM ASRAMA YON ZIPUR 10 : 082264593526 CoronaVac 5/27/2021
16 P-F6672IHQ : 3515024901860002 yeni puspitasari 1/9/1986 UMUM JL. SUKARNO HATTA ZIPUR 10, : 081216138193 CoronaVac 5/27/2021
17 P-IYA70FZJ : 3575015303810003 ROBIATUL ADAWIYAH 3/13/1981 UMUM JL BANDA RT 04 RW 02 : 083848421180 CoronaVac 5/27/2021
18 P-JOPVNUED : 3575034612780003 nugraheni rachmika sapti 6/12/1978 UMUM jln veteran 9f : 082140810747 CoronaVac 5/27/2021
19 P-1A4GWKAK : 3575015707880001 DIAH KRISTANTI 7/17/1988 UMUM JL URIP SUMOHARJO : 082141443874 CoronaVac 5/25/2021
LAPORAN CAPAIAN VAKSINASI COVID-19 SASARAN ANAK-ANAK (6-11 TAHUN) KOTA PASURUAN
PER PUSKESMAS

TARGET CAPAIAN SELISIH KETERANGAN

NO PUSKESMAS %
ANAK-ANAK DOSIS 1 % DOSIS 2 % D1-D2
1 GADINGR 2,454 0.00% #DIV/0! 0 #DIV/0!
2 KARANGK 2,259 0.00% #DIV/0! 0 #DIV/0!
3 SEKARG 3,010 0.00% #DIV/0! 0 #DIV/0!
4 KEBONA 2,828 0.00% #DIV/0! 0 #DIV/0!
5 BUGULKI 3,133 0.00% #DIV/0! 0 #DIV/0!
6 TRAJENG 2,243 0.00% #DIV/0! 0 #DIV/0!
7 KEBONSA 1,916 0.00% #DIV/0! 0 #DIV/0!
8 KANDANG 2,566 0.00% #DIV/0! 0 #DIV/0!
TOTAL 20,409 0 0 0 0 0 0

LAPORAN CAPAIAN VAKSINASI COVID-19 SASARAN LANSIA KOTA PASURUAN

PER PUSKESMAS

TARGET CAPAIAN SELISIH

NO PUSKESMAS
LANSIA DOSIS 1 % DOSIS 2 % DOSIS 3 % D2-D3
1 GADINGR 1,930 301 15.60% 247 82.06% 0.00% 247
2 KARANGK 1,707 0.00% #DIV/0! #DIV/0! 0
3 SEKARG 2,386 0.00% #DIV/0! #DIV/0! 0
4 KEBONA 2,506 0.00% #DIV/0! #DIV/0! 0
5 BUGULKI 2,607 0.00% #DIV/0! #DIV/0! 0
6 TRAJENG 1,710 0.00% #DIV/0! #DIV/0! 0
7 KEBONSA 1,392 0.00% #DIV/0! #DIV/0! 0
8 KANDANG 1,929 0.00% #DIV/0! #DIV/0! 0
TOTAL 16,167 301 0 247 0 0 0 247

LAPORAN CAPAIAN VAKSINASI COVID-19 SASARAN MASYARAKAT UMUM (18 TAHUN KEATAS) KOTA PASURUAN
PER PUSKESMAS

TARGET CAPAIAN SELISIH

NO PUSKESMAS
MASY. UMUM DOSIS 1 % DOSIS 2 % DOSIS 3 % D2-D3
1 GADINGR 12,206 952 7.80% 828 86.97% 0.00% 828
2 KARANGK 10,757 0.00% #DIV/0! #DIV/0! 0
3 SEKARG 15,856 0.00% #DIV/0! #DIV/0! 0
4 KEBONA 15,382 0.00% #DIV/0! #DIV/0! 0
5 BUGULKI 15,768 0.00% #DIV/0! #DIV/0! 0
6 TRAJENG 10,621 0.00% #DIV/0! #DIV/0! 0
7 KEBONSA 8,702 0.00% #DIV/0! #DIV/0! 0
8 KANDANG 12,074 0.00% #DIV/0! #DIV/0! 0
TOTAL 101,366 952 0 828 0 0 0 828
 LAPORAN CAPAIAN VAKSINASI COVID-19 SASARAN REMAJA (12-17 TAHUN) KOTA PASURUAN
PER PUSKESMAS

TARGET CAPAIAN SELISIH

NO PUSKESMAS
REMAJA DOSIS 1 % DOSIS 2 % DOSIS 3 % D2-D3
1 GADINGREJO #DIV/0! #DIV/0! #DIV/0! 0
2 KARANGKETUG #DIV/0! #DIV/0! #DIV/0! 0
3 SEKARGADUNG #DIV/0! #DIV/0! #DIV/0! 0
4 KEBONAGUNG #DIV/0! #DIV/0! #DIV/0! 0
5 BUGULKIDUL #DIV/0! #DIV/0! #DIV/0! 0
6 TRAJENG #DIV/0! #DIV/0! #DIV/0! 0
7 KEBONSARI #DIV/0! #DIV/0! #DIV/0! 0
8 KANDANGSAPI #DIV/0! #DIV/0! #DIV/0! 0
TOTAL 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0

LAPORAN CAPAIAN VAKSINASI COVID-19 SASARAN MASYARAKAT RENTAN (50-59 TAHUN) KOTA PASURUAN
PER PUSKESMAS

TARGET CAPAIAN SELISIH

NO PUSKESMAS
MASY RENTAN
DOSIS 1 % DOSIS 2 % DOSIS 3 % D2-D3
1 GADINGREJO 278 #DIV/0! 241 86.69% 0.00% 241
2 KARANGKETUG #DIV/0! #DIV/0! #DIV/0! 0
3 SEKARGADUNG #DIV/0! #DIV/0! #DIV/0! 0
4 KEBONAGUNG #DIV/0! #DIV/0! #DIV/0! 0
5 BUGULKIDUL #DIV/0! #DIV/0! #DIV/0! 791
6 TRAJENG #DIV/0! #DIV/0! #DIV/0! 0
7 KEBONSARI #DIV/0! #DIV/0! #DIV/0! 0
8 KANDANGSAPI #DIV/0! #DIV/0! #DIV/0! 0
TOTAL 0 278 #DIV/0! 241 #DIV/0! 0 #DIV/0! 241

LAPORAN CAPAIAN VAKSINASI COVID-19 SASARAN HAMIL KOTA PASURUAN

PER PUSKESMAS

TARGET CAPAIAN SELISIH

NO PUSKESMAS
MASY RENTAN
DOSIS 1 % DOSIS 2 % DOSIS 3 % D2-D3
1 GADINGREJO #DIV/0! #DIV/0! #DIV/0! 0
2 KARANGKETUG #DIV/0! #DIV/0! #DIV/0! 0
3 SEKARGADUNG #DIV/0! #DIV/0! #DIV/0! 0
4 KEBONAGUNG #DIV/0! #DIV/0! #DIV/0! 0
5 BUGULKIDUL 59 #DIV/0! 34 57.63% 5 14.71% 791
6 TRAJENG #DIV/0! #DIV/0! #DIV/0! 0
7 KEBONSARI 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0
8 KANDANGSAPI 3 #DIV/0! 3 100.00% 1 33.33% 2
TOTAL 0 62 #DIV/0! 37 #DIV/0! 6 #DIV/0! 31

PUSKESMAS KEBONSARI UNTUK BUMIL MASUK KE MASYARAKAT UMUM

 JANUARI 2021 PEBRUARI 2021 MARET 202
KETERANGAN ANAK ANAK ANAK
DOSIS 1 DOSIS 2 DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1

RUAN

JANUARI 2021 PEBRUARI 2021 MARET 202

LANSIA LANSIA LANSIA
%
DOSIS 1 DOSIS 2 DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1
#DIV/0! 6 6 1 1 98
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
0

ATAS) KOTA PASURUAN

JANUARI 2021 PEBRUARI 2021 MARET 202

UMUM UMUM UMUM
%
DOSIS 1 DOSIS 2 DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1
#DIV/0! 32 93 125 52 52 629
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
0
TA PASURUAN

JANUARI 2021 PEBRUARI 2021 MARET 202

REMAJA REMAJA REMAJA
%
DOSIS 1 DOSIS 2 DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

UN) KOTA PASURUAN

JANUARI 2021 PEBRUARI 2021 MARET 202

RENTAN RENTAN RENTAN
%
DOSIS 1 DOSIS 2 DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1
#DIV/0! 23 23 3 3 181
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

RUAN

JANUARI 2021 PEBRUARI 2021 MARET 202

IBU HAMIL IBU HAMIL IBU HAMIL
%
DOSIS 1 DOSIS 2 DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
15820.00%
#DIV/0!
#DIV/0!
200.00%
#DIV/0!
 MARET 2021 APRIL 2021 MEI 2021
ANAK ANAK ANAK
KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2

MARET 2021 APRIL 2021 MEI 2021

LANSIA LANSIA LANSIA
KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2
104 6 7 163 267 127 134 34 301 113

MARET 2021 APRIL 2021 MEI 2021

UMUM UMUM UMUM
KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2
722 440 492 60 782 252 744 170 952 84
 MARET 2021 APRIL 2021 MEI 2021
REMAJA REMAJA REMAJA
KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2

MARET 2021 APRIL 2021 MEI 2021

RENTAN RENTAN RENTAN
KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2
204 139 142 36 240 73 215 38 278 26

MARET 2021 APRIL 2021 MEI 2021

IBU HAMIL IBU HAMIL IBU HAMIL
KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2 KOMULATIF DOSIS 1 KOMULATIF DOSIS 2
 2021
NAK
KOMULATIF

2021
NSIA
KOMULATIF
247

2021
MUM
KOMULATIF
828
 2021
MAJA
KOMULATIF

2021
NTAN
KOMULATIF
241

2021
HAMIL
KOMULATIF
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 31 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 P-33AW6FGY : 3575015405720001 ARBA'ATIN 5/14/1972 JL URIP SUMOHARJO NO.12 : 0895155645590 CoronaVac 5/31/2021 24002421

2 P-5UQEJZRB : 3575016101810003 NUR MAULIDIYAH 1/21/1981 JL GATOT SUBROTO : 085731906729 CoronaVac 5/31/2021 24002421

3 P-5DLS3FD6 : 3575016106880002 FITRIYAH 6/21/1988 JL. TEUKU UMAR, sebani : 089677022491 CoronaVac 5/31/2021 24002421

4 P-1FPP0PA8 : 3578075002880001 EKA WAHYUNINGTYAS 2/10/1988 JAGALAN 1/32 : 083856525456 CoronaVac 5/31/2021 24002421

5 P-1KSQTXFA : 3578272201870002 KOKOH HIDAYAT 1/22/1987 JAGALAN 1/32 : 082234595405 CoronaVac 5/31/2021 24002421

6 P-1OQS9CLN : 3578075407910001 CYHINTIA WAHYU LESTARI 7/14/1991 JAGALAN 1/32 : 087830320665 CoronaVac 5/31/2021 24002421

7 P-1TRIH80O : 3578072901890001 DAVID WAHYU PUTRA 1/29/1989 JAGALAN 1/32 : 085104971688 CoronaVac 5/31/2021 24002421

8 P-KHPQE3KP : 3575025308790002 SANTI EKO DEWI 8/13/1979 PERUM TAMBAK YUDAN MAKMUR F9 : 081233577818 CoronaVac 5/31/2021 24002421
9 P-KXPBIXAR : 3575030107750057 WAHYO PRIHONO 4/11/1983 JL. ANJASMORO GG XIV : 08813321264 CoronaVac 5/31/2021 24002421

10 P-LD0SFAEN : 3575036704840003 APRILIA 4/27/1984 PERUM KARYA BHAKTI BLOK G - 06 : 085806426262 CoronaVac 5/31/2021 24002421

Mengetahui Pasuruan, 31-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 29 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 Q-B2B9ECCB : 3575014903660002 KHUSNUL KHOTIMAH 3/5/1966 JL GATOT SUBROTO RW 04 RT 001 : 081336889844 CoronaVac 5/29/2021 24002421

2 S-19BC89E8 : 3575020601510001 AINUL HURI, BA 1/6/1951 JL.PANGSUD XVI/01 : 083833263422 CoronaVac 5/29/2021 24002421

3 P-DGZ5VJKA : 3575025909610001 SITI ROHMA 9/19/1961 PANGLIMA SUDIRMAN 16/01 : 085546797100 CoronaVac 5/29/2021 24002421

4 S-DC82AE9A : 3575034501400001 SRI WIDJAJATI 1/5/1940 JL.VETERAN 9F : 081333684854 CoronaVac 5/29/2021 24002421

5 P-KBP1ITAW : 3515065008970003 DHANNYS SAFIRA ZALSABILA 8/10/1997 dsn wates KEDENSARI : 082334990632 CoronaVac 5/29/2021 24002421

6 P-9RQHR14R : 3575036604690004 SOEHARDIJONO 4/6/1969 JL VETERAN 9 F BUGUL LOR : 081336567785 CoronaVac 5/29/2021 24002421

7 P-AGDN0RQ2 : 3575034407010001 SANIY RACHARDIANINGTYAS 7/4/2001 JI VETERAN 9F BUGUL LOR : 081353160214 CoronaVac 5/29/2021 24002421

8 P-AUJMSB7I : 3575030805980001 SETIAWAN HARISH PRADANA 5/8/1998 JI VETERAN 9F BUGUL LOR : 085782162426 CoronaVac 5/29/2021 24002421
9 P-DXLE0U1P : 3575024102690006 DEWI SUSILOWATI 2/1/1969 JL URIP SUMOHARJO : 081281469109 CoronaVac 5/29/2021 24002421

10 P-JUAEUPST : 3575025707750003 NUR FADIAH RUSVIANA 7/17/1975 JL ERLANGGA 7 : 085755459101 CoronaVac 5/29/2021 24002421

11 P-KJ7Z7BU5 : 3511115211820002 NELI KRESNA YUDHA 12/11/1982 JL. GAJAH MADA NO. 31 : 081336468864 CoronaVac 5/29/2021 24002421

12 P-KRJNIOC8 : 3576022710820003 RIZKI HARI NUGROHO 27/10/1982 JL. GAJAH MADA NO. 31 : 082139447082 CoronaVac 5/29/2021 24002421

Mengetahui Pasuruan, 29-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 28 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 P-DEOWXE1F : 3575034110680001 SULASTRI 1/10/1968 Jl. Sultan Agung I/11 : 085736996878 CoronaVac 5/28/2021 24002421

2 P-720JFH6J : 3575016906830002 KHANIFAH 6/29/1983 JL SLAMET RIYADI : 0895395353333 CoronaVac 5/28/2021 24002421

3 P-6DUHXSKH : 3575014707770001 SULAMI 7/7/1977 JL SLAMET RIYADI : 089516531362 CoronaVac 5/28/2021 24002421

4 P-8J6AKA3T : 3514075405930004 IRA TRI HASTUTIK 5/14/1993 KIDUL DALEM WONOREJO : 082302033702 CoronaVac 5/28/2021 24002421

5 P-A2Q9MO00 : 3514071608660001 TOTOK LESMONO 8/16/1966 KIDUL DALEM WONOREJO : 085101767746 CoronaVac 5/28/2021 24002421

6 P-AF5J8IOP : 3514072102620001 ASNARI 2/21/1962 KIDUL DALEM WONOREJO : 081233717981 CoronaVac 5/28/2021 24002421

7 P-JTFCRBBZ : 3575015204730002 MUDIANA HELDA ARIATI 4/12/1967 JL. ANYELIR NO. 17 PERUM GADING PERMAI : 0813122248548 CoronaVac 5/28/2021 24002421

8 P-JK8OZ46E : 3575011711660002 SUGIYO 17/11/1966 JL. ANYELIR NO. 17 PERUM GADING PERMAI : 085233233499 CoronaVac 5/28/2021 24002421
9 S-34F0E121 : 3575015001560001 HERI TYASMANING 1/10/1956 PERUM KARYA BHAKTI F- 41 : 081334146146 CoronaVac 5/28/2021 24002421

10 S-3E33629A : 3514074508580003 HARTATIK 8/5/1958 KIDUL DALEM WONOREJO : 081233626334 CoronaVac 5/28/2021 24002421

11 S-873F379F : 3575014205630001 NINIK HARTINING 5/2/1963 JL SLAMET RIYADI 61 B GENTONG : 082245293319 CoronaVac 5/28/2021 24002421

Mengetahui Pasuruan, 28-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 27 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 P-0TASKTVL : 3575015310820001 TITIK LESTARI 13/10/1982 JL SLAMET RIYADI : 085856904130 CoronaVac 5/27/2021 24002421
2 P-0ZT3FZQ2 : 3575014806920001 Tri Wahyuni 6/8/1992 JL. SLAMET RIYADI : 085784087178 CoronaVac 5/27/2021 24002421
3 P-16XHTY0M : 3575014705750002 SUTIANI 5/5/1975 JL SLAMET RIYADI : 082234035352 CoronaVac 5/27/2021 24002421
4 P-151HMD72 : 3575016504760003 SITI KHODIJAH 4/25/1976 JL SLAMET RIYADI : 082143713192 CoronaVac 5/27/2021 24002421
5 P-8XETB0QR : 3514165510980029 GALUH CITRA CAHYA ROHMANA 15/10/1998 KRAJAN, TAMBAKREJO : 081216850060 CoronaVac 5/27/2021 24002421
6 P-8XETB0QR : 3514160104030020 MUHAMMAD GUGUS SATRIA NUSAN4/1/2003 KRAJAN, TAMBAK REJO : 0895325758107 CoronaVac 5/27/2021 24002421
7 P-1BXL9NHU : 3575012502020002 MUKHAMAD RICKY FEBRIANSYAH 2/25/2002 JL GATOT SUBROTO, : 082213012326 CoronaVac 5/27/2021 24002421
8 P-EIUHLMYQ : 3509035506970005 RISKA WULANDARI 6/15/1997 DUSUN SUMBER ULING, SUMBER BARU : 085755907904 CoronaVac 5/27/2021 24002421
9 P-5FKQFL6G : 3575015503510001 SOEMIJATI 3/15/1951 JL BANDA RT 4 RW 2 No. 20 GADINGREJO : 081233618525 CoronaVac 5/27/2021 24002421
10 P-2GHGV1TL : 3575025101620002 SUKOWATI RETNAN NINGSIH 1/11/1962 JL ERLANGGA GG 4 : 08751331116 CoronaVac 5/27/2021 24002421
11 P-F6672IHQ : 3515024901860002 yeni puspitasari 1/9/1986 JL. SUKARNO HATTA ZIPUR 10, : 081216138193 CoronaVac 5/27/2021 24002421
12 P-FFGF2HWM : 7404305205860002 SUNARLIN 5/12/1986 ASRAMA YON ZIPUR 10 : 082264593526 CoronaVac 5/27/2021 24002421
13 P-IYA70FZJ : 3575015303810003 ROBIATUL ADAWIYAH 3/13/1981 JL BANDA RT 04 RW 02 : 083848421180 CoronaVac 5/27/2021 24002421
14 P-JI96TAAQ : 3514202705920003 NANANG YUSRON 5/27/1992 JL HALMAHERA 13 / 53 : 085755563584 CoronaVac 5/27/2021 24002421
15 P-JSCQ3JJH : 3575032810940002 ari ardiansyah 28/10/1994 jl durian raya no. 16 : 081217107754 CoronaVac 5/27/2021 24002421
16 P-JO2OVH5R : 3514116212730002 siti zulaikhah 22/12/1973 dusun bagagah : 085932233603 CoronaVac 5/27/2021 24002421
17 P-JOB2HL00 : 3514112002690001 ninet teguh winarno, st 2/20/1969 dusun bagagah : 081703369297 CoronaVac 5/27/2021 24002421
18 P-JOPVNUED : 3575034612780003 nugraheni rachmika sapti 6/12/1978 jln veteran 9f : 082140810747 CoronaVac 5/27/2021 24002421
19 P-JXAWTSUR : 3575016601990002 NIKMATUL FITRIYAH 1/26/1999 JL HANGTUAH GG 2 RT 2 RW 3 : 085816182983 CoronaVac 5/27/2021 24002421
20 S-0908FC54 : 3575022009890002 MOHAMMAD CATUR INDARMAWAN 9/20/1989 JL. URIP SUMOHARJO : 082230301385 CoronaVac 5/27/2021 24002421
21 S-2DFEBF75 : 3575011609890002 TRI MULYONO 9/16/1989 JL.GATOT SUBROTO : 0881036754584 CoronaVac 5/27/2021 24002421
22 P-JNTGC9GT : 3575015907000004 SHINTA AMELIA 7/19/2000 JL URIP SUMOHARJO : 083833967165 CoronaVac 5/27/2021 24002421

Mengetahui Pasuruan, 27-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 25 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 P-1YG8Z36C : 3575017112680003 LIS MARITA 31/12/1968 JL URIP SUMOHARJO : 085257910201 CoronaVac 5/25/2021 24002421
2 : P-1MDI0PJO : 3575016501770001 SUNARSIH 1/25/1977 JL URIP SUMOHARJO : 082230911708 CoronaVac 5/25/2021 24002421
3 P-1CM95GKE : 3575015511780001 NURUL FAIDAH 15/11/1978 JL URIP SUMOHARJO : 081331824280 CoronaVac 5/25/2021 24002421
4 P-1FWATCQH : 3575016905920001 LELYTA SOFIA MEI YANTI 5/29/1992 JL. URIP SUMOHARJO : 085606467445 CoronaVac 5/25/2021 24002421
5 P-1GZBVVIL : 3575014301790003 SITI KHALIMAH 1/3/1979 BUKIR, GADINGREJO : 082140341212 CoronaVac 5/25/2021 24002421
6 P-18JBOGWY : 3575015608820001 HEFI AGUSTINA 8/15/1982 JL GATOT SUBROTO, JAWA TIMUR, KOTA PAS : 082140715426 CoronaVac 5/25/2021 24002421
7 P-1L6L6UR6 : 3575015212750001 BAWON SUHERMIN 12/12/1975 JL GATOT SUBROTO RW 05 RT 003 : 089523362641 CoronaVac 5/25/2021 24002421
8 P-1YG8Z36C : 3575014206800002 FATIMAH 6/2/1980 JL GATOT SUBROTO : 089687217262 CoronaVac 5/25/2021 24002421
9 P-26COI5NG : 3575016402660001 SOFEYAH 2/24/1966 JL GATOT SUBROTO, JAWA TIMUR, KOTA PAS : 081333207406 CoronaVac 5/25/2021 24002421
10 P-1NQKPASN : 3575015209910002 NUR MAULIDAH 9/21/1991 JL GATOT SUBROTO : 089519266331 CoronaVac 5/25/2021 24002421
11 P-21V4O7MB : 3575016202800004 SITI AISYAH 2/22/1980 BUKIR , GADINGREJO : 081234337006 CoronaVac 5/25/2021 24002421
12 P-2JLNEHQ2 : 3575014107700016 SOFIYAH 7/1/1970 JL GATOT SUBROTO : 089677021551 CoronaVac 5/25/2021 24002421
13 P-1QRBNLGB : 3575014106720001 SITI ROCHMAH 6/1/1972 JL GATOT SUBROTO : 083841656820 CoronaVac 5/25/2021 24002421
14 P-56JX7Y3R : 3575015304870003 WIDYA LESTARI 4/13/1987 JL HALMAHERA GG XI : 082331912680 CoronaVac 5/25/2021 24002421
15 P-BAMZUHMR : 3575016303720004 SUMARNI 3/23/1972 JL IRIAN JAYA NO 58 : 081334486441 CoronaVac 5/25/2021 24002421
16 P-CMQCRPZU : 3575015012890002 SITI IT FITRIA 7/7/1983 TALANGAN, BEJI : 085806775159 CoronaVac 5/25/2021 24002421
17 P-7JME1OX3 : 3514234510860003 LILIK MAHMUDAH 5/10/1986 BALIDONO rt 1 rw 09 : 085330173192 CoronaVac 5/25/2021 24002421
18 P-AC2LFCLG : 3575016002680002 SRI EMI 2/20/1968 SEBANI, GADINGREJO : 082231373197 CoronaVac 5/25/2021 24002421
19 P-428FG4HC : 3575015112790003 ERNI SUSILOWATI 11/12/1979 JL.SLAMET RIYADI : 085100783695 CoronaVac 5/25/2021 24002421
20 P-0UMG3V8T : 3515062011680002 DAMAT PRAWIYANTO 20/11/1968 dsn wates 8/3 kedensari : 081232503353 CoronaVac 5/25/2021 24002421
21 P-C5ECUH0L : 3575035601010002 ALMIRAH SHAFA RUSARANDI 1/16/2001 PERUM ISTANA BESTARI AC - 12 A, PEKUNCEN: 082139017316 CoronaVac 5/25/2021 24002421
22 P-DW075TN3 : 3575014605900003 LINDA ARIYANI 5/6/1990 JL HALMAHERA GG 13/ 53 RW 06 RT 004 : 0895628100532 CoronaVac 5/25/2021 24002421
23 P-EH9VUUSR : 3575015508660001 SRI BAKTI 2/23/1966 JL HALMAHERA 13 / 53 : 085730628602 CoronaVac 5/25/2021 24002421
24 P-2AWUPZOF : 3575027101020002 andini nur faizah 1/31/2002 jl lks martadinata no.71 : 087872641199 CoronaVac 5/25/2021 24002421
25 P-BVHNONDT : 3575021704030005 AKHMAD KURNIAWAN SETIYANTO 4/17/2003 JL DR WAHIDIN SH NO. 227, JAWA TIMUR, KO : 085236807032 CoronaVac 5/25/2021 24002421
26 S-3667E045 : 3575010510560001 MOH TOHA 5/10/1956 JL SLAMET RIADI NO 14 : 085731339107 CoronaVac 5/25/2021 24002421
27 S-BF9C338E : 3575010101600010 ABD CHOLIQ 1/1/1960 JL SLAMET RIADI : 085649922638 CoronaVac 5/25/2021 24002421
28 S-8D964828 : 3575014306800007 Eka Yuliyanti Wahyuning Tyas 6/3/1980 : 085867642764 CoronaVac 5/25/2021 24002421
29 P-1A4GWKAK : 3575015707880001 DIAH KRISTANTI 7/17/1988 JL URIP SUMOHARJO : 082141443874 CoronaVac 5/25/2021 24002421
30 P-IFLPU5OZ : 3575014808630004 ELIS SENIWATI 8/8/1963 JL HALMAHERA 66 XI : 085749582588 CoronaVac 5/25/2021 24002421
31 P-72CLCZJ7 : 3575015206760004 AYUNINGSIH 6/12/1976 JL HALMAHERA GG XI : 085100668523 CoronaVac 5/25/2021 24002421
32 S-6580851E : 3575012204850004 Samsul Arif 4/22/1985 Jl. Halmahera, Gg 9 RT 02/03 Gadingrejo Pasuruan: 085330138871 CoronaVac 5/25/2021 24002421
33 S-695A70F7 : 3575012308550001 ENGGONO WIJAYA 8/23/1955 JL KARYA BAKTI P.4, : 082230582950 CoronaVac 5/25/2021 24002421

Mengetahui Pasuruan, 25-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
 Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

37 P-32LVIAVM : 3575011205950002 MUHAMMAD ISMAIL 5/12/1995 JL SLAMET RIADI : 081235754230 CoronaVac 5/24/2021 24002421
38 S-C2D03749 : 3575015004530002 MUDJIATI 4/10/1953 JL HALMAHERA GG 11, : 081991283233 CoronaVac 5/24/2021 24002421
39 P-DJ6UQK0U : 3575015507770001 DEWI MASITA 7/15/1977 JL HALMAHERA 66 1X PASURUAN : 081359234206 CoronaVac 5/24/2021 24002421
40 P-F93NR627 : 3575015202760003 KHUSNUL KHOTIMAH 7/1/1976 JL HALMAHERA GG 9 : 085855025554 CoronaVac 5/24/2021 24002421
41 P-EFCDGN0O : 3575015504740002 RAHAYU SETYAWATI 4/15/1974 JL. SINONGO no 6 RT 1 RW 1 : 0812356616148 CoronaVac 5/24/2021 24002421
42 P-HDZGONSJ : 3575015210700001 SRI RAHAYU 12/10/1970 PERUM KARYA BAKTI L. 14 : 085733747892 CoronaVac 5/24/2021 24002421
43 P-1U4AF2TE : 3575017011860002 VIVIN DIAN PERMATASARI 30/11/1986 JL SINONGGO NO /5 : 085755145304 CoronaVac 5/24/2021 24002421
44 P-HEDPZSFI : 3575014107730029 DEWI SUMIATI ARTIKOWATI 7/1/1973 PERUM KARYA BHAKTI J.25 : 082333912198 CoronaVac 5/24/2021 24002421
45 P-4PWFCQ2P : 3575015612760001 ANIK NURMAYA 16/12/1976 JL SLAMET RIYADI : 085852981804 CoronaVac 5/24/2021 24002421
46 P-G9V6CYBW : 3575015604720001 ASTUTIK 9/18/1972 JL SLAMET RIADI RT 1 RW 6 SEBANI : 085821987188 CoronaVac 5/24/2021 24002421
47 S-86052456 : 3575014101490032 MARLIYAH 1/1/1949 JL SLAMET RIYADI CoronaVac 5/24/2021 24002421
48 P-7Y7CZBEN : 3575014409650001 MISTRI 9/4/1965 JL SLAMET RIYADI : 085815571544 CoronaVac 5/24/2021 24002421
49 P-1VYAYQWA : 3575014504830003 SAROFAH 4/1/1983 JL SLAMET RIYADI RW01 RT 002 : 081332709452 CoronaVac 5/24/2021 24002421
50 P-4DPS5BR1 : 3575015501710001 SUMIATI 1/15/1971 JL SLAMET RIYADI : 082132367075 CoronaVac 5/24/2021 24002421
51 P-44E44P9K : 3575014803790004 TIA LAVIVA 3/8/1979 JL SLAMET RIYADI : 0895601121070 CoronaVac 5/24/2021 24002421
52 S-D0D249B6 : 3575014509510001 MUSAJADAH 7/1/1951 JL HALMAHERA GG 11 : 082331376923 CoronaVac 5/24/2021 24002421
53 S-6794A892 : 3575015610590002 SOFIYAH 16/10/1959 JL. HALMAHERA XI/51 : 081991283233 CoronaVac 5/24/2021 24002421
54 S-5E59A059 : 3575010605590001 SUGIAT 7/1/1958 JL SOEKARNO HATTA 2 : 081310106511 CoronaVac 5/24/2021 24002421
55 P-37C4G35J : 3575017011010001 MUTIARA RAMADAMI PUTRI SUPRIA30/11/2001 JL HALMAHERA GG 11 : 083523529541 CoronaVac 5/24/2021 24002421

Mengetahui Pasuruan, 24-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 22 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 P-6UC5K22G : 3575014503930005 NUR AZIZAH RAMADHANI 3/5/1994 JL HASANUDIN VII / 16 : 083848940219 CoronaVac 2021-05-22 24002421
2 S-064DBE7D : 3575010801510002 M SHOLIH 1/8/1951 JL SLAMET RIYADI : 085816359871 CoronaVac 2021-05-22 24002421
3 S-D8D8A4E7 : 3575016005540001 SUPARMI 5/24/1954 JL JEND A YANI NO. 57 : 082257722192 CoronaVac 2021-05-22 24002421
4 S-4BBC756A : 3575014101590027 MARDIYAH 7/1/1959 JL AKHMAD YANI : 085257719631 CoronaVac 2021-05-22 24002421
5 P-DFDL87SU : 3575031904990001 ROBBY PATTY NURRANI PAMBUDI 4/19/1999 JL SULTAN AGUNG GG I / 5 : 085731391607 CoronaVac 2021-05-22 24002421
6 P-5MM4KCHV : 3575016205800003 LILIS SURYANI DWI LESTARI 5/22/1980 JL SULAWESI 11 RT 2 RW 8 TRAJENG : 082251684159 CoronaVac 2021-05-22 24002421
7 P-CZAO6TCK : 3575016907890005 SYAMSUN NAHAR 7/29/1989 JL HANGTUAH 1/3 tambaan : 085102686691 CoronaVac 2021-05-22 24002421
8 S-24A1797E : 3575015210500001 SUMIATI 12/10/1950 JL SLAMET RIADI GG 1 : 08566933150 CoronaVac 5/22/2021 24002421
9 S-034901A4 : 3575015109540001 ICU YULIANTI 9/11/1954 JL KARYA BAKTI P.4 : 082230582950 CoronaVac 5/22/2021 24002421
10 P-58R1L87S : 3575010107700056 SLAMET 7/1/1970 JL BANDA GG MAWAR RW 02 RT 005 : 083846681722 CoronaVac 5/22/2021 24002421
11 S-1D299DD4 : 3575010107410005 YATIMIN 7/1/1941 SEBANI 02/05 : 088237556530 CoronaVac 5/22/2021 24002421
12 S-0DB3CDBC : 3575016503440002 SUYATI 3/25/1944 GADINGREJO : 081358035552 CoronaVac 5/22/2021 24002421
13 P-CDECY89N : 3575015912630001 ALFIYUNI 7/1/1961 JL SOEKARNO HATTA 2 : 082131724411 CoronaVac 5/22/2021 24002421
14 P-2HVMNAW4 : 3509280206790001 HENDRA KURNIAWAN 6/2/1979 DUSUN KRAJAN RT.002 / RW.002 SUMBERLE : 085230979413 CoronaVac 5/22/2021 24002421
15 P-3X00UM8M : 3575014412660001 SITI SALMA 7/1/1966 JL URIP SUMOHARJO : 082337891895 CoronaVac 5/22/2021 24002421
16 P-5FWVLE3G : 3575014303940005 SITI SOFIA 3/3/1994 JL.BANDA GG.MAWAR : 083846681722 CoronaVac 5/22/2021 24002421
17 P-3ZPN7YD9 : 3575010107660019 DJAMIL 7/1/1966 JL URIP SUMOHARJO : 082337891895 CoronaVac 5/22/2021 24002421
18 P-5PIOAVYN : 3575010107930024 ABDUL ROCHIM 3/12/1993 JL.BANDA GG.MAWAR : 083846681722 CoronaVac 5/22/2021 24002421
19 P-6LYU7IJI : 3575015403670002 SULIYAS WATININGSIH 3/14/1967 JL BANDA GANG DAHLIA 63A : 085732390609 CoronaVac 5/22/2021 24002421
20 P-9NIMIIHB : 3575016907670001 SUWARTI 7/29/1967 JL BANDA GANG KAMBOJA : 085732390609 CoronaVac 5/22/2021 24002421
21 S-5B7A657C : 3575014303590002 SITI MARIYATI 3/3/1959 JL BANDA GANG KAMBOJA 84 : 082236234448 CoronaVac 5/22/2021 24002421
22 P-AN7EU8MT : 3575010504650001 KASAN 4/5/1965 JL SLAMET RIADI GG 11 : 085706933402 CoronaVac 5/22/2021 24002421

Mengetahui Pasuruan, 22-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 21 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 P-2V16WS3U : 3575015906940001 SURYANI 6/19/1994 JL. GATOT SUBROTO 81217950487 CoronaVac 2021-05-21 24001821
2 P-3652XGKD : 3575014506760002 SISWANTI 6/3/1979 JL GATOT SUBROTO 81233892613 CoronaVac 2021-05-21 24001821
3 P-CVTEQPTI : 3575034412960003 NOVITA FADELINATUL LAILA 4/12/1996 JL PATIUNUS NO 59 8990111445 CoronaVac 2021-05-21 24001821
4 P-3FZ9EHLM : 3575015103700003 HARINI PURWANDARI 3/11/1970 JL BANDA NO. 89 81555380186 CoronaVac 2021-05-21 24001821
5 P-CGIL0L55 : 3575014107710069 HARTINI 7/1/1971 JL IRIAN JAYA 82338507846 CoronaVac 2021-05-21 24001821
6 P-2G4NF407 : 3575015103630001 TUTIK WAHYUNI 3/11/1963 : P. KARYA BAKTI L 29, 82135462266 CoronaVac 2021-05-21 24001821
7 P-AA7AOEOP : 3575016312880001 hariyati 23/12/1988 : 082231480521 82231480521 CoronaVac 2021-05-21 24001821
8 P-57N6YB46 : 3575016703890005 IKA RINDIANI 1989-03-27 krisna no. f1b, gentong 85103563821 CoronaVac 2021-05-21 24001821
9 P-1S5IEX4S : 3575016808800001 KURNIATI 8/28/1980 JL SLAMET RIYADI GG 9 83830789183 CoronaVac 2021-05-21 24001821
10 P-1FUGLA56 : 3575014202810001 ANIK KOMARIYAH 2/2/1981 SEBANI rt 03 rw 05 81536521608 CoronaVac 2021-05-21 24001821
11 P-1YRDRGYL : 3575015305870002 NUR SUGIARTI 5/13/1987 JL. SLAMET RIYADI GG - 9 85749500506 CoronaVac 2021-05-21 24001821
12 S-08F4E533 : 3575014106610001 SADIYAH 7/1/1960 JL SLAMET RIADI : 083835544280 CoronaVac 2021-05-21 24001821
13 S-4DFEDFE8 : 3575012805600001 MUHAMMAD MUNIR 5/28/1960 : 08123226026 CoronaVac 2021-05-21 24001821
14 P-ZQ7EYZ1I : 3575016302610001 MISRIAH 2/23/1961 JL.GATOT SUBROTO RT 1 RW 7 BUKIR : 081334873286 CoronaVac 2021-05-21 24001821
15 S-C9087CF9 : 3575015407560001 LINDA WIDYAWATI 7/14/1953 PERUM KARYA BHAKTI F 37 : 083833189073 CoronaVac 2021-05-21 24001821
16 S-13CFD0BE : 3575015010560003 ASNAH 10/10/1956 JL SINONGGO 16 : 089506658132 CoronaVac 2021-05-21 24001821
17 S-8ECB4D03 : 3575010107580117 MIYADI 7/1/1958 JL. JEND. A. YANI NO.60 : 089624916534 CoronaVac 2021-05-21 24001821
18 P-AUAIQLBO : 3575017101900002 WIWIN : 1990-01-31 BUKIR rt 03 rw 07 : 082336664017 CoronaVac 2021-05-21 24001821
19 S-7650BED1 : 3575016107810004 NUR ANA : 1981-07-21 KRAPYAK : 085755355505 CoronaVac 2021-05-21 24001821
20 P-FZGKHEOI : 3575016607800001 YOHANA RATNA DEWI 7/26/1980 JL GATOT SUBROTO : 085335760174 CoronaVac 2021-05-21 24001821
21 P-FZNDBIQW : 3575015711880003 MUTMAINAH 17/11/1988 JL. HANGTUAH GG. 2 : 085377104721 CoronaVac 2021-05-21 24001821
22 P-G05Z82HJ : 3575016804950003 NUR AINI 4/28/1995 JL HANGTUAH GG 2/96B : 085895739869 CoronaVac 2021-05-21 24001821
23 P-G2UJSSSQ : 3575016812730003 SITI MARIYAM 7/1/1973 JL BANDA GG MAWAR, GADINGREJO : 083846681722 CoronaVac 2021-05-21 24001821
24 P-8YYE3KS3 : 3575014503800007 DWI IKE ARDIMAS 3/5/1980 JL SLAMET RIYADI : 085649968007 CoronaVac 2021-05-21 24001821
25 S-885ECFE9 : 3575024404600001 ISTININGSIH 9/22/1960 JL URIPSUMOHARJO : 087797094127 CoronaVac 2021-05-21 24001821
26 S-1F5C7B3B : 3575025507540001 ASTUTIK 7/15/1954 JL URIPSUMOHARJO, JAWA TIMUR, KOTA PA : 081335749186 CoronaVac 2021-05-21 24001821
27 P-0WX0HC51 : 3575034107720031 ARNIDA 7/1/1969 JL MT HARYONO TIMUR : 081334251079 CoronaVac 2021-05-21 24001821
28 P-9U4KFO1G : 5103052406670005 FARID SAPUTRO 6/24/1967 JLULUWATU II - 99X KALANGANYR JIMBARAN : 081329630944 CoronaVac 2021-05-21 24001821
29 S-97F84740 : 3575010503710003 SUDIYONO RAMLI 3/5/1971 JL. HASANUDIN 17/91 KARANGANYAR KECAM : 081334663680 CoronaVac 2021-05-21 24001821
30 P-57KOP6QL : 3575010204740003 USEP 4/2/1974 JL SLAMET RIYADI GG 12 : 087703278845 CoronaVac 2021-05-21 24001821
31 P-5FMPE21B : 3575014510740005 SUDJIATI 5/10/1974 JL SLAMET RIYADI GG 12 : 083117931551 CoronaVac 2021-05-21 24001821
32 P-7P62AAU3 : 3575014507790002 ASROMAH 7/5/1979 JL SLAMET RIADI GG 11 : 081359349727 CoronaVac 2021-05-21 24001821

Mengetahui Pasuruan, 21-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 20 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 S-7D10F7AD : 3575010509900001 Mukhamad Junaidi 9/5/1990 Jl. Erlangga selatan No. 33 RT.8 RW.8 : 085790950711 CoronaVac 2021-05-20 24001821
2 P-VBL1SJXY : 3575016712610002 SUNIYA 27/12/1961 JL GATOT SUBROTO RT 2 RW 4 BUKIR : 0895395001768 CoronaVac 2021-05-20 24001821
3 S-C9EC7065 : 3575020903780005 LUKMAN HAKIM 3/9/1978 : 085546630076 CoronaVac 2021-05-20 24001821
4 S-1268B826 : 3575034209520003 INA WIDANINGSIH 9/2/1952 PERUM KARYA BHAKTI BLOK P 29 : 081336552900 CoronaVac 2021-05-20 24001821
5 S-F2B23B68 : 3575014604530001 SOEPATMI 4/6/1953 JL IRIAN JAYA 07 : 085645753979 CoronaVac 2021-05-20 24001821
6 S-585154CA : 3575014101600010 LILIK INDRAYANI 1/1/1960 JL. SLAMET RIYADI II, RT. 001 RW. 001, KEL. : 081232269354 CoronaVac 2021-05-20 24001821
7 S-82855B30 : 3575015806580001 SUUDAH 7/1/1954 JL SLAMET RIADI : 087846269826 CoronaVac 2021-05-20 24001821
8 P-ZEUSWLOW : 3575014108620002 KHOTIMAH 8/1/1962 JL SLAMET RIADI GG 2 NO 2 GENTONG : 081232269352 CoronaVac 2021-05-20 24001821
9 S-63F4F784 : 3575011202550001 PONALI 2/12/1955 JL SLAMET RIADI GG 2 NO 2 : 085815324009 CoronaVac 2021-05-20 24001821
10 Y-00004FUQ : 3575014811550001 PURWASTUTIK 8/11/1955 KOMPLEK PERUM KARYA BHAKTI JALAN - BLOK:085731901873 CoronaVac 2021-05-20 24001821
11 S-F3B0ADC8 : 3575013006530001 ABDUL LATIF 6/30/1953 PERUM KARYA BHAKTI F - 34 : 081233225534 CoronaVac 2021-05-20 24001821
12 S-3FA3FE7A : 3575014508570001 Nuriyani Widiyowati 8/5/1957 : 081230101957 CoronaVac 2021-05-20 24001821
13 S-9BDA5207 : 3575016002590002 WIWIK SUDARWATI 7/1/1959 JL SLAMET RIYADI : 0895800467313 CoronaVac 2021-05-20 24001821
14 P-CDKG62QJ : 3575016003850002 DINA MARIANA 3/20/1985 JL GATOT SUBROTO : 081270365430 CoronaVac 2021-05-20 24001821
15 P-DYLQ6MVC : 3575014802880002 LAILATUL INAYAH 2/8/1988 JL URIP SUMOHARJO : 081233513753 CoronaVac 2021-05-20 24001821
16 P-1FWTAZNN : 3575014706810003 Asmaningsih 6/7/1981 RTBukir RT 03 RW 02. GADINGREJO : 081252881427 CoronaVac 2021-05-20 24001821
17 P-1JWDD0GD : 3575014201720003 SITI ULIFAH 1/2/1972 BUKIR RT 03 RW 02. GADINGREJO : 0852590011808 CoronaVac 2021-05-20 24001821
18 P-F2VLTMQM : 3575015212800003 ANISAH 12/12/1980 JL GATOT SUBROTO : 0895397001390 CoronaVac 2021-05-20 24001821
19 P-1OS0ALBT : 3575014408840003 CINTAMY NIKASARY AGUSTIN 8/4/1984 JL SLAMET RIADI NO 38 : 081904282194 CoronaVac 2021-05-20 24001821
20 P-1TDTYKEE : 3575011403830002 NASHER FAJAR KAUSYAR 3/14/1983 JL SLAMET RIADI NO 38 : 087856911422 CoronaVac 2021-05-20 24001821
21 P-2HUSG3KV : 3575034810640002 TASKIRAH 8/10/1964 JL MT HARYONO GG 6 NO 18 : 085230105899 CoronaVac 2021-05-20 24001821
22 P-2L7GESM2 : 3514160911740004 ABD. BABAK 9/11/1974 JL MT HARYONO 6 : 089654983318 CoronaVac 2021-05-20 24001821
23 P-2SSAIBAG : 3575030107650068 BAHAR 7/1/1965 JL MT HARYONO GG 6 NO 18 : 081325177529 CoronaVac 2021-05-20 24001821
24 P-F4K8Z07O : 3575016312870001 KAROMAH 1/12/1987 JL SLAMET RIYADI RW 01 RT 001 : 082335048788 CoronaVac 2021-05-20 24001821
25 P-F4UJFPSY : 3575014307990002 KHOLIFATUL IMMAMI 7/3/1999 JL SLAMET RIADI : 085727511506 CoronaVac 2021-05-20 24001821
26 P-FEOT5FGU : 3509284505750005 RACHMATUL MAIMUNAH 5/5/1975 DUSUN KRAJAN RT.002 / RW.002 SUMBERLE : 08526677811 CoronaVac 2021-05-20 24001821
27 P-FJ4TEURF : 3514186003940001 HERWINDA PUTRI DANISWARI 3/20/1994 GONDANGREJO NO 65 : 08123456437 CoronaVac 2021-05-20 24001821
28 P-FOW0RK6R : 3575016903930001 ISMY BANI MASHITA 3/29/1993 JL SLAMET RIADI NO 38 : 089679700251 CoronaVac 2021-05-20 24001821
29 P-FP44E3X4 : 3575014212930001 DEWI SALMAH 2/12/1993 PERUM PESONA CANDI I BLOK B-21 : 081359129668 CoronaVac 2021-05-20 24001821
30 P-FPZJPP39 : 3575015201750002 UMIYATI 1/12/1975 JL BANDA, 05/02. GADINGREJO : 081359129668 CoronaVac 2021-05-20 24001821
31 P-FPFLQCLT : 3575015701960001 NURIYANTI 1/17/1996 JL.BANDA GG:MAWAR : 082141345170 CoronaVac 2021-05-20 24001821
32 P-FRFW0342 : 3575025108800007 SISTIARTI FITRI HANDAYANI 8/11/1980 PERUM MUTIARA KELUARGA BLOK. J-6 : 082234261560 CoronaVac 2021-05-20 24001821
33 P-FHQAQL5D : 3575016406970001 YULIA SAFITRI 7/9/1997 JL SLAMET RIYADI : 083848715572 CoronaVac 2021-05-20 24001821

Mengetahui Pasuruan, 20-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 19 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 P-RUIRIL3Y : 3575014106610004 JULAIKHA 6/1/1961 JL SLAMET RIYADI GG 05 SEBANI : 085824633140 CoronaVac 2021-05-19 24001821
2 P-CBLC4ZNQ : 3575015304930001 UMMI ISTI'ANATIN 4/13/1993 JL URIP SUMOHARJO : 082228332696 CoronaVac 2021-05-19 24001821
3 P-43OW5UPZ : 3508076905920001 DWI UTAMI WULANDARI 3/10/1992 ASRAMA YON ZIPUR 10 : 088102656844 CoronaVac 2021-05-19 24001821
4 P-4Q5S5ZZ3 : 3575015507770005 KHUSNUL KHOTIMAH 7/15/1977 GADINGREJO RT 007 RW 001. GADINGREJO : 085230743499 CoronaVac 2021-05-19 24001821
5 P-5J1DL1UW : 3522094201900002 RATNA WIDIANINGSIH 1/2/1990 JL. RAYA GADINGREJO : 081232168310 CoronaVac 2021-05-19 24001821
6 P-D0ZA7QRT : 3575015409750002 LAILATUS ZAHRO 9/14/1975 JL IRIAN JAYA GG ANGGREK : 085101684317 CoronaVac 2021-05-19 24001821
7 P-C7VGRIWC : 3575016911880001 SUTRIASIH 29/11/1988 JL SLAMET RIYADI : 085895735813 CoronaVac 2021-05-19 24001821
8 P-C8VHRADS : 3575016104740001 GIMA INDRAYANI 4/21/1974 JL SLAMET RIYADI : 085742602484 CoronaVac 2021-05-19 24001821
9 S-FF877A03 : 3575035908370002 FATIMATUSSADIJAH 8/19/1937 PERUM ISTANA BESTARI BLOK CA/NO.8 85817779439 CoronaVac 2021-05-19 24001821
10 S-DEA5859D : 3575020404630004 SAMSUL ARIFIN 4/4/1963 jl. urip sumoharjo no 35 81252280252 CoronaVac 2021-05-19 24001821
11 S-61BADED3 : 3575025310580001 TRI EMY AMBARWATI 13/10/1958 jl. urip sumoharjo no 35 81259607895 CoronaVac 2021-05-19 24001821
12 S-2354FDC2 : 3573010405600005 YUDI WIDARYANTO 5/4/1960 jl ciliwung iia / 10 c : 081333260333 CoronaVac 2021-05-19 24001821
13 S-26BE5A0E : 3578275608580001 CAROLINE, SETIAWAN 8/16/1958 SONO INDAH 7/33 : 0818308111 CoronaVac 2021-05-19 24001821
14 P-4ZVHO57X : 3575021005630001 BAMBANG IRIANTO 5/10/1963 JL SULTAN AGUNG III : 087734683022 CoronaVac 2021-05-19 24001821
15 S-EB2F2228 : 3575010202500002 EKHWAN 2/6/1944 JL GATOT SUBROTO : 085858334796 CoronaVac 2021-05-19 24001821
16 P-55D1FB39 : 3575025412660001 DIAN SUNARING ASTITI 14/12/1966 JL SULTAN AGUNG III : 081907922400 CoronaVac 2021-05-19 24001821
17 P-7X9P8UMA : 3575011304000002 ANDIKA FIRMANSYAH ISTIYONO 4/13/2000 JL ANYELIR V A2/19 : 085815786412 CoronaVac 2021-05-19 24001821
18 P-D2WXZAG9 : 3575025711000001 NOVITA RIFANI 17/11/2000 jl. urip sumoharjo no 35 : 081336556450 CoronaVac 5/19/2021 24001821
19 P-D5G30OH7 : 3575026609990001 SRI WAHYU WULANDARI 9/26/1999 JL URIPSUMOHARJO : 087860178690 CoronaVac 2021-05-19 24001821
20 P-D3W8AG9E : 3514174203990003 SRI WAHYUH NINGSIH 3/2/1999 PLERET RT 02 RW 03 POHJENTREK : 081231160997 CoronaVac 2021-05-19 24001821
21 P-DM7CHZN5 : 3575037003930003 atia yulfianita hidayat 3/30/1993 JL SULTAN AGUNG NO 17 : 085649999323 CoronaVac 2021-05-19 24001821
22 P-E35YYG0N : 3575016010710001 warti 20/10/1971 jl irian jaya gg anggrek : 087738014170 CoronaVac 2021-05-19 24001821

Mengetahui Pasuruan, 19-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 18 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 P-VBBOJUBN 3575025105610001 ATIK SUSILOWATI 11/5/1961 KBKA JL PUNTA DEWA B 18 GENTONG 82142024533 CoronaVac 2021-05-18 24001821
2 S-E61445A1 3514165204570002 SUMIATIN 12/4/1957 KRAJAN 82229071110 CoronaVac 2021-05-18 24001821
3 S-376904A4 3514161109440001 MOH IKSAN 11/9/1944 KRAJAN RT 1 RW 1 KRATON 82229071110 CoronaVac 2021-05-18 24001821
4 S-34207742 3575015610560001 UMI HANIK 1/7/1955 JL GATOT SUBROTO 85230618333 CoronaVac 2021-05-18 24001821
5 P-3F8HT5DO 3578066206660004 TAN SHAN SHAN 22-06-1966 sultan agung 7 pasuruan 8165401317 CoronaVac 2021-05-18 24001821
6 P-3FX1P3EA 3578060811630002 PRAMUDJO KARWOTO BUDIONO 8/11/1963 sultan agung 7 pasuruan 816517842 CoronaVac 2021-05-18 24001821
7 P-3NSIRICV 3575011402750002 EDY SUHARJO 7/12/1975 JL URIP SUMOHARJO no 9 RT 1 RW 2 BUKIR 82224073530 CoronaVac 2021-05-18 24001821
8 P-A9LEZ1UL 3575011010700005 TEGUH WIDIANTO 10/10/1970 JL HASANUDIN XI / 48 82335627970 CoronaVac 2021-05-18 24001821
9 P-A7VL2U1U 3575015612730002 CHOMSATUL FARIDA 16-12-1973 JL HASANUDIN XI / 48 8510053315 CoronaVac 2021-05-18 24001821
10 P-57F7MZPI 3514056808940003 SRI WAHYUNINGSIH 28-08-1994 SEBANI RT 2 RW 5 82233093732 CoronaVac 2021-05-18 24001821
11 P-60URBWIO 3575015906670001 AINUL KHOIRIYAH 19-06-1967 JL GATOT SUBROTO RT 3 RW 7 BUKIR 81216545184 CoronaVac 2021-05-18 24001821
12 P-71L4U9AA 3575014705730002 ISMULA 7/5/1973 JL GATOT SUBROTO RT 3 RW 7 BUKIR 81219575327 CoronaVac 2021-05-18 24001821
13 P-8G2T2EFA 3575011708620006 ABD RAHMAN 17-08-1962 DSN PENAWANGAN RT 2 RW 2 BUKIR 81334136035 CoronaVac 2021-05-18 24001821
14 P-8I3C1KGQ 3575015605640002 LISANI 16-05-1964 DSN PENAWANGAN RT 2 RW 2 BUKIR 8179366915 CoronaVac 2021-05-18 24001821
15 P-87LBC6BS 3575015611800001 SOFIYATUR ROKHMAH 16-11-1980 JL URIP SUMOHARJO RT 3 RW 2 BUKIR 83850167619 CoronaVac 2021-05-18 24001821
16 P-7XYFI82K 3575015205880003 RITA 12/5/1987 JL URIP SUMOHARJO RT 3 RW 2 BUKIR 88227107285 CoronaVac 2021-05-18 24001821
17 S-CBBCCEFF 3575032202690001 MUCHAMAD SOLEHUDIN 22-02-1969 PERUM SEKAR INDAH I BLOK A NO.14 RT.01 81334771269 CoronaVac 2021-05-18 24001821
18 P-AE03EJBO 3575036806730002 ANIK CHURNIYAH 28-06-1973 PERUM SEKAR INDAH I BLOK A NO.14 RT.01 81233362028 CoronaVac 2021-05-18 24001821
19 P-AESOVBLL 3575036701030003 AZIZAH WARDAH NURHALIZA 1/27/2003 PERUM SEKAR INDAH I BLOK A NO.14 RT.01 82335132645 CoronaVac 2021-05-18 24001821
20 P-ALUUWWRN 3575016512790001 SAFI'AH 25-12-1979 JL URIP SUMOHARJO RT 2 RW 2 BUKIR 8883315437 CoronaVac 2021-05-18 24001821
21 P-AMRI79D6 3575014910740001 ANIK FARIDA 9/10/1974 JL URIP SUMOHARJO RT 3 RW 2 BUKIR 83834336787 CoronaVac 2021-05-18 24001821
22 P-B6CL16AM 3575022904030002 RAFI RABBANI RAHMADIAN 29-04-2002 TAMAN ASRI II F1/06 82144729513 CoronaVac 2021-05-18 24001821

Mengetahui Pasuruan, 18-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 17 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 S-AB16435C : 3575024102560004 YOLANDA 2/1/1956 JL. RA KARTINI 59 : 082231475701 CoronaVac 2021-05-17 24001821
2 S-B9876DB2 : 3575024909570002 YOANA KRISTINA 9/9/1957 JL. RA KARTINI 59 : 082231475701 CoronaVac 2021-05-17 24001821
3 S-6B7604A1 : 3575010802580001 JOHANES INDRA RAHARDJO 2/8/1958 PERUM KARYA BHAKTI F-11 : 082140566764 CoronaVac 2021-05-17 24001821
4 P-V8YH7DTU : 3575015006610002 WATINI 6/1/1961 JL SLAMET RIYADI RT 02 RW 02 SEBANI : 085859000080 CoronaVac 2021-05-17 24001821
5 S-77AC154E : 3575014107500124 SOLICHAH 7/1/1950 JL SLAMET RIYADI : 081333122122 CoronaVac 2021-05-17 24001821
6 S-43CFF14F : 3575014107600054 SULCHAH 7/1/1960 JL SLAMET RIADI : 089699510380 CoronaVac 2021-05-17 24001821
7 S-802701A9 : 3575014107490060 MUKTI WARNI 7/1/1949 JL SLAMET RIYADI : 081328615757 CoronaVac 2021-05-17 24001821
8 S-E0930E76 : 3575011307570001 BAMBANG MURGIYANTO 7/13/1957 JL KYAI SEPUH GG. IV NO 82 : 081703189150 CoronaVac 2021-05-17 24001821
9 S-C4EF21DF : 3575010309600003 BUDI SUHARNO 9/3/1960 JL HALMAHERA GG. 9 : 081913411455 CoronaVac 2021-05-17 24001821
10 S-6ABC7175 : 3575013006580006 SUGENG SANTOSO 7/1/1960 JL SLAMET RIADI : 082131395259 CoronaVac 2021-05-17 24001821
11 S-90DCE38F : 3575016112560002 KHO KAA LING 21/12/1956 PERUM KARYA BHAKTI F-11 : 081931501638 CoronaVac 2021-05-17 24001821
12 S-C55B04F9 : 3575015608540002 ENDANG SUPIATI 8/16/1954 JL GATOT SUBROTO : 085335260364 CoronaVac 2021-05-17 24001821
13 S-29DAD9FC : 3575014802530001 SUFAATI 5/13/1952 JL.URIP SUMOHARJO : 089530400932 CoronaVac 2021-05-17 24001821
14 S-9901C8BE : 3575014107620009 SUGIATI 7/1/1959 JL SLAMET RIYADI : 081936956992 CoronaVac 5/17/2021 24001821
15 S-EB8BC9BE : 3575015205590001 ASMAH 7/1/1959 JL KYAI SEPUH : 083846832987 CoronaVac 2021-05-17 24001821
16 S-D2E3D629 : 3575010107410041 ASMAT 7/1/1941 JL SLAMET RIYADI : 081328615757 CoronaVac 2021-05-17 24001821
17 S-EB8BC9BE : 3575014612590001 MUSAROFAH 12/6/1959 JL HALMAHERA GG 9 : 087754540369 CoronaVac 2021-05-17 24001821
18 S-264C07BE : 3575014611590001 KHOLIFAH 11/6/1959 JL GATOT SUBROTO : 082229203405 CoronaVac 2021-05-17 24001821
19 P-2F5UPEHT : 3575014710770005 KHOTIMAH 10/7/1977 JL URIP SUMOHARJO : 082140138400 CoronaVac 2021-05-17 24001821
20 P-33AW6FGY : 3575015405720001 ARBA'ATIN 5/14/1972 JL URIP SUMOHARJO NO.12 : 0895155645590 CoronaVac 2021-05-17 24001821
21 P-5DLS3FD6 : 3575016106880002 FITRIYAH 6/21/1988 JL. TEUKU UMAR, sebani : 089677022491 CoronaVac 2021-05-17 24001821
22 P-5UQEJZRB : 3575016101810003 NUR MAULIDIYAH 1/21/1981 JL GATOT SUBROTO : 085731906729 CoronaVac 2021-05-17 24001821

Mengetahui Pasuruan, 17-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 11 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 S-BAFFDFE1 : 3575010107560005 MARTONO SUBAGIO 7/1/1956 P.KARYA BAKTI . M.8 : 08125232690 CoronaVac 2021-05-11 24001821
2 S-087D7819 3575010407490002 M SOLEH 7/4/1949 JL.GATOT SUBROTO BUKIR 81325501529 CoronaVac 2021-05-11 24001821
3 S-E7F11104 3575015205510001 RUKIJATI 5/12/1951 JL.GATOT SUBROTO BUKIR 81325501529 CoronaVac 2021-05-11 24001821
4 S-CE21D0A6 : 3575010507590003 MASUDI SUBAGIONO 7/5/1959 JL KYAI SEPUH GG 4B : 081394654537 CoronaVac 2021-05-11 24001821
5 S-27B2CBC0 : 3575012408580001 GATOT SUTRISNO 7/1/1959 JL URIP SUMOHARJO : 081231393525 CoronaVac 2021-05-11 24001821
6 S-73D9B003 : 3575014101600006 SULASTRI 1/1/1960 JL SLAMET RIYADI : 082328796088 CoronaVac 2021-05-11 24001821
7 S-E03D106C : 3575025005460002 ERNIE SOEPRAPTO 5/10/1946 JL KH WACHID HASYIM NO 16 : 082229391121 CoronaVac 2021-05-11 24001821
8 S-A6434C1A : 3575046508470001 SIANIK SOEPRAPTO 8/25/1947 JL. KH. WACHID HASYIM NO.16 : 085258808989 CoronaVac 2021-05-11 24001821
9 P-UZNDGJSX : 3575015606600001 ririn miranda 5/16/1960 KYAI SEPUH IV NO. 78 GENTONG : 082150388099 CoronaVac 2021-05-11 24001821
10 S-E2123962 : 3575021304540001 SUTIKNO HALIM 4/13/1954 JL. RA KARTINI NO. 59 : 082231475701 CoronaVac 2021-05-11 24001821
11 P-V5UWU1NO : 3575011307820001 GARVENDI PRATOMO 7/13/1982 JL.GATOT SUBROTO RT 2 RW 6 BUKIR : 082142216523 CoronaVac 2021-05-11 24001821
12 P-V5TORX0T : 3575012407670001 MOH TAJUDDIN 7/24/1967 JL GATOT SUBROTO RT 3 RW 7 BUKIR : 085235718245 CoronaVac 2021-05-11 24001821
13 P-5TEX9WLE : 3575015512620001 SUGIARMI 15/12/1962 PERUM KARYA BAKTI O2 - O3 : 085785734631 CoronaVac 2021-05-11 24001821
14 P-1L6L6UR6 : 3575015212750001 BAWON SUHERMIN 12/12/1975 JL GATOT SUBROTO RW 05 RT 003 : 089523362641 CoronaVac 2021-05-11 24001821
15 P-1NQKPASN : 3575015209910002 NUR MAULIDAH 9/21/1991 JL GATOT SUBROTO : 089519266331 CoronaVac 2021-05-11 24001821
16 P-1QRBNLGB : 3575014106720001 SITI ROCHMAH 6/1/1972 JL GATOT SUBROTO : 083841656820 CoronaVac 2021-05-11 24001821
17 P-1YG8Z36C : 3575014206800002 FATIMAH 6/2/1980 JL GATOT SUBROTO : 089687217262 CoronaVac 2021-05-11 24001821
18 P-1GZBVVIL : 3575014301790003 SITI KHALIMAH 1/3/1979 BUKIR, GADINGREJO : 082140341212 CoronaVac 2021-05-11 24001821
19 S-9A7EE490 : 3575014303530002 SUWARTI 7/1/1953 JL IRIAN JAYA : 082322404095 CoronaVac 2021-05-11 24001821
20 P-21V4O7MB : 3575016202800004 SITI AISYAH 2/22/1980 BUKIR , GADINGREJO : 081234337006 CoronaVac 2021-05-11 24001821
21 P-26COI5NG : 3575016402660001 SOFEYAH 2/24/1966 JL GATOT SUBROTO, JAWA TIMUR, KOTA PAS : 081333207406 CoronaVac 2021-05-11 24001821
22 P-2JLNEHQ2 : 3575014107700016 SOFIYAH 7/1/1970 JL GATOT SUBROTO : 089677021551 CoronaVac 2021-05-11 24001821
23 P-CMQCRPZU : 3575015012890002 SITI IT FITRIA 7/7/1983 TALANGAN, BEJI : 085806775159 CoronaVac 2021-05-11 24001821
24 P-428FG4HC : 3575015112790003 ERNI SUSILOWATI 11/12/1979 JL.SLAMET RIYADI : 085100783695 CoronaVac 2021-05-11 24001821
25 P-DW075TN3 : 3575014605900003 LINDA ARIYANI 5/6/1990 JL HALMAHERA GG 13/ 53 RW 06 RT 004 : 0895628100532 CoronaVac 2021-05-11 24001821
26 P-EH9VUUSR : 3575015508660001 SRI BAKTI 2/23/1966 JL HALMAHERA 13 / 53 : 085730628602 CoronaVac 2021-05-11 24001821
27 P-EIUHLMYQ : 3509035506970005 RISKA WULANDARI 6/15/1997 DUSUN SUMBER ULING, SUMBER BARU : 085755907904 CoronaVac 2021-05-11 24001821
28 P-18JBOGWY : 3575015608820001 HEFI AGUSTINA 8/15/1982 JL GATOT SUBROTO, JAWA TIMUR, KOTA PAS 82140715426 CoronaVac 2021-05-11 24001821
29 P-1BXL9NHU : 3575012502020002 MUKHAMAD RICKY FEBRIANSYAH 2/25/2002 JL GATOT SUBROTO : 082213012326 CoronaVac 2021-05-11 24001821
30 P-2AWUPZOF : 3575027101020002 andini nur faizah 1/31/2002 jl lks martadinata no.71 : 087872641199 CoronaVac 2021-05-11 24001821
31 P-BVHNONDT : 3575021704030005 AKHMAD KURNIAWAN SETIYANTO 4/17/2003 JL DR WAHIDIN SH NO. 227, JAWA TIMUR, KO : 085236807032 CoronaVac 2021-05-11 24001821
32 P-C5ECUH0L : 3575035601010002 ALMIRAH SHAFA RUSARANDI 1/16/2001 PERUM ISTANA BESTARI AC - 12 A, PEKUNCEN: 082139017316 CoronaVac 2021-05-11 24001821
33 P-7JME1OX3 : 3514234510860003 LILIK MAHMUDAH 10/5/1986 BALIDONO rt 1 rw 09 : 085330173192 CoronaVac 2021-05-11 24001821

Mengetahui Pasuruan, 11-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

 Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003

 Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

37 P-9LM4OHSX : 3575015005820003 MUDMAINAH 5/10/1982 JL SLAMET RIYADI, JAWA TIMUR, KOTA PASU : 081353692261 CoronaVac 2021-05-10 24001821
38 P-CKH7JBSF : 3575014704780001 SILATURROHMAH 4/7/1977 SEBANI RT 01 RW 06 : 089519261354 CoronaVac 2021-05-10 24001821
39 P-32LVIAVM : 3575011205950002 MUHAMMAD ISMAIL 5/12/1995 JL SLAMET RIADI : 081235759230 CoronaVac 2021-05-10 24001821
40 P-2XG6DW64 : 3575013107640001 ABD DJALIL 7/1/1964 JL SLAMET RIADI : 081235759230 CoronaVac 2021-05-10 24001821
41 P-0UMG3V8T : 3515062011680002 DAMAT PRAWIYANTO 20/11/1968 : dsn wates 8/3 kedensari : 081232503353 CoronaVac 2021-05-10 24001821
42 P-93ONFCJU : 3514160104030020 MUHAMMAD GUGUS SATRIA NUSAN4/1/2003 KRAJAN, TAMBAK REJO : 0895325758107 CoronaVac 2021-05-10 24001821
43 P-8XETB0QR : 3514165510980029 GALUH CITRA CAHYA ROHMANA 15/10/1998 KRAJAN, TAMBAKREJO : 081216850060 CoronaVac 2021-05-10 24001821
44 S-8D964828 : 3575014306800007 Eka Yuliyanti Wahyuning Tyas 6/3/1980 : 085867642764 CoronaVac 2021-05-10 24001821

Mengetahui Pasuruan, 10-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
 Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

37 P-8RH7Q5QI : 3514160708940005 TEGUH PURWANTO 8/7/1994 KRAJAN, TAMBAK REJO : 081553287081 Astra Zeneca 2021-05-08 CTMAV546
38 P-DL9FAPLK : 3575012604960004 WAHYU UJI ISMAIL 4/26/1996 JL HALMAHERA 17 / 36, JAWA TIMUR, KOTA : 081260031616 Astra Zeneca 2021-05-08 CTMAV546
39 P-32Q9VSVE : 3514031207770002 WAHYUDI 7/12/1977 PLERET, POHJENTREK, JAWA TIMUR, PASURU: 082233046896 Astra Zeneca 2021-05-08 CTMAV546
40 P-AWE6XJOL : 3516095501940001 YOLANDA RIZKITA PUTRI 1/15/1994 DUSUN POHKECIK NO.135, POHKECIK : 081335783127 Astra Zeneca 2021-05-08 CTMAV546

Mengetahui Pasuruan, 08-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003
Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 07 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 S-6255DF97 : 3575010107480008 M FADOLI : 1947-07-01 : KEL BUKIR : 081230085033 CoronaVac 2021-05-07 24001821
2 S-E34E88CB : 3575011505730003 TOMIRI : 1973-05-15 JL. IRIAN JAYA GG. ANGGREK RT.001/002 : 085231684412 CoronaVac 2021-05-07 24001821
3 P-ZQIURSYH 3575021709670005 H.SOLEHUDIN : 1967-09-17 JL LKS MARTADINATA NO 71 : 081231569292 CoronaVac 2021-05-07 24001821
4 P-ZZ2D4YHB : 3522185301840001 ENDANG SUSILOWATI : 1984-01-13 Lebak Jaya I Utara / 31 Surabaya : 082336143585 CoronaVac 2021-05-07 24001821
5 P-ZYM673VZ : 3578110704010001 FENDY LOMANJAYA : 2001-04-07 lebak jaya 1 utara/31 surabaya : 08990745364 CoronaVac 2021-05-07 24001821
6 P-ZYTDSENU : 3503045407770008 YAGINI : 1977-07-14 Lebak Jaya I Utara / 31 Surabaya : 082325603756 CoronaVac 2021-05-07 24001821
7 P-AUAIQLBO : 3575017101900002 WIWIN : 1990-01-31 : BUKIR rt 03 rw 07 : 082336664017 CoronaVac 2021-05-07 24001821
8 P-3FZ9EHLM : 3575015103700003 HARINI PURWANDARI : 1970-03-11 JL BANDA NO. 89 : 081555380186 CoronaVac 2021-05-07 24001821
9 P-CVTEQPTI : 3575034412960003 NOVITA FADELINATUL LAILA : 1996-12-04 JL PATIUNUS NO 59 : 08990111445 CoronaVac 2021-05-07 24001821
10 P-AL0VLYZT : 3575015208770001 JUMROTUS SA'ADAH : 1977-08-12 : JL URIP SUMOHARJO : 089514792412 CoronaVac 2021-05-07 24001821
11 P-3652XGKD : 3575014506760002 SISWANTI : 1979-06-03 JL GATOT SUBROTO : 081233892613 CoronaVac 2021-05-07 24001821
12 P-74IXNPIF : 3575015503750001 SUMARNI : 1975-03-15 : JL URIP SUMOHARJO : 087748289492 CoronaVac 2021-05-07 24001821
13 P-2V16WS3U : 3575015906940001 SURYANI : 1994-06-19 JL. GATOT SUBROTO : 081217950487 CoronaVac 2021-05-07 24001821
14 Q-81688753 : 3575015907730001 YULI SUPRAPTI : 1973-07-19 BUKIR I / 10 : 085233068141 CoronaVac 2021-05-07 24001821
15 P-CGIL0L55 : 3575014107710069 HARTINI : 1971-07-01 JL IRIAN JAYA : 082338507846 CoronaVac 2021-05-07 24001821
16 P-AA7AOEOP : 3575016312880001 hariyati : 1988-12-23 : 082231480521 : 082231480521 CoronaVac 2021-05-07 24001821
17 P-57N6YB46 : 3575016703890005 IKA RINDIANI : 1989-03-27 krisna no. f1b, gentong : 085103563821 CoronaVac 2021-05-07 24001821
18 P-295ZJZCY 3575015709810004 SURYATI : 1981-09-17 JL KYAI SEPUH GG 20 : 082302103330 CoronaVac 2021-05-07 24001821
19 P-2G4NF407 : 3575015103630001 TUTIK WAHYUNI : 1963-03-11 : P. KARYA BAKTI L 29, : 082135462266 CoronaVac 2021-05-07 24001821
20 : P-5ZZJZYKE : 3575016505870003 EKO TRI SULISTYANI : 1987-03-25 JL SLAMET RIYADI GG. 15 : 081252399661 CoronaVac 2021-05-07 24001821
21 P-1FUGLA56 3575014202810001 ANIK KOMARIYAH 2/2/1981 SEBANI rt 03 rw 05 81536521608 CoronaVac 2021-05-07 24001821
22 P-4DLU5J1W : 3575035508850003 ANIS UTAMI 8/15/1985 JL SLAMET RIYADI : 081252623149 CoronaVac 2021-05-07 24001821
23 P-1S5IEX4S 3575016808800001 KURNIATI : 1980-08-28 JL SLAMET RIYADI GG 9 : 083830789183 CoronaVac 2021-05-07 24001821
24 P-D0V550YO : 3575015903750001 LATIFATUS SOLICHA 3/19/1974 JL SLAMET RIYADI RW 03 RT 001 sebani : 085816359871 CoronaVac 2021-05-07 24001821
25 P-6GZGOVCK : 3575015710820001 MASRUROH : 1982-10-17 JL SLAMET RIADI GG 11 : 0895397077284 CoronaVac 2021-05-07 24001821
26 P-1YRDRGYL 3575015305870002 NUR SUGIARTI : 1987-05-13 JL. SLAMET RIYADI GG - 9 : 085749500506 CoronaVac 2021-05-07 24001821
27 P-3LOYH816 : 3575014107720072 SITI MUNAWAROH : 1972-07-01 : JL.SLAMET RIYADI : 089530403600 CoronaVac 2021-05-07 24001821
28 S-7650BED1 : 3575016107810004 NUR ANA : 1981-07-21 KRAPYAK : 085755355505 CoronaVac 2021-05-07 24001821
29 P-D361ORY2 : 3575010210980004 AINUL KHILMIAH : 1998-10-02 JL HANGTUAH rt/rw : 4/4 gadingrejo : 085964374048 CoronaVac 2021-05-07 24001821
30 P-DFDL87SU : 3575031904990001 ROBBY PATTY NURRANI PAMBUDI 4/19/1999 JL SULTAN AGUNG GG I / 5 : 085731391607 CoronaVac 2021-05-07 24001821
31 P-DEOWXE1F : 3575034110680001 SULASTRI 10/1/1968 Jl. Sultan Agung I/11 : 085736996878 CoronaVac 2021-05-07 24001821
32 P-5MM4KCHV : 3575016205800003 LILIS SURYANI DWI LESTARI : 1980-05-22 JL SULAWESI 11 RT 2 RW 8 TRAJENG : 082251684159 CoronaVac 2021-05-07 24001821
33 P-CZAO6TCK : 3575016907890005 SYAMSUN NAHAR : 1989-07-29 JL HANGTUAH 1/3 tambaan : 085102686691 CoronaVac 2021-05-07 24001821

Mengetahui Pasuruan, 07-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

 Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003

 Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

37 S-DF661785 : 3575014107450023 MISTIN 7/1/1945 JL URIP SUMOHARJO : 081334332837 CoronaVac 2021-05-06 24001821
38 S-09A6F3F2 : 3575014107540037 MARIJAM 7/1/1956 JL GATOT SUBROTO : 08978861112 CoronaVac 2021-05-06 24001821
39 S-2143DA07 : 3575014107550045 DAWEYAH 7/1/1955 JL.GATOT SUBROTO : 081331835208 CoronaVac 2021-05-06 24001821
40 S-33F1412C : 3575014107600022 DEWI SUMIATI 7/1/1960 JL. GATOT SUBROTO : 082234822451 CoronaVac 2021-05-06 24001821
41 S-804C0D2B : 3575014107600026 S DJUMIRAH 7/1/1959 JL SLAMET RIYADI : 081259656665 CoronaVac 2021-05-06 24001821
42 S-3C3AA6A3 : 3575011008490001 GIMAN 10/8/1949 : 081235980098 CoronaVac 2021-05-06 24001821
43 S-B723ADE7 : 3575014110560001 SUJILAH 1/10/1956 : 085954380502 CoronaVac 2021-05-06 24001821
44 S-FCF2C072 : 3575011209600007 RUSIMIN 9/12/1960 JL ANYELIR II NO 02 PERUM GADING PERMAI : 085733577717 CoronaVac 2021-05-06 24001821
45 S-193CB50B : 3575010909570001 SANUSI 7/1/1959 JL URIP SUMOHARJO : 082245890296 CoronaVac 2021-05-06 24001821
46 S-8294E3AA : 3575010505570001 IMAM SAMSI 5/5/1957 JL URIP SUMOHARJO : 081252528685 CoronaVac 2021-05-06 24001821
47 S-9D7F382F : 3575015406870003 IKA PRATIWI ANGGRAINI 6/14/1987 : 082234090414 CoronaVac 2021-05-06 24001821
48 P-Z22MT7CT : 3575032012950001 Rachmaniar RIZKy PRATAMA 20/12/1995 JL.KH.HASYIM ASHARI 29 : 082140852005 CoronaVac 2021-05-06 24001821
49 S-8536D54C : 3575025005670004 MIFTACHUS SIRODJAH 5/10/1967 JL. HANGTUAH NO. 8 RT 01/RW 02 NGEMPLAK : 087757927724 CoronaVac 2021-05-06 24001821
50 S-D728662F : 3514094303680001 FITRI ANDRI PRASTIWI 3/3/1968 JL. RAYA GLAGAH SARI 139 RT.002 RW.003 : 085655032252 CoronaVac 2021-05-06 24001821
51 P-ZCBNEKOE : 3575016312840003 DEVI TRI UTAMI 23/12/1984 JL.SLAMET RIYADI RT 3 RW 1 SEBANI : 085655024264 CoronaVac 2021-05-06 24001821
52 S-44A3996C : 3575014306920001 MARIA URIFAH 6/3/1992 : 082232861788 CoronaVac 2021-05-06 24001821
53 S-42153AC1 : 3575014107540093 SUMARLIK 7/1/1954 JL URIP SUMOHARJO : 0895601120908 CoronaVac 2021-05-06 24001821
54 S-472B1E2E : 3575011012560002 SUMARSONO 10/12/1956 JL URIP SUMOHARJO : 081232094655 CoronaVac 2021-05-06 24001821
55 S-4A1EC01A : 3575014205530001 CHALIMAH 7/1/1950 JL GATOT SUBROTO : 0895395041713 CoronaVac 2021-05-06 24001821
56 S-8578C148 : 3575016805570001 SRI MULYADANDI 5/28/1957 JL GATOT SUBROTO CoronaVac 2021-05-06 24001821
57 S-94A64BBD : 3575015512580002 SUBAIDAH 15/12/1958 JL.GATOT SUBROTO CoronaVac 2021-05-06 24001821
58 S-A04E03DF : 3575010712530001 ISKAK 12/7/1953 JL GATOT SUBROTO : 082244741800 CoronaVac 2021-05-06 24001821
59 S-A1D4F201 : 3575014107500029 LILIK HANDAYANI 7/1/1948 JL GATOT SUBROTO CoronaVac 2021-05-06 24001821
60 S-A9784087 : 3575034704670001 JUMIYATI 4/7/1967 : 085101632940 CoronaVac 2021-05-06 24001821
61 S-B828F06A : 3575016503330002 TUTIK TRESNAWATI 3/25/1933 JL KARYA BAKTI J 8 CoronaVac 2021-05-06 24001821
62 S-ED3F59D7 : 3575016809580001 SUTIK 7/1/1959 JL GATOT SUBROTO CoronaVac 2021-05-06 24001821
63 P-CDKG62QJ : 3575016003850002 DINA MARIANA 3/20/1985 JL GATOT SUBROTO BUKIR : 081270365430 CoronaVac 2021-05-06 24001821
64 S-D84E3992 : 3575036706630001 SRI WAHJUNI SETYANINGSIH 6/27/1963 PERUM SEKAR ASRI G.4 RT. 004 RW. 005 KEL : 085749266868 CoronaVac 2021-05-06 24001821

Mengetahui Pasuruan, 06-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

 Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003

Nama Puskesmas/Fasyankes/Pos : PKM GADINGREJO
Kabupaten/Kota : PASURUAN
Provinsi : JAWA TIMUR
Tanggal Pelaksanaan : 03 MEI 2021
Kategori : UMUM

Dosis I Dosis 2
Kelomp
No No. Registrasi NIK Nama Penerima Vaksin Umur ok Alamat No. Hp Merek Vaksin Tanggal Tanggal
No.
Umur Pemberian No. Batch Pemberian
Batch
Vaksinasi Vaksinasi

1 S-74332685 3575030709500001 3575030709500001 7/9/1950 PERUM KARYA BHAKTI BLOK P 29 81334234569 CoronaVac 2021-05-03 24001821
2 P-6F7C00C0 3575015004620002 3575015004620002 10/4/1962 JL GATOT SUBROTO RT 5 RW 7 BUKIR 85853184333 CoronaVac 2021-05-03 24001821
3 S-2D3B622A 3575036411600001 3575036411600001 24-11-1960 PERUMAHAN KARYA BHAKTI KENCANA ASR 81331779751 CoronaVac 2021-05-03 24001821
4 S-EFB111B6 3575032407580001 3575032407580001 24-07-1958 PERUMAHAN KARYA BHAKTI KENCANA ASR 85234903894 CoronaVac 2021-05-03 24001821
5 S-F255C41A 3575011805560002 3575011805560002 18-05-1956 JL KYAI SEPUH Gg 4 85230388102 CoronaVac 2021-05-03 24001821
6 S-B0230A03 3575015205390001 3575015205390001 12/5/1939 BUKIR 81230085033 CoronaVac 2021-05-03 24001821
7 S-1F4176D5 3575012303520001 3575012303520001 23-03-1952 JL BANDA 85854471437 CoronaVac 2021-05-03 24001821
8 S-80AF3BA7 3575014505560003 3575014505560003 5/5/1956 JL KYAI SEPUH 82228287626 CoronaVac 2021-05-03 24001821
9 S-75107AD5 3575014401600001 3575014401600001 4/1/1960 PERUM KARYA BAKTI N 6 85230030222 CoronaVac 2021-05-03 24001821
10 S-73997C83 3575011811550001 3575011811550001 18-11-1955 PERUM KARYA BAKTI N 6 811327761 CoronaVac 2021-05-03 24001821
11 S-87090023 3575016606550001 3575016606550001 26-06-1955 JALAN PERUM KARYA BHAKTI BLOK R NOR 85784469994 CoronaVac 2021-05-03 24001821
12 S-859ADCED 3575010708560001 3575010708560001 7/8/1956 JL SLAMET RIADI NO 38 81904271551 CoronaVac 2021-05-03 24001821
13 S-53EB8DF0 3514111402650002 3514111402650002 14-02-1965 JL.MALIAWAN NO.32 JOGOSARI PANDAAN 85855998512 CoronaVac 2021-05-03 24001821
14 P-VTMPBQ3T 3575010209710002 3575010209710002 9/2/1971 JL. ANYELIR V/18 GADING PERMAI 81335887974 CoronaVac 2021-05-03 24001821
15 P-WNQW6XJ5 3515082709000009 3515082709000009 9/27/2000 P SIDOKARE INDAH QQ-23 82230277225 CoronaVac 2021-05-03 24001821
16 P-WO6IHC6X 3575021501010003 3575021501010003 15-01-2001 JL WAHIDIN SUDIRO HUSODO GG RAMBUT 81227806552 CoronaVac 2021-05-03 24001821
17 P-3NSIRICV 3575011402750002 3575011402750002 7/12/1975 JL URIP SUMOHARJO NO.9 RT 1 RW 2 BUK 82224073530 CoronaVac 2021-05-03 24001821
18 P-A7VL2U1U 3575015612730002 3575015612730002 16-12-1973 08510053315 CoronaVac 2021-05-03 24001821
19 P-A9LEZ1UL 3575011010700005 3575011010700005 10-10-1970 082335627970 CoronaVac 2021-05-03 24001821

Mengetahui Pasuruan, 03-05-2021

Kepala UPT Puskesmas Gadingrejo Admin Vaksinasi

Nenny Kusumawardani, SKM, M.AP FARIDA KUSUMAWATI, A.Md.Gz

NIP.19721216 199503 2 003 NIP. 19721016 199603 2 003