LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)

KABUPATEN / KOTA : ROKAN HULU

PUSKESMAS : RAMBAH HILIR 1
TAHUN : AGUSTUS 2021

IDENTITAS KASUS DIDUGA KIPI PEMBERI WAKTU TEMPAT GEJALA YANG DIALAMI BAYI/ANAK (Tanggal & Jam)
JENIS BENGKAK DILOKASI MERAH DILOKASI LAIN-LAIN KONDISI
NO BULAN TANGGAL JENIS VAKSIN No Batch / Exp Date IMUNISASI* IMUNISASI PELAYANAN DEMAM MUNTAH
NAMA ANAK/WUS KELAMIN**** UMUR NAMA ORTU ALAMAT DESA SUNTIKAN SUNTIKAN (SEBUTKAN AKHIR***)
L P LAHIR **** (Tanggal &Jam) IMUNISASI Mulai Gejala Sembuh Mulai Gejala Sembuh Mulai Gejala Sembuh Mulai Gejala Sembuh )
1 2 3 4 5 6 7 8 9 10 11 12
- - - - - - - - - - - - - - - - - - - - - - - - -

*) Tempat Pelaksanaan: RS, Puskesmas, Posyandu, UPS

**) Jika ditemukan gejala :
1. Tidak mau menetek/minum
2. Kejang KEPALA PUSKESMAS RAMBAH HILIR I, PENGELOLA PROGRAM IMUNISASI,
3. Pucat/biru
4. Sesak nafas
5. Muntah berlebihan
6. Demam tinggi (>39) lebih 1 hari KUS AEDY, SKM ROIHANIL JANNAH, Amd.Keb
7. Menangis terus menerus lebih dari 3 jam NIP : 19690303 200012 1 001
8. Kesadaran menurun
9. Anafilaktik
10. Abses

Lanjutkan ke Formulir Pelaporan KIPI Serius

***) Kondisi akhir: Sembuh, Dirawat, Meninggal

****) Pada Kolom Jenis Kelamin di isi tanggal lahir
*****) Pemberi imunisasi : dokter, bidan, perawat, juru imunisasi
 LAPORAN BULANAN HASIL IMUNISASI Td IBU HAMIL DAN WUS DESA
DESA
PUSKESMAS RAMBAH HILIR
BULAN

NO POSYANDU SASARAN JUMLAH DAN PERSENTASE IBU HAMIL DIIMUNISASI JUMLAH DAN PERSENTASE WUS TIDAK HAMIL DIIMUNISASI JUMLAH TOTAL DAN PERSENTASE TT2+BUMIL
WUS (HAMIL+TIDAK HAMIL) DIIMUNISASI TT
BUMIL WUS TT1 TT2 TT3 TT4 TT5 TT1 TT2 TT3 TT4 TT5 TT1 TT2 TT3 TT4 TT5 TT 2 +
# # # % # % # % # % # % # % # % # % # % # % # % # % # % # % # % # %
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
LAPORAN BULANAN HASIL IMUNISASI RUTIN BAYI DESA
PUSKESMAS RAMBAH HILIR I

DINAS KESEHATAN KABUPATEN ROKAN HULU

BULAN Aug-21

BAYI LAHIR HIDUP BAYI 0-11 BULAN HB0<24JAM + HB0<7HR BCG DPTHB HiB 1 DPTHB HiB 2 DPTHB HiB 3 POLIO 1 POLIO 2 POLIO 3 POLIO 4 IPV
KODE

DESA/KELURAHAN
L P JML L P JML #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63

01 RAMBAH HILIR 35 36 71 72 74 146 3 8.6 3 8.3 6 4.1 2 2.8 3 4.1 5 3.4 2.8 4.1 5 3.4 2.8 4.1 5 3.4 2.8 4.1 5 3.4 2 2.8 3 4.1 5 3.4 2 2.8 3 4.1 5 3.4 2 2.8 3 4.1 5 3.4 2 2.8 3 4.1 5 3.4
2 3 2 3 2 3 4

02 RAMBAH 192 393 12 12.4 6 6.3 18 4.6 6 3.0 5 2.6 11 2.8 4.0 4.6 17 4.3 4.5 4.1 17 4.3 4.5 4.1 17 4.3 6 3.0 5 2.6 11 2.8 8 4.0 9 4.6 17 4.3 9 4.5 8 4.1 17 4.3 9 4.5 8 4.1 17 4.3
97 95 198 195 8 9 9 8 9 8 10

03 RAMBAH HILIR TENGAH 34 70 0 0.0 2 11.8 2 2.9 2 5.7 3 8.6 5 7.1 5.7 5.7 4 5.7 8.6 2.9 4 5.7 8.6 5.7 5 7.1 2 5.7 3 8.6 5 7.1 2 5.7 2 5.7 4 5.7 3 8.6 1 2.9 4 5.7 3 8.6 2 5.7 5 7.1
17 17 35 35 2 2 3 1 3 2 3

04 RAMBAH HILIR TIMUR 28 57 1 7.7 0 0.0 1 1.8 1 3.7 1 3.3 2 3.5 0.0 3.3 2 3.5 3.7 0.0 1 1.8 3.7 0.0 1 1.8 1 3.7 1 3.3 2 3.5 1 0.0 1 3.3 2 3.5 1 3.7 0 0.0 1 1.8 1 3.7 0 0.0 1 1.8
13 15 27 30 1 1 1 0 1 0 2

05 SEROMBOU INDAH 41 83 1 4.8 2 10.0 3 3.6 2 4.7 3 7.5 5 6.0 2.3 2.5 2 2.4 0.0 0.0 0 0.0 2.3 2.5 2 2.4 2 4.7 3 7.5 5 6.0 1 2.3 1 2.5 2 2.4 0 0.0 0 0.0 0 0.0 1 2.3 1 2.5 2 2.4
21 20 43 40 1 1 0 0 1 1 4

06 SEI DUA INDAH 10 19 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0.0 0.0 0 0.0 0.0 0.0 0 0.0 0.0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0
5 5 10 9 0 0 0 0 0 0 0

07 MUARA MUSU 56 116 3 11.1 3 10.3 6 5.2 3 5.4 2 3.3 5 4.3 3.6 3.3 4 3.4 1.8 3.3 3 2.6 1.8 3.3 3 2.6 3 5.4 2 3.3 5 4.3 2 3.6 2 3.3 4 3.4 1 1.8 2 3.3 3 2.6 1 1.8 2 3.3 3 2.6
27 29 56 60 2 2 1 2 1 2 1

08 SEJATI 31 63 1 6.3 4 26.7 5 7.9 0 0.0 2 6.7 2 3.2 3.0 3.3 2 3.2 3.0 0.0 1 1.6 3.0 0.0 1 1.6 0 0.0 2 6.7 2 3.2 1 3.0 1 3.3 2 3.2 1 3.0 0 0.0 1 1.6 1 3.0 0 0.0 1 1.6
16 15 33 30 1 1 1 0 1 0 3

JUMLAH 231 232 463 474 473 947 21 9.1 20 8.6 41 4.3 16 3.4 19 4.0 35 3.7 17 3.6 19 4.0 36 3.8 17 3.6 14 3.0 31 3.3 18 3.8 16 3.4 34 3.6 16 3.4 19 4.0 35 3.7 17 3.6 19 4.0 36 3.8 17 3.6 14 3.0 31 3.3 18 3.8 16 3.4 34 3.6 27

LAPORAN KOMULATIF HASIL IMUNISASI RUTIN BAYI

PUSKESMAS RAMBAH HILIR I

DINAS KESEHATAN KABUPATEN ROKAN HULU

PROPINSI RIAU

BULAN Aug-21

BAYI LAHIR HIDUP BAYI 0-11 BULAN HB0<24JAM + HB0<7HR BCG DPTHB HiB 1 DPTHB HiB 2 DPTHB HiB 3 POLIO 1 POLIO 2 POLIO 3 POLIO 4 IPV
KODE

DESA/KELURAHAN
L P JML L P JML #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63

01 RAMBAH HILIR 35 36 71 35 36 71 23 65.7 23 63.9 46 64.8 21 60.0 21 58.3 42 59.2 20 57.1 23 63.9 43 60.6 20 57.1 21 58.3 41 57.7 19 54.3 21 58.3 40 56.3 21 60.0 21 58.3 42 59.2 20 57.1 23 63.9 43 60.6 20 57.1 21 58.3 41 57.7 19 54.3 21 58.3 40 56.3 23

02 RAMBAH 192 192 64 66.0 61 64.2 125 65.1 58 59.8 57 60.0 115 59.9 63 64.9 66 69.5 129 67.2 67 69.1 60 63.2 127 66.1 66 68.0 60 63.2 126 65.6 58 59.8 57 60.0 115 59.9 63 64.9 66 69.5 129 67.2 67 69.1 60 63.2 127 66.1 66 68.0 60 63.2 126 65.6 49
97 95 97 95

03 RAMBAH HILIR TENGAH 34 34 20 117.6 13 76.5 33 97.1 12 70.6 17 100.0 29 85.3 13 76.5 16 94.1 29 85.3 17 100.0 11 64.7 28 82.4 16 94.1 13 76.5 29 85.3 12 70.6 17 100.0 29 85.3 13 76.5 16 94.1 29 85.3 17 100.0 11 64.7 28 82.4 16 94.1 13 76.5 29 85.3 15
17 17 17 17

04 RAMBAH HILIR TIMUR 28 28 8 61.5 9 60.0 17 60.7 11 84.6 7 46.7 18 64.3 12 92.3 9 60.0 21 75.0 9 69.2 8 53.3 17 60.7 9 69.2 7 46.7 16 57.1 11 84.6 7 46.7 18 64.3 12 92.3 9 60.0 21 75.0 9 69.2 8 53.3 17 60.7 9 69.2 7 46.7 16 57.1 10
13 15 13 15

05 SEROMBOU INDAH 41 41 5 23.8 11 55.0 16 39.0 10 47.6 13 65.0 23 56.1 14 66.7 11 55.0 25 61.0 10 47.6 10 50.0 20 48.8 9 42.9 13 65.0 22 53.7 10 47.6 13 65.0 23 56.1 14 66.7 11 55.0 25 61.0 10 47.6 10 50.0 20 48.8 9 42.9 13 65.0 22 53.7 19
21 20 21 20

06 SEI DUA INDAH 10 10 2 40.0 4 80.0 6 60.0 2 40.0 2 40.0 4 40.0 2 40.0 2 40.0 4 40.0 0 0.0 2 40.0 2 20.0 2 40.0 2 40.0 4 40.0 2 40.0 2 40.0 4 40.0 2 40.0 2 40.0 4 40.0 0 0.0 2 40.0 2 20.0 2 40.0 2 40.0 4 40.0 4
5 5 5 5

07 MUARA MUSU 56 56 18 66.7 20 69.0 38 67.9 21 77.8 18 62.1 39 69.6 20 74.1 22 75.9 42 75.0 17 63.0 21 72.4 38 67.9 17 63.0 20 69.0 37 66.1 21 77.8 18 62.1 39 69.6 20 74.1 22 75.9 42 75.0 17 63.0 21 72.4 38 67.9 17 63.0 20 69.0 37 66.1 12
27 29 27 29

08 SEJATI 31 31 8 50.0 18 120.0 26 83.9 3 18.8 16 106.7 19 61.3 10 62.5 13 86.7 23 74.2 11 68.8 8 53.3 19 61.3 13 81.3 5 33.3 18 58.1 3 18.8 16 106.7 19 61.3 10 62.5 13 86.7 23 74.2 11 68.8 8 53.3 19 61.3 13 81.3 5 33.3 18 58.1 15
16 15 16 15

JUMLAH 231 232 463 231 232 463 148 64.1 159 68.5 307 66.3 138 59.7 151 65.1 289 62.4 154 66.6667 162 69.8 316 68.3 151 65.4 141 60.8 292 63.1 151 65.4 141 60.8 292 63.1 138 59.7 151 65.1 289 62.4 154 66.7 162 69.8 316 68.3 151 65.4 141 60.8 292 63.1 151 65.4 141 60.8 292 63.1 147

56.3 52.1 53.5 49.3

55.7 54.2 58.3 56.8

137 91.2 70.6 73.5 70.6

57.1 57.1 67.9 53.6

31.7 43.9 56.1 43.3

60.0 40.0 40.0 40.0

57.1 60.7 67.9 60.7

67.7 54.8 67.7 54.8

57.5 54.9 60.5 55.7

 IPV CAMPAK IDL BAYI LAHIR HIDUP BOSTER DPTHB HiB BOSTER CAMPAK IRL
DESA
DO DPT 1 DO DPT 1 -
% #P % JML % #L % #P % JML % #L % #P % JML % L P JML #L % #P % JML % #L % #P % JML % #L #P JML %
-DPT 3 CAMPAK

64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 95 97 98

5.6 5.4 8 5.5 2 2.8 2 2.7 4 2.7 2 2.8 2 2.7 4 2.7 RAMBAH HILIR 104 3 4 3 4 6 4.1 3 4 2 3 5 3.4 3 2 5 3.4 0 1
4 55 49

5.1 5.6 21 5.3 8 4.0 8 4.1 16 4.1 8 4.0 8 4.1 16 4.1 RAMBAH 240 5 3 6 3 11 2.8 6 3 7 4 13 3.3 6 7 13 3.3 0 1
11 127 113

8.6 8.6 6 8.6 3 8.6 2 5.7 5 7.1 3 8.6 2 5.7 5 7.1 RAMBAH HILIR TENGAH 54 2 6 2 6 4 5.7 2 6 1 3 3 4.3 2 1 3 4.3 -1 -1
3 30 24

7.4 6.7 4 7.0 1 3.7 2 6.7 3 5.3 1 3.7 2 6.7 3 5.3 RAMBAH HILIR TIMUR 47 2 7 2 7 4 7.0 3 11 3 10 6 10.5 3 3 6 10.5 1 -1
2 27 20

9.3 7.5 7 8.4 1 2.3 2 5.0 3 3.6 1 2.3 2 5.0 3 3.6 SEROMBOU INDAH 56 1 2 2 5 3 3.6 1 2 1 3 2 2.4 1 1 2 2.4 0 -1
3 28 28

0.0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 SEI DUA INDAH 24 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0.0 0 0
0 14 10

1.8 3.3 3 2.6 2 3.6 2 3.3 4 3.4 2 3.6 2 3.3 4 3.4 MUARA MUSU 69 3 5 1 2 4 3.4 2 4 0 0 2 1.7 2 0 2 1.7 1 0
2 34 35

9.1 10.0 6 9.5 1 3.0 2 6.7 3 4.8 1 3.0 2 6.7 3 4.8 SEJATI 52 2 6 2 7 4 6.3 2 6 3 10 5 7.9 2 3 5 7.9 1 -1
3 30 22

5.7 28 5.9 55 5.8 18 3.8 20 4.2 38 4.0 18 3.8 20 4.2 38 4.0 18 4 18 4 36 3.8 19 4 17 4 36 3.8 3.8 0 0
343 339 646 19 17 36

IPV CAMPAK IDL BAYI LAHIR HIDUP BOSTER DPTHB HiB BOSTER CAMPAK IRL
DESA
DO DPT 1 DO DPT 1 -
% #P % JML % #L % #P % JML % #L % #P % JML % L P JML #L % #P % JML % #L % #P % JML % #L #P JML %
-DPT 3 CAMPAK

64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

65.7 20 55.6 43 60.6 20 57.1 21 58.3 41 57.7 20 57.1 21 58.3 41 57.7 RAMBAH HILIR 104 53 151.4 24 66.7 77 108.5 22 62.9 19 52.8 41 57.7 16 15 31 43.7 3 2
55 49

50.5 52 54.7 101 52.6 64 66.0 63 66.3 127 66.1 64 66.0 63 66.3 127 66.1 RAMBAH 240 138 142.3 54 56.8 192 100.0 51 52.6 49 51.6 100 52.1 39 35 74 38.5 3 2
127 113

88.2 16 94.1 31 91.2 18 105.9 12 70.6 30 88.2 18 105.9 12 70.6 30 88.2 RAMBAH HILIR TENGAH 54 29 170.6 12 70.6 41 120.6 15 88.2 7 41.2 22 64.7 11 5 16 47.1 0 -1
30 24

76.9 14 93.3 24 85.7 7 53.8 13 86.7 20 71.4 7 53.8 13 86.7 20 71.4 RAMBAH HILIR TIMUR 47 25 192.3 10 66.7 35 125.0 12 92.3 12 80.0 24 85.7 6 6 12 42.9 5 1
27 20

90.5 15 75.0 34 82.9 12 57.1 13 65.0 25 61.0 12 57.1 13 65.0 25 61.0 SEROMBOU INDAH 56 36 171.4 12 60.0 48 117.1 12 57.1 12 60.0 24 58.5 10 10 20 48.8 3 0
28 28

80.0 2 40.0 6 60.0 2 40.0 0 0.0 2 20.0 2 40.0 0 0.0 2 20.0 SEI DUA INDAH 24 5 100.0 2 40.0 7 70.0 4 80.0 0 0.0 4 40.0 4 0 4 40.0 0 2
14 10

44.4 17 58.6 29 51.8 19 70.4 21 72.4 40 71.4 19 70.4 21 72.4 40 71.4 MUARA MUSU 69 41 151.9 10 34.5 51 91.1 15 55.6 5 17.2 20 35.7 11 5 16 28.6 5 2
34 35

93.8 17 113.3 32 103.2 11 68.8 16 106.7 27 87.1 11 68.8 16 106.7 27 87.1 SEJATI 52 26 162.5 15 100.0 41 132.3 12 75.0 14 93.3 26 83.9 8 8 16 51.6 5 -4
30 22

63.6 153 65.9483 300 64.8 153 66.2 159 68.5 312 67.4 153 66.2 159 68.5 312 67.4 646 353 152.8 139 59.9 492 106.3 143 61.9 118 50.9 261 56.4 40.8 5 1
345 301 105 84 189

KEPALA PUSKESMAS RAMBAH HILIR I, 46.5 43.7 PENGELOLA PROGRAM IMUNISASI,

38.5
49.3 52.1 40.6

47.1
41.7 57.8 52.9

42.9
73.5 73.5 57.1

48.8
71.4 60.7 KUS AEDY, SKM 53.7 ROIHANIL JANNAH, Amd.Keb
65.9 53.7 NIP : 19690303 200012 1 001 20.0 40.0

60.0 20.0 33.9 28.6

46.4 64.3 61.3 51.6

83.9 77.4

44.7 40.8

52.9 59.2
 BOSTER DPTHB HiB BOSTER CAMPAK

% #P % JML % #L % #P % JML % #L % #P % JML %

76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92
LAPORAN BULANAN HASIL IMUNISASI RUTIN BAYI DESA
DESA RAMBAH HILIR

DINAS KESEHATAN KABUPATEN ROKAN HULU

BULAN

BAYI LAHIR HIDUP BAYI 0-11 BULAN HB0<24JAM + HB0<7HR BCG DPTHB HiB 1 DPTHB HiB 2 DPTHB HiB 3 POLIO 1 POLIO 2 POLIO 3 POLIO 4 IPV
KODE

POSYANDU
L P JML L P JML #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L % #P % JML % #L %

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64

JUMLAH
 IPV CAMPAK IDL BAYI LAHIR HIDUP BOSTER DPTHB HiB BOSTER CAMPAK IRL
DESA
DO DPT 1 DO DPT 1 -
#P % JML % #L % #P % JML % #L % #P % JML % L P JML #L % #P % JML % #L % #P % JML % #L #P JML %
-DPT 3 CAMPAK

65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 95 97 98

41.7

73.5

71.4 ROSMAWATI ,Amd.Keb

65.9 NIP:19870915 201704 2 009

60.0

46.4

83.9

52.9
 BOSTER DPTHB HiB BOSTER CAMPAK

% #P % JML % #L % #P % JML % #L % #P % JML %

76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92