LAPORAN HASIL PERHITUNGAN BAYI YANG TELAH MENDAPATKAN IMUNISASI DASAR LENGKAP

PUSKESMAS TRAGAH KABUPATEN BANGKALAN PROVINSI JAWA TIMUR 2021

DESA/KELURAHAN : BULAN/TAHUN :
NO NAMA TANGGAL LAHIR L/P ORANG TUA ALAMAT HB 0 BCG/POL 1 DPT 1/POL 2 DPT 2/POL 3 DPT 3/POL 4 IPV MR

Desa……………………………………….
Pelaksana Imunisasi,

(………………………………………………)
NIP/NRPTT :
 LAPORAN IMUNISASI RUTIN (TEPAT WAKTU)

DESA : pacangan BULAN : agustus

NO NAMA POSYANDU SASARAN HB<7HR BCG POLIO 1 DPT 1 POLIO 2 DPT 2 POLIO 3 DPT 3 POLIO 4 IPV MR IDL
L P L P L P L P L P L P L P L P L P L P L P L P L P
PACANGAN

TOTAL

LAPORAN IMUNISASI DOFU ( BAYI < 1 TAHUN )

SASARAN HB<7HR BCG POLIO 1 DPT 1 POLIO 2 DPT 2 POLIO 3 DPT 3 POLIO 4 IPV MR IDL
NO NAMA POSYANDU
L P L P L P L P L P L P L P L P L P L P L P L P L P
PACANGAN

TOTAL

LAPORAN IMUNISASI BLF > 1 TAHUN

SASARAN HB<7HR BCG POLIO 1 DPT 1 POLIO 2 DPT 2 POLIO 3 DPT 3 POLIO 4 IPV MR IDL
NO NAMA POSYANDU
L P L P L P L P L P L P L P L P L P L P L P L P L P

TOTAL
 LAPORAN BOOSTER PEMAKAIAN VAKSIN

DESA : BULAN :
SASARAN DPTHB-HIB MR 2 TANGGAL
NO POSYANDU HB0 BCG POLIO DPT MR
L P L P L P PENGAMBILAN

LAPORAN TT HAMIL DAN NON HAMIL

NON HAMIL HAMIL

NO SASARAN WUS SASARAN HAMIL
T1 T2 T3 T4 T5 T1 T2 T3 T4 T5

TOTAL

Diterima Pada Tanggal………………………… BIDAN DESA………………………………..

(……………………………………………………………) (………………………………………………….)
NIP/NRPTT :
TD IPV
 IMUNISASI DOFU < 1 TAHUN
ALAMAT IMUNISASI
NO NAMA BAYI NAMA ORANGTUA UMUR KET
(DUSUN) HB0 BCG P1 DPT1 P2 DPT2 P3 DPT3 P4 IPV MR

IMUNISASI BLF > 1 TAHUN

ALAMAT IMUNISASI
NO NAMA BAYI NAMA ORANGTUA UMUR KET
(DUSUN) HB0 BCG P1 DPT1 P2 DPT2 P3 DPT3 P4 IPV MR

IMUNISASI LANJUTAN
ALAMAT IMUNISASI
NO NAMA BAYI NAMA ORANGTUA UMUR KETERANGAN
(DUSUN) DPT4 MR2 Desa…………………………………
Pelaksana Imunisasi, VALIDASI : Tgl
(……………………………………….)
NIP/NRPTT :
KABUPATEN/KOTA :
PROVINSI :
BULAN/TAHUN :

IDENTITAS GEJALA YANG DIALAMI

No. No.
JENIS Batch/Exp JENIS Batch/Exp PEMBERIAN TEMPAT TANGGAL
NO JENIS PELAYANAN DEMAM BENGKAK MERAH MUNTAH
TANGGAL VAKSIN 1 Date Vaksin VAKSIN 2 Date Vaksin IMUNISASI IMUNISASI LAIN-LAIN
NAMA ANAK KELAMIN UMUR NAMA ORTU ALAMAT IMUNISASI
LAHIR 1 2 (SEBUTKAN)
L/P Jika Ya Tandai √
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Jika ditemukan gejala :

1. Tidak mau menetek/minum
2. Kejang
3. Pucat biru
4. Sesak nafas
5. Muntah berlebihan
6. Demam tinggi > 39˚C Lebih 1 hari
7. Menangis terus menerus lebih dari 3 jam
8. Kesadaran menurun
9. Anafilaktik
10. Abses

lanjutkan ke Formulir Pelaporan KIPI Serius

 LAPORAN SWEEPING IMUNISASI UPTD PUSKESMAS TRAGAH TAHUN 2021

TANGGGAL : LAPORAN IMUNISASI TEPAT WAKTU

ALAMAT IMUNISASI
NO NAMA BAYI NAMA ORANGTUA UMUR (DUSUN) KET.
HB 0 BCG P1 DPT 1 P2 DPT 2 P3 DPT 3 P4 IPV MR
 LAPO

Aug-21
TGL LAHIR/ JENIS
NO NAMA ORANG TUA ALAMAT
UMUR KELAMIN
1 Aliya Halimah/Rusdi 4/5/2019 Pacangan laok P
2 Latifa Novi/Solihin 4/7/2019 Pacangan Dajah P
3 Nizar Rohmah/Toyib 4/12/2019 Pacangan Dajah L
4 Rama Hotijah/Mat Zehri 5/2/2019 Pacangan tengah L
5 Karina Hofifah/Sueb 5/7/2019 Pacangan Laok P
6 Ezra Nurhayati/Yanto 6/1/2019 Pacangan Dajah L
7 Jihan Juaria/Hasan 7/7/2019 Pacangan laok P
8 Azka Novi/Rohman 7/22/2019 Pacangan tengah L
9 Abil Siti Rohmah/Samsul 9/23/2019 Pacangan laok L
10 Raihan Samia/Abu Bakar 7/17/2019 Pacangan tengah L
11 Amelia Nurul/Solihin 9/5/2019 Pacangan laok P
12 Atika Ainia/Hasan 9/10/2019 Pacangan tengah P
13 Laili Romlah/M Nur 8/5/2019 Pacangan Dajah P
14 Hoirul Aman Hamimah/Handi 10/8/2019 Pacangan Dajah L
15 Arga Anggun/ 11/27/2019 Pacangan Dajah L
16 Abdillah Fadilah/Imron 1/20/2020 Pacangan Dajah L
17 Najwa Saodah/Mat Taim 1/5/2020 Pacangan tengah P
18 Hanindiyah Hoiriyah 1/1/2020 Pacangan laok P
19 Dimas Halimatus.s/Khoirul 3/2/2020 Pacangan laok L
20 Rafanza Ustiah/Hafid 3/15/2020 Pacangan tengah L
21 Munawaroh Mia/Sueb 3/16/2020 Pacangan laok P
22 Aisyah Salimah/Mosleh 3/22/2020 Pacangan laok P
23 Refa Saidah/Roni 4/3/2020 Pacangan laok P
24 Fatimatus Zahra Oktaviani 5/12/2020 Pacangan Dajah P
25 Kalif Muyessaroh 5/15/2020 Pacangan Dajah P
26 Aisyah Putri Kamelia 6/11/2020 Pacangan Dajah P
27 By Ny. Laila Lailatul Qomaria 6/6/2020 Pacangan Dajah L
28 Sefa Nur Farida 6/2/2020 Pacangan tengah P
29 Safa Halimah/Rusdi 6/5/2020 Pacangan tengah P
30 Arka Muammaroh 6/20/2020 Pacangan Dajah L
31 Silvia Erika 7/5/2020 Pacangan laok P
32 Angraini Siati 7/6/2020 Pacangan Tengah P
33 Elsa Afia 7/11/2020 Pacangan Tengah P
34 Nurul Jannah Homsa Asaroh 11/20/2020 Pacangan Dajah P
35 Moh. Ammar Dzurroin Sirriatul Mardiyah 12/5/2020 Pacangan Dajah L
36 Moh. Nasrulloh Fatima 12/14/2020 Pacangan Laok L
37 Putri Khumairo Jamila 1/2/2021 Pacangan Dajah P
38 Roida Zainiyah 2/1/2021 Pacangan Laok P
39 Aurel Muawanah 2/23/2021 Pacangan Dajah L
40 by. Muamaroh Muammaroh Pacangan tengah P
41 Ahmad Daniyal. R Indah 3/23/2021 Pacangan Dajah L
42 Elsa Yuliana 3/25/2021 Pacangan Laok p
43 Elsi Yuliana 3/25/2021 Pacangan Laok p
44 Nadifa Salsabila. R Hafifah 4/23/2021 Pacangan Dajah P
45 Celsi Fadilatus 5/5/2021 Pacangan Dajah P
46 Kevin Maulana Wulan 6/10/2021 Pacangan Dajah L
47 Aisyah nurafifah Anisa 6/21/2021 Pacangan Laok P
 LAPORAN IMUNISASI BULANAN RUTIN
PUSKESMAS TRAGAH

JENIS PEMBERIAN VAKSIN (TANGGAL)

HB 0 BCG P1 DPT-HB 1 P2 DPT-HB 2 P3
4/5/2019 4/21/2019 4/21/2019 6/19/2019 6/19/2019 9/18/2019 9/18/2019
4/7/2019 6/18/2019 6/18/2019 7/18/2019 7/18/2019 8/23/2019 8/23/2019
4/12/2019 6/18/2019 6/18/2019 7/18/2019 7/18/2019 8/23/2019 8/23/2019
5/2/2019 6/19/2019 9/19/2019 9/18/2019 9/18/2019 10/23/2019 10/23/2019
5/7/2019 6/19/2019 9/19/2019 9/18/2019 9/18/2019 10/23/2019 10/23/2019
6/1/2019 8/18/2019 8/18/2019 9/23/2019 9/23/2019 11/19/2019 11/19/2019
7/7/2019 10/23/2019 10/23/2019 11/23/2019 11/23/2019 1/20/2020 1/20/2020
7/22/2019 9/13/2019 9/13/2019 11/23/2019 11/23/2019 1/20/2020 1/20/2020
9/23/2019 10/23/2019 10/23/2019 11/23/2019 11/23/2019 1/20/2020 1/20/2020
7/1/2019 10/23/2019 10/23/2019 11/23/2019 11/23/2019 1/20/2020 1/20/2020
9/5/2019 10/23/2019 10/23/2019 11/23/2019 11/23/2019 1/20/2020 1/20/2020
9/10/2019 11/23/2019 11/23/2019 1/20/2020 1/20/2020 2/26/2020 2/26/2020
8/5/2019 10/18/2019 10/18/2019 11/19/2019 11/19/2019 1/21/2020 1/21/2020
10/8/2019 11/19/2019 11/19/2019 1/21/2020 1/21/2020 4/22/2020 4/22/2020
11/27/2019 12/11/2019 12/11/2019 1/21/2020 1/21/2020 6/17/2020 6/17/2020
1/20/2020 2/20/2020 2/20/2020 4/22/2020 4/22/2020 6/17/2020 6/17/2020
1/5/2020 2/20/2020 2/20/2020 4/22/2020 4/22/2020 6/17/2020 6/17/2020
1/1/2020 2/20/2020 2/20/2020 4/22/2020 4/22/2020 6/17/2020 6/17/2020
3/2/2020 4/22/2020 4/22/2020 6/17/2020 6/17/2020 9/24/2020 9/24/2020
3/15/2020 4/22/2020 4/22/2020 6/17/2020 6/17/2020 8/19/2020 8/19/2020
3/16/2020 4/22/2020 4/22/2020 6/17/2020 6/17/2020 8/19/2020 8/19/2020
3/22/2020 4/22/2020 4/22/2020 6/17/2020 6/17/2020 9/24/2020 9/24/2020
4/3/2020 6/17/2020 6/17/2020 8/19/2020 8/19/2020 9/24/2020 9/24/2020
5/12/2020 6/17/2020 6/17/2020 8/19/2020 8/19/2020 11/10/2020 11/10/2020
5/15/2020 6/17/2020 6/17/2020 Pindah SBY Pindah SBY Pindah SBY Pindah SBY
6/11/2020 8/19/2020 8/19/2020 9/24/2020 9/24/2020 11/10/2020 11/10/2020
6/6/2020 Tidak Hadir Tidak Hadir Pindah SBY Pindah SBY Pindah SBY Pindah SBY
6/2/2020 8/19/2020 8/19/2020 9/24/2020 9/24/2020 11/11/2020 11/11/2020
6/5/2020 8/19/2020 8/19/2020 9/24/2020 9/24/2020 11/10/2020 11/10/2020
6/20/2020 8/19/2020 8/19/2020 9/23/2020 9/23/2020 11/10/2020 11/10/2020
7/5/2020 9/24/2020 9/24/2020 11/11/2020 11/11/2020 12/16/2020 12/16/2020
7/6/2020 8/19/2020 8/19/2020 9/23/2020 9/23/2020 11/11/2020 11/11/2020
7/11/2020 8/19/2020 8/19/2020 9/23/2020 9/23/2020 11/11/2020 11/11/2020
11/20/2020 12/16/2020 12/16/2020 1/19/2021 1/19/2021 2/23/2021 2/23/2021
12/5/2020 1/18/2021 1/18/2021 2/23/2021 2/23/2021 4/12/2021 4/12/2021
12/14/2020 1/18/2021 1/18/2021 2/22/2021 2/22/2021 4/8/2021 4/8/2021
1/2/2021 2/23/2021 2/23/2021 4/12/2021 4/12/2021
2/1/2021 2/22/2021 2/22/2021 4/8/2021 4/8/2021 8/25/2021 8/25/2021
2/23/2021 8/26/2021 8/26/2021
pindah
3/23/2021 8/26/2021 8/26/2021
3/25/2021 8/25/2021 8/25/2021
3/25/2021 8/25/2021 8/25/2021
4/23/2021 8/26/2021 8/26/2021
5/5/2021 8/26/2021 8/26/2021
6/10/2021 8/25/2021 8/25/2021
6/21/2021 8/26/2021 8/26/2021
SIN (TANGGAL)
DPT-HB 3 P4 IPV MR IDL
10/23/2019 10/23/2019 1/20/2020 1/20/2020
9/23/2018 9/23/2018 10/23/2019 1/21/2020 1/21/2020
9/23/2018 9/23/2018 10/23/2019 1/21/2020 1/21/2020
11/23/2019 11/23/2019 2/26/2020 2/26/2020
11/23/2019 11/23/2019 2/26/2020 2/26/2020
1/21/2020 1/21/2020 4/22/2020 4/22/2020
2/26/2020 2/26/2020 4/22/2020 4/22/2020
2/26/2020 2/26/2020 4/22/2020 4/22/2020
2/26/2020 2/26/2020 6/17/2020 6/17/2020
2/26/2020 2/26/2020 6/17/2020 6/17/2020
2/26/2020 2/26/2020 6/17/2020 6/17/2020
4/23/2020 4/23/2020 6/17/2020 6/17/2020
4/22/2020 4/22/2020 6/17/2020 6/17/2020
6/17/2020 6/17/2020 9/24/2020 9/24/2020
9/24/2020 9/24/2020 11/11/2020 11/11/2020 11/11/2020
8/25/2020 8/25/2020 11/11/2020 11/11/2020 11/11/2020
8/25/2020 8/25/2020 11/11/2020 11/11/2020 11/11/2020
8/25/2020 8/25/2020 1/18/2021 12/16/2020 1/18/2021
11/11/2020 11/11/2020 11/11/2020 1/18/2021 1/18/2021
9/24/2020 9/24/2020 2/22/2021 1/18/2021 2/22/2021
9/24/2020 9/24/2020 2/22/2021 1/19/2021 2/22/2021
11/11/2020 11/11/2020 2/22/2021 1/19/2021 2/22/2021
11/11/2020 11/11/2020 4/8/2021 2/22/2021 4/8/2021
12/18/2020 12/18/2020 4/8/2021 2/22/2021 4/8/2021
Pindah SBY Pindah SBY Pindah SBY Pindah SBY Pindah SBY
12/18/2020 12/18/2020 4/8/2021
Pindah SBY Pindah SBY Pindah SBY Pindah SBY Pindah SBY
12/16/2020 12/16/2020 4/8/2021
12/16/2020 12/16/2020 4/8/2021
12/18/2020 12/18/2020 4/8/2021
1/18/2021 1/18/2021 8/26/2021
1/18/2021 1/18/2021 8/26/2021
1/19/2021 1/19/2021 8/26/2021
4/12/2021 4/12/2021 8/26/2021
8/26/2021 8/26/2021 8/26/2021
8/25/2021 8/25/2021