JK(L/P)
No. Nama Anak Tgl lahir Umur Nama orang tua
a b c d e f
1 A.Ahmad Khaerunnas 5/26/2016 6 L Fatmawati
2 Yasmine Syam 6/14/2017 5 p Mesi Angraeni
3 Inayah Ufairah 6/3/2015 7 p Harianti
4 Muh.Aidil 11/14/2015 6 L Ramlah
5 Muh.Hafiz Juhair 10/8/2016 5 L Salwatiah
6 Hilya Nurul Azkiyah 6/7/2016 6 P Rosmiati
7 Afifah safira 3/19/2015 7 P Hasnawati
8 Fahmi Alqadim 10/13/2014 7 L Parida
9 Salsabila 1/7/2016 6 P Riska
10 Achmad Dzaky Khayriel 11/12/2015 6 L St.Fatimah
11 Haibah Hurairah 9/5/2015 7 P Yuhasni
12 Keisya 4/29/2015 7 p Anita
13 Jinan shafwatul rihab 11/4/2014 7 p suryani
14 Ibnu hadi al hayat 1/27/2015 7 L Almi
15 Nahdatul Gitra 4/13/2017 5 p Indo bulu
16 Jaisah yasmine 12/1/2015 6 p Rahma
17 Mutmainnah 5/17/2016 6 P Hasnia
18 Aflahul Ramadhan 5/29/2017 5 L Sarnida
19 Muh Faiz Haeril 3/30/2015 7 L Rahmawati
20 Sri Nabila Kesya 11/11/2017 4 L Sahariana
21 Fitri Ramadhani 6/27/2016 6 P Nurhayati
22 Aqil Fhauzan Ramadhan 7/13/2015 7 L Rahmawati
23 Abd.Riad Jinan 8/4/2014 8 L Jusmawati
24 ahmad Rafli Azzani 10/19/2015 6 L Kasmawati
25 Sarmita 12/11/2015 6 P Rosdiana
26 Nur Rafia Fakhira 5/26/2016 6 P Nur Rahma
27 Nabil Irsya 4/20/2016 6 L Nurhayani
28 Alfiah Hasanah Kamila 11/22/2015 6 P Hajriani
29 Muh.Rafa Putra 8/11/2016 6 L Dina
30 Aisyah Aqila 2/8/2017 5 P Hadria
31 Muh.Ridho 3/14/2016 6 L Hj.Semma
32 Nur Syakila 4/13/2017 5 P Lara
33 Sakila Safri 2/22/2015 7 P Hamsati
34 Aisyah Inara 5/17/2016 6 P Asriani
35 Riska Rahman 11/23/2015 6 P Rosnawati
36 Fakira Meysha 1/12/2016 6 P Evita
37 Alfat 1/29/2017 5 L Ramlah
38 Alda Meriska 3/3/2017 5 P Emma
39 Arini Mustar 8/15/2015 7 P Rosalinda
40 Khadijah Nurul Jannah 7/30/2016 6 P Sarnia
41 Agam Pratama 11/19/2015 6 L Darnasari
42 Haria Abdullah 3/8/2015 7 L Jumahida
43 Muh.Ali Al Fatih 12/15/2015 6 L Nuryanti
44 Muh.Risqi 10/27/2015 6 L Masna
45 Muh.Kalmuddin Rauf 11/8/2016 5 L Samrina Branti
46 Agus Dirgantara 8/17/2015 7 L Samsia
47 Ahmad Dzaki Al Gibran 7/14/2015 7 L Megawati
48 Dafa Al Fairus 11/8/2014 7 L Rasnida
49 Fajria Salsabila 7/13/2015 7 P Salwatia
50 Resti Soraya 5/5/2015 7 p Salmiah
Jumlah 5 Vial
Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterang
MAT PENCATATAN HASIL PELAYANAN
Nama petugas : Jumail,S.Kep.Ns
UPTD Puskesmas : Watunohu
Kabupaten : Kolaka Utara
Imunisasi Kejar
(Ya = 1, Tidak=0)
Campak
Rubela
Alamat No.Hp NIK
(Ya=1,
Tidak=0) DPT-HB-
OPV IPV
Hib
g h i j k l m
Tambuha 7408092605160001 1 0 0 0
Tambuha 7408095406170001 1 0 0 0
Tambuha 7408094306150001 1 0 0 0
Tambuha 7408091411150001 1 0 0 0
Tambuha 7408090810160001 1 0 0 0
Tambuha 740809 1 0 0 0
Tambuha 740809 1 0 0 0
Tambuha 7408095310140001 1 0 0 0
Tambuha 7408094701160001 1 0 0 0
Tambuha 7322021211150001 1 0 0 0
Tambuha 740809 1 0 0 0
Tambuha 7408098964150000 1 0 0 0
Tambuha 7408094411140000 1 0 0 0
Tambuha 740809 1 0 0 0
Tambuha 74080995304170001 1 0 0 0
Tambuha 7408094112150001 1 0 0 0
Tambuha 7408095705160001 1 0 0 0
Tambuha 7408092905170001 1 0 0 0
Tambuha 7408093003140001 1 0 0 0
Tambuha 7408095111170001 1 0 0 0
Tambuha 7408096706160001 1 0 0 0
Tambuha 7408091307150001 1 0 0 0
Tambuha 7408090408140001 1 0 0 0
Tambuha 7408091910150001 1 0 0 0
Tambuha 7408095112150001 1 0 0 0
Tambuha 7408096605160001 1 0 0 0
Tambuha 7408092004160001 1 0 0 0
Tambuha 7408092111150001 1 0 0 0
Tambuha 7408091708160001 1 0 0 0
Tambuha 7408094802170001 1 0 0 0
Tambuha 7408091403160001 1 0 0 0
Tambuha 7322115304170001 1 0 0 0
Tambuha 7408096202150001 1 0 0 0
Tambuha 7408095705160001 1 0 0 0
Tambuha 7408096311150001 1 0 0 0
Tambuha 7408095201160001 1 0 0 0
Tambuha 7408092901170001 1 0 0 0
Tambuha 7408094303170001 1 0 0 0
Tambuha 7408095508150001 1 0 0 0
Tambuha 7408097007160001 1 0 0 0
Tambuha 7408091911150001 1 0 0 0
Tambuha 7408090803150001 1 0 0 0
Tambuha 7371111512150010 1 0 0 0
Tambuha 7408092710150001 1 0 0 0
Tambuha 7408090811160001 1 0 0 0
Tambuha 7408091708160001 1 0 0 0
Tambuha 740809 1 0 0 0
Tambuha 740809 1 0 0 0
Tambuha 740809 1 0 0 0
Tambuha 740809 1 0 0 0
Pelarut Campak
Dropper ADS 0,5 ML ADS 5 ML Safety Box Pen Marker
Rubela