TANGGAL :2 November 2021

Nama Puskesmas/Fasyankes/Pos : Puskesmas X Koto II

Kabupaten/Kota : Tanah Datar
Provinsi :Sumatera Barat
Tempat " Nagari Jaho

No No. Registrasi NIK Nama Penerima Vaksin

1
Q-001SUOMS 1406077112780007 YUSMARNI
2 Q-001SUON5 1304012309770002 YUFIANDI

3
Q-001UT73D 1304011010940006 RIDWAN
4 Q-001RAF2Q 1304015407990003 ECA SWI RAHAYU
5 Q-001OUZEA 1304011607850005 ZUL FADLI
6 q-001YL4IV 3603280802800014 MASRIL
7 Q-001SEVNB 1304011802730002 SUPARDI
8 S-ACDD5E8B 1304020209870001 HENDRIKO SEPTRIADY
9 Q-001Q1XEC 1374022303840001 IRWAN EFENDI
10 q-001XGLR8 1304010810620001 SYAHRIZAL
11 Q-001US75C 1304011901950002 SYAIFAL
12 P-VDGCLICR 1304015301030003 DINA ASWITA
13 q-001WKE5K 1803051001820003 SUPRIYADI
14 q-001WKE8D 1803055808780002 NURBAITI
15 q-001XOQL8 1304010711720005 JONI
16 Q-001OXZM6 1304015503930006 DELVI YANTI
17 Q-001SD31N 1404055006750004 ERLINDA REFIDA
18 Q-001PYN5J 1304016009680001 HARLINA
19 Q-001L07W3 1304016803970003 MIRNA SISKA DEWI
20 q-001XH5QY 1304014605700001 ROSLITA
21 Z-000F5VE7 1304014107570003 AJISAH
22 Q-001T5UEE 1304011105800002 JUNAIDI
Q-001MDJSG 1304010505720004 ZULFITRI
24 Q001xmxw6 2171091005860006 RAHMAT DENI
25 P-VEN6P8BH 1304010806980003 RODI SAPUTRA
26 Q-001NZ79U 1304010808730006 TAFRINALDI
27 P-VCCS0GNH 1304012002850001 EDI SUGIANTO
28 S-06E7B972 1304012205570003 SAMSUAR
29 Q-001L03MU 1304016106840003 YANTI YOSOFIA
30 Z-000F6CXH 1304010105480001 MUHAMMAD NUR
31 Q-001S9UNI 3603184703850016 MERI SUSANTI
32 Q-001B5RO6 1304014811750003 YEL NOFIA
33 Q-001S8M0X 1304010702940005 ARIF FIRMAN
34 Q-001EJ9PM 1304010701020003 ROBBY RUSTAM
35 q-001Y7W2F 1374015104960001 TIKA AFRINUR LAILA
36 1304016311600002 RATNA WILIS
37 1304015606810001 YETI APRIANI
1304016403830004 DELI YARSI
39
40
41
42
43
44
45
46
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Keterangan ***Merek Vaksin

* Pekerjaan dikelompokkan menjadi: A = Sinovac

A = Petugas Medis dan Non Medis di Fasilitas Pelayanan B = Lainnya (Mohon disebutkan jenis vaksin yang dit
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
 Kelompok Umur:
18-30 10
31-45 15
46-59 10
Remaja 0
Lansia 3
Total 38
Pekerjaan:
A 0
B 0
C 0
D 38
E 0
Total 38
 FORMAT PENCATATAN PELAKS
TINGKAT PUSKESMAS/FASYANKES

Jenis Umur Kelompok

Pekerjaan* Alamat
Kelamin (18-59 tahun) Umur

p D 44 31-45 TIGO SUKU

L D 44 31-45 TIGO SUKU

27 18-30 TABU BARAIE

L D

P D 22 18-30 TABU BARAIE

L D 36 31-45 TABU BARAIE

L D 41 31-45 TIGO SUKU

L D 48 46-59 TABU BARAIE

L D 35 31-45 LUBUAK BUAYA

L D 36 31-45 BALAI BALAI

L D 59 46-59 TIGO SUKU

L D 26 18-30 TABU BARAIE

P D 18 18-30 HILIE BALAI

L D 39 31-45 TIGO SUKU

P D 43 31-45 TIGO SUKU

L D 48 46-59 TIGO SUKU

P D 28 18-30 TABU BARAIE

P D 46 46-59 SUNGAI SALAK

P D 53 46-59 HILIR BALAI

P D 24 18-30 TABEK RABUN TABU BARAIE
P D 51 46-59 TIGO SUKU
P D 53 46-59 TABU BARAIE
L D 41 31-45 TABU BARAIE
P D 49 46-59 KEBUMEN
L D 35 31-45 PANINJAUAN
L D 23 18-30 TABU BARAIE
L D 48 46-59 TABU BARAIE
L D 36 31-45 TABU BARAIE
L D 64 LANSIA TIGO SUKU

P D 37 31-45 PANINJAUAN

L D 73 LANSIA TABU BARAIE

P D 36 31-45 PANINJAUAN

P D 46 46-59 TIGO SUKU

L D 27 18-30 PANINJAUAN

L D 19 18-30 PANINJAUAN

P D 25 18-30 PADANG PANJANG TIMUR

P D 61 LANSIA BALAI SATU
P D 39 31-45 BALAI SATU
P D 37 31-45 TABU BARAIE
n disebutkan jenis vaksin yang diterima Puskesmas/Faskes)
Kepesertaan BPJS JORONG
BPJS PBI 0 BINTUNGAN
BPJS Non PB 0 KB. AMBACANG
Non Anggota 0 KOTO TUO
Total 0 KOTO SUBARANG
Pemberian Dosis KUBU DIATEH
Dosis 1 35 P. RABAA
Dosis 2 30 P. TINGGI
Total 65 SAWAH PARIK
BALAI SATU
35 HILIE BALAI
TABU BARAIE
TIGO SUKU
HILIA
MUDIAK
MUDIAK AIE
P.GALUNDI
SOLOK
SUNGAI RAYO

Total
ATAN PELAKSANAAN VAKSINASI COVID-19
S/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya'

pada kolom yang sesuai)

Merek Tanggal
No. Hp
Vaksin*** Screening
BPJS Non
BPJS PBI
Non PBI Anggota

A 31-12-2021
082384073748
082384073748 A 31-12-2021

A 31-12-2021
081261258884

083183983015 PF 31-12-2021

085265202164 A 31-12-2021
081380930328 PF 31-12-2021

085264471833 A 31-12-2021

082382134085 A 31-12-2021

082268562484 PF 31-12-2021

082268567211 A 31-12-2021

083184016772 A 31-12-2021
083165624440 A 31-12-2021

085383816759 A 31-12-2021

085383816759 PF 31-12-2021

082268450004 A 31-12-2021

082390129016 A 31-12-2021
082372489441 A 31-12-2021

082391257806 PF 31-12-2021
082391257806 A 31-12-2021
081363210654 A 31-12-2021
081266845496 A 31-12-2021
082172879323 A 31-12-2021
081392152769 A 3/11/2021
085278000110 A 31-12-2021
082386430976 A 31-12-2021
081276169739 A 31-12-2021
081374832703 A 31-12-2021
085356073745 PF 31-12-2021

085265019960 A 31-12-2021
082283122849 A 31-12-2021

085356073372 A 31-12-2021

081276778835 A 31-12-2021

082113182530 A 31-12-2021

082268819368 A 31-12-2021

081363647609 PF 31-12-2021
081270008152
081374891005
081374092662
C = Administrator Pemerintahan

D = Lainnya
E = Tidak Bekerja
JORONG
0
0
0
0
0
0
0
0
2
1
8
10
0
0
0
0
0
0

0
 Dosis I Dosis 2

Keterangan
(Ditunda/Tidak
Tanggal Tanggal Diberikan/Lanjut)
Pemberian No. Batch Pemberian No. Batch
Vaksinasi Vaksinasi

19-11-021 24203621 31-12-2021 202109138O

19-11-2021 24203621 31-12-2021 202109138O

25-11-2021 202109175M 31-12-2021 202109138O

15-11-2021 SDEH4 31-12-2021 330408D

11-Sep-21 24203621 31-12-2021 202109138D

12-Jun-21 FK1754 31-12-2021 330408D
18-11-2021 24203621 31-12-2021 202109138O
31-12-2021 202109138O
11/11/2021 SDEH4 31-12-2021 330408D
2/12/2021 202109175M 31-12-2021 202109138O
25-11-2021 202109175M 31-12-2021 202109138O
31-12-2021 202109138O
29-11-2021 202109175M 31-12-2021 202109138O
29-11-2021 SDEU1 31-12-021 202109138O
2/12/2021 202109175M 31-12-2021 202109138O
11-Sep-21 24203621 31-12-2021 202109138O
18-11-2021 24203621 31-12-2021 202109138O
11/11/2021 SDEH4 31-12-2021 330408D
30-10-2021 24203621 31-12-2021 202109138O
2/12/2021 202109175M 31-12-2021 202109138O
25-11-2021 202109175M 31-12-2021 202109138O
20-11-2021 24203621 31-12-2021 202109138O
3/11/2021 24203621 31-12-2021 202109138O
2/12/2021 202109175M 31-12-2021 202109138O
31-12-2021 202109138O
6/11/2021 24203621 31-12-2021 202109138O
31-12-021 202109138O
31-12-2021 330408D
30-10-2021 24203621 31-12-2021 202109138O
25-11-2021 202109175M 31-12-2021 202109138O
18-11-2021 24203621 31-12-2021 202109138O
11/10/2021 202107140K 31-12-2021 202109138O
18-11-2021 24203621 31-12-2021 202109138O
16-10-2021 202108171F 31-12-2021 202109138O
4/12/2021 FK1754 31-12-2021 330408D
TUNDA
TUNDA
TUNDA
 12/24/2021
dr RIRI
Mela Astri
Liana
marianis
KIKI
Velli
Dona
Ridwan