1.

Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 V 3 4 5 6
7 2 7 1 0 1 2 Bulan : 2022
NAMA FASKES/ PUSKESMAS NOSARARA 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN SUMBER ALOKON

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
STATUS PESERTA KB

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN
ISTRI

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN
PENCABUTAN

PENCABUTAN

KEGAGALAN
PEMBERIAN/

KOMPLIKASI
NAMA SUAMI

OPERATIF/

LAINNYA
TANGGAL

MANDIRI
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

BERAT
LAHIR

(Kode)

TIDAK

APBN

APBD
DAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

01-February- 18-December-
1 RIZAL 7 2 7 1 0 2 5 4 1 2 8 9 0 0 0 3 DEWI JL. KERAMIK 3 1 0 0 1 0 0 1 0 1 0 0
2022 1989
23-February- 10-December-
2 RUDI 7 2 0 3 1 8 5 6 1 2 9 9 0 0 0 2 FITRIANI BTN PENGAWU 082291596468 3 1 0 0 1 1 0 0 0 1 0 0
2022 1999

3 18-March-2022 Ramli 7 2 7 1 0 3 5 6 0 3 8 1 0 0 0 5 Husaini 16-March-1981 BTN BUkit Sira 082296710470 3 1 0 0 1 1 0 0 0 1 0 0

14-August-1994
4 26-March-2022 Hendra 7 3 7 2 0 4 6 2 0 5 9 0 0 0 0 2 ANGGUN BTN Palupi 3 1 0 0 1 1 0 0 0 1 0 0

5 04-April-2022 Ismail 7 3 7 2 0 4 6 2 0 5 9 0 0 0 0 2 Anggun 22-May-1990 BTN Palupi 3 1 0 0 1 1 0 0 0 1 0 0

10-September-
6 07-April-2022 Irwan 7 2 7 1 0 3 5 0 0 9 8 0 0 0 0 4 Sukmawati BTN Pengawu 1 1 1 0 1 1 0 0 0 1 0 0
1980

7 14-April-2022 Rahmad 7 2 7 1 0 3 6 0 0 4 0 0 0 0 0 1 Avia Huwaida 20-April-2000 Jl Padanjakaya Pengawu 3 1 0 0 1 1 0 0 0 1 0 0

8 16-April-2022 Ramli 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Husaini 01-July-1989 BTN Bukit siu Duyu 3 1 0 0 1 1 0 0 0 1 0 0

9 19-April-2022 Amat 7 5 2 0 6 9 0 0 0 0 1 2 7 1 0 2 Norma 12-June-1990 Gawalise Duyu 3 1 0 0 1 1 0 0 0 1 0 0

13-December-
10 19-April-2022 Ikbal 7 2 7 1 0 2 7 1 1 2 8 4 0 0 0 4 Irmawati Padanjakaya Pengawu 3 1 0 0 1 1 0 0 0 1 0 0
1984
29-October-1990
11 19-April-2022 Indra 7 2 7 1 0 3 6 9 1 0 9 0 0 0 0 1 Riska Prisila BTN Pengawu jl. Padnjakaya 3 1 0 0 1 1 0 0 0 1 0 0

08-December-
12 22-April-2022 Rudi 7 2 0 3 1 8 5 6 1 2 9 4 0 0 0 2 Fitriani BTN Pengawu 082291566468 3 1 0 0 1 1 0 0 0 1 0 0
1994

13 25-April-2022 Rahman 7 2 7 1 0 3 6 7 0 7 8 2 0 0 0 1 Nurpandan 27-May-1982 Jl. Padanjakaya 1 1 1 0 1 1 0 0 0 1 0 0

14 10-May-2022 Rahmad 7 2 7 1 0 3 6 0 0 4 0 0 0 0 0 1 Havia HUwaida 20-April-2000 Padanjakaya 3 1 0 0 1 0 0 1 0 1 0 0

29-October-1990
15 18-May-2022 Mahmudin 7 2 7 1 0 3 6 9 1 0 9 0 0 0 0 1 Riska Jl. Malontara Pengawu 3 1 0 0 1 1 0 0 0 1 0 0

08-August-2000
16 18-May-2022 Saiful 7 2 0 3 1 8 5 6 1 2 9 9 0 0 0 2 Fitriani Jl. Malontara Pengawu 3 1 0 0 1 1 0 0 0 1 0 0

17 21-May-2022 Ramli 7 2 7 1 0 3 5 6 0 3 8 1 0 0 0 5 Husaeni 16-March-1981 BTN Bukit sura 3 1 0 0 1 1 0 0 0 1 0 0

20-January-1989
18 23-May-2022 Muh. Toha 7 2 7 1 0 3 0 0 0 1 8 9 0 0 0 1 Silvana Jl. Malontara Pengawu 3 1 0 0 1 0 0 1 0 1 0 0

19 02-June-2022 Ismail 7 3 7 2 0 4 6 2 0 5 9 0 0 0 0 2 Anggun 22-May-1990 Jl. Malontara Pengawu 3 1 0 0 1 1 0 0 0 1 0 0

02-January-1991
20 14-June-2022 Arfan 7 2 7 1 0 2 4 2 0 1 9 1 0 0 0 6 RIRI JL Padanjakaya 3 1 0 0 1 1 0 0 0 1 0 0

16-December-
21 16-June-2022 Rudi 7 2 0 3 1 8 5 6 1 2 9 9 0 0 0 2 Fitriani Jl. Malontara Pengawu 3 1 0 0 1 1 0 0 0 1 0 0
1999

22 20-June-2022 Ramli 7 2 7 1 0 3 5 6 0 3 8 1 0 0 0 5 Husaeni 16-March-1981 Jl. Bukit Sira 3 1 0 0 1 1 0 0 0 1 0 0

23 02-July-2022 ISMAN 7 3 7 2 0 4 6 2 0 5 9 0 0 0 0 2 ANGGUN 27-July-1992 BTN PENGAWU 0909090909090 3 1 0 0 1 1 0 0 0 1 0 0

25-January-1994
24 07-July-2022 MOH. ADITIA 7 2 7 1 0 3 6 3 0 1 9 4 0 0 0 6 DINATIA PUTRI BTN PENGAWU 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

25 07-July-2022 RAHMAD 7 2 7 1 0 3 6 0 0 4 0 0 0 0 0 1 AVIA H 20-April-2000 JL. PADANJAKAYA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

08-December-
26 14-July-2022 YASIR 7 2 0 3 1 8 5 6 1 2 9 9 0 0 0 2 FITRIANI BTN PENGAWU 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0
2000
20-January-1989
27 23-July-2022 MOH. TOHA 7 2 7 1 0 3 0 0 0 1 8 9 0 0 0 1 SILVANA JL. MALONTARA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0
 14-January-1990
28 27-July-2022 ANDI 7 6 0 4 0 2 5 4 0 1 9 0 0 0 0 5 RESKY JL. SUHARSO 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

29 27-July-2022 ANGGA 7 2 7 1 0 3 6 8 0 6 9 3 0 0 0 4 MARIAM 29-May-1993 JL. MALONTARA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

07-December-
30 27-July-2022 BAGUS 7 2 0 3 1 2 4 7 1 2 0 0 0 0 0 6 DESI OKTAVIANI BTN KINTABARU 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0
2000
17-August-1989
31 27-July-2022 DANI 7 2 7 1 0 3 5 7 0 9 8 7 0 0 0 1 VERONIKA JL. MALONTARA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

31-December-
32 27-July-2022 FARID SAKTI 7 2 0 3 1 4 7 1 1 2 9 5 0 0 0 1 MAGFIRA JL. KANCIL 0000000000000 1 1 1 0 1 1 0 0 0 1 0 0
1995

33 27-July-2022 HARIS 7 2 0 4 0 1 7 0 0 6 9 2 0 0 0 1 UMMU KALSUM 30-June-0192 JL. ANGGREK 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

34 27-July-2022 RAHMAD 7 2 7 1 0 3 6 5 5 0 4 8 7 0 0 0 KARTINI 25-April-1987 JL. MALONTARA 0000000000000 1 1 1 0 1 1 0 0 0 1 0 0

35 27-July-2022 RISMAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NURHAYATAI 02-May-1982 JL. GANOGO 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

06-November-
36 27-July-2022 RUDI 7 2 7 1 0 3 4 6 1 1 8 0 0 0 0 1 AJERUS JL. MALONTARA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0
1980

37 27-July-2022 SADAM 7 2 7 1 0 3 5 3 0 4 8 7 0 0 0 4 EVA RAMZANI 13-April-1987 JL. PADANJAKAYA 0000000000000 1 1 1 0 1 1 0 0 0 1 0 0

08-October-1998
38 27-July-2022 YUNUS 7 2 0 8 1 9 4 8 1 0 9 8 0 0 0 1 OKTAVIA JL. MALONTARA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

39 29-July-2022 BAHTIAR 6 4 7 1 0 5 6 2 0 3 8 7 0 0 0 1 SUMIATI 22-March-1987 JL. PUEBONGO 0000000000000 1 1 1 0 1 1 0 0 0 1 0 0

05-August-2022 25-January-1994
40 MOH. ADITIA 7 2 7 1 0 3 6 0 0 4 0 0 0 0 0 1 DITANIA JL. PADANJAKAYA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

05-August-2022
41 RAHMAT 7 2 7 1 0 3 6 0 0 0 4 0 0 0 0 0 AFIYA 20-April-2000 JL. PADANJAKAYA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

11-August-2022 02-January-1991
42 ARFAN 7 2 7 1 0 2 4 2 0 1 9 1 0 0 0 6 RIRI INDRAWATI JL. PADANJAKAYA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

19-August-2022
43 RAMLI 7 2 7 1 0 3 5 6 0 3 8 1 0 0 0 5 HUSAINI 16-March-1981 JL. BUKIT SIRA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

20-August-2022 02-December-
44 ADI PUTRA 7 2 7 1 0 2 0 2 1 2 0 2 0 0 0 1 FADLIA JL. MALONTARA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0
2002
20-August-2022 20-January-1989
45 MOH. TOHA 7 2 7 1 0 3 6 0 0 1 8 9 0 0 0 1 SILVANA JL. MALONTARA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

22-August-2022
46 SURIADI 7 2 7 1 0 8 4 2 0 5 8 2 0 0 0 1 NURHAYATI 02-May-1982 JL. GANOGO 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

25-August-2022
47 ISMAIL 7 3 7 2 0 4 6 2 0 5 9 0 0 0 0 2 ANGGUN 22-May-1990 BTN PENGAWU 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

25-August-2022 06-November-
48 JUANDA 7 2 7 1 0 3 4 6 1 1 8 1 0 0 0 1 MERLIN JL. PENGAWU 0000000000000 1 1 1 0 1 1 0 0 0 1 0 0
1987
25-August-2022
49 RAHMAN 7 2 7 1 0 3 6 5 0 4 8 7 0 0 0 1 KADINI 25-April-1987 JL. MALONTARA 0000000000000 3 1 0 0 1 1 0 0 0 1 0 0

01-September- 14-September-
50 ZALDIN 7 2 0 4 0 2 5 4 0 9 8 9 0 0 0 1 sarika jl. agatis 123456789900 1 1 1 0 1 1 0 0 0 1 0 0
2022 1989
05-September- 03-January-1994
51 ADITIA 7 2 7 1 0 3 6 0 3 1 9 4 0 0 0 6 DITANIA PUTRI BTN PENGAWU 123456789000 1 1 1 0 1 1 0 0 0 1 0 0
2022
05-September- 20-November-
52 RAHMAT 7 2 7 1 0 3 6 0 0 4 0 0 0 0 0 0 AVIA JL. PADANJAKAYA 12345678900 1 1 1 0 1 1 0 0 0 1 0 0
2022 2000
08-September-
53 INDRA 7 1 0 1 1 0 6 1 0 3 9 3 0 0 0 2 MIRA SUAL 21-March-1993 BTN PENGAWU 1234567899 1 1 1 0 1 1 0 0 1 0 0 0
2022
17-September- 17-October-2000
54 ANDI FITRA 7 2 7 1 0 2 0 2 1 2 0 2 0 0 0 1 FADLIA JL. MALONTARA 1234567678899 3 1 0 0 1 1 0 0 0 1 0 0
2022
17-September- 20-November-
55 MOH. TOHA 7 2 7 1 0 3 6 0 0 1 1 8 9 0 0 0 SILVANA JL. MALONTARA 1234566788766 3 1 0 0 1 1 0 0 0 1 0 0
2022 1989
17-September- 14-January-1981
56 RAMLI 7 2 7 1 0 3 6 0 0 1 8 9 0 0 0 1 HASALMI BTN BUKIT SIRA 1234567890000 3 1 0 0 1 1 0 0 0 1 0 0
2022
19-September-
57 ALFIANUS 7 2 7 1 0 3 5 5 0 7 9 1 0 0 0 6 NIRMALA 15-July-1991 BTN PUSKUD 1234567788999 1 1 0 0 1 1 0 0 0 1 0 0
2022
20-September- 01-December-
58 MORTEN 7 2 0 8 0 3 4 1 1 2 9 2 0 0 0 1 CHERRY BTN BALIASE 1234567899999 1 1 1 0 1 1 0 0 0 1 0 0
2022 1994
20-September-
59 ZAENAL 7 2 7 1 0 3 5 4 0 5 7 9 0 0 0 1 WAHYUNINGSIH 14-May-1978 JL. PUEBONGO 1234567899900 1 1 1 0 1 1 0 0 0 1 0 0
2022
27-September-
60 ISMAIL 7 3 7 2 0 4 6 2 0 5 9 0 0 0 0 2 ANGGUN 22-May-1990 BTN PALUPI 1234567778899 3 0 0 0 1 1 0 0 0 1 0 0
2022
27-September-
61 TOFAN 7 2 7 1 0 3 5 9 0 7 7 9 0 0 0 6 DIAN 19-July-1979 JL. LEKATU 1234567890000 3 1 0 0 1 1 0 0 0 1 0 0
2022
18-January-2022
62 MAMAN 7 2 7 1 0 3 5 5 0 7 8 3 0 0 0 8 FITRIANI 15-July-1993 JL LEKATU 3 1 0 0 2 1 0 0 1 0 0 0

01-February-
63 IDRUS 7 2 7 1 0 3 4 1 0 7 7 5 0 0 0 4 NURALANG 01-July-1975 PALUPI PERMAI 3 1 0 0 2 1 0 0 1 0 0 0
2022
01-February- 30-October-1986
64 KHAERUDIN 7 2 0 3 1 4 7 0 1 0 8 6 0 0 0 1 FATIMAH BTN PENGAWU BLOK B4 2 1 0 0 2 0 0 1 1 0 0 0
2022
01-February- 08-February-
65 TANHAR 7 2 7 1 0 6 4 8 0 2 9 1 0 0 0 1 ASRIANI JL. MALONTARA 082395087983 3 1 0 0 2 1 0 0 1 0 0 0
2022 1991
 02-February- 21-December-
66 BAHARUDIN 7 6 0 2 1 4 6 1 1 2 7 7 0 0 0 1 DIANA JL. MALONTARA 1 1 1 0 2 1 0 0 1 0 0 0
2022 1977
03-February- 20-January-1989
67 MOHAMMAD TOHA 7 2 7 1 0 3 0 0 0 1 8 9 0 0 0 1 SILVANA JL. MALONTARA 082349680003 1 1 1 0 2 1 0 0 1 0 0 0
2022
22-February- MOHAMMAD 19-August-1978
68 7 2 7 1 0 3 5 9 0 8 7 0 0 0 0 4 SOLEHA JL. PADANJAKAYA 3 1 0 0 2 1 0 0 1 0 0 0
2022 DAHLAN
22-February- 29-October-1990
69 MUHAMMAD INDRA 7 2 7 1 0 3 6 9 1 0 9 0 0 0 0 1 RIZKA PRICILLA BTN PENGAWU BLOK C2/07 3 0 0 0 2 1 0 0 1 0 0 0
2022
23-February- 11-October-1973
70 AGUS PRIYANTO 7 2 7 1 0 3 5 1 1 0 7 3 0 0 0 2 NUR'ANDI BTN PENGAWU 082293131680 3 1 0 0 2 0 0 1 1 0 0 0
2022

71 01-March-2022 Rahmad 7 2 7 1 0 3 6 0 0 4 8 0 0 0 0 1 Avia 11-April-2000 Padanjakaya 3 1 0 0 2 1 0 0 1 0 0 0

08-February-
72 02-March-2022 Rahman 7 2 0 8 0 7 6 2 0 9 9 1 0 0 0 1 Yusri Padanjakaya 3 1 0 0 2 1 0 0 1 0 0 0
2001
08-October-1998
73 11-March-2022 Salim 7 2 0 8 1 9 4 8 1 0 9 8 0 0 0 1 OKtavia JL. Malontara 1 1 1 0 2 1 0 0 1 0 0 0

29-October-1990
74 17-March-2022 Moh. Indra 7 2 7 1 0 3 6 9 1 0 9 2 0 0 0 1 Riska BTN Pengawu 081242462676 3 1 0 0 2 1 0 0 1 0 0 0

75 24-March-2022 Deni Aprianto 7 2 7 1 0 1 5 8 0 6 8 1 0 0 0 6 Erni 18-June-1976 BTN Pengawu 085756619617 3 1 0 0 2 1 0 0 1 0 0 0

76 24-March-2022 Zamrud 7 2 7 1 0 3 7 0 0 5 7 7 0 0 0 1 Ramni 30-May-1977 Uvempemata 3 1 0 0 2 1 0 0 1 0 0 0

77 25-May-2022 Zamrud 7 2 7 1 0 3 7 0 0 5 7 7 0 0 0 1 Ramni 30-May-1977 Uvempemata 3 1 0 0 2 1 0 0 1 0 0 0

02-September-
78 07-July-2022 NURHOLIS 7 2 7 1 0 3 4 2 0 9 9 2 0 0 0 6 ITA MUSTIANI BTN PALUPI 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0
1992
12-December-
79 11-July-2022 AFANDI 7 2 7 1 0 5 5 2 1 2 8 9 0 0 0 1 DEWI JL. PADANJAKAYA 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0
1989

80 11-July-2022 AGUS 7 2 7 1 0 3 4 3 0 3 7 6 0 0 0 6 LATIFA 03-March-1974 JL. UWEMPEMATA 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

13-November-
81 11-July-2022 HASMA 7 2 7 1 0 3 5 3 1 1 0 0 0 0 0 6 ULFAJRA JL. RANGI NGAMAGI 0000000000000 1 1 1 0 2 1 0 0 1 0 0 0
2000
07-August-1977
82 19-July-2022 RUSADI 7 2 7 1 0 2 6 7 0 8 7 7 0 0 0 4 SUTARTI JL. BERINGIN 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

02-December-
83 21-July-2022 ADI PUTRA 7 2 7 1 0 2 0 2 1 2 0 2 0 0 0 1 FADLIA JL. MALONTARA 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0
2002

84 21-July-2022 YUSUP MOH.S 7 2 7 1 0 6 4 9 0 6 8 0 0 0 0 1 ERLIN 05-June-1980 JL. AGATIS 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

18-December-
85 27-July-2022 HASMAN 7 2 1 0 1 4 5 8 1 2 7 4 0 0 0 5 FAJRIANI JL. AKASIA 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0
1974
05-August-2022
86 MANTO 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WINDRIANI 16-July-2003 BTN PUSKUD 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

11-August-2022
87 BAHAR 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SURIANI 07-May-1987 JL. MALONTARA 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

11-August-2022
88 SUJONO 7 2 7 1 0 2 4 7 0 4 8 3 0 0 0 4 SITI AISYAH 01-April-1989 .JL. AGATIS 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

12-August-2022 05-November-
89 RINTO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 LIANATU S JL. AGATIS 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0
2003
12-August-2022 16-December-
90 RUDI 7 2 0 3 1 8 5 6 1 2 9 9 0 0 0 2 FITRIANI JL. MALONTARA 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0
1999
14-August-2022
91 MUIS HERMANSYAH 7 2 7 1 0 2 5 8 0 3 8 1 0 0 0 6 RATNA 18-March-1981 JL. AGATIS 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

14-August-2022
92 ZAMRUD 7 2 7 1 0 3 7 0 0 5 7 7 0 0 0 1 RANI 30-May-1977 JL. UWEMPEMATA 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

22-August-2022 06-October-1976
93 DAMUN 7 2 7 1 0 2 4 6 1 0 7 6 0 0 0 3 RODIAH JL. SERUT 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

23-August-2022 22-September-
94 SULTAN Z 7 2 7 1 0 2 6 3 0 9 9 6 0 0 0 3 YENI JL AGATIS 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0
1996
25-August-2022
95 TONO 7 2 7 1 0 3 6 7 0 7 8 2 0 0 0 1 NURPANDAN 04-July-1980 JL. PENGAWU 0000000000000 3 1 0 0 2 1 0 0 1 0 0 0

02-September- 07-January-2000
96 RUSTADI 7 2 0 8 0 7 4 7 0 1 0 0 0 0 0 2 MILEN FITRI JL. AGATIS 123456789990 3 1 0 0 2 1 0 0 1 0 0 0
2022
08-September- 06-December-
97 ISMAIL 7 2 7 1 0 3 4 5 1 2 9 1 0 0 0 1 FADILA JL. MALONTARA 12345678999 3 1 0 0 2 1 0 0 1 0 0 0
2022 1991
14-September- 01-August-1989
98 HUSMIN 7 2 7 1 0 8 4 1 0 8 8 9 0 0 0 1 SUKMA AYU JL. AGATIS 1234567890000 3 1 0 0 2 1 0 0 1 0 0 0
2022
14-September-
99 SUNARI 7 2 7 1 0 2 5 3 0 4 7 2 0 0 0 1 NGATEMI 13-April-1971 JL. AGATIS 123456789990 3 1 0 0 2 1 0 0 1 0 0 0
2022
17-September- 10-November-
100 BAGAS 7 2 7 1 0 3 7 0 0 6 9 9 0 0 0 3 SRI YUNITA JL. UWEMPEMATA 1234568899999 3 1 0 0 2 1 0 0 1 0 0 0
2022 1999
17-September- 10-December-
101 HAMID 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 IIN HUNTAP DUYU 1245789999999 3 1 0 0 2 1 0 0 1 0 0 0
2022 1993
29-September- 21-November-
102 SADAM 7 2 0 3 0 4 5 9 1 1 9 2 0 0 0 1 SITI KORIAH JL. GANOGO 1234567888888 3 1 0 0 2 1 0 0 1 0 0 0
2022 1990

103 02-April-2022 Agus 7 2 7 1 0 3 4 3 0 3 7 6 0 0 0 6 Latifa 03-March-1976 Uwempumata 3 1 0 0 3 1 0 0 1 0 0 0

 14-January-1989
104 07-April-2022 Hardin 7 3 0 7 0 5 4 4 0 1 8 9 0 0 0 3 Andi wana BTN Pengawu 1 1 1 0 3 1 0 0 1 0 0 0

105 22-April-2022 Daman 7 2 7 1 0 2 4 6 1 0 7 6 0 0 0 3 Rodiah 24-June-1976 Jl. Beringin 081524774274 3 1 0 0 3 1 0 0 1 0 0 0

106 22-April-2022 Fendi 7 2 0 3 0 3 6 7 0 9 9 8 0 0 0 1 Hariyanti 06-July-1999 Jl. Beringin 082197406306 3 1 0 0 3 1 0 0 1 0 0 0

06-December-
107 23-April-2022 Ismail 7 2 7 1 0 3 9 5 1 2 9 1 0 0 0 1 Fadila Jl. Malontara 082271511385 3 1 0 0 3 1 0 0 1 0 0 0
1991

108 25-April-2022 Hakim 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Kartini 25-April-1987 Padanjakaya 1 1 1 0 3 1 0 0 1 0 0 0

109 26-April-2022 Suadin 7 2 7 1 0 2 4 5 0 5 8 9 0 0 0 4 Sri Nurfianti 03-May-1989 Jl. Malontara Pengawu 082347318289 1 1 1 0 3 1 0 0 1 0 0 0

11-August-1989
110 28-April-2022 Riswan 7 2 7 1 0 8 4 1 0 8 8 9 0 0 0 1 Sukma Ayu Jl. Agatis 1 1 1 0 3 1 0 0 1 0 0 0

111 28-April-2022 Sunadi 7 2 7 1 0 2 5 3 0 4 7 2 0 0 0 1 Ngateni 13-April-1971 Jl. Agatis 3 1 0 0 3 1 0 0 1 0 0 0

112 29-April-2022 Andi 7 2 7 1 0 6 4 9 0 6 8 0 0 0 0 1 Erlin 05-June-1980 Jl. Agatis 3 1 0 0 3 1 0 0 1 0 0 0

113 29-April-2022 Faiz 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Nurintan 01-July-1980 Jl. Padanjakaya 3 1 0 0 3 1 0 0 1 0 0 0

114 17-May-2022 Abd, Kadir 7 2 7 1 0 3 4 1 0 7 7 5 0 0 0 4 Nuralang 07-July-1975 Palupi Permai 2 1 0 0 3 1 0 0 1 0 0 0

115 20-May-2022 Bahar 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Suriani 07-May-1989 Jl. Malontara Pengawu 3 1 0 0 3 1 0 0 1 0 0 0

11-November-
116 23-May-2022 Muh. Syafaat 7 2 1 0 0 2 5 1 1 8 9 0 0 0 0 5 Warni BTN Pengawu 1 1 0 0 3 1 0 0 1 0 0 0
1989
27-February-
117 23-May-2022 Reski 7 2 0 3 0 6 6 7 0 2 2 9 0 0 0 1 Ratna Nurhayati Darma Purba 1 1 1 0 3 1 0 0 1 0 0 0
1999

118 23-May-2022 Rudi 7 2 7 1 0 2 5 8 0 3 8 1 0 0 0 6 Ratna Nurhayati 18-March-1981 Jl. Agatis 3 1 0 0 3 1 0 0 1 0 0 0

119 02-June-2022 Rahman 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Alita 01-July-1991 BTN Palupi 3 1 0 0 3 1 0 0 1 0 0 0

29-December-
120 02-June-2022 Rustadi 7 2 0 8 0 7 4 7 0 1 0 0 0 0 0 2 Milan Fitri Jl Agatis 3 1 0 0 3 1 0 0 1 0 0 0
1990

121 03-June-2022 Novianto 7 2 7 1 0 3 4 5 0 4 9 6 0 0 0 3 Norma 15-April-1996 BTN Palupi 1 1 1 0 3 1 0 0 1 0 0 0

08-February-
122 10-June-2022 Tanhar 7 2 7 1 0 6 4 8 0 2 9 1 0 0 0 1 Asriani Jl. Malontara Pengawu 3 1 0 0 3 1 0 0 1 0 0 0
1991
18-October-1981
123 20-June-2022 Abdul 7 2 7 1 0 3 4 8 1 0 8 1 0 0 0 3 Mashiani BTN Palupi 1 1 1 0 3 1 0 0 1 0 0 0

01-August-1989
124 20-June-2022 Rusmin 7 2 7 1 0 8 4 1 0 8 8 9 0 0 0 1 Sukma Jl Beringin 3 1 0 0 3 1 0 0 1 0 0 0

125 20-June-2022 Sunadi 7 2 7 1 0 2 5 3 0 4 7 2 0 0 0 1 Ngatemi 13-April-1971 Jl. Agatis 3 1 0 0 3 1 0 0 1 0 0 0

02-November-
126 27-June-2022 Muh. Toha 7 2 7 1 0 3 6 0 0 1 8 9 0 0 0 1 Silvana Jl. Malontara Pengawu 3 1 0 0 3 1 0 0 1 0 0 0
1989
23-August-1996
127 28-June-2022 Risman 7 2 7 1 0 6 6 3 0 8 9 6 0 0 0 1 Sri Dewi Jl. Lekatu 3 1 0 0 3 1 0 0 1 0 0 0

08-February-
128 28-June-2022 Supriyanto 7 2 1 0 1 2 4 6 0 2 9 5 0 0 0 1 Defi Irma Jl. Dewi Sartika 3 1 0 0 3 1 0 0 1 0 0 0
1995

129 28-June-2022 Tasdim 9 1 7 1 0 2 5 2 0 6 9 3 0 0 0 5 Mardiana 12-June-1992 Jl. Lelemina 1 1 1 0 3 1 0 0 1 0 0 0

130 28-June-2022 Yuda 7 2 7 1 0 3 6 3 0 5 9 2 0 0 0 2 Oubin Wulan 23-May-1992 Kalukubula 1 1 1 0 3 1 0 0 1 0 0 0

131 29-July-2022 SLAMET R 7 2 0 4 0 1 4 7 0 7 9 4 0 0 0 1 FITRIANI 04-June-1994 JL. PADANJAKAYA 0000000000000 1 1 1 0 3 1 0 0 1 0 0 0

01-September- 25-September-
132 HADI 7 2 7 1 0 1 6 5 0 9 8 9 0 0 0 1 EHYANDITA JL. BUKIT SIRA 1234567899 1 1 1 0 3 1 0 0 1 0 0 0
2022 1989
18-December-
133 06-June-2022 Kasmanb 7 2 1 0 1 4 5 8 1 2 7 4 0 0 0 3 Fajriani Jl. Akasia 3 0 0 0 4 1 0 0 1 0 0 0
1974
06-December-
134 16-June-2022 Ismail 7 2 7 1 0 3 4 5 1 2 9 1 0 0 0 1 Fadila Jl. Malontara Pengawu 3 0 0 0 4 1 0 0 1 0 0 0
1991

135 18-June-2022 Rahman 7 2 7 1 0 3 6 7 0 9 9 8 0 0 0 1 Haliyanti 03-June-1999 Jl. Agatis 3 0 0 0 4 1 0 0 1 0 0 0

14-August-1994
136 01-March-2022 MOHAMMAD RIZAL 7 2 7 1 0 3 5 4 0 8 9 4 0 0 0 3 SITTI MA'ARIFAH BTN PENGAWU BLOK C3/31 1 0 1 0 5 1 0 0 1 0 0 0

08-August-1986
137 02-March-2022 Ahmad 7 2 0 8 0 7 4 8 0 8 8 6 0 0 0 3 Saromiyah Limgkar Stadion 1 0 1 0 5 1 0 0 1 0 0 0

138 02-March-2022 Salim 7 2 0 8 0 1 5 7 0 4 9 6 0 0 0 1 Rani. DR 17-April-1996 BTN Pengawu 1 0 1 0 5 1 0 0 1 0 0 0

139 05-March-2022 Taufik 7 2 7 1 0 3 5 5 0 7 9 5 0 0 0 9 Hikmawati 15-July-1995 Jl. Malontara 081393600626 3 0 0 0 5 1 0 0 1 0 0 0

140 11-March-2022 Hidayat 7 2 7 1 0 3 7 1 0 8 9 4 0 0 0 5 Nur Aeni 03-July-1989 Jl. Jati 1 0 1 0 5 1 0 0 1 0 0 0

141 14-March-2022 Salim 7 2 7 1 0 2 5 2 0 4 4 6 0 0 0 3 REVI 13-April-1996 Jl. Anoa 1 0 0 0 5 1 0 0 1 0 0 0

142 01-April-2022 Nuscholil 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Ita Mustimin 01-July-1988 BTN Palupi 1 0 1 0 1 0 0 1 0 0 0

143 14-April-2022 Muh. Ikbal 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Rusdiana 01-July-1990 Jl. Puebongo 1 0 0 0 1 0 0 1 0 0 0

144 14-April-2022 Muh. Ramli 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Yulianti 01-July-1987 Kampung Tengah Pengawu 1 0 1 0 1 0 0 1 0 0 0

145 14-April-2022 Ruslan 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Rahmayunita 01-July-1980 Lekatu Pengawu 1 0 1 0 1 0 0 1 0 0 0

146 19-April-2022 Aliyus 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Eka Ainun 01-July-1990 Tavanjuka 1 0 1 0 1 0 0 1 0 0 0

147 23-May-2022 Muh. Rafi 7 2 7 1 0 3 4 1 0 7 0 2 0 0 0 1 Reka.W 18-March-2002 Uwepemata 1 0 1 0 5 1 0 0 1 0 0 0

148 14-June-2022 Rusdin 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Rahma 03-July-1989 Jl. Malontara Pengawu 3 0 0 0 5 1 0 0 1 0 0 0

149 14-June-2022 Saiful 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Ellen 20-July-1984 Pengawu 3 0 0 0 5 1 0 0 1 0 0 0

10-December-
150 14-June-2022 Samsul 7 2 7 1 0 3 6 0 1 2 9 2 0 0 0 2 Elvia Jl. Malontara Pengawu 3 0 0 0 5 1 0 0 1 0 0 0
1992

151 14-June-2022 Tamrin 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Nurhanjayani 01-July-1987 Jl. Padanjakaya 3 0 0 0 5 1 0 0 1 0 0 0

22-September-
152 28-June-2022 David 7 2 7 1 0 3 6 2 0 9 8 4 0 0 0 7 Nurmin Jl. Lafata 1 0 1 0 5 1 0 0 1 0 0 0
1984

153 26-July-2022 SLAMET R 7 2 0 4 0 1 4 7 0 7 9 4 0 0 0 1 FITRIANI 06-May-1994 JL. PADANJAKAYA 0000000000000 1 0 1 0 5 1 0 0 1 0 0 0

10-September-
154 WAWAN 7 2 0 3 2 4 6 7 0 3 9 1 0 0 0 1 SITI RAHMA 27-March-1991 BTN BANUA GAYA 12345678999 1 0 1 0 5 1 0 0 1 0 0 0
2022
14-September-
155 ANDI ARDIANSYAH 7 2 7 1 0 1 5 0 0 4 0 2 0 0 0 4 AISAH NURUL 10-April-2002 BTN PUSKUD 1234567888 1 0 1 0 5 1 0 0 1 0 0 0
2022
04-August-2022 15-August-2000
156 ARIFAL 7 2 7 1 0 3 6 3 0 1 9 4 0 0 0 6 ZULFAH DIANTI JL. MALONTARA 0000000000000 1 0 0 0 6 1 0 0 1 0 0 0

26-September- 02-January-1991
157 ARFAN 7 2 7 1 0 2 4 2 0 1 9 1 0 0 0 6 RIRI INDRAWATI JL. PADANJAKAYA 1234567899999 3 0 0 0 6 1 0 0 1 0 0 0
2022
01-January-2022 01-December-
158 ASNAD 7 2 0 8 1 0 4 7 1 1 9 4 0 0 0 1 NORMA YUNITA JL. GAWALISE 1 1 1 0 8 1 0 0 1 0 0 0
1994
01-January-2022 29-February-
159 DEDI SUTRISNO 7 2 7 1 0 3 6 9 0 2 9 2 0 0 0 7 HETY HERAWATY MALONTARA 1 1 1 0 8 1 0 0 1 0 0 0
1992
01-January-2022 11-December-
160 VERI 7 2 7 1 0 3 5 1 1 2 8 9 0 0 0 3 SUYATNI JL. MALONTARA 1 1 1 0 8 1 0 0 1 0 0 0
1989
15-January-2022 09-December-
161 BUDIANTO 7 2 0 8 0 7 4 9 1 2 9 4 0 0 0 3 WIRASANTI BTN PALUPI 085242009109 1 1 1 0 8 1 0 0 1 0 0 0
1994
15-January-2022
162 YUDI KAIFAR 7 2 1 0 1 4 5 8 0 7 9 2 0 0 0 1 SUHARNI 18-July-1992 MALONTARA 1 1 1 0 8 1 0 0 1 0 0 0

22-January-2022
163 ARDIANSYAH 7 2 7 1 0 3 4 9 0 6 9 8 0 0 0 5 SRI WAHYUNI 09-June-1998 JL. MALONTARA 082290411426 1 1 1 0 8 1 0 0 1 0 0 0

22-January-2022 30-December-
164 SAMSURI 7 2 7 1 0 3 7 0 1 2 8 8 0 0 0 4 SITI AMINA PERUMAHAN TK 3 1 0 0 8 1 0 0 1 0 0 0
1988
01-February- 10-October-2003
165 FAKIMUKTI 7 2 7 1 0 3 5 0 1 0 0 3 0 0 0 3 NADIRA MALONTARA 1 1 1 0 8 0 1 0 1 0 0 0
2022
01-February- 02-February-
166 IBNU 7 2 7 1 0 2 6 0 0 2 0 0 0 0 0 1 YASMIN JL. DELIMA 1 1 1 0 8 0 0 1 1 0 0 0
2022 2000

167 24-March-2022 Ediyanto 7 2 7 1 0 2 5 7 0 3 8 4 0 0 0 5 Partina 17-March-1984 cemangi 1 1 1 0 8 1 0 0 1 0 0 0

168 24-March-2022 Nur Solihin 7 2 0 8 1 2 4 2 0 4 0 0 0 0 0 1 Sundari 02-April-2000 Malontara 085656283768 1 1 1 0 8 1 0 0 1 0 0 0

20-November-
169 02-July-2022 PUTU SUDI 7 2 0 4 0 6 6 0 1 1 9 8 0 0 0 1 WAYAN SUDI JL. TOWUA 0000000000000 1 1 1 0 8 1 0 0 1 0 0 0
1998
26-August-2022 02-February-
170 HADIYATNUR 7 2 7 1 0 3 4 2 0 2 8 8 0 0 0 7 RENI JL. PADANJAKAYA 0000000000000 1 1 1 0 8 1 0 0 1 0 0 0
1988
30-September- 04-December-
171 INAL 7 2 1 0 0 9 4 4 1 2 9 7 0 0 0 1 NURJANNAH JL. UWEMPEMATA 1234567899999 1 1 1 0 8 1 0 0 1 0 0 0
2022 1997
01-January-2022
172 MOHAMAD YASIN 7 2 7 1 0 3 4 8 0 7 9 3 0 0 0 4 RINI 06-June-1993 JL. MALONTARA 1 1 1 0 9 1 0 0 1 0 0 0

03-January-2022
173 UMAR YUNUS 7 2 7 1 0 3 4 2 0 5 7 7 0 0 0 4 FEMY LAGINTA 02-May-1974 BTN PENGAWU BLOK K2/04 1 1 1 0 9 1 0 0 1 0 0 0

06-January-2022 14-December-
174 SUHENDRA 7 2 7 1 0 3 5 4 1 2 9 6 0 0 0 2 ISNENI TRIANA JALAN LEKATU 3 1 0 0 9 1 0 0 1 0 0 0
1996
06-January-2022
175 WAHYUDIN 7 2 7 1 0 3 6 5 0 4 9 6 0 0 0 8 APRIYANTI 26-April-1996 JL. MALONTARA 1 1 1 0 9 1 0 0 1 0 0 0

08-January-2022 02-December-
176 MUH. SALENG 7 3 1 4 0 1 4 2 1 2 8 2 0 0 0 1 ARLINA JL I GUSTI NGURARAI 1 1 1 0 9 1 0 0 1 0 0 0
1982
08-January-2022
177 WAWAN 7 2 7 1 0 3 5 8 0 3 8 3 0 0 0 4 MARLINA 18-March-1983 JL. MALONTARA 082221119435 1 1 1 0 9 1 0 0 1 0 0 0

10-January-2022 11-August-1993
178 IMAD 7 2 7 1 0 1 7 1 0 8 9 3 0 0 0 3 NURWITRI JL SRIWIJAYA 085241484368 1 1 1 0 9 1 0 0 1 0 0 0

15-January-2022 05-September-
179 GILANG 7 2 7 1 0 2 4 5 0 9 9 5 0 0 0 3 BUNGA UTRAJJAN N JALAN. JATI. LRG II 085256246481 1 1 1 0 9 1 0 0 1 0 0 0
1995
 15-January-2022 23-August-1997
180 MOH.SAPRUN 7 2 7 1 0 3 6 3 0 8 9 7 0 0 0 4 CAHYA AMALIA JALAN LEKATU 1 1 1 0 9 1 0 0 1 0 0 0

17-January-2022 24-November-
181 MOH ZADLY 7 2 7 1 0 3 6 4 1 1 9 2 0 0 0 6 FERLINI JL. BASUKI RAHMAD 1 1 1 0 9 1 0 0 1 0 0 0
1992
18-January-2022 14-November-
182 MOH. IKBAL 7 2 7 1 0 3 5 4 1 1 8 9 0 0 0 1 NUR FITA SARI JL. UWEMPEMATA 1 1 1 0 9 1 0 0 1 0 0 0
1989
18-January-2022 30-October-1995
183 RAFZAN 7 2 0 9 0 5 7 0 1 0 9 4 0 0 0 4 WIDYW. A.F JL. BERINGIN BOYAOGE 1 1 1 0 9 1 0 0 1 0 0 0

20-January-2022 16-September-
184 ABD. RAHMAN 7 2 1 5 1 1 5 6 0 9 9 4 0 0 0 3 IIN HANDAYANI JL. TOMBOLOTUTU 1 1 1 0 9 1 0 0 1 0 0 0
1994
20-January-2022 28-September-
185 IRLAN 7 2 7 1 0 3 6 8 0 9 7 3 0 0 0 2 NIRMALA JL. WOMPEWATA 1 1 1 0 9 1 0 0 1 0 0 0
1973
24-January-2022 13-December-
186 AMIGA 3 6 0 2 1 4 5 3 1 2 9 8 0 0 0 1 SINDI HIDAYATI BTN PENGAWU INDAH 2 1 0 0 9 1 0 0 1 0 0 0
1998
24-January-2022 30-October-1986
187 KHAERUDIN 7 2 0 3 1 4 7 0 1 0 8 6 0 0 0 1 FATIMAH BTN PENGAWU BLOK B4 1 1 1 0 9 1 0 0 1 0 0 0

27-January-2022 14-January-1990
188 NIRWAN 7 2 0 3 1 2 4 1 0 7 8 8 0 2 2 0 ARIANA BTN PALUPI PUSKUD 1 1 1 0 9 1 0 0 1 0 0 0

29-January-2022 20-October-2000
189 WILDAN 7 2 7 1 0 3 6 0 1 0 0 0 0 0 0 8 SARINA BTN PENGAWU 1 1 1 0 9 1 0 0 1 0 0 0

01-February- 23-December-
190 JUFRI SAHE 7 2 7 1 0 3 6 3 1 2 7 9 0 0 0 4 SRI DEWI GANI BTN PALUPI 1 1 1 0 9 0 1 0 1 0 0 0
2022 1979
04-February- 01-November-
191 FARID 7 2 7 1 0 3 4 1 1 1 8 0 0 0 0 1 LINA NOVITA JL. UVEMPENATA 1 1 1 0 9 1 0 0 1 0 0 0
2022 1980
11-February- 07-November-
192 HERMAN 7 2 7 1 0 2 6 0 0 6 9 4 0 0 0 1 MARLINA JL MALONTARA 082217397623 1 1 1 0 9 1 0 0 1 0 0 0
2022 1994
11-February- 22-September-
193 RIDWAN 7 2 0 8 0 7 6 2 0 9 9 1 0 0 0 1 MASMIDA JL. KERAMIK 082246443619 1 1 1 0 9 1 0 0 1 0 0 0
2022 1991
15-February- 13-August-1996
194 RIDWAN 7 2 7 1 0 3 5 3 0 8 9 6 0 0 0 1 SUCI JL. PUE BONGO 1 1 1 0 9 1 0 0 1 0 0 0
2022
16-February-
195 MUH. ASDIR 7 2 7 1 0 3 5 8 0 7 8 9 0 0 0 7 EMI AMIRA 08-July-1989 BTN PENGAWU 1 1 1 0 9 1 0 0 1 0 0 0
2022
24-February- 27-August-2002
196 AMIR 7 2 0 8 0 1 6 7 0 8 0 2 0 0 0 2 INDAH PRISILIA JL. LEKATU 1 1 1 0 9 1 0 0 1 0 0 0
2022
24-February- 14-December-
197 SUHENDRA 7 2 7 1 0 3 5 4 1 2 9 6 0 0 0 2 ISNENI TRIANA JL LEKATU 082243975443 2 1 0 0 9 1 0 0 1 0 0 0
2022 1996
25-February-
198 SAFRUDIN 7 2 7 1 0 3 6 7 0 5 8 4 0 0 0 3 DINAR 27-June-1984 PENGAWU 2 1 0 0 9 1 0 0 1 0 0 0
2022
25-February- 27-December-
199 SUPIANTO 7 2 7 1 0 3 6 7 1 2 0 2 0 0 0 5 JIHAN TAVANJUKA 1 1 1 0 9 1 0 0 1 0 0 0
2022 2002

200 02-March-2022 Didik Priyanto 7 2 7 1 0 3 6 1 0 5 8 8 0 0 0 5 Indah Suciati 21-May-1988 BTN Pengawu 081341122799 1 1 1 0 9 1 0 0 1 0 0 0

14-September-
201 05-March-2022 MOH. Renaldi 7 2 7 1 0 2 5 4 0 9 9 3 0 0 0 2 Atika BTN Pengawu 082217772868 1 1 1 0 9 1 0 0 1 0 0 0
1993

202 10-March-2022 Indra 7 2 0 7 0 4 6 8 0 3 8 9 0 0 0 1 ASTIN 28-March-1989 Uvempemata 1 1 1 0 9 1 0 0 1 0 0 0

14-September-
203 16-March-2022 Moh. Ronal 7 2 7 1 0 3 5 4 0 9 9 9 0 0 0 2 Dewi Malontara 1 1 1 0 9 1 0 0 1 0 0 0
1999

204 18-March-2022 Rizal 7 2 7 1 0 3 4 5 0 3 9 3 0 0 0 1 Elvira 05-March-1993 Padanjakaya 082348245170 1 1 1 0 9 1 0 0 1 0 0 0

31-January-1970
205 19-March-2022 Rahmad 7 2 7 1 0 6 7 1 0 1 7 0 0 0 0 1 Erna Hose Bundaran Palupi 081341108972 2 1 0 0 9 1 0 0 1 0 0 0

02-December-
206 02-April-2022 muh. Saleh 7 3 1 4 0 1 4 2 1 2 8 2 0 0 0 1 Arlina Jl. I. Gusti Ngurarai 3 1 0 0 9 1 0 0 1 0 0 0
1982
30-October-1985
207 16-April-2022 Umar Daud 7 2 7 1 0 3 7 0 1 0 8 5 0 0 0 6 Hestin BTN Bukui Siu Duyu 1 1 1 0 9 1 0 0 1 0 0 0

23-November-
208 19-April-2022 Arjun 7 2 2 1 0 3 6 3 1 1 9 7 0 0 0 1 Nova Darma Putra 3 1 0 0 9 1 0 0 1 0 0 0
1997

209 19-April-2022 Sadam 7 2 0 3 1 2 4 8 0 5 9 3 0 0 0 4 Santi 18-May-1993 Jl. Wahid Hasim 3 1 0 0 9 1 0 0 1 0 0 0

12-December-
210 28-April-2022 Budiyono 7 2 0 3 0 6 5 2 1 2 9 2 0 0 0 4 Wiwik BTN Palupi 082293341909 1 1 1 0 9 1 0 0 1 0 0 0
1992
31-January-1985
211 28-April-2022 Risapah 7 2 0 3 0 6 7 1 0 1 8 5 0 0 0 1 Munifah BTN Palupi 082238240259 1 1 1 0 9 1 0 0 1 0 0 0

212 28-April-2022 Saifullah 7 2 0 4 0 1 4 7 0 3 0 0 0 0 0 1 Fitriani 07-March-2000 Jl. Malontara Pengawu 1 1 1 0 9 1 0 0 1 0 0 0

213 28-April-2022 Taufik 7 6 0 2 1 4 4 1 0 4 8 5 0 0 0 1 Mardiana 01-April-1985 Jl. Padanjakaya 1 1 1 0 9 1 0 0 1 0 0 0

23-November-
214 10-May-2022 Arjan 7 2 7 1 0 3 6 3 1 1 9 7 0 0 0 1 Nova Darma Pura 2 1 0 0 9 1 0 0 1 0 0 0
1997
03-September-
215 14-May-2022 Abd. Rahim 7 3 2 2 0 6 4 3 0 9 9 3 0 0 0 5 Hastianti Keramik 1 1 0 0 9 1 0 0 1 0 0 0
1993

216 18-May-2022 Muh. Fadli 7 2 7 1 0 3 4 7 0 4 9 8 0 0 0 1 Klara Sinta 07-April-1998 Padanjakaya 1 1 1 0 9 1 0 0 1 0 0 0

06-October-1984
217 18-May-2022 Wahyudi 6 3 0 3 0 3 4 6 1 0 8 4 0 0 0 5 Nurmala BTN Pengawu 2 1 0 0 9 1 0 0 1 0 0 0
218 25-May-2022 Abd. Azis 7 2 7 1 0 1 5 8 0 6 8 1 0 0 0 6 Erni 16-June-1976 BTN Pengawu 2 1 0 0 9 1 0 0 1 0 0 0

15-November-
219 25-May-2022 Ipang 7 2 0 5 1 3 5 5 1 1 8 7 0 0 0 1 Yulianti Padanjakaya 1 1 1 0 9 1 0 0 1 0 0 0
1987
19-December-
220 02-June-2022 Ikbal 7 2 7 1 0 3 6 9 1 2 9 0 0 0 0 1 Fikrawati jl maleo 3 1 0 0 9 1 0 0 1 0 0 0
1990

221 20-June-2022 Ainul 7 2 7 1 0 3 5 1 0 6 9 2 0 0 0 3 Alingga 11-June-1992 BTN Puskud 1 1 1 0 9 1 0 0 1 0 0 0

222 20-June-2022 Dodi Prawira 7 2 7 1 0 6 5 0 0 4 9 0 0 0 0 1 Widya 10-April-1996 BTN Palupi 1 1 1 0 9 1 0 0 1 0 0 0

24-September-
223 20-June-2022 Fahrudin 7 2 0 4 0 7 6 4 0 9 9 1 0 0 0 6 Dian Safitri BTN Palupi 3 1 0 0 9 1 0 0 1 0 0 0
1991

224 20-June-2022 Frengki 7 2 7 1 0 3 4 2 0 3 8 0 0 0 0 1 Nur Intan 02-March-1980 Padanjakaya 3 1 0 0 9 1 0 0 1 0 0 0

07-December-
225 20-June-2022 Imran 7 2 7 1 0 6 4 7 1 2 9 2 0 0 0 1 Nurlia Jati Baru 1 1 1 0 9 1 0 0 1 0 0 0
1992
01-November-
226 20-June-2022 Khaerul 7 2 7 1 0 6 4 1 1 1 9 1 0 0 0 1 Fitria Tavanjuka 1 1 1 0 9 1 0 0 1 0 0 0
1991
16-August-1985
227 20-June-2022 Nanang 7 2 7 1 0 3 5 6 0 8 8 5 0 0 0 6 Rohani Jl. Jati Baru 1 1 0 0 9 1 0 0 1 0 0 0

18-October-1993
228 20-June-2022 Ranti 7 2 7 1 0 3 4 8 1 0 9 3 0 0 0 7 Novi kurnia sari Perumnas 1 1 1 0 9 1 0 0 1 0 0 0

22-September-
229 30-June-2022 Sultan Zukifli 7 2 7 1 0 2 6 3 0 9 9 6 0 0 0 3 Yeni Jl. Agatis 1 1 1 0 9 1 0 0 1 0 0 0
1996

230 08-July-2022 HALIM 6 4 7 4 0 1 5 5 0 5 9 5 0 0 0 5 AYU RATNASRI 15-May-1995 JL. PUEBONGO 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

23-January-2001
231 13-July-2022 ILHAM K 7 2 7 1 0 6 6 3 0 1 0 1 0 0 0 1 RIRIN SABRINA JL. PADANJAKAYA 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

27-December-
232 19-July-2022 ALWI AHMDA 6 1 7 1 0 6 6 7 1 2 8 3 0 0 0 1 SYARIFAH JL. LEKATU 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0
1983

233 19-July-2022 ANANJAYA 7 2 1 0 1 4 4 2 0 5 8 4 0 0 0 4 RAHMI 02-May-1984 BTN BANUA GAYA 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

234 23-July-2022 IDAM KHALID 7 2 7 1 0 3 4 5 0 6 9 7 0 0 0 1 SRI WAHYUNI 05-June-1997 BTN PENGAWU 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

235 28-July-2022 OKTAVIANUS 7 2 7 1 0 1 5 1 0 6 9 7 0 0 0 2 INDRIYANI 11-June-1997 BTN PALUPI 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

28-October-1993
236 29-July-2022 FADLAH AHMAD 7 2 0 4 0 2 4 7 0 7 9 4 0 0 0 1 INDRIWATI JL. AGATIS 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

237 29-July-2022 RIKI GUNAWAN 7 3 7 1 1 0 4 2 0 5 8 3 0 0 0 3 SURAHMI 02-May-1983 JL. PADANJAKAYA 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

01-August-2022 02-August-1994
238 HAMID 7 2 0 8 1 4 4 2 0 8 9 4 0 0 0 1 UMAIRA BTN PALUPI 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

02-August-2022
239 ANJAS 7 2 7 1 0 3 6 1 0 4 8 4 0 0 1 4 RAODA 21-April-1984 JL. LEKATU 2 1 0 0 9 1 0 0 1 0 0 0

04-August-2022
240 BAHTIAR 6 4 7 1 0 5 6 2 0 3 8 7 0 0 0 1 SUMIATI 22-March-1987 JL. PUEBONGO 0000000000000 2 1 0 0 9 1 0 0 1 0 0 0

25-August-2022 31-August-1994
241 JUMRIN 7 2 7 1 0 3 7 1 0 8 9 4 0 0 0 5 NURAINUN JL. LEKATU 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0

05-September-
242 DWI MEGA 7 2 7 1 0 3 4 4 0 4 9 2 0 0 0 8 FITRIANI 04-April-1992 JL. LEKATU 1234567890 1 1 1 0 9 1 0 0 1 0 0 0
2022

1) Keterangan Kode

STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi

2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA CENTANG (V)
1. Petugas Entri Lamp.R/I/KB/20
Data LAMPIRAN R/I/KB/20 Lembar 8

1 2 3 4 5 6
7 2 7 1 0 1 2 Bulan : 2022
NAMA FASKES/ PUSKESMAS NOSARARA 7 8 V 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

RINGKASAN HASIL PELAYANAN KB

PESERTA KB BARU (PB) PESERTA KB ULANGAN PELAYANAN KASUS

PEMBERIAN
PEMBERIAN INFORMED PB DAN KESERTAAN JKN INFORMED CONSENT
METODE
NO. CONSENT (Untuk Peserta KB
KONTRASEPSI
(Untuk PB) PB PASCA PB PASCA Ulangan) PELAYANAN ULANG KOMPLIKASI BERAT
GANTI CARA PENCABUTAN KEGAGALAN
PERSALINAN KEGUGURAN
PB JKN PB NON JKN TOTAL PB

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
2 IUD 0 0 0 0 0 0 1 1 0 0 0 0
3 IUD 1 1 0 1 1 0 0 0 0 0 0 0
4 IUD 0 0 0 0 0 0 1 1 0 0 0 0
5 SUNTIKAN 1 1 0 1 1 0 0 0 0 0 0 0
6 IUD 0 0 0 0 0 0 1 1 0 0 0 0
7 IUD 1 1 0 1 1 0 0 0 0 0 0 0
8 SUNTIKAN 1 1 0 1 1 0 0 0 0 0 0 0
9 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
10 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
11 IUD 1 1 0 1 1 0 0 0 0 0 0 0
12 SUNTIKAN 1 1 0 1 1 0 0 0 0 0 0 0
13 IUD 1 1 0 1 1 0 0 0 0 0 0 0
14 IUD 1 1 0 1 1 0 0 0 0 0 0 0
15 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
16 IUD 0 0 0 0 0 0 1 0 1 0 0 0
17 IUD 1 1 0 1 1 0 0 0 0 0 0 0
18 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
19 SUNTIKAN 1 1 0 1 1 0 0 0 0 0 0 0
20 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
21 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
22 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0

JUMLAH 98 111 2 113 107 0 117 11 117 0 0 0

Kota Palu , 30-September-2022

Pimpinan Faskes KB/Jaringan/Jejaring*

ASRIATI, Amd. Keb

( .................................................................................................)
197008281992032008

NIP/NRP
* Coret yang tidak perlu