SASARAN

PENCATATAN IMUNISASI RUTIN BAYI / BALITA DI UNIT PELAYANAN
NAMA UNIT PELAYANAN KESEHATAN : POSYANDU TEDUH

DESA / KELURAHAN : CAMPOR 2
PUSKESMAS : PANAGUAN
BULAN / TAHUN : OKTOBER 2021
TANGGAL IMUNISASI
NO NAMA BAYI L/P TGL LAHIR NAMA ORTU ALAMAT DPT + HB - Hib
HB 0 (<24 Jam) BCG POL 1 POL 2 DPT - HB Hib (2) POL 3 DPT - HB Hib (3) POL 4 IPV MR DPT-HB HIB(4) MR(2)
(1)
1 2 3 4 5 6 7 8 9 10 11 12 14 15 17 21 22 23 24
1 HARIROH P 7/12/2020 NAWARIYEH / BAIDOWI ANGSANAH 7/12/2020 10/10/2020 10/10/2020 11/16/2020 11/16/2020 3/8/2021 3/8/2021 8/9/2021 8/9/2021 8/14/2021 9/16/2021
2 SABILATUL JANNAH P 9/2/2021 RIZQIYAH / BASORI ANGSANAH 9/2/2021 2/8/2021 2/8/2021 3/8/2021 3/8/2021 8/9/2021 8/9/2021
3 FATIMAH AZ-ZAHRA P 9/9/2020 HOLILA ANGSANAH 9/9/2020 2/8/2021 2/8/2021 3/8/2021 3/8/2021 8/9/2021 8/9/2021
4 NIZAM AL AYYUBI L 10/19/2020 RINA ANGSANAH 10/19/2020 2/8/2021 2/8/2021 3/8/2021 3/8/2021 8/9/2021 8/9/2021
5 AKROM ZAIDAN L 10/26/2020 NURYAMAH ANGSANAH 10/26/2020 2/8/2021 2/8/2021 3/8/2021 3/8/2021
6 FELIYANA MAULIDINA P 11/26/2020 ROMLAH ANGSANAH 11/26/2020 2/8/2021 2/8/2021 3/8/2021 3/8/2021
7 SALMAN AL FARISI L 12/29/2020 ANISA ANGSANAH 12/29/2020 2/8/2021 2/8/2021 3/8/2021 3/8/2021
8 AUNATULLAH UZHMA P 1/18/2021 HAYATUN ANGSANAH 1/18/2021 2/8/2021 2/8/2021
9 MOH ADAM R L 1/31/2021 MAGHFIROH ANGSANAH 1/31/2021 8/9/2021 8/9/2021
10 SITI KHUMAIROH P 2/10/2021 RUQOYYAH ANGSANAH 2/10/2021 8/9/2021 8/9/2021
11 RAFKA ARSHA L 4/28/2021 FATIM ANGSANAH 4/28/2021 8/9/2021 8/9/2021
12 FATIMAH AZ ZAHRA P 5/4/2021 NURHASANAH / HOLIK ANGSANAH 5/4/2021 8/9/2021 8/9/2021
13 P 6/5/2021 SLAMI ANGSANAH 8/9/2021 8/9/2021
14
15
16
17
18
Pembina desa
HALIMATUS SAKDIYAH
NAMA UNIT PELAYANAN KESEHATAN : POSYANDU SEJUK

TANGGAL IMUNISASI
<24 JAM BCG POL 1 POL 2 DPT - HB Hib (2) POL 3 DPT - HB Hib (3) POL 4 IPV MR DPT-HB HIB(4) MR(2)
(1)
1 2 3 4 5 6 7 8 9 10 11 12 14 15 17 21 22 23 24
2 M ALFARIZI L 4/27/2020 FAIZAH CENTREN 4/27/2020 3/9/2021
3 ALFIATUS SOLIHAH P 6/26/2020 ROMLAH CENTREN 6/26/2020 3/9/2021 3/9/2021 6/15/2021 6/15/2021
4 SAFAR MAULANA L 6/27/2020 JUMA'ATI CENTREN 6/27/2020 3/9/2021 3/9/2021 6/15/2021 6/15/2021
5 RUMAISYAH IBATUL ANAM P 10/27/2020 NITA SUGIARTI CENTREN 10/27/2020 3/9/2021 3/9/2021 8/10/2021 8/10/2021 9/14/2021 9/14/2021
6 SYAFINATUS ZAHRA P 11/28/2020 HAYATUN CENTREN 11/28/2020 3/9/2021 3/9/2021 8/10/2021 8/10/2021 9/14/2021 9/14/2021
7 FITRIANA SABILA P 2/8/2021 SUBI'AH CENTREN 2/8/2021 3/9/2021 3/9/2021 8/10/2021 8/10/2021 9/14/2021 9/14/2021
8 MOH ARSYA AL FAQIH L 2/27/2021 LAILATUN N CENTREN 2/27/2021 3/9/2021 3/9/2021 8/10/2021 8/10/2021 9/14/2021 9/14/2021
9 ANDINI AFKARINA P 4/8/2021 IIS DAHLIIA CENTREN 4/8/2021 8/9/2021 8/9/2021
10 P 6/11/2021 HUSNUL CENTREN 6/11/2021 8/9/2021 8/9/2021
Pembina desa
HALIMATUS SAKDIYAH
NAMA UNIT PELAYANAN KESEHATAN : POSYANDU ASRI 2

TANGGAL IMUNISASI
<24 JAM BCG POL 1 POL 2 DPT - HB Hib (2) POL 3 DPT - HB Hib (3) POL 4 IPV MR DPT-HB HIB(4) MR(2)
(1)
1 2 3 4 5 6 7 8 9 10 11 12 14 15 17 21 22 23 24
1 AHMAD FARHAN L 5/13/2020 TUMINA JENGLETEH T 5/13/2020 7/9/2020 7/9/2020 8/13/2020 8/13/2020 9/16/2020 9/16/2020 10/14/2020 10/14/2020 11/12/2020 3/13/2021
2 MOH ALI IBRAHIM L 6/27/2020 SYAIPAH JENGLETEH T 6/27/2020 9/16/2020 9/16/2020 10/14/2020 10/14/2020 3/13/2021 3/13/2021 8/14/2021 8/14/2021 5/20/2021 9/16/2021
3 AISYAH FARHANA P 7/3/2020 PUTRI JENGLETEH T 7/3/2020 9/16/2020 9/16/2020 10/14/2020 10/14/2020 3/13/2021 3/13/2021 8/14/2021 8/14/2021 5/20/2021 9/16/2021
4 KHAIRUL ANAM L 11/27/2020 MAIMUNA JENGLETEH T 11/27/2020 5/20/2021 5/20/2021 8/14/2021 8/14/2021 9/17/2021 9/17/2021
5 MOH SAMIR ERFATAN L 12/26/2020 FATIMAH JENGLETEH T 12/26/2020 5/20/2021 5/20/2021 8/14/2021 8/14/2021 9/17/2021 9/17/2021
6 M SYAUQIL ABIDIN L 12/26/2020 IRAWATI JENGLETEH T 12/26/2020 5/19/2021 5/19/2021 9/17/2021 9/17/2021
7 SYAIFUL BAHRI L 12/26/2020 SOFI JENGLETEH T 12/26/2020 5/19/2021 5/19/2021 9/17/2021 9/17/2021
8 ZAIMAK L 1/1/2021 ROHMAH JENGLETEH T 1/1/2021 5/20/2021 5/20/2021 9/17/2021 9/17/2021
10 TIKA P 2/16/2021 LULUK JENGLETEH T 2/16/2021 6/17/2021 6/17/2021 9/17/2021 9/17/2021
11 RANA P 4/15/2021 HABILAH JENGLETEH T 4/15/2021 6/17/2021 6/17/2021
12 IZZUDIN KAROMI L 3/10/2021 NURUL JENGLETEH T 3/10/2021 6/17/2021 6/17/2021
13 MOH ILZAM RAMADHAN L 5/15/2021 HALIMA JENGLETEH T 6/17/2021 6/17/2021
Pembina desa
HALIMATUS SAKDIYAH
NAMA UNIT PELAYANAN KESEHATAN : POSYANDU ASRI 1

TANGGAL IMUNISASI
HB 0 (0-7 HARI) BCG POL 1 POL 2 DPT - HB Hib (2) POL 3 DPT - HB Hib (3) POL 4 IPV MR DPT-HB HIB(4) MR(2)
(1)
1 2 3 4 5 6 7 8 9 10 11 12 14 15 17 21 22 23 24
1 IRHAM MAULUDI L 7/26/2020 ROSIDEH DUMPOL 7/26/2020 10/13/2020 10/13/2020 11/11/2020 11/11/2020 8/12/2021 8/12/2021 9/15/2021 9/15/2021 9/16/2021
2 MOH IZAM BAKRI L 10/16/2020 NAEMAH DUMPOL 10/16/2020 11/11/2020 11/11/2020 8/12/2021 8/12/2021 9/15/2021 9/15/2021
3 AMELIA P 11/8/2020 VINA DUMPOL 11/8/2020 6/17/2021 6/17/2021 9/15/2021 9/15/2021
4 MAULIDIYA P 11/26/2020 SURATNI DUMPOL 11/26/2020 6/17/2021 6/17/2021 9/15/2021 9/15/2021
5 MOH FATIR L 12/26/2020 ZAINAB DUMPOL 12/26/2020 5/19/2021 5/19/2021 9/15/2021 9/15/2021
6 M WILDAN L 12/27/2020 FATIMAH DUMPOL 12/27/2020 5/19/2021 5/19/2021 9/15/2021 9/15/2021
7 SITI NUR ALIFA P 12/28/2020 PUTIYEH DUMPOL 12/28/2020 5/19/2021 5/19/2021 9/15/2021 9/15/2021
8 KEYSHA AURELIA P 2/27/2021 BUNIYEH DUMPOL 2/27/2021 5/19/2021 5/19/2021
9 IZZATUL UMMAH P 1/12/2020 YASMANI DUMPOL 1/12/2020 5/19/2021 5/19/2021
10 M FAIDUL M L 4/26/2021 YULIANA DUMPOL 4/26/2021 5/19/2021 5/19/2021
11 P 5/28/2021 RoOFIYEH DUMPOL 5/28/2021 8/12/2021 8/12/2021
12 L 6/8/2021 ST ARINI DUMPOL 6/8/2021 8/12/2021 8/12/2021
13 L 6/24/2021 NAIMATUL KUMALA DUMPOL 6/24/2021 8/12/2021 8/12/2021
14 P 8/8/2021 ELOK DUMPOL 8/8/2021 9/15/2021 8/12/2021
15 P 5/6/2021 MASRUROH DUMPOL 5/6/2021 8/12/2021 8/12/2021
Pembina desa
HALIMATUS SAKDIYAH
NAMA UNIT PELAYANAN KESEHATAN : POSYANDU RINDANG

TANGGAL IMUNISASI
(1)
1 2 3 4 5 6 7 8 9 10 11 12 14 15 17 21 22 23 24
1 LINDAWATI P 5/30/2020 HOMSINA 5/30/2020 8/14/2021 8/14/2021 9/18/2020 9/18/2020 2/15/2021 2/15/2021 3/15/2021 3/15/2021 5/20/2021 5/20/2021
2 AZKA L 6/18/2020 LELY 6/18/2020 8/14/2021 8/14/2021 9/18/2020 9/18/2020 2/15/2021 2/15/2021 3/15/2021 3/15/2021 5/20/2021 5/20/2021
3 MOHAMMAD IQBAL HAQIQI L 8/2/2020 FAIZAH 8/2/2020 3/15/2021 3/15/2021 8/14/2021 8/14/2021 9/17/2021 9/17/2021
4 SITTI SUSANTI P 8/29/2020 SUMIYATI 8/29/2020 3/15/2021 3/15/2021 8/14/2021 8/14/2021 9/17/2021 9/17/2021
5 FATANATUS SULFA P 10/18/2020 TUNI 10/18/2020 3/15/2021 3/15/2021 8/14/2021 8/14/2021 9/17/2021 9/17/2021
6 IMELDA P 11/8/2020 JUNAIYEH 11/8/2020 3/15/2021 3/15/2021 8/14/2021 8/14/2021 9/17/2021 9/17/2021
7 HAMIDAN ABDILLAH L 11/11/2020 MARWAH 11/11/2020 3/15/2021 3/15/2021 8/14/2021 8/14/2021 9/17/2021 9/17/2021
8 SALMAN AL FARISI L 1/26/2021 ISMIYANTI 1/26/2021 3/15/2021 3/15/2021
9 ROYDA FAHIRA P 2/16/2021 ILA 2/16/2021 3/15/2021 3/15/2021
10 NURHASANAH P 3/3/2021 MISKIYEH 3/3/2021 5/20/2021 5/20/2021
11 L 5/4/2021 HOZEIMAH 5/4/2021 5/20/2021 5/20/2021
12 ATIQA FIAIRUS KHALIZA P 3/28/2021 ANISAUL M 3/28/2021 6/17/2021 6/17/2021
13 SHAFA AULIA P 4/8/2021 NURHAYATI 4/8/2021 8/9/2021 8/9/2021
14 DEVIA ASSYIFA P 5/20/2021 LISA 5/20/2021 8/9/2021 8/9/2021
15 L 6/25/2021 ST ZAINAB 6/25/2021 9/15/2021 9/15/2021
16 L 7/27/2021 MUNA 7/27/2021 9/15/2021 9/15/2021
17 P 8/16/2021 NIKMAH 8/16/2021 9/15/2021 9/15/2021
Pembina desa
HALIMATUS SAKDIYAH
NAMA UNIT PELAYANAN KESEHATAN : POSYANDU SEGAR

TANGGAL IMUNISASI
(1)
1 2 3 4 5 6 7 8 9 10 11 12 14 15 17 21 22 23 24
1 MUHAMMAD AZKAL HASAN L 9/3/2020 ATMI JENGLETEH B 10/15/2021 10/15/2021 3/12/2021 3/12/2021 8/14/2021 8/14/2021 9/16/2021 9/16/2021 9/16/2021
2 SILFIATUN P 9/6/2020 ZEINAB JENGLETEH B 10/15/2021 10/15/2021 2/11/2021 2/11/2021 8/14/2021 8/14/2021 9/16/2021 9/16/2021 9/16/2021
3 MUHAMMAD MUAFA L 9/28/2020 SOFIYAH JENGLETEH B 2/11/2021 2/11/2021 8/14/2021 8/14/2021 9/16/2021 9/16/2021
4 SAFINATUN NAJAH P 11/11/2020 SA'ADAH JENGLETEH B 2/11/2021 2/11/2021
5 AHMAD HUDAIFI L 11/20/2020 UMMI JENGLETEH B 2/11/2021 2/11/2021
6 MAULIDIYA P 11/25/2020 KULSUM JENGLETEH B 5/20/2021 5/20/2021
7 ADIFA KHANZA P RUMMI JENGLETEH B 2/11/2021 2/11/2021
8 ROYHAN MUSTOFA L 12/25/2020 HASIYEH JENGLETEH B 5/20/2021 5/20/2021 9/16/2021 9/16/2021
9 ACHMAD DIMYET L 1/16/2020 SOFWATUL WIDAD JENGLETEH B 5/20/2021 5/20/2021
10 Faizur R L 1/12/2021 MUFARROHAH JENGLETEH B 5/20/2021 5/20/2021
11 L 3/8/2021 LULUK/IMAM JENGLETEH B 3/8/2021 5/20/2021 5/20/2021
12 P 4/10/2021 MUKIMAH JENGLETEH B 6/17/2021 6/17/2021
13 SYAHIRA P 5/10/2021 LAILATUL JENGLETEH B 5/10/2021 6/17/2021 6/17/2021
14 L 4/26/2021 FITRIYA JENGLETEH B 6/17/2021 6/17/2021
15 P 5/1/2021 JUHAIRIYAH JENGLETEH B 6/17/2021 6/17/2021
16 P 5/7/2021 RINI JENGLETEH B 6/17/2021 6/17/2021
17 P SUPYANA JENGLETEH B 9/15/2021 9/15/2021
18 P SOFI JENGLETEH B 9/15/2021 9/15/2021
Pembina desa
HALIMATUS SAKDIYAH
LAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI)
Form KIPI Non Serius
TEMPAT PELAKSANAAN *)
PUSKESMAS : PANAGUAN / CAMPOR 2
KABUPATEN : PAMEKASAN
BULAN / TAHUN : SEPTEMBER2021
IDENTITAS GEJALA YANG DIALAMI

JENIS TEMPAT
KELAMIN JENIS No Batch / PEMBERI TANGGAL DEMAM BENGKAK MERAH MUNTAH
NO TANGGAL PELAYANAN LAIN-LAIN
NAMA ANAK UMUR NAMA ORTU ALAMAT VAKSIN Exp Date IMUNISASI IMUNISASI
LAHIR IMUNISASI (SEBUTKAN)
L/P Jika ya di tandai ü
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
NIHIL
3
Mengetahui PAMEKASAN, 28 SEPTEMBER 2021

Kepala Upt Puskesmas Panaguan
BIDAN DESA CAMPOR
NURUL INAYAH,S.ST
NIP.19771103 2005 HALIMATUS SAKDIYAH
9. Anafilaktik
10. Abses
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PENCATATAN IMUNISASI RUTIN BAYI / BALITA DI UNIT PELAYANAN

NAMA UNIT PELAYANAN KESEHATAN : POSYANDU TEDUH

NAMA UNIT PELAYANAN KESEHATAN : POSYANDU SEJUK

NAMA UNIT PELAYANAN KESEHATAN : POSYANDU ASRI 2

NAMA UNIT PELAYANAN KESEHATAN : POSYANDU ASRI 1

NAMA UNIT PELAYANAN KESEHATAN : POSYANDU RINDANG

NAMA UNIT PELAYANAN KESEHATAN : POSYANDU SEGAR

PUSKESMAS : PANAGUAN / CAMPOR 2

BULAN / TAHUN : SEPTEMBER2021

IDENTITAS GEJALA YANG DIALAMI

Mengetahui PAMEKASAN, 28 SEPTEMBER 2021

Lanjutkan ke Formulir Pelaporan KIPI Serius

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