FORMAT PENCATATAN HASIL PE

Nama SEKOLAH SD 2
Nama Desa/kelurahan : SEUMIRAH
Tanggal : 05 DESEMBER 2022

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin
(L/P)
a b c d e
1 Abdul Azis 2016-04-28 L
2 ABDULLAH 2010-09-17 L
3 AFSADUL AFKAR 2010-10-17 L
4 AGUSWANDI 2011-05-21 L
5 Ahmad Syuhada 2014-05-22 L
6 AL HAFIDZAKI 2011-12-03 L
7 ALFI SHAHRIL 2011-05-01 L
8 ALFIN FITRA AULIA 2011-06-01 L
9 Ali Akbar 2015-08-17 L
10 Alia Sabila 2012-02-03 L
11 Aliza Khairunnisa 2015-11-11 P
12 AMILIA IBRAHIM 2011-09-12 P
13 Aminah 2013-01-02 P
14 Amira Zahra Saffana 2013-07-18 P
15 Amirahtul umairah 2013-10-14 P
16 ANA SAFIRA 2011-12-05 P
17 Andi Arsyil 2014-08-28 L
18 Anis Iis Dahlawi 2013-02-04 L
19 Aqilul Zaki 2014-12-25 L
20 Arina Azkia 2012-11-01 P
21 Ariza Rizqi 2014-05-25 L
22 Asyifa Nadila 2014-06-04 P
23 ASYIFA ZUHRINA 2011-04-26 P
24 ASYRAFIL MAULANA 2011-04-19 L
25 Aulia Izzatunnisa 2013-02-06 P
26 AULIA RAHMI 2011-05-18 P
27 Aulia Saputra 2015-07-24 L
28 AURA MOLIZA 2010-12-06 P
29 Ayudia Nuha Afiqa 2016-03-02 P
30 Azam Fazzal 2012-12-19 L
31 AZDRA NAFISA 2011-06-25 P
32 AZHARI 2011-07-01 L
33 Azkia Ulfaturrahmah 2011-12-21 P
34 AZKIYA 2016-02-10 P
35 Baiynatun Nafis 2016-03-01 P
36 Cut Andriani 2015-03-23 P
37 Cut Lupviana 2014-07-06 P
38 Cut Mutia Murni 2012-05-15 P
39 Cut Natasya Mahira 2016-02-02 P
40 Cut Zahra Aulia 2012-10-12 P
41 Desiani 2012-05-03 P
42 Dia Safkia 2012-03-26 P
43 FADHLURRAHMAN 2011-09-08 L
44 Faitul Ahmad Sayuti 2013-12-14 L
45 Faizal Asykari 2016-05-01 L
46 Fajriadi 2012-12-08 L
47 Faris Munawar 2012-01-15 L
48 Fatimah Zuhra 2014-03-03 P
49 Fatin Ulfira 2013-05-25 P
50 FAZLUL 2011-04-04 L
51 FAZLURRAHMAN 2011-10-04 L
52 Finatul Muhram 2014-02-28 P
53 FITRI NAZIRA 2010-11-17 P
54 Ghina Fika Ulan 2014-11-27 P
55 Hafiz Qutbhi Zayan 2016-07-13 L
56 Harni 2012-12-10 P
57 Hasna Kamila 2014-07-31 P
58 Hidayatun Nafisa 2012-06-11 P
59 Humayratul Qalby 2015-10-02 P
60 Husnul Ulfia 2014-04-26 P
61 Husnul Ulvia 2014-05-04 P
62 Ibrahim 2013-04-05 L
63 Iqramatul Ulfi 2014-11-27 P
64 Jalaluddin 2015-07-22 L
65 JUNILA 2012-06-01 P
66 Kaila Alfa 2012-05-16 P
67 Khaira Maulida 2014-02-09 P
68 Khaira Mouliza 2016-01-05 P
69 Khairi Ananda 2016-08-01 L
70 Khairul Rijal 2012-10-26 L
71 Khayla Alisha 2016-04-25 P
72 Lidia Fitri 2014-03-13 P
73 Loni Mastura 2014-01-11 P
74 M AIDIL FITRA 2011-05-30 L
75 M. Riansyah Putra 2015-01-09 L
76 MAULANA FIKRI 2010-09-30 L
77 Mauliana 2014-02-18 P
78 Mauliza 2014-12-24 P
 79 Miftahuddin 2016-04-19 L
80 Miratul Hayati 2013-06-12 P
81 Misbahul Ikram 2013-01-20 L
82 Misra Yulis 2012-10-28 P
83 MOULANA RIZKI 2011-06-22 L
84 Moulia Mirza 2015-12-13 L
85 Muammar 2014-03-21 L
86 Muazis Saputra 2012-05-14 L
87 MUHAMMAD 2009-10-06 L
88 Muhammad Afkar Al Fatih 2014-10-11 L
89 Muhammad Al-Ghazali 2014-12-24 L
90 Muhammad Alif 2012-06-02 L
91 Muhammad Amin 2015-11-16 L
92 Muhammad Andika 2014-12-06 L
93 Muhammad Arsya 2015-01-10 L
94 Muhammad Ashraf Firdaus 2013-09-03 L
95 MUhammad Bilal 2016-04-02 L
96 MUHAMMAD DANIL 2011-07-22 L
97 Muhammad Farhan 2016-03-17 L
98 Muhammad Farhan Alfaris 2014-06-19 L
99 Muhammad Fazil 2014-12-04 L
100 Muhammad Fazil Nasution 2016-04-18 L
101 Muhammad Haiqal 2013-10-09 L
102 Muhammad hanafiah 2015-09-03 L
103 Muhammad Ikbar 2013-07-03 L
104 Muhammad Ikhlas 2015-09-22 L
105 Muhammad Ikram 2015-09-14 L
106 Muhammad Ilham 2014-05-10 L
107 Muhammad Ilham 2016-03-01 L
108 Muhammad Ismail 2014-03-10 L
109 Muhammad Kabir 2015-05-29 L
110 Muhammad Khaidir Zafwan 2012-06-03 L
111 MUHAMMAD KIFLAINI 2011-05-24 L
112 Muhammad Marhaban 2015-03-20 L
113 Muhammad Maulana 2014-04-14 L
114 Muhammad Nazaruddin 2015-05-02 L
115 Muhammad Raihan 2014-06-02 L
116 Muhammad Ramzi 2011-11-11 L
117 Muhammad Razi 2013-12-06 L
118 Muhammad Rizki 2014-08-06 L
119 Muhammad Rizki 2012-06-27 L
120 Muhammad Syafa 2013-12-18 L
121 Muhammad Zilfalhi 2014-10-16 L
122 Muklis 2015-07-20 L
123 MUKLIS SAPUTRA 2010-03-14 L
124 Munawar 2012-06-10 L
125 Munawar 2015-07-15 L
126 MUNAWIR 2011-08-15 L
127 Nadia Syarkila 2013-04-19 P
128 Naila Ulfa 2014-12-05 P
129 Najwa Maliha 2015-09-07 P
130 Naratul Ghina 2014-12-09 P

TOTAL

Jumlah vial Jumlah vial

Jumlah Vial nOPV dibawa dipakai
MAT PENCATATAN HASIL PELAYANAN SUB PIN POLIO

nisasi susulan pada kolom keterangan

NIK Nama orang tua NIK Orang Tua Alamat

f g h i
1108272804160001 IDA 1108164107830509 Seumira
1108271709100002 NURAIDA 1108164107700540
1108271710100001 KASMIATI 1108164107770351 Seumira
1108272105110002 CUT BISMIATI 1108165012840002 Seumira
1108272205140002 Nazariah 1108165706930001 Seumira
1173040312110001 NURLIATI ISMAIL 1173044107870081 Seumira
1108270105110001 HAFNIDAR 1108164605840002 Seumira
1108270106110001 YUSNAWATI 1108164107840399 Seumira
1108271708150001 Yusmani Hasballah 1108165203860002 Seumira
1108274302120000 Nurjannah Ibrahim 1108165511720001 Seumira
1108274302120001 Husna Zabidin 1108274107770005 Seumira
1108274302120001 MURSYIDAH 1108164107780551 Seumira
1108274302120001 Nuraida 1108164107700540 Seumira
1108274302120001 Warsi 3674065007810016 Seumira
1108274302120001 Yusrawati Ahmad 1108165912800001 Seumira
1108274302120001 ANTIKAH 1108164804820002 Seumira
1108274302120001 Liza Yani 1108164301890001 Seumira
1108274302120001 Darmani 1108164107820474 Seumira
1108274302120001 Maryani Seumira
1108274302120001 Marliah 1108274804920001 Seumira
1108274302120001 Jasmaniah 1108165111850003 Seumira
1108274302120001 Asfarina 1108274411890001 Seumira
1108274302120001 SURYANA 1108164107800557 Seumira
1108274302120001 NURBAYA 1108275109840001 Seumira
1108274302120001 Maryani 1108164107900601 Seumira
1108274302120001 ZUR Seumira
1108274302120001 Dewi Saputri 1108024107970340 Seumira
1108274302120001 ZUBAIDAH 1108274107770004 Seumira
1108274302120001 Rita Wati 1108025808590001 Seumira
1108274302120001 Mawardah 1108276501890001 Seumira
1108274302120001 ZURAINI 1108165603780001 Seumira
1108274302120001 KASMIATI 1108164107750446 Seumira
1108274302120001 Maimunah 1108164107860562 Seumira
1108274302120001 Nilawati 1103176503900003 Seumira
1108274302120001 Isnamurni M. Hasan 1108164107870578 Seumira
1108274302120001 Nur Asmawati Seumira
1108274302120001 Antikah Adnan 1108164604820002 Seumira
1108274302120001 Ariska Dewi Seumira
1108274302120001 Ita Zahara 1108157096950002 Seumira
1108274302120001 Khairiah Jamil 1108164107750445 Seumira
1108274302120001 Kartini 1108167112780012 Seumira
1108274302120001 Mahdalena 1108167112860005 Seumira
1108274302120001 NURASIYAH 1108164107800519 Seumira
1108274302120001 Yusnita 1108164608870002 Seumira
1108274302120001 Nuryani 1108275911910001 Seumira
1108274302120001 Syamsyidah 1108274405900001 Seumira
1108274302120001 Rosyita 1108165011920003 Seumira
1108274302120001 Khairati 1108166403930001 Seumira
1108274302120001 Yusmani Hasballah 1108165203860002 Seumira
1108274302120001 ANTIKAH 1111074711900004 Seumira
1108274302120001 NURLIZA 1108156605910001 Seumira
1108274302120001 Maryani 1108167112730004 Seumira
1108274302120001 NURHAYATI 1108166405770001 Seumira
1108274302120001 Salihati Seumira
1108274302120001 Annisah Putri 1108164107920458 Seumira
1108274302120001 Sapiah Abdullah 1108164107780518 Seumira
1108274302120001 Karmiani 1108164107910442 Seumira
1108274302120001 Yusnawati 1108164107840399 Seumira
1108274302120001 Bismiana 1108164303930002 Seumira
1108274302120001 Nursyidah Seumira
1108274302120001 Maryati Ibrahim 1108164107840448 Seumira
1108274302120001 Nuraini Awahab 1108164107720348 Seumira
1108274302120001 Suryani Seumira
1108274302120001 Miftahul Jannah 1108154908950002 Seumira
1108274302120001 Nurhayati Ali 1108164107740296 Seumira
1108274302120001 Nilawati 1108164107810327 Seumira
1108274302120001 Yusnidarwati 1108164107870585 Seumira
1108274302120001 Nafsiah Usman 1108164107770355 Seumira
1108274302120001 Asmarawati Seumira
1108274302120001 Isnawati 1108164107770360 Seumira
1108274302120001 Fatimah 1108166307870002 Seumira
1108274302120001 Nursiyah 1108164107910449 Seumira
1108274302120001 Yusnawati 1108164107840399 Seumira
1108274302120001 NURHAYATI 1108104107820204 Seumira
1108274302120001 Putriani Seumira
1108274302120001 ZAINABON 1108167003780001 Seumira
1108274302120001 Suryati Abdulmain 1108164505830004 Seumira
1108274302120001 Zuraini Seumira
1108274302120001 Suryati 1108164505830004 Seumira
1108274302120001 Ruhamah 1108164509710001 Seumira
1108274302120001 Muslina 1108164107880482 Seumira
1108274302120001 Nur Asma 1108164304880001 Seumira
1108274302120001 NILAWATI 1108164406840002 Seumira
1108274302120001 Nuraini Ali 1108164205822000 Seumira
1108274302120001 Mursidah 1108164107890664 Seumira
1108274302120001 Maimanah Abdurrahman 1108275104860001 Seumira
1108274302120001 NURMALA 1108274607870001 Seumira
1108274302120001 Marhami Baktiar Seumira
1108274302120001 Ulfa Rahmi Seumira
1108274302120001 Dahliana 1108164107800621 Seumira
1108274302120001 Khatijah 1108275111950003 Seumira
1108274302120001 Jamiliah Seumira
1108274302120001 Noratul Husna Seumira
1108274302120001 Juliana 1108164202900003 Seumira
1108274302120001 Halimah 1108066303830001 Seumira
1108274302120001 RACHIDAH 1108164107790322 Seumira
1108274302120001 Darwati Adam 1108167112800012 Seumira
1108274302120001 Nurdiana 1108274210940002 Seumira
1108274302120001 Jamaliah Hasan Seumira
1108274302120001 Ana Fitria 1108276011950001 Seumira
1108274302120001 Risni 1108164209940001 Seumira
1108274302120001 Suryati 1108167112280001 Seumira
1108274302120001 Halimah 1108066303830001 Seumira
1108274302120001 Ainol Mardhiah 1108164107890618 Seumira
1108274302120001 Jasmiati 1108164107860610 Seumira
1108274302120001 Budiyani 1108167003860001 Seumira
1108274302120001 Maryani 1108275409920002 Seumira
1108274302120001 Saidah 1108164107750398 Seumira
1108274302120001 Nurhayati 1108104107820204 Seumira
1108274302120001 Syamsyiah Thalib 1108164107720342 Seumira
1108274302120001 TI NURMA 1108165312710001 Seumira
1108274302120001 Dawati Daud Seumira
1108274302120001 Maryani 1108164107840394 Seumira
1108274302120001 Muliana Seumira
1108274302120001 Ernawati M Yusuf 1108155506940003 Seumira
1108274302120001 Salmiati 1108166107870001 Seumira
1108274302120001 Zainabon Abdurrahman 1108164107820538 Seumira
1108274302120001 Faizah 1108164107850560 Seumira
1108274302120001 Nurasma Usman 1108167112800014 Seumira
1108274302120001 Safriani 1111094812840001 Seumira
1108274302120001 Fitriani 1108164101890008 Seumira
1108274302120001 Nuraida 1108164107700540 Seumira
1108274302120001 DARMIYATI 1106166007810001 Seumira
1108274302120001 Saudah Abdullah 1108164107790331 Seumira
1108274302120001 Murdiana 1108165106820001 Seumira
1108274302120001 SALBIAH Seumira
1108274302120001 Yusnidar 1108164304910001 Seumira
1108274302120001 Rasyidah Seumira
1108274302120001 Rahmiyana 1108175708930002 Seumira
1108274302120001 Nurlaila Seumira

Jumlah Vial Sisa

0
Nama petugas :
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

Tanggal Diimunisasi Polio (nOPV2) Keterangan

No.Hp
Dosis 1 Dosis 2
j k l m
1
082366825821 1
082363817552 1
082277261368 1
082367291040 1
082362514569 1
085270765805 1
085248966407 1
1
1
1
1
852366825821 1
082273114959 1
082367559097 1
082277261368 1
082269852990 1
085276644376 1
1
082229166470 1
1
1
082213296044 1
1
082277092990 1
081360880477 1
1
085270765805 1
085358208696 1
082297748259 1
085261374198 1
082362514569 1
085266605701 1
 1
1
1
1
081360880477 1
1
081360880477 1
082277910286 1
1
082284762549 1
1
082370179708 1
085270037859 1
082277533974 1
085218343960 1
085260108274 1
081313827501 1
082363837939 1
1
082246261940 1
1
1
1
085370514627 1
082297748259 1
1
1
1
1
1
1
082277047169 1
085290094682 1
085341809786 1
1
1
1
081361686036 1
085261950588 1
085248966407 1
085296553915 1
1
1
085370703538 1
1
 1
081362966460 1
082230492745 1
085270829081 1
1
1
082367837111 1
082181166167 1
1
1
1
1
082299229809 1
1
1
082261906304 1
1
081265939364 1
1
1
1
082277345158 1
085361137663 1
1
1
082370424792 1
1
1
1
085213753166 1
1
1
082370179708 1
1
1
1
1
1
085298843834 1
1
1
082217585022 1
085260081711 1
1
085270379930 1
 1
1
082364153461 1
085260238938 1
1
1
1

130
 FORMAT PENCATATAN HASIL PE

Nama SEKOLAH SD 5
Nama Desa/kelurahan :
Tanggal :

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin
(L/P)
a b c d e
1 ADITYA RIFKI RAMAZAN 24/06/2016 L
2 ANISAH HUMAIRAH 28/03/2016 P
3 BILKIS AKILA 12/01/2016 P
4 FATIMAH ZUHRA 24/12/2014 P
5 LUKFI AL AYUBI 06/04/2016 L
6 MAIMUNAH 07/01/2016 P
7 MIZANUL AFKAR 28/08/2015 L
8 MIRSYAD ALGHANAWI 27/11/2015 L
9 MUHAMMAD NAZAR 29/06/2016 L
10 MUHAMMAD RAMADHAN 12/06/2016 L
11 MUHAMMAD BAIHAQI 23/05/2016 L
12 MUHAMMAD RIZAL 28/11/2015 L
13 MUHAMMAD ASKAL 21/06/2016 L
14 MUHAMMAD ALFATIH 01/09/2015 L
15 MUHAMMAD NAUFAL 24/04/2016 L
16 MUHAMMAD RAYYAN ALBARIZI S 14/04/2016 L
17 MUHAMMAD RIZALUL FIKRI 03/04/2016 L
18 MUHAMMAD KHAIDIR 19/09/2015 L
19 MUNIRA ALFAKIRA 09/12/2015 P
20 NAILA AZUHRA 21/10/2015 P
21 NUR AZIZI 30/12/2015 P
22 RAGIL AR'SYI 11/02/2016 L
23 RISKA MUNAIYA 05/05/2016 P
24 RISKI MAULANA 14/01/2016 P
25 SAIDATUL RIFKA 10/09/2015 P
26 USYRAFUL MUNIRA 08/02/2016 P
27 MAULANA 21/01/2015 L
28 AKILA ZAHWA 03/06/2015 P
29 ALFIAN PUTRA 29/10/2014 L
30 HABBA SAUDA 01/04/2014 P
31 MUHAMMAD ADAM 12/05/2015 L
32 MUHAMMAD AHYAR 03/08/2015 L
33 MUHAMMAD ALFARISYI 06/02/2015 L
34 MUHAMMAD ARIS 20/03/2015 L
35 MUHAMMAD ASHRAF 10/06/2015 L
36 M. AQSAL RIVALDI 20/02/2015 L
37 MUHAMMAD HAFIZ 28/04/2015 L
38 MUHAMMAD IKBAL 29/09/2014 L
39 M.SYARIF FUDDIN 01/06/2015 L
40 M. REZA SAPUTRA 07/05/2015 L
41 MUHAMMAD ZAFRAN 09/10/2015 L
42 MUHAMMAD ZIKRAR 08/11/2015 L
43 NASYIRA ALQIA 10/09/2015 P
44 NATASYA KHAIRA 05/09/2015 P
45 NISAUL FITRI 14/04/2015 P
46 OCHA SAVIRA 17/01/2015 P
47 REYNA RUMAYSHA S 26/05/2015 P
48 SAIDATUN NAFISA 19/11/2015 P
49 SYAFA SYATILA 02/02/2015 P
50 SYIFA UNNISA 19/03/2015 P
51 VITA ALVIA 31/01/2015 P
52 YUSUF QARDHAWI 13/07/2014 L
53 ZUSUFIA 12/05/2015 P
54 ZAHRUL AKBAR 18/04/2015 L
55 AFKAR ULIA 18/12/2013 L
56 AINUL MARDIAH 20/02/2014 P
57 ALFINA KHAIRA 13/09/2013 P
58 AZKA ALDRIC 22/05/2014 L
59 DINA AKMALIA 05/09/2013 P
60 HAFIZA AL MAHIRA 12/02/2014 P
61 KHAIRATUL FITRI 25/ 06/2014 P
62 MAHYUNI 28/01/2014 P
63 MAULIZA HUMAIRAH 03/02/2014 P
64 MUHAMMAD BALYAN 16/04/2014 L
65 MUHAMMAD AIKAL 04/02/2014 L
66 MUHAMMAD DAFFA 25/ 06/2014 L
67 MUHAMMAD IQBAL 23/10/2013 L
68 MUHAMMAD SULTAN KHALIS 25/05/2014 L
69 Alya Azzuhra 29/04/2013 P
70 CUT FAIKA 06/05/2013 P
71 HUMAIRA 01/01/2013 P
72 FIKRAN MAULANA 11/07/2013 L
73 FITRIA RAMADHANI 27/07/2013 P
74 FITRIA SYAFIA 24/10/2012 P
75 MUHAMMAD ANDI 09/03/2012 L
76 MUHAMMAD FAZIL 07/07/2012 L
77 MUHAMMAD FAYYADH 01/12/2012 L
78 MUHAMMAD FAIS 06/05/2013 L
 79 AFZAL MAULANA 27/03/2012 L
80 CUT ASYIFA 05/07/2012 P
81 DINA AKMALIA 19/09/2011 P
82 FAHRIJADILLAH 22/02/2012 L
83 M.ALIF FURQAN 22/02/2012 L
84 MUHAMMAD FADIL 10/02/2012 L
85 MUHAMMAD HAJIL 27/11/2012 L
86 MUHAMMAD KHAIRIN 05/11/2012 L
87 MUHAMMAD RAFI 03/04/2012 L
88 MUHAMMAD RIFKI 26/04/2012 L
89 MUHAMMAT RISKI 17/03/2012 L
90 MUHAMMAD RIZKIY 09/02/2012 L
91 ALYA SALSABILA 14/01/2011 P
92 ANA ALTAUFUN NISA 07/07/2011 P
93 EPA NADILA 22/11/2010 P
94 ILHAM SAPUTRA 31/10/2010 L
95 KHAIRUL AZMI 22/11/2010 L
96 LAHIYA MAHYA 27/06/2011 L
97 M. AZRI KAMUDA 22/05/2011 L
98 MUHAMMAD FAZIL 10/05/2011 L
99 MUKSAL MINA 21/08/2011 L
100 MUHAMMAD HAIKAL 04/01/2011 L
101 MUHAMMAD ZULQIRAM 28/06/2011 L
102 MUHAMMAD YANI 10/10/2010 L
103 MUHAMMAD FAZIL 11/03/2011 L
104 MUHAMMAD FAJAR 25/12/2011 L
105 NISA HUMAIRA 26/07/2011 P
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
TOTAL

Jumlah vial Jumlah vial

Jumlah Vial nOPV dibawa dipakai
AT PENCATATAN HASIL PELAYANAN SUB PIN POLIO

asi susulan pada kolom keterangan

NIK Nama orang tua NIK Orang Tua Alamat

f g h i
1108272406160001 Seumirah
1108276803160001 SURYANI Seumirah
1108275201160002 IRWANI Seumirah
1108276412140002 SALMAWATI Seumirah
1108020604160001 NURUL AISYAH (ALM) Seumirah
1108274701160002 MUTIA AFRIDA Seumirah
1108272808150001 NURAIDA Seumirah
1108272711150001 WARDIAH Seumirah
1173022906160001 MERA MULYA Seumirah
1108061206160002 ROSMAWATI Seumirah
1117092305160001 RUHAMAH Seumirah
1108272811150001 KARTINI Seumirah
1108272106160002 SALMAWATI Seumirah
1108270109150001 AINIATUL FITRI Seumirah
1108272404160001 DARMIATI Seumirah
1108151404160004 ZURYANA Seumirah
1108270304160001 JASMANI NASRUDDIN Seumirah
1108271909150001 RASYIDAH Seumirah
1108274912150003 NURAINI Seumirah
1108276110150001 MARLINA Seumirah
1108277012150001 MARDIANI Seumirah
1108271102160001 AINSYAH Seumirah
1108274505160001 SYARBANI M KASEM Seumirah
1108271401160002 NURLAILAWATI Seumirah
1108271009150005 SYARBANI Seumirah
1108274802160001 SURYANI ZAINUDDIN Seumirah
1108272101150001 KHADIJAH Seumirah
1108274306150001 ELLYYANA Seumirah
1108272910140001 YUSNIDAR Seumirah
1108154104140002 NUR JANNAH Seumirah
1108271005150001 NURLIANA Seumirah
1108270308150001 HASTUTI Seumirah
1108150620150002 NUR ASIAH Seumirah
1108062003150001 ROSMAWATI Seumirah
1108271006150002 SAFRIANA Seumirah
1108272002150001 FATMAH ZUHRA Seumirah
1108272804150001 NURHABSAH Seumirah
1108272909140001 NURHAJJAH Seumirah
1108274106150001 NURASIAH Seumirah
1108270705150001 ROSDIANA Seumirah
1108270910150001 HASDIANA Seumirah
1173010811150003 NURLIANA Seumirah
1108275009150001 WARDIYAH Seumirah
1108274509150002 YUSNIDAR Seumirah
1108275404150001 AYU AZHARI Seumirah
1108275701150001 KASMIATI Seumirah
1108156605150002 ZURYANA Seumirah
1108275911150001 JUMIANA Seumirah
1108274202150001 SAFRINA Seumirah
1108275903150001 ISNA YANTI Seumirah
1111177101150001 SUARNI Seumirah
1108271307140001 WARDIAH Seumirah
1108275205010003 NURBAITI Seumirah
1108151804150003 MUTIA WATI Seumirah
1108271812130001 NURAINI Seumirah
1108276002140002 FITRIANI Seumirah
1108275309130001 LATIFAH Seumirah
1108272205140001 NURBAITI Seumirah
1108274509130001 IDAWATI Seumirah
1108275202140001 JASMANI Seumirah
1108276508140001 IDAWATI Seumirah
1108278801140001 ROHANI Seumirah
1108274302140001 ISNAWATI JAFAR Seumirah
1108221604140002 ASMAWATI Seumirah
1108270402140001 FARIDAH Seumirah
Seumirah
1108272310130001 JUWAIRIAH Seumirah
1108272505140002 NURLINA Seumirah
1108274107790001 FADLIAH Seumirah
1118025901860001 HUSNAWATI Seumirah
1108164107730378 AISYAH Seumirah
1108164312890005 NURHADANI Seumirah
1108275301820001 RUHAMAH ISHAK Seumirah
1108165508840003 SURYANI Seumirah
1108154107890378 DARMIATI Seumirah
1108164106870001 DAHLIANA Seumirah
1108155006820001 MASKINAH Seumirah
1118025901850001 HUSNAWATI Seumirah
1108164107880472 SURYATI Seumirah
1108154107730261 NURFAUZILAH Seumirah
1108164107840388 FARYATI Seumirah
1108274611920001 SAFIDAR Seumirah
1108275706860001 HASTUTI Seumirah
1108274107820004 WARDIAH Seumirah
1108164107780609 NURBAYANI Seumirah
1108164107880560 KARTINI Seumirah
1108025612820001 SYARBANI Seumirah
1108164107880358 ELVIANA Seumirah
1108164107860607 YUSMANI ADNAN Seumirah
1108274412920002 NURBAITI Seumirah
1108275401110002 RAUZAH Seumirah
1108274707110001 NURMASYITAH Seumirah
1108276211100001 MULYANA Seumirah
1108273110100001 SAIDAH AHMAT Seumirah
1108022011100002 IDAWATI Seumirah
1171042706110001 NURJANNAH Seumirah
1108272205110001 DELA HASRAD FITRI Seumirah
1108271005110001 FITRI WAHYUNI Seumirah
1108161411060038 METIA AFRIDA Seumirah
1108161511060117 NURBAYANI Seumirah
1108272806110002 SURYANI Seumirah
1108271010100003 FATIMAH Seumirah
1108271103110001 SURYANI Seumirah
1108032512110001 IDAWATI IDRIS Seumirah
1108276607110001 FATIMAH ZUHRA Seumirah
Jumlah Vial Sisa

0
Nama petugas :
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

Tanggal Diimunisasi Polio (nOPV2) Keterangan

No.Hp
Dosis 1 Dosis 2
j k l m
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
105
 FORMAT PENCATATAN HASIL PEL

Nama POSYANDU : SD 10
Nama Desa/kelurahan SEUMIRAH
Tanggal 05 DESEMBER 2022

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin
(L/P)
a b c d e
1 Abdul Khalid 2011-05-17 L
2 ABIL MOULANA 2013-03-30 L
3 AFKAR AULIA 2013-07-24 L
4 Afzalul Zikri 2011-06-01 L
5 AL GHIFARI 2015-05-18 L
6 ALFINA KHAIRA 2015-02-17 P
7 ALIA SABILA 2016-01-05 P
8 Alya Syakira 2012-01-02 P
9 AMELYA ZAHWA 2016-01-18 P
10 Arif Maulana 2011-03-24 L
11 Aris Munandar 2012-05-05 L
12 ASYRAF ZULFA 2012-12-09 L
13 AWIS ALKARANI 2016-03-06 L
14 AZHARI 2016-03-22 L
15 Azkia 2010-10-10 P
16 CAHAYA ACKILA 2014-05-21 P
17 CUT FAZILAH RAHMAWATI 2015-05-28 P
18 Cut Mutia 2012-08-07 P
19 Dimas Khatami 2011-01-07 L
20 FADHLUN AKHTIARI 2014-05-18 L
21 FARHAN MUNTADHAR 2014-07-25 L
22 Firdausi 2011-12-27 L
23 Fitri wahyuni 2012-06-12 P
24 FURQAN 2013-05-03 L
25 HAJATUN NAILA 2013-10-23 P
26 HARIF AL HISYAM 2015-10-17 L
27 Hayatul Husna 2011-03-01 P
28 Hilnawati 2012-08-15 P
29 Husna 2011-07-07 P
30 INDAH MUSYIFIATI 2016-06-12 P
31 Indah Permatasari 2011-06-26 P
32 Intan 2011-12-27 P
33 INTAN SUCI 2016-06-15 P
34 Ira Irwana 2011-10-10 P
35 ISMIL MUBARAQ 2013-09-27 L
36 JANNATUN NISA 2013-04-16 P
37 Liyana Zahira 2013-11-13 P
38 MAISYA ILFIZAH 2015-11-21 P
39 MAISYA MAQFIRAH 2013-09-29 P
40 Maisya Nianda 2012-05-14 P
41 MAULANA REZA 2015-04-02 L
42 MELLY TASLIMA 2013-11-25 P
43 Muhammad Alfian 2011-03-01 L
44 MUHAMMAD ALIF MAULANA 2012-11-19 L
45 MUHAMMAD ARIF 2014-02-22 L
46 MUHAMMAD FURKAN 2016-06-15 L
47 MUHAMMAD HAFIZ RIANDA 2012-09-04 L
48 MUHAMMAD IMRAN 2016-01-20 L
49 MUHAMMAD IRSYADI 2013-05-12 L
50 MUHAMMAD KHAIDIR 2013-07-19 L
51 MUHAMMAD NAJASYI 2014-03-04 L
52 MUHAMMAD NASIR 2014-10-18 L
53 MUHAMMAD NAZAR 2015-06-08 L
54 MUHAMMAD NAZARUDDIN 2014-06-04 L
55 Muhammad Raih 2012-02-10 L
56 MUHAMMAD REZA 2014-08-20 L
57 MUHAMMAD RIZA AL-FATA 2015-06-12 L
58 MUHAMMAD RIZKI 2013-06-14 L
59 MUHAMMAD SAPUTRA 2015-05-15 L
60 MUHAMMAD SARBULIS 2015-06-12 L
61 MUHAMMAD SARYULIS 2016-06-23 L
62 Mukrazil 2011-09-15 L
63 Nabila nofa 2011-05-15 P
64 NAHYATUL ULA 2013-11-29 P
65 Natasya Salsabila 2012-11-20 P
66 Nuraini 2010-10-10 P
67 Nurhajijah 2012-09-04 P
68 RAFINA AULIA 2013-10-18 P
69 Rahmatul Maula 2010-12-13 L
70 RAHUL KIRAM 2015-11-14 L
71 Raisul Alfarisyi 2011-01-09 L
72 RAISUL FATNI 2015-01-25 L

Jumlah vial Jumlah vial

Jumlah Vial nOPV dibawa dipakai
MAT PENCATATAN HASIL PELAYANAN SUB PIN POLIO

nisasi susulan pada kolom keterangan

NIK Nama orang tua NIK Orang Tua Alamat

f g h i
1108271705110001 Basyariah 1108064107780220 Lhok drin
1108273003130001 WARDIAH 1108164107840404 Lhok drin
1108272407130001 NADARIAH JALIL 1108164107890535 Lhok drin
1108270106110002 Fatimah Zuhra 1108164306920002 Lhok drin
1108021805150002 ROSNITA 1108027110830001 Lhok drin
1108275702150001 MARYAMAH YUSUF 1108166409850001 Lhok drin
1108274501160001 NURHAYATI IBRAHIM 1108164107800521 Lhok drin
1108274201120001 Dewi Saputri 1108024107970340 Lhok drin
1108275801160001 FARYANI 1108164107960358 Lhok drin
1108272403110002 Mawarni 1108164107890549 Lhok drin
1108270505120002 Putriani 1108165506900003 Lhok drin
1108020912120001 TIAMINAH 1108024204720002 Lhok drin
1108270603160001 BASYARIAH 1108054107780220 Lhok drin
1108272203160001 NIDARWATI 1108164803880001 Lhok drin
1108275010100004 Tikamariah 1108165108800001 Lhok drin
1108276105140002 HENDON 1111175212800005 Lhok drin
1108276805150001 NURHAYATI 1108165407760001 Lhok drin
1173024708120001 Nila Wati 1174034404830004 Lhok drin
1108270701110001 Anaroyani Brama 1108165212880003 Lhok drin
1108271807140001 MAHDALIANA Lhok drin
1108272507140002 NIDARWATI 1108164803880001 Lhok drin
1108272712110002 Nurmala Harun 1108165110770002 Lhok drin
1108275206120003 Kasmiati 1108278105950001 Lhok drin
1108270305130002 MAWARNI 1108164107890549 Lhok drin
1108166310130001 MARWIDAH IDRIS 1108164709860003 Lhok drin
1108271710150001 DARWATI JALIL 1108166007750001 Lhok drin
1108274103110002 Nurlaila Harun 1108185107700001 Lhok drin
1108275508120001 Harlina 1108165111840001 Lhok drin
1108274606110002 Kasmi lela 1108144107880270 Lhok drin
1108274409160002 HENDON 1111175212800005 Lhok drin
1108276606110001 Tarwiah Agani 1108160911860003 Lhok drin
1108276712110002 Kartisyah 1108168002720002 Lhok drin
1108275510160001 TARWIAH 1108164911860003 Lhok drin
1108275010110001 Murtiani M. Ali 1108164107880523 Lhok drin
1108272709130001 AFNIDAR YUSUF 1108166711730001 Lhok drin
1108275604140001 MOINIAH SULAIMAN 1108166210820001 Lhok drin
1108165311130001 Satriani Lhok drin
1108276111150001 MARYATI 1108166111810001 Lhok drin
1108276909130001 SURYATI 1108165508840002 Lhok drin
1108275405120001 Mahdaliana 1108164709790002 Lhok drin
1108270204150001 SURYATI SYAMAUN 1108164806800001 Lhok drin
1108276511130003 NURISMAWATI 1108164208870002 Lhok drin
1108270103110001 Nuraini 1108165007840001 Lhok drin
1108271911120001 ANI FAGITA 1108274608900001 Lhok drin
1108272202140001 MURTIANI M. ALI 1108164107880523 Lhok drin
1108271511160001 NURHAYATI ABIDIN 1108165104750001 Lhok drin
1108270409120002 NURDIANA 1108274607880001 Lhok drin
1108272001160001 FITRI JULITA 1111104107900055 Lhok drin
1108271210130001 MURHAMI 1108275205730001 Lhok drin
1108271907130001 HAZIANTI HAMDAH 1108162911790001 Lhok drin
1108270403140001 HARLINA ALAMSYAH 1108165111840001 Lhok drin
1108271810140001 BAITI HARUN 1108165504720001 Lhok drin
1108270812150001 NURHAYATI MAJID Lhok drin
1108270406140001 MARYANI 1108064107820238 Lhok drin
1108271002120002 Asnidar Yusuf 1108165308740002 Lhok drin
1108272008140001 RUSDIANA 1108165511830001 Lhok drin
1108271209150001 HENDON 1111175212800005 Lhok drin
1108271406130001 KASMAWATI 1108271908810001 Lhok drin
1108271209150001 DARMAWATI 1108165806910001 Lhok drin
1108271208150001 JUWAIRIAH 1108154103800001 Lhok drin
1108272306160001 ERNI SAFITRI 1108254608950001 Lhok drin
1108271509110001 Nurlaili 1108274107880005 Lhok drin
1108275505110002 zuryati Usman 1108168001890002 Lhok drin
1108276911130002 DARMAWATI 1108165806910001 Lhok drin
1108276012120001 Ataniah 1108166710800001 Lhok drin
1108275010100002 Hazianti 1108168911790001 Lhok drin
1108274409120001 Nurleli Hasanuddin 1103195106800001 Lhok drin
1108275810130001 LILIS FITRIANI M.ALI 1108164107880522 Lhok drin
1108271312100001 Ani Fagita 1108274608900001 Lhok drin
1108271409150001 ZURYATI USMAN 1108165001890002 Lhok drin
1108270901110001 Maryati.S.Pd 1108277112810002 Lhok drin
1108272501150001 YUSNANI 1108164612860002 Lhok drin

Jumlah Vial Sisa

0
Nama petugas :
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

Tanggal Diimunisasi Polio (nOPV2) Keterangan

No.Hp
Dosis 1 Dosis 2
j k l m
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
 FORMAT PENCATATAN HASIL PELA

Nama SEKOLAH SD 11
Nama Desa/kelurahan :
Tanggal :

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin
(L/P)
a b c d e
1 AL-FARIL 2014-01-14 L
2 ALFANI KHAIRA 2013-10-18 L
3 ALFIZANNUR 2013-08-24 L
4 AMAT FADILAH 2008-11-09 L
5 AMNA YUSRA MONA 2014-11-18 P
6 AMNATUL FAJRI 2011-02-02 P
7 ANISA HUMAIRA 2015-07-14 P
8 Ardina Rahayu 2016-06-06 P
9 Arif Maulana 2013-04-19 L
10 Ayu Nazira 2012-06-12 P
11 CUT KHALISA 2011-12-14 P
12 CUT ULFA RAMAZAN 2016-06-10 P
13 DARNILA 2012-07-08 P
14 DINA AKMALIA 2011-07-23 P
15 ELVIA SALSABILA 2013-06-06 P
16 FADHLULLAH 2015-10-06 L
17 FAKHRUL ULA 2013-10-17 L
18 FARHAN 2013-10-10 L
19 FAUZAN AZHIMI 2016-10-31 P
20 FITRIA RAMADANI 2010-08-17 P
21 HABIBAH 2016-02-28 P
22 HASANUDDIN 2009-05-29 L
23 HAYATUL HUSNA 2012-12-08 P
24 IBRAHIM 2014-12-17 L
25 ISAN MOULANA 2016-12-01 L
26 IZZATUN NAFIS 2015-10-07 P
27 Izzatun Nafiza 2015-11-27 P
28 IZZATUN ZAHIRA 2015-10-07 P
29 KALILA NATIFA 2013-07-05 P
30 KAMILATON NISA 2015-05-13 P
31 KHAIRANI ATTAHYA 2016-08-04 P
32 KHAIRUL UMUR 2013-05-01 L
33 LAINA NAZIRA 2012-08-22 P
34 Lutfi Ananda 2011-07-29 L
35 MARFUYATI 2011-08-13 P
36 Marza Rahmalina 2015-11-30 P
37 MAULIDA SHANI 2016-01-22 P
38 MAULIDI AL-FATA 2013-04-16 L
39 MIFTAHUL FITRI 2012-08-08 P
40 MIFTAHUL RIZKI 2013-11-13 P
41 MISRINA MUNIRA 2014-04-05 P
42 MUHAMMAD ABIDZHAR AL - GHIFARI 2014-08-14 L
43 MUHAMMAD AHYAL 2015-12-30 L
44 Muhammad Alif 2016-05-28 L
45 Muhammad Arif 2012-10-10 L
46 MUHAMMAD ARYS MAULANA 2012-10-03 L
47 MUHAMMAD ASRAR 2016-02-13 L
48 MUHAMMAD ASYRAF 2015-09-04 L
49 MUHAMMAD AYSRAF 2014-06-20 L
50 MUHAMMAD AZRIL 2016-09-18 L
51 MUHAMMAD BALIYAN 2012-04-11 L
52 MUHAMMAD DARMAWAN 2014-05-13 L
53 MUHAMMAD DIA ULHAQ 2016-09-11 L
54 MUHAMMAD FADIL 2011-02-05 L
55 MUHAMMAD FARHAN 2009-05-05 L
56 MUHAMMAD FAZAR 2010-11-20 L
57 MUHAMMAD FAZIL 2010-03-29 L
58 Muhammad Fazil Oula 2012-02-14 L
59 MUHAMMAD FIKAR 2010-04-01 L
60 Muhammad Fozan 2011-10-19 L
61 Muhammad Hafizd 2015-08-14 L
62 MUHAMMAD IKHSAN 2014-06-12 L
63 Muhammad Ikram 2012-01-10 L
64 MUHAMMAD KHAIR 2013-05-05 L
65 MUHAMMAD KHAYIR 2015-11-03 L
66 Muhammad Nafis 2014-01-25 L
67 Muhammad Reza Maulana 2012-02-12 L
68 MUHAMMAD RIJAL 2009-09-17 L
69 MUHAMMAD RIZKI 2013-11-03 L
70 MUHAMMAD SAFARI 2013-12-17 L
71 MUHAMMAD SARYULIS 2014-02-25 L
72 MUHAMMAD ZAINI 2014-10-05 L
73 MUHAMMAT REZA RAMAZANA 2014-07-01 L
74 MUNIRATUL HUSNA 2014-09-19 P
75 MUNIRATUL HUSNA 2011-11-13 P
76 MUSTAFA 2011-01-04 L
77 MUTIA RAHMI 2012-03-03 P
78 NADIA SAFWA 2012-07-08 P
 79 NADIATUL FAJRI 2015-12-09 P
80 NAFISATUN NURI 2015-01-23 P
81 Naila Rizka 2013-09-18 P
82 NAILA ULIA 2013-10-29 P
83 Nailul Humaira 2016-04-26 P
84 NASRUDDIN 2013-12-23 L
85 NAZARUDDIN 2012-10-11 L
86 NISA HUMAIRA 2013-08-20 P
87 NISA ULHAFIZA 2012-05-02 P
88 NOVIYA 2010-10-14 P
89 NURDIN 2010-10-14 L
90 Nurrahmi 2009-08-11 P
91 NURUL KHAIRA 2014-03-23 P
92 Nurul Maulina 2007-09-02 P
93 OJA SAPUTRA 2010-10-20 L
94 PUTRI BALKIS 2011-07-14 P
95 RAUZATUL JANNAH 2013-10-24 P
96 RAZUL AL-FARIZI 2014-12-10 L
97 Riski Bahri 2013-02-28 L
98 RIZKA KHAIRA 2016-04-25 P
99 SALIMIN 2013-04-05 L
100 SALMAN QARDHAWI 2016-04-29 L
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127

Jumlah vial Jumlah vial

Jumlah Vial nOPV dibawa dipakai
AT PENCATATAN HASIL PELAYANAN SUB PIN POLIO

nisasi susulan pada kolom keterangan

NIK Nama orang tua NIK Orang Tua Alamat

f g h i
1108271401140001 ILYAS ABDUL GANI 1108164110780050
1108275810130003 ABDUL MUTALEB 1108164107880530
1108276408130001 ZAINAL ABIDIN 1108164107810334
1108270911080002 ADIAR 1108274107800002
1108275811140001
1108274202110001 BASRI USMAN 1108164107860543
1108275407150002
1108274606160001
1108271904130001 Riswan M Yunus 1108164107920474
1108275206120002 Razali 1108164107770330
1108275412110001 IBRAHIM 1108164107820466
1108025006160003 M. NUR ALI 1108024805790001
1108274807120002 ISKANDAR 1108164107800510
1108276307110001 M. YAHYA 1108164107780511
1108274606130001 MOHD YUSUF USMA 1108164107760383
1108270610150001
1108271710130001 ABUBAKAR M. ISIN 1108164107860541
1108271010130001 RAZALI USMAN 1108164107790301
1108273110160001 MOHD. KASEM 1108164107510083
1108275708100001 NURIMAN 1108164107720320
1108276802160001 RASYIDI 1108165103900001
1108272905090001 NURDIN 1108164107840390
1108274812120001 NURDIN 1108164107840390
1108271712140001
1108270112160002 MUZAKIR 1108154503000002
1108274710150001 ISTARDI 1108164107800498
1108276711150001 Nurdin
1108274710150002 ISTARDI 1108164107800498
1108274507130001 ISMAIL AHMAD 1108164107777032
1108275305150003
1108274408160002 KALAMUDDIN 1108275605860001
1108270105130001 BURHANUDDIN ALM 1108164107770326
1108276208120001 JAFARUDDIN ADAM 1108164303870002
1173042907110001 Ridwan 1173046510760001
1108275308110002 RASYIDI 1108165103900001
1108277011150001 Sumardi Abdullah 1108274306930001
1108276201160001 SYAHRUL UMRI 1103074809870002
1108271604130002 BAKTIAR 1108184107800503
HASANUDDIN 1108164706890003
1108271211130001 M. YUSUF 1108164107880470
1108274504140001
1108111408140001
1108273012150001 AGUS RIZAL 1108164107880471
1108112805160002 Muhammad Ramadhani
1108271010120001 Armia 1108166002910001
1108270310120001 SYARIFUDDIN 1108164107760384
1108271302160001 MUHAMMAD YATIM 1108155103950001

1108272006140001 JAFARUDDIN ADAM 1108164303870002

1103151809160001 DARWIS M. YUNUS 1103155502940001
1108271104120001 Ilyas 1108164107800602
1108271305140002 SYARIFUDDIN 1108164107760384
1108271109160001 BOIHAKI 1108164107840435
1108270502110001 ZULKIFLI 1108164107730373
1108276505090001 MURDANI 1108274107840002
1108272011100001 ABUBAKAR 1108164107700555
1108272903100001 ISMAIL DAUD 1108274205900001
1108271402120001 Tgk. Arifin 1108164107810341
1108270104100001 A. KADER USMAN 1108164107750396
1108271910110001 M. Daud Yahya 1108164107630336
1271091408150002 Muliadi Ismail
1108271206140002 ABDULLAH ARAHMA 1108164107890571
1108271001120001 Murdani 1108274107840002
1108270505130002 HERIADI ANWAR 1108274102910001
1108270311150002
1108272501140001 Darsuki Abdullah
1108271202120001 M. Kasem Taleb 1108164107830617
1108271709090001 M. NASIR 1108164107850426
1108270311130002 ZULKIFLI 1111014212890002
1108271712130001 MUNIZAR USMAN 1108274110930001
1108272502140001 AZHARI 1108275006910002
1108270510140001
1108270107140001 Agus Rizal 1108164107880471
1108275909140001
1108275311110001 RISWAN 1108164107920474
1108170802020001 M. ALI 1108164107750393
1108274303120001 Afifiddin 1108164107750392
1108274807120003 SAIFUL AMNA 1108164107830464
1108274912150001 ABUBAKAR 1108164107860541
1108276301150001
1108275809130001 Marzuki M. Yusuf 1108164107910463
1108276910130001 ISMAIL DAUD 1108274206900001
1108276604160001
1108272312130001 M. NASIR 1108164107850428
1108271110120001 ISRANUDDIN HASBI 1108276506910001
1108276008130001 MOHAMMAD ALI 1108164107800500
1108274205120001 Saifuddin Zikri 1108164107820523
1108275410100002 ADIAR M. YATIM 1108274107800002
1108271410100002 ADIAR 1108274107800002
1108275108090001 T. ARIFIN
1108276303140001 ISMUHAR 1108274107940013
1108274209070002 ARIFIN 1108164107810341
1108272010100001 BAIHAKI 1108164107840435
1108275407110001 EDIYAN 1108164107810335
1108276410130001 Abdullah M. Amin 1108164107790306
1108271012140002
1108272802130002 Baktiar 1108164107840486
1108276504160001 MOHD ISA HASAN 1108275504960001
1108270504130001 AZHAR SARONG 1108164107780510
1108272904160001 JAMALUDDIN 1108165009930002
Jumlah Vial Sisa

0
Nama petugas :
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

Tanggal Diimunisasi Polio (nOPV2) Keterangan

No.Hp
Dosis 1 Dosis 2
j k l m
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
 FORMAT PENCATATAN HASIL PELA

Nama POSYANDU : PAUD ANISAMI

Nama Desa/kelurahan : SEUMIRAH
Tanggal : 06 DESEMBER 2022

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin
(L/P)
a b c d e
1 Syindi Oulia 17-02-2017 5 Tahun P
5 Tahun
2 Indah Fitria 10/8/2017 P
3 Muhammad Awwari 29-08-2017 5 Tahun L
4 Silfia Munira 14-11-2016 6 Tahun P
5 Rauzatul Jannah 29-10-2017 5 Tahun P
6 Nur Azizah 14-11-2017 5 Tahun P
7 Fatimah Zuhra 12/12/2016 6 Tahun P
8 Muhammad Hafiz Haikal 20-01-2017 5 Tahun L
9 Munzirul Umam 6/3/2017 5 Tahun L
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
 79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
TOTAL

Jumlah vial Jumlah vial

Jumlah Vial nOPV dibawa dipakai
AT PENCATATAN HASIL PELAYANAN SUB PIN POLIO

nisasi susulan pada kolom keterangan

NIK Nama orang tua NIK Orang Tua Alamat

f g h i
1108275702170001 Susandri 1116070512880002 Dusun Lhok Drien
1108275006170001 Samsul Bahri Adam 1108160107720295 Dusun Lhok Drien
1108272908170001 Mansurni 1108162704890001 Dusun Lhok Drien
1108275411160002 Irawadi 1108162708830001 Dusun Lhok Drien
1108276910170001 Anwar 1108272601750001 Dusun Lhok Drien
1108275411170002 Mulyadi 1108161303840001 Dusun Lhok Drien
1108275212160001 Syukri Ismail 1108162901880001 Dusun Lhok Drien
1108272001170001 Jafaruddin Syamaun 1108270906850001 Dusun Lhok Drien
1108270603170001 Muhammad Wali 1108270310870001 Dusun Lhok Drien
Jumlah Vial Sisa

0
Nama petugas :
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

Tanggal Diimunisasi Polio (nOPV2) Keterangan

No.Hp
Dosis 1 Dosis 2
j k l m
1 ✓
1
✓
1 ✓
1
1
1
1
1
1
9
 FORMAT PENCATATAN HASIL PELAY

Nama sekolah TK BUNGA DESA

Nama Desa/kelurahan SEUMIRAH
Tanggal 06 DESEMBER 2022

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin
(L/P)
a b c d e
1 MUHAMMAD IKHSANUDDIN 15-03-2017 L
2 DEA AFRIJA 3/1/2017 P
3 SYAFATUL HUSNA 1/11/2016 P
4 AULIA ZULFA 23-03-2017 P
5 AURA RIZKIA 7/12/2016 P
6 NAJUWA ASYILA 21-06-2017 P
7 SABRAN MALASI 7/4/2017 L
8 MUHAMMAD IQBAL NAZRIL 2/12/2017 L
9 HABIB ARRIZIK 28-03-2017 L
10 SYAFITRI RAHMADANI 27-06-2017 P
11 MUHAMMAD RIZKI MUBARAQ 22-06-2017 L
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
 79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
TOTAL

Jumlah vial Jumlah vial

Jumlah Vial nOPV dibawa dipakai
T PENCATATAN HASIL PELAYANAN SUB PIN POLIO

Nama petugas
Puskesmas
Kabupaten

nisasi susulan pada kolom keterangan

NIK Nama orang tua NIK Orang Tua Alamat No.Hp

f g h i j
1111071503170000 DIA ULFA SEUMIRAH
1111044301170001 RAUDHAH SEUMIRAH
1111154111160001 MULYANI SEUMIRAH
1108275103190001 MAULIDA WATI SEUMIRAH
1108274712160001 ASMAUL HUSNA SEUMIRAH
1108276106170001 SAFNIDAR SEUMIRAH
1108270704170001 KARMIANI SEUMIRAH
1108272112170003 FITRIANI SEUMIRAH
1108272803170001 NURBAITI SEUMIRAH
1108276706170001 TIHALIMAH SEUMIRAH
1108272206170001 RUWAIDA SEUMIRAH
Jumlah Vial Sisa

0
:
NISAM ANTARA
: ACEH UTARA

Tanggal Diimunisasi Polio (nOPV2) Keterangan

Dosis 1 Dosis 2
k l m
1
1
1
1
1
1
1
1
1
1
1
11
 FORMAT PENCATATAN HASIL PELAYANAN SUB PIN

NAMA SEKOLAH TK BUNGA PADE

DESA SEUMIRAH
TANGGAL 06 DESEMBER 2022

Jenis
Nama Anak Tgl lahir Umur Kelamin NIK
(L/P)
b c d e f
1 Abbyyu Dzaky 02-05-2017 5 Tahun L 1108270205180001
Alfia Rahma 31-12-2016 6 Tahun p 1271095312150001
Isani Maulana 01-12-2016 6 Tahun L 1108270112160001
Maulida Shani 22-01-206 6 Tahun p 1108276201160001
Muhammad Khadafi 19-06-2017 5 Tahun L 1108271907180002
Mutia Rahmi 26-08-2016 6 Tahun p 1108276608160001
Salman Qardhawi 29-04-2016 6 Tahun L 1108272904160001
Urwatul Wasqa Azqia 08-02-2016 6 Tahun P 1111034802160001
Muhammad Alif 28-05-2016 6 Tahun L 1108272009180001
Salsabila Magfirah 23-09-2016 6 Tahun P 1108106309160001
Muhammad Khalil 19-11-2016 6 Tahun L 1108271911160001
Muhammad Azis 16-06-2017 5 Tahun L 1108271606170002
TOTAL

Jumlah
Jumlah vial
vial Jumlah Vial Sisa
Jumlah Vial nOPV dibawa
dipakai
0
ASIL PELAYANAN SUB PIN POLIO

Nama petu:
Puskesmas NISAM ANTARA
Kabupaten : ACEH UTARA

Tanggal Diimunisasi
Nama orang tua NIK Orang Tua Alamat No.Hp Polio (nOPV2)
Dosis 1 Dosis 2
g h i j k l
1108270205180001 Seumirah 1
1271095312150001 Seumirah 1
1108270112160001 Seumirah 1
1108276201160001 - Seumirah 1
1108271907180002 1108024107920433 Seumirah 1
1108276608160001 - Seumirah 1
1108272904160001 - Seumirah 1
1111034802160001 - Seumirah 1
1108272009180001 1108106206090001 Seumirah 1
1108106309160001 1108164107810341 Seumirah 1
1108271911160001 1108164107800500 Seumirah 1
1108271606170002 Seumirah 1
12
 FORMAT PENCATAT
Nama Posy Seroja 1
Nama Desa/kelurahan :Alue Dua
Tanggal :06-12-2022

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi su
Jenis
No. Nama Anak Tgl lahir Umur Kelamin
(L/P)
a b c d e
1
AHMAD KHAIRUL KHALIDI 2018-07-16 
2 AIDIL DAHWAN 2018-06-26 
3 AQILATUN NISA 2019-12-03 
4 AULIATUN NISA 2019-09-22 
5 AZIZAH 2018-02-06 
6 AZIZAH MAYYIRA 2020-10-03 
7 BAHYAL ALKHATAMI 2018-07-24 
8 BILQIS PURATUN AQNIYA 2021-02-03 
9 CUT ZUHRATUL ATIQAH 2019-08-31 
10 DANIS ALFAYAT 2018-08-27 
11 FAIZA NAFISATUN NAJA 2020-05-13 
12 KHANZA ASKANTILA 2020-01-17 
13 LANVISA MALAHA 2018-08-20 
14 MIFZAL ALFARIZKI 2017-12-10 
15 MIFZAL AZZANI 2019-12-21 
16 MILKA MAISYURA 2018-02-15 
17 MUHADIR 2018-06-20 
18
MUHAMMAD FIZAL ASHFA 2018-10-18 
19 MUHAMMAD SYADDA
AISY 2019-07-08 
20 MUHAMMAD SYAUQAL 2019-11-08 
21 MUHAMMAD ZAFRAN
ABRAR 2018-12-18 
22 NABILA SALSABILA 2019-04-01 
23 NAIFA ZAHIRA 2018-12-25 
24 NAISA HUMAIRA 2018-05-25 
25 NAJWA TANISYA 2017-12-06 
26 NAURATUL AZIZI 2018-07-02 
27 NAZIRATUL AULIA 2019-02-04 
28 NISA ATTAHIRA 2017-12-15 
29 NISAMI SABILA 2018-04-03 
30 NISAUL SABILA 2018-04-03 
31 RAISA AQILA 2019-11-26 
32 RAISA HIDAYANTI 2018-09-20 
33 RAISUL ISTIKBAL 2019-03-09 
34 RIFATUL AMNA 2018-02-11 
35 RISLA LABIQA 2019-01-09 
36 SALMAN ALFARISYI 2019-09-11 
37 SALWA NABILA 2018-07-23 
38 SITI LUTHFIATUNNISA 2018-09-17 
39 SULFI HUMAIRA 2020-07-10 
40 ZAKIUL FUADI 2018-03-26 
41 ZAWIR ARHAN 2020-07-22 
42 ZUMAR ZAMAWI 2018-02-15 
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
 73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127

Jumlah vial Jumlah

vial
Jumlah Vial nOPV dibawa
dipakai
 FORMAT PENCATATAN HASIL PELAYANAN SUB PIN POLIO
Nama petu
Puskesmas
Kabupaten

adwal pemberian imunisasi susulan pada kolom keterangan

NIK Nama orang tua NIK Orang Tua Alamat No.Hp

f g h i j

1108151607140001  A RISAL ALUE DUA

1108272606180001  MUHADAR ALUE DUA
1111214312199791  JAMALUDDIN ALUE DUA
1108276209190001  MANSYURNI ALUE DUA
1108274602180001  M. JAMUDDIN ALUE DUA
1108274310200001  fadli ALUE DUA
1108272407180001  FAUZI ALUE DUA
1108274302210001  bachtiar ALUE DUA
1108160812060039  LUKMAN HAKIM ALUE DUA
1108272708180001  MUSYIDIN ALUE DUA
1108275305200001  fachrurizal ALUE DUA
1111215701202052  ZULFIKAR ALUE DUA
1111216008180000  MUHIBBUDIN ALUE DUA
1108271012170001  MULYADI ALUE DUA
1111212112192658  IZHAR ALUE DUA
1111215502180000  ZULKIFLI ALUE DUA
1111212006180000  MUHADAR ALUE DUA

1108271810180001  ZULKIFLI ALUE DUA

1111170807190001  AZAMI ALUE DUA

1111210811191685  ZULKIFLI ALUE DUA

1108271812180001  ABDURRAHMAN ALUE DUA

1108274104190001  MAHARDI ALUE DUA
1108276512180001  ISKANDAR ALUE DUA
1108276504118000  SAIFUL ALUE DUA
1108274612170001  TGK. MAWARDI ALUE DUA
1108274207180001  ABDUL WAHAB ALUE DUA
1108274402190001  ISWADI ALUE DUA
1108275512170001  AYAH NISA ATTAHIRA ALUE DUA
1108274304160001  NAHARUDDIN ALUE DUA
1108274304180001  NAHARUDDIN ALUE DUA
1111216611196855  M. DAINI ALUE DUA
1108276009180001  ABADI ALUE DUA
1108270803190001  TARMIZI ALUE DUA
1108275102180002  ABDULLAH TUBEN ALUE DUA
1108274901190001  ABDURRAHMAN ALUE DUA
1111211109193524  ASNAWI ALUE DUA
1108276307180001  SOFIYAN ALUE DUA
1111215709180000  HERMANSYAH ALUE DUA
1108275007200001  hasanusi ALUE DUA
1108272603180001  M. ALI ALUE DUA
1108272207200001  zulkifli ALUE DUA
1111211502189484  MUHAMMAD ALUE DUA
Jumlah Vial Sisa

0
:Maulida Amd.Keb
NISAM ANTARA
: ACEH UTARA

Tanggal Diimunisasi
Polio (nOPV2)
Dosis 1 Dosis 2
k l
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
 FORMAT PENCATATAN HASIL PELAYA
Nama Posya Seroja 2
Nama Desa/kelurahan :Alue Dua
Tanggal :06-12-2022

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK
(L/P)
a b c d e f
1 ABIDHAR ALGHIFFARY 2018-06-26 
2 AFI GHBRAN 2018-02-20 
3 AINOL MARZIAH 2020-03-03 
4 AKMAL MAULANA 2018-04-16 
5 ALIVIA MUNAJA 2019-04-16 
6 ALMAHDIL KURMI 2018-06-30 
7 AMIRA 2018-05-02 
8 AOLA ALFAZILA 2019-04-23 
9 ARISYA MAQFIRAH 2020-12-29 
10 AZKIA MAWADDAH 2018-02-17 
11 BALQIS KEYLA 2019-09-29 
12 CUT AIDA SYUTRI 2019-11-13 
13 CUT AZRIKA 2018-08-08 
14 DAFFA IBNU HAFIZ 2019-02-11 
15 ELIA SOFIA 2018-12-10 
16 FAIRUZZA MAULIDIA 2017-12-09 
17 ITA AFRIYANI 2019-06-24 
18 M.ADAM 2020-07-03 
19 M.HANIF 2020-05-03 
20 M.RANGGA 2021-04-13 
21 MARHABAN 2018-07-26 
22 MIFTAHUL JANNAH 2018-02-09 
23 MIKA AZZUHRA 2019-03-04 
24 MUDHAFFA 2020-09-09 
25 MUHAMMAD AFKAR AULIA 2018-01-24 
26 MUHAMMAD ALFATIH 2018-06-22 
27 MUHAMMAD ARSYA 2017-11-03 
28 MUHAMMAD AZRIL 2017-12-11 
29 MUHAMMAD AZZAM ALFATIH 2020-02-28 
30 MUHAMMAD DAFA AQRAMUL 2019-08-10 
31 MUHAMMAD DASTUR 2018-01-13 
32 MUHAMMAD HAFIS 2018-09-18 
33 MUHAMMAD JUNA 2018-10-05 
34 MUHAMMAD MUZAMMIR 2021-03-18 
35 MUHAMMAD RAJU 2018-06-30 
36 MUHAMMAD REZA 2017-11-20 
37 MUHAMMAD YAA SIIN 2019-06-12 
38 NABILA TABA 2018-08-14 
39 NAJWA SALSABILA 2019-07-05 
40 NUFUS TIHAJAR 2019-11-01 
41 NURUL HUSNA 2018-10-18 
42 RAFIA SHABINA 2019-04-20 
43 RAHMAT ZULFAN 2018-01-05 
44 RAHMATULLAH 2017-11-24 
45 RAIHAN MAULIANDA 2018-01-09 
46 SALMAN ALFARISI 2019-01-10 
47 SHAFIA HUMAIRA 2018-01-31 
48 SHIFA NAZIRA 2018-01-20 
49 SULTAN ALFARISI 2020-01-01 
50 SYIFATUN NISA 2017-12-04 
51 WILDATUL KHAFIZA 2018-04-06 
52 ZAHIRATUL KHAIRA 2019-10-29 
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127

Jumlah vial Jumlah

vial Jumlah Vial Sisa
Jumlah Vial nOPV dibawa
dipakai
0
TATAN HASIL PELAYANAN SUB PIN POLIO
Nama petu:Maulida Amd.Keb
PuskesmasNISAM ANTARA
Kabupaten: ACEH UTARA

ulan pada kolom keterangan

Tanggal Diimunisasi
Nama orang tua NIK Orang Tua Alamat No.Hp Polio (nOPV2)
Dosis 1 Dosis 2
g h i j k l
DUSUN BANDA SELAMAT 1
SIMPANG IV SANDI 1
simpng iv sandi 1
DUSUN SIMPANG KURSI 1
DUSUN SIMPANG IV SANDI 1
DUSUN SIMPANG IV SANDI 1
DUSUN ALUE BANIE 1
DUSUN SIMPANG IV SANDI 1
DUSUN BANDA SEULAMAT 1
BND SELAMAT 1
DUSUN SIMPANG IV SANDI 1
DUSUN BANDA SELAMAT 1
DUSUN SIMPANG IV SANDI 1
DUSUN SIMPANG IV SANDI 1
DUSUN ALUE BANIE 1
DUSUN BANDA SELAMAT 1
DUSUN SIMPANG KURSI 1
simpang iv sandi 1
DSN SP KURSI 1
DUSUN SIMPANG IV SANDI 1
DUSUN SIMPANG KURSI 1
DUSUN SIMPANG KURSI 1
DUSUN BANDA SELAMAT 1
sIMPANG IV SANDI 1
DUSUN SIMPANG KURSI 1
DUSUN SIMPANG KURSI 1
DUSUN BANDA SELAMAT 1
DUSUN ALUE BANIE 1
SIMPANG IV SANDI 1
DUSUN SIMPANG KURSI 1
DUSUN SIMPANG IV SANDI 1
SIMPANG IV SANDI 1
DUSUN BANDA SELAMAT 1
dsn sp iv sandi 1
DUSUN SIMPANG IV SANDI 1
DUSUN ALUE BANIE 1
DUSUN SIMPANG KURSI 1
DUSUN SIMPANG KURSI 1
ALUE BANE 1
ALUE BANE 1
DUSUN SIMPANG KURSI 1
DUSUN SIMPANG IV SANDI 1
DUSUN SIMPANG IV SANDI 1
DUSUN BANDA SELAMAT 1
DUSUN SIMPANG IV SANDI 1
DUSUN SIMPANG KURSI 1
DUSUN ALUE BANIE 1
DUSUN BANDA SELAMAT 1
SIMPANG IV SANDI 1
DUSUN ALUE BANIE 1
SIMPANG IV SANDI 1
DUSUN SIMPANG IV SANDI 1
 FORMAT PENCATATAN HASIL PELA
Nama Posyandu :Seroja 3
Nama Desa/kelurahan :Alue Dua
Tanggal :06-12-2022

Jenis
Nama Anak Tgl lahir Umur Kelamin NIK
(L/P)
b c d e f
AFIKA ZAHIRA 2018-10-21 
AISYA FAIHA 2018-03-23 
ANNISA HUMAIRA 2019-05-22 
CUT AZKIATUL ULFA 2019-07-05 
CUT INTAN PUTRIANA 2019-04-26 
CUT NADIVA 2017-11-19 
CUT SYIFA RAHMADANI 2018-08-21 
CUT ZAKIATUL ULFA 2019-11-07 
FATIA ZAMIRA 2020-02-22 
FIKRI 2019-06-05 
HAFIZ NOFAHAIDAR 2019-02-17 
HANIFA 2019-01-25 
INTAN JUWITA 2018-07-14 
INTAN JUWITA 2018-07-14 
KHAIRUL AZZAM 2019-05-25 
LUDHFIA KHAIRA 2018-04-18 
MAYA ALISHA 2019-05-10 
MUHAMMAD ALFARISI 2018-07-09 
MUHAMMAD ALFATANI 2017-12-21 
MUHAMMAD ALIF ILHAM 2018-05-26 
MUHAMMAD ALKAUSAR 2018-10-01 

MUHAMMAD ARSYAD ALGHIFARI 2021-02-04 

MUHAMMAD AZIZUL HAKIM 2019-12-17 
MUHAMMAD AZRIL AL FATIH 2019-04-13 
MUHAMMAD FAIRUZ 2019-11-09 
MUHAMMAD KHAIRIL 2018-05-01 
MUHAMMAD RAMADHAN 2018-06-12 
MUHAMMAD ZAFRAN 2019-09-02 
MUHAMMAD ZAIYAN 2019-09-02 
MUHAMMAD ZIKRI 2019-01-10 
NADIA ULFA 2017-11-23 
NAZRIL ALFARIZ 2017-12-19 
NISFAUL KAILA 2018-04-23 
NUR SYAKILA 2018-07-28 
NURI FAZILA 2018-03-17 
PUTRI SYAKILA 2018-07-08 
SAFRIYATI 2019-10-29 
SAIRA LATHFA 2019-04-24 
SUHAILA 2019-05-16 
SULTAN M. ZAMANHURI 2019-03-06 
SYAKILA AZZAHRA 2018-04-17 
ZAHRA LUTFIA 2018-11-24 
ZAHRA LUTFIYA 2018-11-24 
ZAHWA AKILA 2019-03-07 
ZAHWA AQILA 2019-07-10 
ZIYAD ASYRAF 2020-04-28 
ATATAN HASIL PELAYANAN SUB PIN POLIO
Nama petugas
Puskesmas
Kabupaten

Nama orang tua NIK Orang Tua Alamat No.Hp

g h i j
1108272611018001  ABDULLAH DUSUN BLANG RIMEH
1108276303180001  ASMADI DUSUN BLANG RIMEH
1108276205190001  BAKHTIAR DUSUN BLANG RIMEH
1111214507191417  rasyidin blang rimeh
1108276604190001  MUNIZAR MUHAMMAD DUSUN BLANG RIMEH
1108275911170001  YUSNI ZAINAL DUSUN BLANG RIMEH
1108276108180001  ARMIA DUSUN BLANG RIMEH
1108274711190001  RASYIDIN BLANG RIMEH
1108276302200001  RASYIDIN BLANG RIMEH
1108270506190001  SUDIRMAN DUSUN BLANG RIMEH
1108271702190001  BAKHTIAR DUSUN BLANG RIMEH
1108276501190001  ZULKIFLI ZAKARIA DUSUN BLANG RIMEH
1108275407180001  LUKMAN ALI BLANG RIMEH
1111215407185761  lukman ali blang rimeh
1108272505190001  HAMDANI DUSUN BLANG RIMEH
1108275804180001  MARZUKI DUSUN BLANG RIMEH
1108275005190001  MALAUDDIN DUSUN BLANG RIMEH
1111210907180000  NURDIN DUSUN BLANG RIMEH
1111212112174269  JUMADI BLANG RIMEH
1108272605180001  JUNAIDI DUSUN BLANG RIMEH
1108270110180001  SAIFUDDIN DUSUN BLANG RIMEH

1108270402210001  muhammad iskandar dsn sp rambong

1108271712190001  AFIFUNIJI AB DUSUN BLANG RIMEH
1108271304190001  ARFANUDDIN DUSUN BLANG RIMEH
1108270911190001  M. JUFRI DUSUN BLANG RIMEH
1108270105180001  FAKRURRAZI DUSUN BLANG RIMEH
1108271206180001  JUNAIDI DUSUN BLANG RIMEH
1108270209190001  FAISAL DUSUN BLANG RIMEH
1108270209190002  FAISAL DUSUN BLANG RIMEH
1108271001190001  HUSAINI DUSUN BLANG RIMEH
1108276311170001  NURDIN DUSUN BLANG RIMEH
1108271912170001  MUSAWIN DUSUN BLANG RIMEH
1108276304180002  IBRAHIM DUSUN BLANG RIMEH
1108274807180001  MUS MULYADI DUSUN BLANG RIMEH
1111211703180000  AHMADI DUSUN BLANG RIMEH
1111212003180000  ILYAS DUSUN BLANG RIMEH
1108272910190001  RIZWAN DUSUN BLANG RIMEH
1108276404190001  SYARIFUDDIN DUSUN BLANG RIMEH
1108275605190001  ZULKIFLI HASAN DUSUN BLANG RIMEH
1111210603199768  FAUZAN AZMI BLANG RIMEH
1108275704180001  MUSTAFA DUSUN BLANG RIMEH
1111216411187161  muslim blang rimeh
1117016411180001  MUSLIM BLANG RIMEH
1108024703190002  WAHYUDI FAHMI BLANG RIMEH
1111215007191159  wayudi fahmi blang rimeh
1108272804200001  bakhtiar blang rimeh
:Maulida Amd.Keb
NISAM ANTARA
: ACEH UTARA

Tanggal Diimunisasi Polio

(nOPV2)
Dosis 1 Dosis 2
k l
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
 FORMAT PENCATATAN HASIL PELAYANAN SUB PIN P
Nama Posyandu :Seroja 4
Nama Desa/kelurahan :Alue Dua
Tanggal :06-12-2022

Jenis
Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua
(L/P)
b c d e f g
ALISYA NADILA 2018-04-23  1108276304180001 
ALIYA NAZRIATI 2019-12-22  1108272910170001 
ASKAR IFATA 2019-02-21  1108272102190004 
ASMAUL HUSNA 2019-06-26  1108271604999999 
AWIS KARNAINI 2018-05-22  1108272208160001 
FATIMAH ZUHRA 2019-07-21  1108276107190001 
HAURA TAQIYA 2018-05-31  1108277105180001 
KHALISA AULIA 2018-09-04  1108274409180001 
LIZA HUMAIRA 2018-08-08  1108274808180002 
M.HUMAN AL HAFIS 2021-07-13  110827210160001 
MUHAMMAD ARUL MAULANA 2020-11-07  1108270711200001 
MUHAMMAD IRFAN 2018-03-01  1108271205999999 
MUHAMMAD SYARIF 2017-11-09  1108270911170001 
NASYA SYAKIRA 2018-03-04  1108274403180001 
NOVA ARSYILA 2019-11-07  1108274711190002 
NUR AINA 2019-06-26  1108271602199999 
NURAINI 2019-05-02  1108274205190001 
QAILA ALISHA HUSNA 2020-09-27  1108276709200002 
RIAN ARAFIS 2019-11-20  1108272011190001 
RIZKI ANADA 2019-03-09  1108270903190001 
SARYULIS 2018-11-23  1108272311180001 
SRI WAHYUNI 2018-03-08  1108274803180002 
TIARA ALISSA 2020-01-16  1108275601200001 
ULFA 2019-01-01  1108274164190002 
PELAYANAN SUB PIN POLIO
Nama petu:Maulida Amd.Keb
PuskesmasNISAM ANTARA
Kabupaten: ACEH UTARA

Tanggal Diimunisasi Polio

NIK Orang Tua Alamat No.Hp (nOPV2)
Dosis 1 Dosis 2
h i j k l
BAKHTIAR DUSUN KRUENG TUAN 12/6/2022
sayuti krueng tuan 12/6/2022
mustafa kreng tuan 12/6/2022
FAISAL DUSUN KRUENG TUAN 12/6/2022
BUDIAMIN DUSUN KRUENG TUAN 12/6/2022
JUNAIDI DUSUN KRUENG TUAN 12/6/2022
nurdin krueng tuan 12/6/2022
SOFYAN DUSUN KRUENG TUAN 12/6/2022
ASNAWI DUSUN KRUENG TUAN 12/6/2022
rasyidi ds krueng tuan 12/6/2022
jefri krueng tuan 12/6/2022
MAWARDI DUSUN KRUENG TUAN 12/6/2022
SOPIAN DUSUN KRUENG TUAN 12/6/2022
YUSUF DUSUN KRUENG TUAN 12/6/2022
M. RIZAL DUSUN KRUENG TUAN 12/6/2022
SAIFUDDIN DUSUN KRUENG TUAN 12/6/2022
amri babussalam 12/6/2022
sulmahdi krueng tuan 12/6/2022
sulaiman ds krueng tuan 12/6/2022
M. RIZAL DUSUN KRUENG TUAN 12/6/2022
DARMAWA
N DUSUN KRUENG TUAN 12/6/2022
JAFRIADI DUSUN KRUENG TUAN 12/6/2022
MULYADI DUSUN KRUENG TUAN 12/6/2022
muslem kruengtuan 12/6/2022
 FORMAT PENCATATAN HASIL PELAYANA
Nama Posyandu :Seroja 5
Nama Desa/kelurahan :Alue Dua
Tanggal :06-12-2022

Jenis
Nama Anak Tgl lahir Umur Kelamin NIK
(L/P)
b c d e f
ALIFA MAGHFIRAH 1/14/2020 P 1108275401200000
JAMALUDDIN FAHRI 3/27/2018 L 1108272703180000
RIDWAN TALEB 3/7/2018 L 1111210703184840
WAFA AZKA AZZAHRA 1/2/2020 P 1109024201200000
SYAKILA NAJWA P 1117070507780000
ARDIN PADDIL L 1108272310150000
M.RADIANSYAH L 1108272210150000
ALANDA FEBRIAN L 1108272009150000
NURUL ELISA P 1108274601220000
SYILFA P 1108276403150000
PENCATATAN HASIL PELAYANAN SUB PIN POLIO
Nama petu
Puskesmas
Kabupaten

Nama orang tua NIK Orang Tua Alamat No.Hp

g h i j
MUHAMMAD KASIM 1108270805880001 JABAL ANTARA
SAHARA 1108270204870001 JABAL ANTARA
MUHAMMAD 1108275309800001 JABAL ANTARA
YAYAN MIKRASAPUTRA 11090202122900003 JABAL ANTARA
HASANUDDIN JABAL ANTARA
MUHAMMAD ALI JABAL ANTARA
JAILANI JABAL ANTARA
GUN SUPRIADI JABAL ANTARA
JABAL ANTARA
MUKHLIS JABAL ANTARA
:Maulida Amd.Keb
NISAM ANTARA
: ACEH UTARA

Tanggal Diimunisasi
Polio (nOPV2)
Dosis 1 Dosis 2
k l
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
12/6/2022
 FORMAT PENCATATAN HASIL PELAYANAN SUB
Paud Putroe nisam antara

JENIS
NO NAMA ANAK KELAMI TANGGAL NIK ANAK
N LAHIR

1 M RIZKI AKBAR L 29/04/2017 1108272904170001

2 MUHAMMAD NABIL A L 15/01/2018 1108271501180001
3 M. RIJAL L 22/11/2016 1108272211160001
4 LUTHFIA IZZA P 17/08/2016 1108271708160001
5 CUT INTAN KHAIRANI P 22/10/2017 1108276210170001
6 M RAFFI ALMAN L 31/05/2017 1108273105170001
7 SYAKILA ADILA P 12/10/2016 1108275210160001
8 ECA INDRIANI P 03/07/2016 1108275910160001
9 KHAIRUL AZZAM L 08/04/2017 1108270804170001
10 ALYA MUKHBITA P 08/01/2017 1108264901170001
11 SAFIATUN NAJA P 03/12/2017 1108154312170001
12 AKIFA NAILA P 1108275210160001
ATATAN HASIL PELAYANAN SUB PIN POLIO

NAMA IBU/AYAH NIK IBU NO HP PUTARAN I PUTARAN 2

1
Nurjannah 1108271201960001 1
AFNIDAR 1108164107940456 1
RAHMI 1108275402950001 1
MARLIAH 1
CUT FITRIANI SYAMAUN 1
JASMANI 1108277112910001 1
MURDANI 1
RAMAZANI 1108164107920470 1
NURKASMI 1
SALYATI 1
YUSNA 1
T.M DANISI 1188160107700374 1