FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO

Nama Posyandu/Sekolah/Pos layanan : ANYELIR Nama petugas :

Nama Desa/kelurahan : CIMPAEUN Puskesmas : CIMPAEUN
Tanggal : Kabupaten : DEPOK

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Dosis 1 Dosis 2
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua Alamat No.Hp Keterangan
(L/P)
Tanggal
Diimunisasi
No Batch Tanggal
Diimunisasi
No Batch
nOPV2 Vaksin nOPV2 Vaksin
a b c d e f g h i j k l m n o
1 42
Adiba 10/6/2019 3276410610194254  Aman Cimpaeun RW 16 14
2 49
Aidil Syam 2/27/2019 3276426902190066  Ridwan Cimpaeun RT 1/16 14
3 23
Alea 4/25/2021 3276416504212523  Resky Cimpaeun RT 2/16 14
4 42
Aletta 9/25/2019 3276416509194970  Fauzi Cimpaeun RW 16 14
5 47
Almayra 5/3/2019 3276420305190044  Dwi Cimpaeun RT 3/16 14
6 46
Azelia 6/12/2019 3276415206192394  Ahmad Cimpaeun RT 3/16 14
7 48
Azril 3/29/2019 3276427103190066  Usup Cimpaeun RT 3/16 14
8 58
Eirazia 6/4/2018 3276420406100044  Endar Cimpaeun RT 3/16 14
9 20
El Hafiz 7/4/2021 3276410407215949  Rival Cimpaeun RT 3/16 14
10 45
Elisa 6/29/2019 3276422906190044  Abdul Cimpaeun RT 1/16 14
11 32
Erlita 7/11/2020 5107205955  Aroy Cimpaeun RT 1/16 14
12 23
Flita 4/19/2021 3276415904214759  Jaenal Cimpaeun RT 2/16 14
13 33
Galuh 7/7/2020 3276410707202303  Aridwan Cimpaeun RT 1/16 14
14 23
Giandra 4/13/2021 3276411304214928  Rasto Cimpaeun RT 1/16 14
15 51
Hanipah 1/12/2019 3276421201190044  Diana Cimpaeun RT 2/16 14
16 47
Hulwah 4/29/2019 3276422904190044  Biyan Cimpaeun RT 3/16 14
17 24
Humairah 3/8/2021 3276410803211992  Mila Cimpaeun RT 3/16 14
18 43
Kaniya 8/29/2019 3276422908190044  Wanto Cimpaeun RT 2/16 14
19 50
Kholid 1/29/2019 3276426901190066  Alimansyah Cimpaeun RT 2/16 14
20 48
Kinanty 3/29/2019 3276422903190044  Topik Cimpaeun RT 3/16 14
21 20
Kinza 7/28/2021 3276412807213501  Biyan Cimpaeun RT 3/16 14
22 39
M Patih 12/14/2019 3276411412192437  Ade Cimpaeun RT 1/16 14
23 52
M. Arsya 12/2/2018 3276424212180066  Iwan Cimpaeun RT 2/16 14
24 46
M. Bilal 6/2/2019 3276424206190066  Abidin Cimpaeun RT 3/16 14
25 56
M. Zikri 8/17/2018 3276425708180066  Lukman Cimpaeun RT 2/16 14
26 53
Mahira 11/2/2018 3276420211180044  Amir Cimpaeun RT 1/16 14
27 21
Nayla 6/23/2021 3276416306216298  Zae Cimpaeun RT 3/16 14
28 55
Parhan 9/15/2018 3276425509180066  Asep Cimpaeun RT 1/16 14
29 58
Patih A. 6/9/2018 3276424906180066  Ramzi Cimpaeun RT 3/16 14
30 44
Pitri 8/13/2019 3276421308190044  Subandi Cimpaeun RT 1/16 14
31 30
Qiyana 9/20/2020 3276416009201594  Hilda Cimpaeun RT 2/16 14
32 53
Rara Relania 11/3/2018 3276420311180044  Sanin Cimpaeun RT 1/16 14
33 21
Renata 7/2/2021 3276414207204857  Mawan Cimpaeun RT 1/16 14
34 19
assyifa kha 9/1/2021 sanisin cimpaeun 03/16
35
axeo el. Ks 23/12/2020 tri sunarto cimpaeun 03/16
36 24
Syaira 3/17/2021 3276415703211224  Iyan Cimpaeun RT 3/16
37 48
Syaqila 4/12/2019 3276421204190044  Abdulloh Cimpaeun RT 3/16
38 #VALUE!
andara shanum 19/09/2021 3276105909210004 Indra cimpaeun rt 01/16
39 #VALUE!
Raffasya 18/08/2021 Rahmat cimpaeun rt 01/ 16
40 #VALUE!
M Albiandra 18/08/2021 Fajri cimpaeun rt 01/16
41 #VALUE!
M Atharifai 23/10/2021 3276102710210003 Ridwan cimpaeun rt 03/16
42 #VALUE!
Idam Mallik 20/10/2021 3276102010210003 Abdulloh cimpaeun rt 03/16
43 #VALUE!
rapa 26/08/2020 Sanih cimpaeun 02/16
44 #VALUE!
raisa 26/08/2020 sanih cimpaeun 02/16
45 13
rubina 2/7/2022 apip cimpaeun 03/16
46 15
zea s a 12/11/2021 indri cimpaeun 01/16
47
Ukhasya 30/1/2023 abdulloh cimpaeun 01/16
48
Zulfiar 20/11/2022 sri bunga cimpaeun 02/16
49 #VALUE!
azzahra 17/08/2020 mila cimpaeun 01/16
50
azkheano s 17/12/2020 rey
cimpaeun 02/16
 51 azkiya 7/4/2021
angga cimpaeun 02/16

52 28/12/2020
cantika az maman cimpaeun 02/16
53 16/4/2018
kanaya minta cimpaeun 02/16

54 keanu 7/4/2018 saripudin cimpaeun 02/16

55 kenzie s.a 13/3/2020 lesno cimpaeun 02/16

56 m zaidan a 15/10/2019 maemunah cimpaeun 02/16

57 naura 30/7/2020 rizki cimpaeun 02/16

Jumlah
Jumlah vial Jumlah vial
vial
dibawa rusak
dipakai
Jumlah Vial nOPV