FORMAT PENCATATAN HASIL PELAYANAN

Posyandu/Pos ayanan BIAN lainnya : Nama petugas :Yuli Fitriyanti

Desa/kelurahan Puskesmas tanjung kerang
Tanggal Kabupaten musibanyuasin

Imunisasi Kejar
(Ya = 1, Tidak=0)
Ket** (bila anak mendapatkan
Campak dosis kedua/keetiga/keempat
Jenis Kelamin Rubela OPV/Penta saat BIAN, maka
No. Nama Anak Tgl lahir Umur (L/P) Nama orang tua Alamat No.Hp NIK (Ya=1, tetap dicatat namun tidak
Tidak=0) dimasukkan sebagai cakupan
OPV IPV DPT-HB-Hib BIAN)

a b c d e f g h i j k l m n

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Jumlah vaksin (vial) dan logistik yang digunakan
Pelarut Campak
Jenis logistik OPV IPV DPT-HB-HIB CAMPAK RUBELA Dropper ADS 0,5 ML ADS 5 ML Safety Box Pen Marker
Rubela
Jumlah
Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
 FORMAT REKAPITULASI HASIL PELAYANAN BULAN IMUNISASI ANAK NASIONAL TINGKAT PUSKESMAS
Desa/kelurahan : LAIS Tanggal :
Puskesmas : LAIS Nama petugas :
Isilah pada kolom yang berwarna

Sasaran dan Cakupan Imunisasi Kejar Sasaran dan cakupan imunisasi campak rubela
Usia 12 -<15 thn
Usia 12 - 59 bulan Usia 9-59 bulan Usia 5 - <7 thn Usia 7-<12 thn (bagi 5 Prov.) Total
No Posyandu/Pos layanan BIAN lainnya OPV IPV DPT-HB-Hib Campak Rubella Campak Rubela Campak Rubela Campak Rubela Sasaran
Jumlah Campak
Jumlah Jumlah % Jumlah Jumlah % Jumlah diimuni % Jumlah Jumlah % Jumlah Jumlah % Jumlah Jumlah % Jumlah Jumlah % Rubella
sasaran diimunisasi sasaran diimunisasi sasaran sasi sasaran diimunisasi sasaran diimunisasi sasaran diimunisasi sasaran diimunisasi
a b c d e f g h i j k l m n o p q r s t u v w x
5/19/2022 POSYANDU TERATAI LAIS 0 0.0% 0 0 0.0% 0 0.0% 20 20 100.0% 0.0% 0 0 0.0% 0 0 0.0% 20

5/23/2022 SDN 1 EPIL 0.0% 0.0% 0.0% 0.0% 0.0% 236 209 88.6% 0.0% 236

5/24/2022 SDN 2 EPIL 0.0% 0.0% 0.0% 0.0% 0.0% 109 95 87.2% 0.0% 109
SDN MUARA PADANG 0.0% 0.0% 0.0% 0.0% 0.0% 41 41 100.0% 0.0% 41
SDN JAYA SAKTI 0.0% 0.0% 0.0% 0.0% 0.0% 21 21 100.0% 0.0% 21

5/25/2022 SDN 1 DANAU CALA 0.0% 0.0% 0.0% 0.0% 0.0% 94 88 93.6% 0.0% 94
MI EPIL 0.0% 0.0% 0.0% 0.0% 0.0% 128 125 97.7% 0.0% 128
SDN KP SAWIT VI 0.0% 0.0% 0.0% 0.0% 0.0% 81 77 95.1% 0.0% 81

5/27/2022 SDN 3 EPIL 0.0% 0.0% 0.0% 0.0% 0.0% 80 80 100.0% 0.0% 80
SDN 2 DANAU CALA 0.0% 0.0% 0.0% 0.0% 0.0% 129 114 88.4% 0.0% 129

5/28/2023 MI DANAU CALA 0.0% 0.0% 0.0% 0.0% 0.0% 103 87 84.5% 0.0% 103

5/30/2022 SDN 1 LAIS 0.0% 0.0% 0.0% 0.0% 0.0% 302 233 77.2% 0.0% 302
TK AISYAH 0.0% 0.0% 0.0% 0.0% 30 13 43.3% 0.0% 30
PAUD KASIH BUNDA 0.0% 0.0% 0.0% 0.0% 41 13 31.7% 0.0% 41
PAUD PERMATA BUNDA 0.0% 0.0% 0.0% 0.0% 23 8 34.8% 0.0% 23
TK ABADI 0.0% 0.0% 0.0% 0.0% 26 24 92.3% 0.0% 26
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0
5/31/2022 SDN 2 LAIS 0.0% 0.0% 0.0% 0.0% 0.0% 228 205 89.9% 0.0% 228
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0
6/2/2022 SDN EKA BHAKTI 0.0% 0.0% 0.0% 0.0% 0.0% 225 165 73.3% 0.0% 225
SDN 2 TELUK 0.0% 0.0% 0.0% 0.0% 0.0% 155 139 89.7% 0.0% 155
SDN TASSA IX 0.0% 0.0% 0.0% 0.0% 0.0% 183 129 70.5% 0.0% 183
SDN POM SAWIT 0.0% 0.0% 0.0% 0.0% 0.0% 133 93 69.9% 0.0% 133
SDN KP Sawit V 0.0% 0.0% 0.0% 0.0% 0.0% 60 56 93.3% 0.0% 60
SDN KB UMUR 0.0% 0.0% 0.0% 0.0% 0.0% 42 32 76.2% 0.0% 42
TK ANUGRAH 0.0% 0.0% 0.0% 0.0% 31 5 16.1% 0.0% 31
TK AL HAPIDZ 0.0% 0.0% 0.0% 0.0% 29 10 34.5% 0.0% 29
PAUD SERUMPUN BANGSA 0.0% 0.0% 0.0% 0.0% 49 47 95.9% 0.0% 49
PAUD BINTANG KEJORA 0.0% 18 16 88.9% 18
PAUD UTAMA KARYA 0.0% 33 21 63.6% 33
0.0%
6/3/2022 SDN TL DUKU 0.0% 208 170 81.7% 208
MUHAMADIYAH TELUK 0.0% 197 150 76.1% 197
RA ADATIYAH 0.0% 25 25 100.0% 25
PAUD MENTARI 0.0% 33 8 24.2% 33
0.0%
 6/4/2022 SDN TL BONOT 0.0% 190 165 86.8% 190
0.0%
6/6/2022 PAUD TUNAS MUDA 0.0% 41 27 65.9% 41
TK IKI POM/BETUNG 0.0% 35 14 40.0% 35
PAUD NURSERY 0.0% 38 27 71.1% 38
PAUD FLAMBOYAN 0.0% 25 10 40.0% 25
TK BINA DESA 0.0% 25 10 40.0% 25
PAUD PURNAMA 0.0% 25 25 100.0% 25
0.0%
6/7/2022 SDN 1 TELUK 0.0% 39 25 64.1% 39
PAUD SINAR BUNDA 0.0% 15 6 40.0% 15
PAUD PERMATA BUNDA 0.0% 39 26 66.7% 39
0.0% 0
6/8/2022 PAUD PELANGI 0.0% 25 24 96.0% 25
PAUD KASIH IBU 0.0% 21 20 0.0% 21
POSYANDU ANGGREK (PILIP V ) 47 47 100.0% 0.0% 47
0.0% 0.0% 0
6/9/2022 PAUD BINA SAHABAT 0.0% 24 23 95.8% 24
0.0% 0
6/10/2022 Posyandu Ranggonang 1 Danau Cala 60 60 100.0% 60
0.0% 0
6/11/2022 Posyandu Ranggonang 2 Danau Cala 42 42 100.0% 42
Posyandu flamboyan Tassa IX 38 38 100.0% 4 4 100.0% 42
0.0% 0.0% 0
6/13/2022 Posyandu Ranggonang 3 (DC) 20 20 100.0% 0.0% 20
0.0% 0.0% 0
6/15/2022 Posyandu Aster Lais 50 50 100.0% 0.0% 50
Merpati 2 Epil 30 30 100.0% 0.0% 30
Posyandu Mawar Telki 3 30 30 100.0% 0.0% 30
Posyandu Teratai Telki 3 20 20 100.0% 0.0% 20
0.0% 0.0% 0
6/16/2022 Posyandu Merpati 3 Epil 40 40 100.0% 0.0% 40
Posyandu Delima Lais 30 30 100.0% 0.0% 30
Posyandu Latulif Teluk 70 70 100.0% 0.0% 70
0.0% 0.0% 0
6/17/2022 Posyandu Mawar Teluk 30 30 100.0% 0.0% 30
0.0% 0.0% 0
6/20/2022 Posyandu Bulan Telki 3 30 30 100.0% 30
0.0% 0
6/22/2022 Posyandu Merpati 2 Epil 30 30 100.0% 30
0.0% 0
6/23/2022 Posyandu Teratai Lais 20 20 100.0% 20
0.0% 0
6/27/2022 Posyandu Aster Lais 5 5 30 30 100.0% 30
0.0% 0.0% 0
6/28/2022 Posyandu Sedap malam (m pdg) 10 10 100.0% 0.0% 10
Posyandu Kutilang /jy sakti 20 20 100.0% 20
Posyandu Cendrawasih/kb umur 25 25 100.0% 25
0.0% 0
6/29/2022 Posyandu Sakura/Pilip VI 30 30 100.0% 30
Posyandu Asparagus/Bonot 50 50 100.0% 50
0.0% 0
6/30/2022 Posyandu Buah hati Lais 5 5 40 40 100.0% 40
Posyandu Merpati 1 Epil 5 5 30 30 30
0
7/1/2022 Posyandu Delima Lais 25 25 15 15 10 10 50
0
 7/4/2022 SDN 1 Lais 50 50 50
0
7/5/2022 Posyandu Melati teluk 25 25 25
Posyandu Flamboyan tassa IX 28 28 28
0
7/12/2022 Posyandu merpati 1 Epil 26 26 26
Paud permata bunda epil 14 14 14
0
7/13/2022 SDN TL Duku 30 30 30
SDN Pom sawit 12 12 12
0.0% 0
7/14/2022 SDN EKA BHAKTI LAIS 40 40 40
Paud Flamboyan tassa IX 0.0% 16 16 16
0
7/18/2022 Posyandu merpati Epil 30 30 30
Posyandu mawar telki 3 28 28 28
Posyandu bulan Telki3 30 30 30
0
7/19/2022 Posyandu merpati 2 Epil 30 30 30
Posyandu Mekarsari Dc 25 25 25
Puskesmas Lais 6 6 5 5 45 45 45
0
7/20/2022 Posyandu Mawar Teluk 4 4 5 5 30 30 30
Posyandu mMerpati 2 Epil 8 8 7 7 55 55 55
Posyandu Buah hati Lais 7 7 6 6 40 40 40
Puskesmas Lais 4 4 5 5 22 22 22
0
7/21/2022 Posyandu Merpati Epil 60 60 60
Posyandu latulif teluk 10 10 10

9/7/2022 Puskesmas Lais 30 30 30

9/9/2022 Puskesmas Lais 37 37 37

9/12/2022 Puskesmas Lais 38 38 10 10 12 12 60

9/14/2022 Puskesmas Lais 10 10 10

9/15/2022 Puskesmas Lais 10 10 10

Posyandu merpati Epil 10 10 20 20 30
Posyandu mawar telki3 8 8 8

9/23/2022 Posyandu bulan telki3 28 28 28

9/29/2022 Posyandu merpati epil 10 10 20 20 30

Puskesmas Lais 8 8 10 10 18

10/12/2022 Posyandu merpati Epil 7 7 10 10 17

10/19/2022 Posyandu Latulif teluk 10 10 8 8 18

0.0% 0.0% 0
Total 34 34 ### 10 10 100.0% 28 28 100.0% 1571 1571 100.0% 698 449 64.3% 3204 2719 84.9% 0 0 0.0% 5473
 Total
dimunisasi Total
Campak Cakupan
Rubella

y z
20 100.0%

209 88.6%

95 87.2%
41 100.0%
21 100.0%

88 93.6%
125 97.7%
77 95.1%

80 100.0%
114 88.4%

87 84.5%

233 77.2%
13 43.3%
13 31.7%
8 34.8%
24 92.3%
0
205 89.9%
0
165 73.3%
139 89.7%
129 70.5%
93 69.9%
56 93.3%
32 76.2%
5 16.1%
10 34.5%
47 95.9%
16 88.9%
21 63.6%

170 81.7%
150 76.1%
25 100.0%
8 24.2%
165 86.8%

27 65.9%
14 40.0%
27 71.1%
10 40.0%
10 40.0%
25 100.0%

25 64.1%
6 40.0%
26 66.7%

24 96.0%
20 95.2%
47 100.0%

23 95.8%

60 100.0%
0
42 100.0%
42 100.0%
0 0.0%
20 100.0%
0 0.0%
50 100.0%
30 100.0%
30 100.0%
20 100.0%
0 0.0%
40 100.0%
30 100.0%
70 100.0%
0 0.0%
30 100.0%
0 0.0%
30 100.0%
0 0.0%
30 100.0%
0 0.0%
20 100.0%
0 0.0%
30 100.0%
0 0.0%
10 100.0%
20 100.0%
25 100.0%
0 0.0%
30 100.0%
50 100.0%
0 0.0%
40 100.0%
30 100.0%
0 0.0%
50 100.0%
0 0.0%
 50 100.0%
0 0.0%
25 100.0%
28 100.0%
0 0.0%
26 100.0%
14 100.0%
0 0.0%
30 100.0%
12 100.0%
0 0.0%
40 100.0%
16 100.0%
0 0.0%
30 100.0%
28 100.0%
30 100.0%
0 0.0%
30 100.0%
25 100.0%
45 100.0%
0 0.0%
30 100.0%
55 100.0%
40 100.0%
22 100.0%
0 0.0%
60 100.0%
10 100.0%

30

37

60

10

10
30
8

28

30
18

17

18
0 0.0%
4739 86.6%
 FORMAT REKAPITULASI LOGISTIK PUSKESMAS
Provinsi : Sumatera selatan Tanggal :
Kabupaten/Kota :
Musibanyuasin
Puskesmas : LAIS

Isilah Kolom yang berwarna kuning!

OPV IPV DPT-HB-Hib Campak Rubela Jumlah Logistik yang digunakan

No. Posyandu/Pos Imunisasi lainnya

Jumlah Jumlah Vial IP Jumlah Jumlah Vial IP Jumlah Jumlah Vial IP Jumlah Jumlah Vial IP Pelarut Dropper ADS 0,5 ADS 5 Safety Pen
diimunisasi digunakan diimunisasi digunakan diimunisasi digunakan diimunisasi digunakan ML ML Box Marker

a b c d e f g h i j k l m n o p q r s t
5/19/2022 Posyandu Teratai desa lais 0 0 #DIV/0! 0 0 #DIV/0! 0 0 #DIV/0! 20 2 10 2 0 20 2 1 1

5/23/2022 SDN 1 Epil #DIV/0! #DIV/0! #DIV/0! 209 21 9.95 21 209 21 2 2

5/24/2022 SDN 2 Epil #DIV/0! #DIV/0! #DIV/0! 95 8 11.88 8 95 8 1 2

SDN Muara Padang #DIV/0! #DIV/0! #DIV/0! 41 4 10.25 4 41 4 1 1
SDN Jaya sakti #DIV/0! #DIV/0! #DIV/0! 21 2 10.50 2 21 2 1 1

5/27/2022 SDN 1 Danau Cala #DIV/0! #DIV/0! #DIV/0! 88 8 11.00 8 88 8 1 1

MI Epil #DIV/0! #DIV/0! #DIV/0! 125 11 11.36 11 125 11 1 2
SDN KP Sawit VI #DIV/0! #DIV/0! #DIV/0! 77 7 11.00 7 77 7 1 1
SDN 3 Epil #DIV/0! #DIV/0! #DIV/0! 80 8 10.00 8 80 8 1 1
SDN 2 Danau Cala #DIV/0! #DIV/0! #DIV/0! 114 11 10.36 11 114 11 1 1

5/28/2022 MI Danau cala #DIV/0! #DIV/0! #DIV/0! 87 8 10.88 8 87 8 1 1

5/30/2022 SDN 1 Lais #DIV/0! #DIV/0! #DIV/0! 233 22 10.59 22 233 22 2 2

TK Aisyah #DIV/0! #DIV/0! #DIV/0! 13 1 13.00 1 13 1 1 1
Paud Kasih Bunda #DIV/0! #DIV/0! #DIV/0! 13 1 13.00 1 13 1 1 1
Paud Permata Bunda #DIV/0! #DIV/0! #DIV/0! 8 1 8.00 1 8 1 1 1
TK Abadi #DIV/0! #DIV/0! #DIV/0! 24 2 12.00 2 24 2 1 1

5/31/2022 SDN 2 Lais 205 20 10.25 20 205 20 2 2

6/2/2022 SDN Eka Bhakti 165 15 11.00 15 165 15 2 2

SDN 2 Teluk 139 14 9.93 14 139 14 2 2
SDN TASSA IX 129 13 9.92 13 129 13 2 2
SDN POM Sawit 93 9 10.33 9 93 9 1 1
SDN KP Sawit V 56 5 11.20 5 56 5 1 1
SDN KB Umur 32 3 10.67 3 32 3 1 1
TK Anugrah 5 1 5.00 1 5 1 1 1
TK AL Hapidz 10 1 10.00 1 10 1 1 1
PAUD Serumpun Bangsa 47 5 9.40 5 47 5 1 1
PAUD Bintang Kejora 16 2 8.00 2 16 2 1 1
PAUD Utama Karya 21 2 10.50 2 21 2 1 1

6/3/2022 SDN TL DUKU 170 17 10.00 17 170 17 2 2

Muhammadiyah Teluk 150 15 10.00 15 150 15 2 2
Ra adatiyah 25 2 12.50 2 25 2 1 1
Paud Mentari 8 1 8.00 1 8 1 1 1

6/4/2022 SDN TL BONOT 165 16 10.31 16 165 16 2 2

 6/6/2022 PAUD TUNAS MUDA 27 3 9.00 3 27 3 1 1
TK IKI POM/BETUNG 14 2 7.00 2 14 2 1 1
PAUD NURSERY 27 3 9.00 3 27 3 1 1
PAUD FLAMBOYAN 10 1 10.00 1 10 1 1 1
TK BINA DESA 10 1 10.00 1 10 1 1 1
PAUD PURNAMA 25 3 8.33 3 25 3 1 1
#DIV/0!
6/7/2022 SDN 1 TELUK 25 3 8.33 3 25 3 1 1
PAUD SINAR BUNDA 6 1 6.00 1 6 1 1 1
PAUD PERMATA BUNDA 26 3 8.67 3 26 3 1 1

6/8/2022 PAUD PELANGI 24 2 12.00 2 24 2 1 1

PAUD KASIH IBU 20 2 10.00 2 20 2 1 1
POSYANDU ANGGREK (PILIP V ) 47 5 9.40 5 47 5 1 1

6/9/2022 PAUD BINA SAHABAT 23 2 2 23 2 1 1

6/10/2022 Posyandu Ranggonang 1 Danau cala 60 6 6 60 6 1 1

6/11/2022 Posyandu Ranggonang 2 Danau Cala 42 4 4 42 4 1 1

Posyandu flamboyan Tassa IX 42 4 4 42 4 1 1

6/13/2022 Posyandu Ranggonang 3 (DC) 20 2 2 20 2 1 1

6/15/2022 Posyandu Aster Lais 50 5 5 50 5 1 1

Merpati 2 Epil 30 3 3 30 3 1 1
Posyandu Mawar Telki 3 30 3 3 30 3 1 1
Posyandu Teratai Telki 3 20 2 2 20 2 1 1

6/16/2002 Posyandu Merpati 3 Epil 40 4 4 40 4 1 1

Posyandu Delima Lais 30 3 3 30 3 1 1
Posyandu Latulif Teluk 70 7 7 70 7 1 1

6/17/2022 Posyandu Mawar Teluk 30 3 3 30 3 1 1

6/20/2022 Posyandu Bulan Telki 3 30 3 3 30 3 1 1

2/22/2022 Posyandu Merpati 2 Epil 30 3 3 30 3 1 1

6/23/2022 Posyandu Teratai Lais #DIV/0! #DIV/0! #DIV/0! 20 2 10.00 2 20 2 1 1

6/27/2022 Posyandu Aster Lais 5 1 5 #DIV/0! #DIV/0! 30 3 10.00 3 30 3 1 1

6/28/2022 Posyandu Sedap malam (m pdg) 10 1 1 10 1 1 1

Posyandu Kutilang /jy sakti 20 2 2 20 1 1 1
Posyandu Cendrawasih/kb umur 25 2 2 25 1 1 1

6/29/2022 Posyandu Sakura/Pilip VI 30 3 3 30 1 1 1

Posyandu Asparagus/Bonot 50 5 5 50 1 1 1

6/30/2022 Posyandu Buah hati Lais 40 4 4 40 1 1 1

Posyandu merpati 1 Epil 30 3 3 30 1 1 1

7/1/2022 Posyandu Delima Lais 50 5 5 50 1 1 1

 7/4/2022 SDN 1 Lais 50 5 5 50 1 1 1

7/5/2022 Posyandu Melati Teluk 25 3 3 25 1 1 1

Posyandu Flamboyan tassaIX 28 3 3 28 1 1 1

7/12/2022 Posyandu merpati 1epil 26 3 3 26 1 1 1

Paud permata Bunda epil 14 2 2 14 1 1 1

7/13/2022 SDN TL Duku 39 3 3 39 1 1 1

SDN Pom sawit 12 1 1 12 1 1 1

7/14/2022 SDN EKA BHAKTI LAIS 40 4 4 40 1 1 1

Paud Flamboyan tasa IX 16 2 2 16 1 1 1

7/18/2022 Posyandu merpati Epil 30 3 3 30 1 1 1

Posyandu mawar telki3 28 3 3 28 1 1 1

7/19/2022 Posyandu merpati 2 Epil 30 3 3 30 1 1 1

Posyandu Mekarsari Dc 25 3 3 25 1 1 1
Puskesmas Lais 6 1 5 1 45 5 5 45 1 1 1

7/20/2022 Posyandu Mawar Teluk 4 1 5 1 30 3 3 30 1 1 1

Posyandu mMerpati 2 Epil 8 1 7 1 55 5 5 55 1 1 1
Posyandu Buah hati Lais 7 1 6 1 40 4 4 40 1 1 1
Puskesmas Lais 4 1 5 1 22 2 2 22 1 1 1

7/21/2022 Posyandu merpati Epil 60 6 6 60 1 1 1

Posyandu latulif teluk 10 1 1 10 1 1 1

9/7/2022 Puskesmas lais 30 3 3 30 1 1 1

9/9/2022 Puskesmas Lais 37 4 4 37 1 1 1

9/12/2022 Puskesmas Lais 60 6 6 60 1 1 1

9/14/2022 Puskesmas Lais 10 1 1 10 1 1 1

9/15/2022 Puskesmas Lais 10 1 1 10 1 1 1

Posyandu merpati Epil 30 3 3 30 1 1 1
Posyandu mawar telki3 8 1 1 8 1 1 1

9/23/2022 Posyandu bulan telki3 28 3 3 28 1 1 1

9/29/2022 Posyandu merpati Epil 30 3 3 30 1 1 1

Puskesmas Lais 18 2 2 18 1 1 1

10/12/2022 Posyandu merpati epil 17 2 2 17 1 1 1

19-10-20222 Posyandu Latulif teluk 18 2 2 18 1 1 1

TOTAL 34 6 5.66667 5 1 5 23 4 5.75 4718 466 10.12 466 0 4718 386 111 111

Catatan :
IP = Jumlah yang diimunisasi/jumlah vial vaksin yang digunakan