1.

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

1 2 3 V 5 6
3 6 0 3 3 7 6 Bulan : 2023
NAMA FASKES/ KLINIK CITRA OMEGA 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

1 01-April-2023 Agus Supriyanto 3 2 0 1 2 3 5 0 0 5 8 6 0 0 1 4 Lina Wandayani 10-May-1986 KP. CIIPARE 08963072934 3 1 0 0 3 1 0 0 1 0 0 0

17-December-
2 01-April-2023 Handi 3 6 0 3 0 4 5 7 1 2 0 1 0 0 0 9 Dela Salsabila KP. JAMBE 08953488114 3 1 0 0 3 1 0 0 1 0 0 0
2001

3 01-April-2023 HARIANTO 3 6 0 3 0 3 4 4 0 6 8 8 0 0 0 4 MASPUPAH 04-June-1988 KP. PINANG TIGARAKSA 08381117582 3 1 0 0 3 1 0 0 1 0 0 0

YOHANES ERICK
4 01-April-2023 3 6 7 1 0 2 4 2 0 5 8 6 0 0 0 8 MEGAWATI 02-May-1986 PERUM PURI PERMAI 0821556695454 3 1 0 0 3 1 0 0 1 0 0 0
CHISTIAN
05-October-1980
5 02-April-2023 Bakri 3 6 0 3 0 3 4 5 1 0 8 0 0 0 0 2 Titin Komala KP. MAMPELEM 0821566995548 3 1 0 0 3 1 0 0 1 0 0 0

KP KADONGDONG DS
6 02-April-2023 MUSTAR BIN EMAD 3 6 0 3 2 9 4 4 0 4 8 3 0 0 0 1 ICE HAYANI 04-April-1983 08963031198 3 1 0 0 3 1 0 0 1 0 0 0
PASIRNANGKA
23-February- PERUM SUDIRMAN INDAH, BLOK
7 04-April-2023 TURMUDI 3 6 7 1 0 5 6 3 0 2 7 8 0 0 0 3 HARYANTI 08521560771 3 1 0 0 3 1 0 0 1 0 0 0
1998 E19/25

8 05-April-2023 ANJAR TRI WIRAWAN 3 6 0 3 0 3 4 6 0 6 8 5 0 0 0 2 SUKMA YANTI 06-June-1985 PURI 2 D5 NO 4 0821554488855 3 1 0 0 3 1 0 0 1 0 0 0

9 05-April-2023 SUMARYONO 3 6 0 3 1 8 7 0 0 6 8 4 0 0 0 2 FITRFITRI ASTUTI 30-June-1986 PERUMAHAN PURI3 PERMAI 08578157030 3 1 0 0 3 1 0 0 1 0 0 0

10 07-April-2023 M. Yamin 3 6 0 3 3 1 4 8 0 6 0 0 0 0 0 3 Amelia Sari 08-June-2000 KP. PASIR 08317065645 3 1 0 0 3 1 0 0 1 0 0 0

25-October-1980
11 08-April-2023 Cecep 3 6 0 3 0 3 6 5 1 0 8 0 0 0 0 1 Suhani KP. MUNJUL 08131634789 3 1 0 0 3 1 0 0 1 0 0 0

12 08-April-2023 M KUSEN 3 2 0 1 2 3 5 6 0 5 7 9 0 0 0 1 MEMEN HUMAEROH 16-May-1979 KP. BARU 0085282406328 3 1 0 0 3 1 0 0 1 0 0 0

26-October-1976
13 09-April-2023 TRI MARYANTO 3 6 0 3 0 3 6 6 1 0 7 6 0 0 0 2 SADEWI PURI PERMAI BLOK H09 NO 18 85213283961 3 1 0 0 3 1 0 0 1 0 0 0

30-September- PERUM GRAND METRO SODONG 1

14 11-April-2023 AHMAD MANSUR 3 6 0 3 0 3 7 0 0 9 8 9 0 0 0 9 NIA KORNALIA 083897635909 3 1 0 0 3 1 0 0 1 0 0 0
1989 BLOK C1

15 11-April-2023 taupik nurdin 3 6 0 3 0 3 6 6 0 6 7 6 0 0 1 0 siti nurhasanah 26-June-1976 KP. KADONGDONG 085710955838 3 1 0 0 3 1 0 0 1 0 0 0

MUHAMMAD GERRY 25-February-

16 12-April-2023 3 6 0 3 0 3 6 5 0 1 0 0 0 0 0 1 SITI NURAIDA KP. PASIR NANGKA 0083873689293 3 1 0 0 3 1 0 0 1 0 0 0
HARYANTO 2000
26-January-1996
17 13-April-2023 RIRI AKMAL 3 6 0 3 1 8 6 8 0 1 9 6 0 0 0 1 SRI MULYATI SINDANG ASIH 0087871087360 3 1 0 0 3 1 0 0 1 0 0 0

18 13-April-2023 supriadi 3 6 0 3 0 3 4 5 0 6 8 1 0 0 0 8 sartinah 05-June-1981 KELAPA DUA 0821554455884 3 1 0 0 3 1 0 0 1 0 0 0

01-January-1992
19 14-April-2023 MOHAMAD KUSMAN 3 6 0 1 1 4 1 0 7 9 2 0 0 0 5 2 EMAH MUHAEMAH KP. KEDONGDONG 0081281667879 3 1 0 0 3 1 0 0 1 0 0 0

20 15-April-2023 Siswanto 3 6 0 3 0 3 5 2 0 7 9 6 0 0 0 8 Epi Sriyanti 12-July-1996 KP. LENGSIR 08992344376 3 1 0 0 3 1 0 0 1 0 0 0

21 17-April-2023 ANDRI SUTARYA 3 6 0 3 0 3 6 5 0 4 9 6 0 0 0 2 SITI PATONAH 25-April-1996 KP. KALUWUNG 8215545558 3 1 0 0 3 1 0 0 1 0 0 0

22 18-April-2023 Ahmad Fachrozi 3 6 0 3 0 3 6 2 0 6 8 7 0 0 0 2 Ropiah 22-June-1987 KP. CISEREH 08231101494 3 1 0 0 3 1 0 0 1 0 0 0

DESA PEMATANG KECAMATAN

23 18-April-2023 AWING 3 6 0 3 0 3 5 7 0 7 8 9 0 0 0 1 RUMSIAH 17-July-1991 0814582254458 3 1 0 0 3 1 0 0 1 0 0 0
TIGARAKSA
DESA PEMATANG KECAMATAN
24 18-April-2023 SALEH 3 6 0 3 0 3 6 5 1 0 8 4 0 0 0 1 MARYANI 20-May-1984 082156695545 3 1 0 0 3 1 0 0 1 0 0 0
TIGARAKSA
BERNANDA YULIA 22-February-
25 19-April-2023 3 5 7 8 1 3 6 2 0 2 8 4 0 0 0 1 NURHAYATI PERUM MUSTIKA BLOK C14/16 08223420859 3 1 0 0 3 1 0 0 1 0 0 0
SANJA 1984

26 19-April-2023 MOH ROSUL 3 5 2 6 1 8 6 2 0 9 8 8 0 0 0 3 ZEKINAH 22-June-1988 TIGARAKSA 04/05 083899680590 3 1 0 0 3 1 0 0 1 0 0 0

13-October-1977
27 19-April-2023 Mulyadi 3 2 0 1 2 3 5 3 1 0 7 7 0 0 0 1 Suhrerni KP. CIPARE 08129596521 3 1 0 0 3 1 0 0 1 0 0 0
 28 24-April-2023 AKHMAD ALAUTONI 3 6 0 3 0 3 4 7 0 7 8 5 0 0 0 4 NENENG IHDRIATI 07-July-1985 KP GUDANG 088201043530 3 1 0 0 3 1 0 0 1 0 0 0

29 24-April-2023 NURJAYA 3 6 0 3 0 3 5 7 0 4 7 7 0 0 0 1 INAH SEPTIANI 17-April-1977 PURI 2 A1 NO 7 085294076340 3 1 0 0 3 1 0 0 1 0 0 0

17-October-1982
30 24-April-2023 Suherman 3 6 0 3 3 1 5 7 1 0 8 2 0 0 0 2 Wati Suarni KP. RANCA GEDE 08120350837 3 1 0 0 3 1 0 0 1 0 0 0

01-October-1992
31 24-April-2023 Tiyas Purnama 1 8 0 2 0 6 4 1 1 0 9 2 0 0 0 2 Dwi Saktia PERUM TRIRAKSA 2 080125470605 3 1 0 0 3 1 0 0 1 0 0 0

17-August-1989
32 25-April-2023 H. SAMPURNA 3 6 0 3 3 3 5 7 0 8 8 9 0 0 0 2 SUAYI KP. WALIWIS CIBARU 085691139370 3 1 0 0 3 1 0 0 1 0 0 0

08-January-1995
33 25-April-2023 RIKO TAMPATI 3 6 0 3 0 9 4 8 0 1 9 5 0 0 0 2 MUAWIYAH lontar 085158687792 3 1 0 0 3 1 0 0 1 0 0 0

01-January-1979
34 25-April-2023 Turmuzi 3 6 7 1 0 9 4 1 0 1 7 9 0 0 2 6 Wiwin GRAHA CIBADAK 0812800378924 2 1 0 0 3 1 0 0 1 0 0 0

35 26-April-2023 BAHRI 3 6 0 3 1 8 5 5 0 7 8 8 0 0 0 2 YULIAH 15-July-1988 PERUM PURI 3 BLOK D10 NO 21 0821665545855 3 1 0 0 3 1 0 0 1 0 0 0

22-August-1982
36 26-April-2023 Dedi Haryanto 3 6 0 3 0 4 6 2 0 8 8 2 0 0 0 4 Yuningsih KP. JAMBE 081366554558 3 1 0 0 3 1 0 0 1 0 0 0

37 26-April-2023 MUHAMMAD RIZAL 3 2 0 8 0 9 4 3 0 6 8 4 0 0 0 7 AYU ROSILAWATI 03-May-1987 PERUM PURI PERMAI 3 082155455854 3 1 0 0 3 1 0 0 1 0 0 0

01-August-1978
38 27-April-2023 DENY SUMARNA 3 6 0 3 0 3 4 1 0 8 7 8 0 0 0 1 NURHANDAYANI KP GUDANG 08126010130 3 1 0 0 3 1 0 0 1 0 0 0

24-August-1984
39 27-April-2023 EDI SUCIPTO 3 6 7 1 0 8 6 4 0 8 8 4 0 0 0 5 YATI SUMIATI PURI PERMAI 1 08384146817 3 1 0 0 3 1 0 0 1 0 0 0

KP. KALELET 003/004 DS. RANCA

40 27-April-2023 TATANG 3 6 0 3 1 9 6 3 0 5 9 3 0 0 0 1 SYIFA FAUJIAH 23-May-1993 085694432243 3 1 0 0 3 1 0 0 1 0 0 0
KALAPA
06-December- PERUM SUDIRMAN INDAH BLOK
41 28-April-2023 AHMAD SATIBI 3 6 0 2 2 1 4 6 1 2 8 9 0 0 0 5 SITI MAEMUNAH 0822991818 3 1 0 0 3 1 0 0 1 0 0 0
1989 G19 NO01

42 28-April-2023 AMSORI 3 6 0 3 0 3 4 3 0 5 8 4 0 0 1 2 SARI 03-June-1984 KP.CANGKRING 08387923103 3 1 0 0 3 1 0 0 1 0 0 0

43 28-April-2023 Daud Hamonangan 3 6 0 3 0 3 5 8 0 3 9 4 0 0 0 3 Rolina Wati 18-March-1994 PERUM SUDIRMAN INDAH 082211809630 3 1 0 0 3 1 0 0 1 0 0 0

30-December-
44 29-April-2023 ANDRY GUNAWAN 3 6 0 3 0 3 7 0 1 2 7 9 0 0 0 4 META GUNAWAN PERUM MUSTIKA BLOK B 11 NO 15 08517203353 3 1 0 0 3 1 0 0 1 0 0 0
1979
11-February-
45 29-April-2023 Wawan 3 6 0 3 1 8 6 1 1 0 8 6 0 0 0 6 Eha Sulastri PERUM TRIRAKSA 2 08129524162 3 1 0 0 3 1 0 0 1 0 0 0
1986
11-November- KP. SODONG KECAMATAN
46 29-April-2023 YAYAN HERYANA 3 6 0 3 0 3 5 1 1 1 8 6 0 0 0 2 DESI NOVITASARI 0895148688 3 1 0 0 3 1 0 0 1 0 0 0
1986 TIGARAKSA
PASIR NANGKA
47 15-April-2023 HAMID 3 6 0 3 0 3 5 9 0 4 8 3 0 0 0 1 JULEHA 19-April-1983 08967713733 3 0 0 0 4 1 0 0 1 0 0 0
KEC TIGARAKSA
31-December-
48 15-April-2023 Sahidin 1 6 0 8 1 4 7 1 1 2 8 8 0 0 0 1 Hartati KP. WIDARA 08575892418 3 0 0 0 4 1 0 0 1 0 0 0
1988
25-October-1992
49 16-April-2023 Kuat Santoso 3 5 2 0 1 5 6 5 1 0 9 2 0 0 0 1 Yuliatun PERUM MUSTIKA BLOK C10/23 08138226261 3 0 0 0 4 1 0 0 1 0 0 0

50 17-April-2023 ROHMAN 3 6 0 3 0 3 5 6 0 5 8 8 0 0 0 3 LISNA SAFITRI 18-June-1988 KAMPUNG TEGAL BAJU 02/05 08521848313 3 0 0 0 4 1 0 0 1 0 0 0

51 18-April-2023 Deni Yogi M 3 6 0 3 0 3 6 7 0 7 8 7 0 0 0 4 Risnawati 17-July-1987 PERUM SUDIRMAN BLOK H11/14 08521705872 3 0 0 0 4 1 0 0 1 0 0 0

03-February-
52 19-April-2023 SARIP HIDAYAT 3 6 0 3 0 3 4 3 0 2 7 9 0 0 0 6 LENI MARLINA KP COGREG 082155445585 3 0 0 0 4 1 0 0 1 0 0 0
1979

53 19-April-2023 Sopian 3 6 0 3 0 3 4 5 0 6 8 2 0 0 1 7 Nurhayati 05-June-1982 KP GURADOG 08956061507 3 0 0 0 4 1 0 0 1 0 0 0

54 25-April-2023 NUR RIDWAN 3 6 0 3 0 3 5 2 0 4 8 2 0 0 0 2 SUPRIHATINI 12-April-1982 KP.PABUARAN 0812009636551 2 0 0 0 4 1 0 0 1 0 0 0

21-September-
55 26-April-2023 DEDE MUSTADI 3 6 0 3 1 8 6 1 0 9 7 5 0 0 0 6 NURETIN TIGARAKSA 08138639769 1 0 0 0 4 1 0 0 1 0 0 0
1975

56 27-April-2023 AHMAD HIDAYAT 3 6 0 3 1 8 4 3 0 3 7 8 0 0 1 9 NANING 03-March-1978 TIGARAKSA 08141119313 3 0 0 0 4 1 0 0 1 0 0 0

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 3

1 2 3 V 5 6
3 6 0 3 3 7 6 Bulan : 2023
NAMA FASKES/ KLINIK CITRA OMEGA 7 8 9 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 PIL 0 0 0 0 0 0 0 0 1 0 0
2 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
3 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
4 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
5 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
6 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
7 PIL 0 0 0 0 0 0 0 0 1 0 0
8 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
9 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
10 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
11 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
12 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
13 PIL 0 0 0 0 0 0 0 0 1 0 0
14 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
15 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
16 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
17 PIL 0 0 0 0 0 0 0 0 1 0 0
18 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
19 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
20 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
21 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
22 PIL 0 0 0 0 0 0 0 1 0 0 0

JUMLAH 0 1 0 1 0 0 46 2 53 0 0 0

03 - TANGERANG ,
Pimpinan Faskes KB/Jaringan/Jejaring*

Ana Yanti Subandiah

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0

NIP/NRP
* Coret yang tidak perlu