FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : Oktober 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
10/23/2021 10/24/2021 10/25/2021 10/26/2021 10/27/2021 10/28/2021 10/29/2021 10/30/2021 10/31/2021
1 Rahmaniar Pr 39 085260127997 10/22/2021
x x x x x x x x x
10/23/2021 10/24/2021 10/25/2021 10/26/2021 10/27/2021 10/28/2021 10/29/2021 10/30/2021 10/31/2021
2 Dara Amalia Pr 19 0812697564 10/22/2021
x x x x x x x x x

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 31 Oktober 2021
Tim Pemantauan
1. dr. Cut Nella Arya Neva (__________________)
Nip.19860214 201412 2 002

dr.Cut Nella Arya Neva

Nip.1986 0124 201412 2 002
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Mengetahui Beureunuen, 30 April 2021

Kepala Puskesmas Mutiara Tim Pemantauan
1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
dr.Maizaryani 2. dr. Mutiya Ifriza (__________________)
Nip.19770513 200312 2 001 -
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
Nip.19720921 199202 2 001
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 31 Maret 2021
Tim Pemantauan
1. dr. Maizaryani (__________________)
dr.Maizaryani Nip. 19770513 2001312 2 001
Nip.19770513 200312 2 001 2. dr. Mutiya Ifriza (__________________)
-
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
Nip.19720921 199202 2 001
 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : September 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
9/9/2021 9/10/2021 9/11/2021 9/12/2021 9/13/2021 9/14/2021 9/15/2021 9/16/2021 9/17/2021 9/18/2021 9/19/2021 9/20/2021 9/21/2021 9/22/2021 9/23/2021
1 Nurjanah Pr 55 082256362243 9/8/2021
x x x x x x x x x x x x x x
9/9/2021 9/10/2021 9/11/2021 9/12/2021 9/13/2021 9/14/2021 9/15/2021 9/16/2021 9/17/2021 9/18/2021 9/19/2021 9/20/2021 9/21/2021 9/22/2021 9/23/2021
2 Zainuddin Lk 53 9/8/2021
x x x x x x x x x x x x x x
9/7/2021 9/8/2021 9/9/2021 9/10/2021 9/11/2021 9/12/2021 9/13/2021 9/14/2021 9/15/2021 9/16/2021 9/17/2021 9/18/2021 9/19/2021 9/20/2021 9/21/2021
3 Zulfadli Lk 33 085359104816 9/6/2021
x x x x x x x x x x x x x x
9/12/2021 9/13/2021 9/14/2021 9/15/2021 9/16/2021 9/17/2021 9/18/2021 9/19/2021 9/20/2021 9/21/2021 9/22/2021 9/23/2021 9/24/2021 9/25/2021 9/26/2021
4 Marliana Pr 47 9/11/2021
x x x x x x x x x x x x x x
9/10/2021 9/11/2021 9/12/2021 9/13/2021 9/14/2021 9/15/2021 9/16/2021 9/17/2021 9/18/2021 9/19/2021 9/20/2021 9/21/2021 9/22/2021 9/23/2021 9/24/2021
5 Abu Bakar Hasan Lk 71 085370060626 9/9/2021
x x x x x x x x x x x x x x
9/12/2021 9/13/2021 9/14/2021 9/15/2021 9/16/2021 9/17/2021 9/18/2021 9/19/2021 9/20/2021 9/21/2021 9/22/2021 9/23/2021 9/24/2021 9/25/2021 9/26/2021
6 Sumiati Pr 43 081360527058 9/11/2021
x x x x x x x x x x x x x x
9/19/2021 9/20/2021 9/21/2021 9/22/2021 9/23/2021 9/24/2021 9/25/2021 9/26/2021 9/27/2021 9/28/2021 9/29/2021 9/30/2021 31/09/2021
7 Nurlaili Pr 52 085260337921 9/18/2021
x x x x x x x x x x x x x
9/2/2021 9/3/2021 9/4/2021 9/5/2021 9/6/2021 9/7/2021 9/8/2021 9/9/2021 9/10/2021 9/11/2021 9/12/2021 9/13/2021 9/14/2021 9/15/2021 9/16/2021
8 M.Gade Lk 64 0811264203045 9/1/2021
x x x x x x x x x x x x x x
9/2/2021 9/3/2021 9/4/2021 9/5/2021 9/6/2021 9/7/2021 9/8/2021 9/9/2021 9/10/2021 9/11/2021 9/12/2021 9/13/2021 9/14/2021 9/15/2021 9/16/2021
9 Junaidi Lk 45 085297963770 9/1/2021
x x x x x x x x x x x x x x

Mengetahui Beureunuen, 31 September 2021

Kepala Puskesmas Mutiara Tim Pemantauan
1. dr. Cut Nella Arya Neva (__________________)
Nip.19860214 201412 2 002

2. Eva Nali, Amd.Keb (__________________)

dr.Cut Nella Arya Neva Nip. 198504008 201705 2 003
Nip.1986 0124 201412 2 002
3. Nurbaiti,Amd.Keb (__________________)
Nip. 19740402 200701 2 016
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Mengetahui Beureunuen, 30 April 2021

Kepala Puskesmas Mutiara Tim Pemantauan
1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
dr.Maizaryani 2. dr. Mutiya Ifriza (__________________)
Nip.19770513 200312 2 001 -
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
Nip.19720921 199202 2 001
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 31 Maret 2021
Tim Pemantauan
1. dr. Maizaryani (__________________)
dr.Maizaryani Nip. 19770513 2001312 2 001
Nip.19770513 200312 2 001 2. dr. Mutiya Ifriza (__________________)
-
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
Nip.19720921 199202 2 001
 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : Januari 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
1/5/2021 1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 19/01/2021
1 Junaidi L 28 1/4/2021
x x x x x x x x x x x x x x
1/5/2021 1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 19/01/2021
2 Napis P 25 1/4/2021
x x x x x x x x x x x x x x
1/5/2021 1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 19/01/2021
3 Nyak Ubit L 60 1/4/2021
x x x x x x x x x x x x x x
1/5/2021 1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 19/01/2021
4 Dek Nong P 5 1/4/2021
x x x x x x x x x x x x x x
1/5/2021 1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 19/01/2021
5 Mariani P 35 1/4/2021
x x x x x x x x x x x x x x
1/5/2021 1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 19/01/2021
6 Safrijal L 38 1/4/2021
x x x x x x x x x x x x x x
1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021 02/10/20
7 Cut Khatijah P 63 1/5/2021
x x x x x x x x x x x x x x x
1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021
8 Nyak Kaoy P 60 1/5/2021
x x x x x x x x x x x x x x x
1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021
9 Umi Salamah P 58 1/5/2021
x x x x x x x x x x x x x x x
1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021
10 Makmur L 42 1/5/2021
x x x x x x x x x x x x x x x
1/6/2021 1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021
11 Jamaliah P 38 1/5/2021
x x x x x x x x x x x x x x x
1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021 1/21/2021
12 Maulana P 50 1/6/2021
x x x x x x x x x x x x x x x
1/7/2021 1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021 1/21/2021
13 Mauliana L 46 1/6/2021
x x x x x x x x x x x x x x x
1/8/2021 1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021 1/21/2021 1/22/2021
14 Muhammad Jaiz P 21 1/7/2021
x x x x x x x x x x x x x x x
1/9/2021 1/10/2021 1/11/2021 1/12/2021 1/13/2021 1/14/2021 1/15/2021 1/16/2021 1/17/2021 1/18/2021 1/19/2021 1/20/2021 1/21/2021 1/22/2021 1/23/2021
15 Umam Nafis L 4 1/8/2021
x x x x x x x x x x x x x x x
1/21/2021 1/22/2021 1/23/2021 1/24/2021 1/25/2021 1/26/2021 1/27/2021 1/28/2021 1/28/2021 1/29/2021 1/30/2021 1/30/2021 1/31/2021
16 Nafis L 25 1/20/2021
x x x x x x x x x x x x x
1/21/2021 1/22/2021 1/23/2021 1/24/2021 1/25/2021 1/26/2021 1/27/2021 1/28/2021 1/28/2021 1/29/2021 1/30/2021 1/30/2021 1/31/2021
17 Muhajir L 33 1/20/2021
x x x x x x x x x x x x x

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 31 Januari 2021
Tim Pemantauan
1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
dr.Maizaryani 2. dr. Mutiya Ifriza (__________________)
Nip.19770513 200312 2 001 -
3. Nurbaiti,Amd.Keb (__________________)
Nip.197404402 200701 2 016
4. Cut Meutia Ratna (__________________)
Nip.19750806200701012004
5. Eva Nali, Amd.Keb (__________________)
Nip. 1985040082017052003
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Beureunuen, 30 November 2020

Tim Pemantauan
Mengetahui 1. dr. Maizaryani (__________________)
Kepala Puskesmas Mutiara Nip. 19770513 2001312 2 001
2. dr. Mutiya Ifriza (__________________)
-
dr.Maizaryani 3. Nurbaiti,Amd.Keb
Nip.19770513 200312 2 001 Nip.197404402 200701 2 016 (__________________)
4. Cut Meutia Ratna
Nip.19750806200701012004 (__________________)
5. Leni Liana Amd.Keb
Nip. 197603052007012003
6. Eva Nali, Amd.Keb
Nip. 1985040082017052003 (__________________)
7. Hj.Zuriati
'Nip. 197209211992022001 (__________________)
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

18/09/20
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Beureunuen, 02 November 2020

Mengetahui, Tim Pemantauan
Kepala Puskesmas Mutiara 1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
2. dr. Mutiya
3. Nurbaiti,Amd.Keb (__________________)
4. 197404402 200701 2 016
dr. Maizaryani 5. Nurbaiti,Amd.Keb (__________________)
Nip. 19770513 2001312 2 001 6. 197404402 200701 2 016
7. Leni Liana Amd.Keb (__________________)
8. Nip. 197603052007012003
9. Eva Nali, Amd.Keb (__________________)
10. Nip.1985040082017052003
11. Hj.Zuriati,Amd.Keb
12. Nip.197209211992022001 (__________________)
Nurzahra
Zahrina
Nanda Maulanda
Erni
Afra
Juan
Yusniar
Khatijah
Abdul Gani
Megawati
Mufiza
Radiah
Rohati
Maryah
03/10/20
Marliana
Bunaya
Aisyah
Kesya salsabila
Rusli ABD
Lukmanul Hakim
Nasifa Hariani
Muhammad Haikal
Muhammad Hariski
Muhammad Aiden Sidan
Boy Sandi
Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Nurzahra
Zahrina
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin
Nurzahra
Zahrina

Wardani
Erni
Fauzi
Jamalludin
Nurzahra
Zahrina

18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20

 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : Februari 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
2/2/2021 2/3/2021 2/4/2021 2/5/2021 2/6/2021 2/7/2021 2/8/2021 2/9/2021 2/10/2021 2/11/2021 2/12/2021 2/13/2021 2/14/2021 2/15/2021 2/16/2021
1 Mariati P 70 Th 2/1/2021
X X X X X X X X X X X X X X X
2/2/2021 2/3/2021 2/4/2021 2/5/2021 2/6/2021 2/7/2021 2/8/2021 2/9/2021 2/10/2021 2/11/2021 2/12/2021 2/13/2021 2/14/2021 2/15/2021 2/16/2021
2 Yusni P 63 Th 2/4/2021
X X X X X X X X X X X X X X X
2/2/2021 2/3/2021 2/4/2021 2/5/2021 2/6/2021 2/7/2021 2/8/2021 2/9/2021 2/10/2021 2/11/2021 2/12/2021 2/13/2021 2/14/2021 2/15/2021 2/16/2021
3 Atika Zahara P 65 Th 3/4/2021
X X X X X X X X X X X X X X X
2/2/2021 2/3/2021 2/4/2021 2/5/2021 2/6/2021 2/7/2021 2/8/2021 2/9/2021 2/10/2021 2/11/2021 2/12/2021 2/13/2021 2/14/2021 2/15/2021 2/16/2021
4 Latifah P 69 Th 3/4/2021
X X X X X X X X X X X X X X X
2/2/2021 2/3/2021 2/4/2021 2/5/2021 2/6/2021 2/7/2021 2/8/2021 2/9/2021 2/10/2021 2/11/2021 2/12/2021 2/13/2021 2/14/2021 2/15/2021 2/16/2021
5 Rusli L 52 Th 3/4/2021
X X X X X X X X X X X X X X X
2/9/2021 2/10/2021 2/11/2021 2/12/2021 2/13/2021 2/14/2021 2/15/2021 2/16/2021 2/17/2021 2/18/2021 2/19/2021 2/20/2021 2/21/2021 2/22/2021 2/23/2021
6 Fadli L 36 Th 2/8/2021
X X X X X X X X X X X X X X X
2/11/2021 2/12/2021 2/13/2021 2/14/2021 2/15/2021 2/16/2021 2/17/2021 2/18/2021 2/19/2021 2/20/2021 2/21/2021 2/22/2021 2/23/2021 2/23/2021 2/24/2021
7 Nursiah P 53 Th 2/10/2021
X X X X X X X X X X X X X X X
2/11/2021 2/12/2021 2/13/2021 2/14/2021 2/15/2021 2/16/2021 2/17/2021 2/18/2021 2/19/2021 2/20/2021 2/21/2021 2/22/2021 2/23/2021 2/23/2021 2/24/2021
8 Hamdiah P 54 Th 2/10/2021
X X X X X X X X X X X X X X X
2/23/2021 2/24/2021 2/25/2021 2/26/2021 2/27/2021 2/28/2021
9 Lindaraiti L 21Th 2/22/2021
X X X X X X
2/24/2021 2/25/2021 2/26/2021 2/27/2021 2/28/2021
10 Edi Saputra P 25 Th 2/23/2021
X X X X X

Beureunuen, 28 Februari 2021

Tim Pemantauan
Mengetahui 1. dr. Maizaryani (__________________)
Kepala Puskesmas Mutiara Nip. 19770513 2001312 2 001
2. dr. Mutiya Ifriza (__________________)
-
dr.Maizaryani 3. Nurbaiti,Amd.Keb
Nip.19770513 200312 2 001 Nip.197404402 200701 2 016 (__________________)
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Wardani
Erni
Fauzi
Jamalludin

Beureunuen, 02 November 2020

Mengetahui, Tim Pemantauan
Kepala Puskesmas Mutiara 1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
3. Nurbaiti,Amd.Keb (__________________)
4. 197404402 200701 2 016
dr. Maizaryani 5. Nurbaiti,Amd.Keb (__________________)
Nip. 19770513 2001312 2 001 6. 197404402 200701 2 016
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
7. Leni Liana Amd.Keb (__________________)
8. Nip. 197603052007012003
9. Eva Nali, Amd.Keb (__________________)
10. Nip.1985040082017052003
11. Hj.Zuriati,Amd.Keb
12. Nip.197209211992022001 (__________________)

18/09/20 18/09/20
18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20
 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : Maret 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
3/1/2021 3/2/2021 3/3/2021 3/4/2021 3/5/2021 3/6/2021 3/7/2021 3/8/2021 3/9/2021
1 Lindaraiti L 21Th 2/22/2021
X X X X X X X X X
3/1/2021 3/2/2021 3/3/2021 3/4/2021 3/5/2021 3/6/2021 3/7/2021 3/8/2021 3/9/2021 3/10/2021
2 Edi Saputra P 25 Th 2/23/2021
X X X X X X X X X X
3/6/2021 3/7/2021 3/8/2021 3/9/2021 3/10/2021 3/11/2021 3/12/2021 3/13/2021 3/14/2021 3/15/2021 3/16/2021 3/17/2021 3/18/2021 3/19/2021 3/20/2021
3 Ibrahim L 60 Th 3/5/2021
X X X X X X X X X X X X X X X
3/9/2021 3/10/2021 3/11/2021 3/12/2021 3/13/2021 3/14/2021 3/15/2021 3/16/2021 3/17/2021 3/18/2021 3/19/2021 3/20/2021 3/21/2021 3/22/2021 3/23/2021
4 Tibade L 60 3/8/2021
X X X X X X X X X X X X X X X
3/17/2021 3/18/2021 3/19/2021 3/20/2021 3/21/2021 3/22/2021 3/23/2021 3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
5 Nilawati p 43
X X X X X X X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
6 Nursiah P 65 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
7 Junaidi L 28 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
8 Sabriah P 22 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
9 Darwis L 37 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
10 Surniati P 32 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
12 Delisha Darwis P 2 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
11 Suhaimi P 43 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
12 Wardiana s P 46 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
13 Nasuha P 9 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
14 Alfi Husna P 37 3/23/2021
X X X X X X X X
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
15 Yusmiadi P 39 3/23/2021
X X X X X X X X
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021

16 M.Haribs alfatih L 22 3/23/2021
X X X X X X X X
3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
17 Sri wahyuni P 66 3/24/2021
X X X X X X X
3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
18 Safira Maulidar P 25 3/25/2021
X X X X X X
3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
19 Syarifah Nuraini P 33 3/26/2021
X X X X X
3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
20 Kamaruddin L 51 3/26/2021
X X X X X
3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
21 Fahril Akhsar L 7 3/26/2021
X X X X X

Beureunuen, 31 Maret 2021

Tim Pemantauan
Mengetahui 1. dr. Maizaryani (__________________)
Kepala Puskesmas Mutiara Nip. 19770513 2001312 2 001
2. dr. Mutiya Ifriza (__________________)
-
dr.Maizaryani 3. Nurbaiti,Amd.Keb
Nip.19770513 200312 2 001 Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Lindaraiti L 21Th

Edi Saputra P 25 Th

Ibrahim L 60 Th

Tibade L 60

Nilawati p 43

Nursiah P 65

Junaidi L 28

Sabriah P 22

Darwis L 37

Surniati P 32

Delisha Darwis P 2

Suhaimi P 43

Wardiana s P 46
Beureunuen, 30 November 2020
Tim Pemantauan
Nasuha P 9
1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
Alfi Husna P 37
2. dr. Mutiya Ifriza (__________________)
-
Yusmiadi P 39
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)
4. Cut Meutia Ratna
Nip.19750806200701012004 (__________________)
M.Haribs alfatih
5. Leni Liana Amd.Keb
Sri wahyuni Nip. 197603052007012003
6. Eva Nali, Amd.Keb
Safira Maulidar
Nip. 1985040082017052003 (__________________)
7. Hj.Zuriati
Syarifah Nuraini
'Nip. 197209211992022001 (__________________)
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Kamaruddin

Fahril Akhsar

18/09/20

Beureunuen, 02 November 2020

Mengetahui, Tim Pemantauan
Kepala Puskesmas Mutiara 1.

2.
3.
4.
dr. Maizaryani 5.
Nip. 19770513 2001312 2 001 6.
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
7.
8.
9.
10.
11.
12.
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

dr. Maizaryani (__________________)

Nip. 19770513 2001312 2 001
dr. Mutiya
Nurbaiti,Amd.Keb (__________________)
197404402 200701 2 016
Nurbaiti,Amd.Keb (__________________)
197404402 200701 2 016
Leni Liana Amd.Keb (__________________)
Nip. 197603052007012003
Eva Nali, Amd.Keb (__________________)
Nip.1985040082017052003
Hj.Zuriati,Amd.Keb
Nip.197209211992022001 (__________________)
Wardani
Erni
Fauzi
Jamalludin
Wardani
Erni
Fauzi
Jamalludin
18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20
 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : April 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
4/1/2021
1 Ibrahim p 58

4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021

2 Rizal Fasri P 65 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
3 Darmini L 28 3/23/2021
x x x x x x
Abdul Azis 4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
4 P 22 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
5 Zulfikar L 37 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
6 Junaidi P 32 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
7 Ernawati P 2 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
8 Fakriati P 43 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
9 Mjurniati P 46 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
10 Fadillah P 9 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
11 Erita Zahara P 37 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
12 Mahdalena P 39 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021
13 Asmaul Husna L 22 3/23/2021
x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
14 Syauqas P 22 3/23/2021
x x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
15 Husna L 37 3/23/2021
x x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
16 Yusra P 32 3/23/2021
x x x x x x x
3/23/2021 4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
17 Yusri P 33
x x x x x x x
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
18 Rizal Fahri P 43 3/23/2021
x x x x x x x
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
19 Nurjannah P 46 3/23/2021
x x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
20 Heriyanto P 9 3/23/2021
x x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
21 Ridwan P 37 3/23/2021
x x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
22 Zulfikar P 39 3/23/2021
x x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
23 Masruroh P 9 3/23/2021
x x x x x x x
4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
24 Nuryusni Afriza L 22 3/23/2021
x x x x x x x
Rizki Abdi 4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021
25 P 66 3/24/2021
x x x x x x x
Muhamamad Nasir 4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021 4/9/2021 4/10/2021
26 P 25 3/25/2021
x x x x x x x x x
Nurbayani 4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/8/2021 4/9/2021 4/10/2021 4/10/2021
27 P 33 3/26/2021
x x x x x x x x x
4/10/2021 4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021
28 Muhamamad P 18 4/9/2021

4/10/2021 4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021
29 Idawati P 18 4/9/2021

4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
30 Wardiana P 18 4/9/2021
X X X X X X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
31 M.Thaleb P 18 4/9/2021
X X X X X X X X X X X X X X X
Junaidi 4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
32 L 17 4/9/2021
X X X X X X X X X X X X X X X
Sabariah 4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
33 L 17 4/9/2021
X X X X X X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
34 Darwis L 17 4/9/2021
X X X X X X X X X X X X X X X
4/9/2021 4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
35 Surniati L 17
X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
36 Ibrahim L 58 4/10/2021
X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
37 Rizal Fasri L 40 4/10/2021
X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
38 Darmini L 44 4/10/2021
X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
39 Abd.Azis L 64 4/10/2021
X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
40 Zulfikar L 38 4/10/2021
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
40 Zulfikar L 38 4/10/2021
X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
41 Junaidi L 42 4/10/2021
X X X X X X X X X X
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
42 Ernawati P 41 4/10/2021
X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
43 Fakriati L 44 4/10/2021
X X X X X X X X X X
4/10/2021 4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
44 Murniati p 40
X X X X X X X X X X
4/11/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/16/2021 4/17/2021 4/18/2021 4/19/2021 4/20/2021 4/21/2021 4/22/2021 4/23/2021 4/24/2021 4/25/2021
45 Idawati p 38 4/10/2021
X X X X X X X X X X
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

4/30/2021
66 Maskur P 32 4/29/2021
X
4/30/2021
67 Munazir P 26 4/29/2021
X
4/30/2021
68 Rahmad Adami L 35 4/29/2021
X
4/30/2021
69 Maulidiatun P 28 4/29/2021
X
4/30/2021
70 Asyika P 8 Bln 4/29/2021
X
4/30/2021
71 Nurhanifah P 33 4/29/2021
X
4/30/2021
72 Zulkifli L 35 4/29/2021
X
4/30/2021
73 Arisa Nasifa P 9 4/29/2021
X
4/30/2021
74 Gauzi L 6 4/29/2021
X
4/30/2021
75 M.Baki Bila L 8 4/29/2021
X
4/30/2021
76 Gauzi L 13 4/29/2021
X

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 31 Maret 2021
Tim Pemantauan
1. dr. Maizaryani (__________________)
dr.Maizaryani Nip. 19770513 2001312 2 001
Nip.19770513 200312 2 001 2. dr. Mutiya Ifriza (__________________)
-
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
Nip.19720921 199202 2 001
 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : Agustus 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
02/Mai /2021 5/3/2021 5/4/2021 5/5/2021 5/6/2021 5/7/2021 5/8/2021 5/9/2021 5/10/2021 5/11/2021 5/12/2021 5/13/2021 5/14/2021 5/15/2021 5/16/2021 5/17/2021
1 Abdul Muthalib L 61
x x x x x x x x x x x x x x x
03/Mai /2021 5/4/2021 5/5/2021 5/6/2021 5/7/2021 5/8/2021 5/9/2021 5/10/2021 5/11/2021 5/12/2021 5/13/2021 5/14/2021 5/15/2021 5/16/2021 5/17/2021 5/18/2021
2 Hendon P 45
x x x x x x x x x x x x x x x
06 Mai /2021 5/7/2021 5/8/2021 5/9/2021 5/10/2021 5/11/2021 5/12/2021 5/13/2021 5/14/2021 5/15/2021 5/16/2021 5/17/2021 5/18/2021 5/19/2021 5/20/2021 5/21/2021
3 Kamaruddin Syamsah L 45
x x x x x x x x x x x x x x x
17Mai 2021 5/18/2021 5/19/2021 5/20/2021 5/21/2021 5/22/2021 5/23/2021 5/24/2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
4 Ismail L 67
x x x x x x x x x x x x
20 Mai 2021 5/21/2021 5/22/2021 5/23/2021 5/24/2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
5 Hasballah Yusuf L 63
x x x x x x x x x x x
21 Mai 2021 5/22/2021 5/23/2021 5/24/2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
6 Nurhayati P 50
x x x x x x x x x x x
21 Mai 2021 5/22/2021 5/23/2021 5/24/2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
7 Zubaidah P 48
x x x x x x x x x x
22Mai /2021 5/23/2021 5/24/2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
8 Tibariah P 79
x x x x x x x x x x
22 Mai /2021 5/23/2021 5/24/2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
9 Sapiah P 75
x x x x x x x x x
23Mai /2021 5/24/2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
10 Hilda P 30
x x x x x x x x x
23 Mai 2021 5/24/2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
11 Sarah Nadia P 19
x x x x x x x x
24 Mai 2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
12 Zainab P 57
x x x x x x x x
24 Mai 2021 5/25/2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
13 Zunaidi Yunus L 50
x x x x x x x x
26 Mai 2021 5/26/2021 5/27/2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
14 Syamsiah Umar P 73
x x x x x x
27 Mai 2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
15 Yusnidar P 30
x x x x
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
27 Mai 2021 5/28/2021 5/29/2021 5/30/2021 5/31/2021
16 Rohani P 68
x x x
28 Mai 2021 5/29/2021 5/30/2021 5/31/2021
17 Siti Halimah P 73
x x x
30 Mai 2021 5/31/2021
18 Nyak Bungong P 68
31 Mai 2021
19 Syamsiah P 75

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 31 Mai 2021
Tim Pemantauan
1. dr. Mutiya Ifriza (__________________)
-
dr.Cut Nella Arya Neva 2. Eva Nali, Amd.Keb (__________________)
Nip.1986 0124 201412 2 002 Nip. 1985040082017052003
3. Cut Meutia Ratna (__________________)
Nip.19750806200701012004
4. Leni Liana, Amd.Keb (__________________)
19760305 200701 2 003
5. Hj.Zuriati (__________________)
19720921 199202 2 001
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

18/09/20
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Beureunuen, 02 November 2020

Mengetahui, Tim Pemantauan
Kepala Puskesmas Mutiara 1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
2. dr. Mutiya
3. Nurbaiti,Amd.Keb (__________________)
4. 197404402 200701 2 016
dr. Maizaryani 5. Nurbaiti,Amd.Keb (__________________)
Nip. 19770513 2001312 2 001 6. 197404402 200701 2 016
7. Leni Liana Amd.Keb (__________________)
8. Nip. 197603052007012003
9. Eva Nali, Amd.Keb (__________________)
10. Nip.1985040082017052003
11. Hj.Zuriati,Amd.Keb
12. Nip.197209211992022001 (__________________)
Wardani
Erni
Fauzi
Jamalludin
Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin
Wardani
Erni
Fauzi
Jamalludin
18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20
 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : Juni 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
01/06/2021 6/2/2021 6/3/2021 6/4/2021 6/5/2021 6/6/2021 6/7/2021 6/8/2021 6/9/2021 6/10/2021 6/11/2021 6/12/2021 6/13/2021 6/14/2021 6/15/2021
1 Nasrullah lk 34
x x x x x x x x x x x x x x
6/3/2021 6/4/2021 6/5/2021 6/6/2021 6/7/2021 6/8/2021 6/9/2021 6/10/2021 6/11/2021 6/12/2021 6/13/2021 6/14/2021 6/15/2021 6/16/2021 6/17/2021
2 Nurhikmah pr 25
x x x x x x x x x x x x x x
6/8/2021 6/9/2021 6/10/2021 6/11/2021 6/12/2021 6/13/2021 6/14/2021 6/15/2021 6/16/2021 6/17/2021 6/18/2021 6/19/2021 6/20/2021 6/21/2021 6/22/2021
3 Muhammad lk 52
x x x x x x x x x x x x x x
6/10/2021 6/11/2021 6/12/2021 6/13/2021 6/14/2021 6/15/2021 6/16/2021 6/17/2021 6/18/2021 6/19/2021 6/20/2021 6/21/2021 6/22/2021 6/23/2021 6/24/2021
4 Fitri Juliana pr 42
x x x x x x x x x x x x x x
6/14/2021 6/15/2021 6/16/2021 6/17/2021 6/18/2021 6/19/2021 6/20/2021 6/21/2021 6/22/2021 6/23/2021 6/24/2021 6/25/2021 6/26/2021 6/27/2021 6/28/2021
5 Ainol Mardiah pr 63
x x x x x x x x x x x x x x
6/15/2021 6/16/2021 6/17/2021 6/18/2021 6/19/2021 6/20/2021 6/21/2021 6/22/2021 6/23/2021 6/24/2021 6/25/2021 6/26/2021 6/27/2021 6/28/2021 6/29/2021
6 Ubaidilah pr 34
x x x x x x x x x x x x x x
6/16/2021 6/17/2021 6/18/2021 6/19/2021 6/20/2021 6/21/2021 6/22/2021 6/23/2021 6/24/2021 6/25/2021 6/26/2021 6/27/2021 6/28/2021 6/29/2021 6/30/2021
7 Iskandar Ali lk 54
x x x x x x x x x x x x x x
6/17/2021 6/18/2021 6/19/2021 6/20/2021 6/21/2021 6/22/2021 6/23/2021 6/24/2021 6/25/2021 6/26/2021 6/27/2021 6/28/2021 6/29/2021 6/30/2021
8 Keumala Sari pr 44
x x x x x x x x x x x x x x
6/21/2021 6/22/2021 6/23/2021 6/24/2021 6/25/2021 6/26/2021 6/27/2021 6/28/2021 6/29/2021 6/30/2021
9 Saiful Bahri lk 58
x x x x x x x x x x
6/24/2021
10 Saudah pr 50
x

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 30 Juni 2021
Tim Pemantauan
1. -dr. Mutiya Ifriza (__________________)
dr.Cut Nella Arya Neva 2. Cut Meutia Ratna,Amd.Keb (__________________)
Nip.1986 0124 201412 2 002 Nip.19750806200701012004

3. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

5/10/2021 5/11/2021 5/12/2021 5/13/2021

44
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

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
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

73

74

75

76

77

18/09/20
78
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Beureunuen, 02 November 2020

Mengetahui, Tim Pemantauan
Kepala Puskesmas Mutiara 1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
2. dr. Mutiya
3. Nurbaiti,Amd.Keb (__________________)
4. 197404402 200701 2 016
dr. Maizaryani 5. Nurbaiti,Amd.Keb (__________________)
Nip. 19770513 2001312 2 001 6. 197404402 200701 2 016
7. Leni Liana Amd.Keb (__________________)
8. Nip. 197603052007012003
9. Eva Nali, Amd.Keb (__________________)
10. Nip.1985040082017052003
11. Hj.Zuriati,Amd.Keb
12. Nip.197209211992022001 (__________________)
Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin

Wardani
Erni
Fauzi
Jamalludin
Wardani
Erni
Fauzi
Jamalludin
18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20 18/09/20
 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : Juli 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
3/23/2021 3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
1 Akbar Muzain P 31 085260447480 3/22/2021
x x x x x x x x x
3/24/2021 3/25/2021 3/26/2021 3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
2 Nursiah P 62 085296922447 7/23/2021
x x x x x x x x
3/27/2021 3/28/2021 3/29/2021 3/30/2021 3/31/2021
3 Zahara L 35 081359045760 3/26/2021
x x x
3/30/2021 3/31/2021
4 Nurhafnita P 30 08126959979 3/29/2021
x x
3/31/2021
5 Nursiah P 32 082361780134 3/30/2021
x

Mengetahui
Kepala Puskesmas Mutiara

dr.Cut Nella Arya Neva

Nip.1986 0124 201412 2 002
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Mengetahui Beureunuen, 30 April 2021

Kepala Puskesmas Mutiara Tim Pemantauan
1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
dr.Maizaryani 2. dr. Mutiya Ifriza (__________________)
Nip.19770513 200312 2 001 -
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
Nip.19720921 199202 2 001
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 31 Maret 2021
Tim Pemantauan
1. dr. Maizaryani (__________________)
dr.Maizaryani Nip. 19770513 2001312 2 001
Nip.19770513 200312 2 001 2. dr. Mutiya Ifriza (__________________)
-
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
Nip.19720921 199202 2 001
 FORMULIR PEMANTAUAN KONTAK ERAT

Tempat Pemantauan :
Puskesmas/Kecamatan : Mutiara / Mutiara Timur
Kab/Kota : Pidie
Bulan Pemantauan : Agustus 2021
Nama Kasus Konfirmasi (Hanya diisi untuk pemantauan kontak erat) :
Nama Petugas :

Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai

No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan
8/3/2021 8/4/2021 8/5/2021 8/6/2021 8/7/2021 8/8/2021 8/9/2021 8/10/2021 8/11/2021 8/12/2021 8/13/2021 14/08/2021 8/15/2021 8/16/2021 8/17/2021
1 Khuzaimah Pr 21 085274748089 8/2/2021
x x x x x x x x x x x x x x
8/3/2021 8/4/2021 8/5/2021 8/6/2021 8/7/2021 8/8/2021 8/9/2021 8/10/2021 8/11/2021 8/12/2021 8/13/2021 14/08/2021 8/15/2021 8/16/2021 8/17/2021
2 Nurmala Pr 56 8/2/2021
x x x x x x x x x x x x x x
8/6/2021 8/7/2021 8/8/2021 8/9/2021 8/10/2021 8/11/2021 8/12/2021 8/13/2021 8/14/2021 8/15/2021 8/16/2021 8/17/2021 8/18/2021 8/19/2021 8/20/2021
3 RR.Rachmania Koesnindyasari Pr 21 8/5/2021
x x x x x x x x x x x x x x
8/12/2021 8/13/2021 8/14/2021 8/15/2021 8/16/2021 8/17/2021 8/18/2021 8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021
4 Cut Intan Sari Pr 31 082165220915 8/12/2021
x x x x x x x x x x x x x x
8/13/2021 8/14/2021 8/15/2021 8/16/2021 8/17/2021 8/18/2021 8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021
5 Mariyam M.Saad Pr 61 082115191117 8/12/2021
x x x x x x x x x x x x x x
8/14/2021 8/15/2021 8/16/2021 8/17/2021 8/18/2021 8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021
6 Yusnidar Pr 42 8/14/2021
x x x x x x x x x x x x x x
8/17/2021 8/18/2021 8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/29/2021
7 Mutia Kardila Ulfa Pr 28 082278793522 8/16/2021
x x x x x x x x x x x x x x
8/17/2021 8/18/2021 8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
8 Abdullah Ali Lk 71 8/16/2021
085325745211 x x x x x x x x x x x x x x
8/17/2021 8/18/2021 8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
9 Nurul Fitri Pr 42 081377152622 8/16/2021
x x x x x x x x x x x x x x
8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
10 Faridah Pr 56 082311178791 8/20/2021
x x x x x x x x x x x
8/17/2021 8/18/2021 8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
11 Geni Saktianto Wibisono Lk 27 085225859936 8/16/2021
x x x x x x x x x x x x x x
8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/30/2021 8/31/2021
12 Khatijah Pr 76 082339597753 8/18/2021
x x x x x x x x x x x x x x
8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/30/2021 8/31/2021
13 Murniati Pr 46 085370243866 8/19/2021
x x x x x x x x x x x x x
8/18/2021 8/19/2021 8/20/2021 8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
14 Marzuki Lk 37 8/17/2021
x x x x x x x x x x x x x x
8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
15 Dwi Yanti Pr 71 085243884918 8/20/2021
x x x x x x x x x x x
8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
16 Kamariah AD Pr 20 082388423818 8/20/2021
x x x x x x x x x x x
8/21/2021 8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
17 Rosdiana Pr 40 8/20/2021
x x x x x x x x x x x
8/22/2021 8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
18 Muhammad Arbai Ramadhan Lk 71 085270691907 8/21/2021
x x x x x x x x x x
8/23/2021 8/24/2021 8/25/2021 8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
19 Sapiah A.Samad Pr 70 8/22/2021
x x x x x x x x x
8/29/2021 8/30/2021 8/31/2021
20 Nuraini Pr 61 081398104000 8/28/2021
x x x
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021

21 M.Jamil Lk 40 082219594233 8/25/2021
x x x x x x
8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
22 Mursyidah Pr 40 085371023429 8/25/2021
x x x x x x
8/26/2021 8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
23 A.Gani Lk 62 085270815102 8/25/2021
x x x x x x
8/27/2021 8/28/2021 8/29/2021 8/30/2021 8/31/2021
24 Hamdani Lk 51 8/26/2021
x x x x x
8/28/2021 8/29/2021 8/30/2021 8/31/2021 8/31/2021
25 Syamsiah Pr 75 8/27/2021

Mengetahui
Kepala Puskesmas Mutiara

Beureunuen, 31 Agustus 2021

Tim Pemantauan
1. dr. Cut Nella Arya Neva (__________________)
dr.Cut Nella Arya Neva Nip.19860214 201412 2 002
Nip.1986 0124 201412 2 002
2. Eva Nali, Amd.Keb (__________________)
Nip. 198504008 201705 2 003

3. Nurbaiti,Amd.Keb (__________________)
Nip. 19740402 200701 2 016

4. Ahmadi, SKM (__________________)

Nip. 19781212 200701 1 037

5. Leni Liana,Amd.Keb (__________________)

Nip. 19760305 200701 2 003

6. Hj.Zuriati, Amd.Keb (__________________)

Nip. 19720921199202 2 001

7. Cut Meutia Ratna, Amd.Keb (__________________)

Nip. 19750806 200701 2 004
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Mengetahui Beureunuen, 30 April 2021

Kepala Puskesmas Mutiara Tim Pemantauan
1. dr. Maizaryani (__________________)
Nip. 19770513 2001312 2 001
dr.Maizaryani 2. dr. Mutiya Ifriza (__________________)
Nip.19770513 200312 2 001 -
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
Nip.19720921 199202 2 001
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

Mengetahui
Kepala Puskesmas Mutiara Beureunuen, 31 Maret 2021
Tim Pemantauan
1. dr. Maizaryani (__________________)
dr.Maizaryani Nip. 19770513 2001312 2 001
Nip.19770513 200312 2 001 2. dr. Mutiya Ifriza (__________________)
-
3. Nurbaiti,Amd.Keb
Nip.197404402 200701 2 016 (__________________)

4. Cut Meutia Ratna (__________________)

Nip.19750806200701012004

5. Eva Nali, Amd.Keb (__________________)

Nip. 1985040082017052003
(__________________)
6. Ahmadi,SKM
Nip. 19781212 200701 1 037 (__________________)

7 Eliana,Amd.Keb
Nip.19740323 200701 2 002 (__________________)

8. Safriyanti, Amd.Keb (__________________)

Nip.19871013 201705 2 006
 Tanggal Tanggal dan Hasil Pemantauan Tgl Selesai
No Nama JK Umur No. Telp Keterangan
Kedatangan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pemantauan

9. Fauziah ,S.ST (__________________)

Nip.19820320 200801 2 001
10. Lindawati, Amd.Keb (__________________)
Nip.19731012 200701 2 001
11. Leni Liana,Amd.Keb (__________________)
Nip.19760305 200701 2 003
12. Hj.Zuriati (__________________)
Nip.19720921 199202 2 001