1.

PetugasEntriDa REGISTERPELAYANANKB R/I/KB/20

ta Lembar1

PMB PIPIN SUHARTINI 3 6 7 3 1 2 3 4 5 V

0 3 4 Bulan: 2023
NAMAFASKES/ 7 8 9 10 11 12

JARINGAN/JEJARING KodeProvinsi KodeKabup No.RegisterFaskes No.

aten/Kota Jaringan/Jejaring
Faskes

PESERTAKB JENISTINDAKAN Kasus( PENGGUNAANA SUMBERALOKON

(Kode) Kode) SURANSI

PELAYANANBERGERAK
STATUSPESERTAKB

INFORMEDCONSENT

PASCAKEGUGURAN
ISTRI

PASCAPERSALINAN

BPJSKESEHATAN
PENCABUTANDA

KOMPLIKASIBER
NO. TANGGAL ALAMA NO.HANDPHONE

PENCABUTAN
PEMASANGAN

KEGAGALAN
PEMBERIAN/
T
NAMASUAMI

OPERATIF/

LAINNYA

MANDIRI
TANGGALL
NIK(NOMORINDUKKEPENDUDUKAN) NAMA
AHIR

TIDAK
(Kode)

APBN

APBD
AT
N
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 14-Jun-2023 Achmad 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Maskunah 07-03-1998 Kp.ciwuni enggan 3 1 0 0 2 0 0 1 1 0 0 0

2 14-Jun-2023 Jeklin 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Sahyati 01-01-2001 Kp.cigerem 3 1 0 0 0 0 1 1 0 0 0

3 14-Jun-2023 Masdin 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Suneni 12-05-1997 Kp.kemanggusan 3 1 0 0 1 0 0 1 0 0 1 0

4 14-Jun-2023 Samad 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Kinah 12-02-1989 KP.sukabungah 3 1 0 0 1 0 0 1 0 0 1 0

5 14-Jun-2023 Nasa 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Naprikah 02-04-1992 Kp.ciwuni 1 1 1 0 8 0 0 1 0 0 1 0

6 14-Jun-2023 Deden enoh 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Sukilah 20-05-1993 kp.ciwuni tengah 3 1 0 0 2 0 0 1 1 0 0 0

7 14-Jun-2023 Bakreni 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Kasmawati 20-07-1981 kp.ciwuni tengah 089999999999 3 1 0 0 1 0 0 1 0 0 1 0

8 14-un-2023 saepudin 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Rohmawati 22-04-1987 Kp.ciwuni 089999999999 3 1 0 0 1 0 0 1 0 0 1 0

9 14-Jun-2023 Kodani 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Een suenah 24-01-1983 kp.cibajo 089999999999 3 1 0 0 2 0 0 1 1 0 0 0

10 14-Jun-2023 Turyadi 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Arbaiyah 04-10-1989 Kp.ciwuni 089999999999 3 1 0 0 1 0 0 1 0 0 1 0

11 14-Jun-2023 Boin 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Sukranah 07-10-1968 Kp.ciwuni enggan 089999999999 3 1 0 0 1 0 0 1 0 0 1 0

12 14-Jun-2023 Ahmad yani 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Nakiroh 16-02-1984 kp.ciwuni 089999999999 3 1 0 0 2 0 0 1 1 0 0 0

13 14-Jun-2023 Widi erdianto 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Susi susanti 12-05-1993 Kp.ciwuni lebak 089999999999 3 1 0 0 2 0 0 1 1 0 0 0

14 14-Jun-2023 Kastawi 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Munawaroh 13-10-1990 Kp.ciwuni 089999999999 3 1 0 0 2 0 0 1 1 0 0 0

15 14-Jun-2023 Mad sanan 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Tati suharti 12-04-1982 Kp.cigerem 089999999999 3 1 0 0 2 0 0 1 1 0 0 0

16 14-Jun-2023 Jemali 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Ribah 03-09-1962 Kp.kebon sawo 089999999999 3 1 0 0 2 0 0 1 1 0 0 0

17 14-jun-2023 Mamun 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Tuti herawati 06-06-1974 Kp.ciwuni enggan 089999999999 3 1 0 0 1 0 0 1 0 0 1 0

18 14-Jun-2023 Medi humaedi 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Sahyati 12-05-1997 Kp.cigerem 089999999999 3 1 0 0 2 0 0 1 1 0 0 0

1) KeteranganKode

STATUSPESERTAKB KODEJENISALOKON(DiisiPadaJenisTindakandanKasus)
1 :PesertaKBBaru 3 :PesertaKBUlangan 1 :Suntikan1Bulanan 3 :Suntikan3Bulanan 5 :PilProgestin 7 :Implan1Batang 9 :IUD 11 :Tubektomi
2 :PesertaKBGanti 4 :Komplikasi 2 :Suntikan3Bulanan 4 :PilKombinasi 6 :Kondom 8 :Implan2Batang 10 :Vasektomi

2) SELAINSTATUSPESERTAKB,JENISTINDAKANDANKASUSDIISITANDACENTANG(V)
1.PetugasEntriDa Lamp.R/I/KB/20
ta LAMPIRANR/I/KB/20 Lembar4

3 6 7 3 1 2 3 4 5 V
NAMAFASKES/ PMB PIPIN SUHARTINI Bulan:
7 8 9 10 11 12
2023

0 3 4
: KodeProvinsi KodeKabup No.RegisterFaskes No.
JARINGAN/JEJARING aten/Kota Jaringan/Jejaring
Faskes

RINGKASANHASILPELAYANANKB

PESERTAKBBARU(PB) PESERTAKBULANGAN PELAYANANKASUS

PEMBERIANINFORME
PEMBERIANINFORMEDC PBDANKESERTAANJKN DCONSENT
METODEKONT
NO. ONSENT (UntukPesertaKBUl
RASEPSI
(UntukPB) PB PB angan) PELAYANANULANG KOMPLIKASIBERAT
GANTICARA PENCABUTAN KEGAGALAN
PASCAPERSALIN PASCAKEGUGUR
PBJKN PBNONJKN TOTALPB AN AN

1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 IMPLAN 1 0 0 0 0 0 0 0 0 0 0
2 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
3 IUD 1 0 0 0 1 0 0 0 0 0 0
4 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
5 IUD 1 0 0 0 1 0 0 0 0 0 0
6 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
7 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
8 SUNTIKAN 1 0 0 0 1 0 0 0 0 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 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
14 IMPLAN 0 0 0 0 0 0 1 0 1 0 0
15 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
16 SUNTIKAN 1 0 0 0 1 0 0 0 0 0 0
17 SUNTIKAN 0 0 0 0 0 0 1 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 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0

JUMLAH 25 0 0 0 23 0 71 0 71 0 0 0

,
PimpinanFaskesKB/Jaringan/Jejaring*

Hj.LILISMARYATIS,ST
( .................................................................................................)
-

NIP/NRP
*Coretyangtidakperlu