* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABDUL RAFLI 2018-04-04 L 3278600404180000 AULIA 327808
2
ADILA PUTRI ARSANDI 2022-12-09 P 3278084912220001 Sandi/rani 3278082007830012
3
AJI AGHNI AULIA 2020-07-18 L 3278081807200008 AGUNG 327808
4
AKBAR MAULANA 2018-04-16 L 3278081604180003 SODIK 3278081810900001
5
AKIFA 2020-11-23 P 3278606311203015 Yuyus/siti 3278082710850003
6
ALIFA 2022-03-28 P 3278086803220004 Irma
7
ALMIRA NURAISA 2018-09-21 P 3278086109180002 SIDIK 3278082403870008
8
ANANDA DZIKRI 2022-03-02 L 3278080203220003 Anton / nita 3278042510860003
9
ANNISA PUTRI MAULIDA 2021-10-17 P 3278085710210002 joni/enur 3278081506850020
10
AQILLA 2020-08-20 P 3278086008200001 Rian/ai lina 3278020104980009
11
ARIMBA 2019-03-02 L 3278080203190008 AGUNG 327808
12
ARYA WIGUNA 2021-02-25 L 3278082502210002 HERYANTO/AULIA 3278010506840005
13
AULIA NURAINI 2020-08-07 P 3278084708200003 RIDWAN 3206301007930001
14
BAGAS 2018-08-25 L 3278082508180001 BASARUDIN 3278080206770012
15
BINTANG YOSRI JULIANTI 2019-07-27 P 3278086307190008 YOYO 3278080101890033
16
DAFA FATHUL F 2021-09-13 L 3278081309210005 aca/dede 3278080608770002
17
DAFFI 2018-11-15 L 3278081511180003 RIKI 3278081810870011
18
DALFA 2020-11-19 L 3278081911200001 JONO/YUYUN 3173010911901002
19
DZAKIRA 2019-01-17 P 3278085701190003 YAYAN 3278085609980006
20
FAISAL 2021-02-08 L 3278080802210002 YANA/HETI 3278080503820014
21
FATIAH NUR SABIAH 2020-12-07 P 3278084212200002 IYAN/HETI 3278082309710008
22
FITRI NADIA FARHA 2021-05-27 P 3278086705210002 Gungun 3278081003860014
23
GHAISAN 2020-02-01 L 3278080102200002 DEDI 3278081803640008
24
GILANG M.ABDILLAH 2019-07-19 L 3278081907190001 deni 3278082308960005
25
HAFEEZ ALFARIQ 2021-11-01 L 3278080111210001 undang/emay 3278080304720006
26
HASNA 2019-07-03 P 3278084307190008 YANTO 3278080707780012
27
HILYA 2018-04-12 P 3278605204180000 ASEP 327808
28
IZRUL PADLAN SYABAN 2019-05-01 L 3278080105190003 DADAN 3278082007780009
29
KEVEN ZAHIR AL-BUKHARI 2023-02-01 L 3278080102230001 Zeri janwari/nadia ulfa 3207242501880002
30
KEYNARRA ALMASHYRA A 2019-12-08 P 3218014812190001 ZERRI / nadia ulfa 3207242501880002
31
KHAIRA MYESHA SHADIQAH 2022-11-26 P 3278086611220005 Rizal/riska 3278080609940002
32
KHANHA AYIDIL FITRIYANA 2021-05-13 L 3278081305210001 ahmad/susi 3207043006860002
33
KHANSA AULIA 2020-08-01 P 3278084108200001 JAJA 3207110705750001
34
KHANSA FITRI RAHMAN 2020-11-04 P 3278604411215721 ATANG/AI WANTI 3278011209900001
35
KHAYRA 2021-03-12 P 3278605203212571 Asep Andi 3278031003940015
36
KHAYRA NADIRA ASYFA 2022-07-31 P 3278087107220004 Yuyun/sri 3278081403890013
37
KINARA 2021-10-18 P 3278605810214345 wildan/tita 3278083107950007
38
M WILDAN 2021-03-22 L 3278602203219935 WILLY/WIDA 3278020411950005
39
M. ADAM DZIKRI 2020-10-30 L 3278083010200001 RICKI/HERNI 3278082910970009
40
M. FATIH 2021-10-26 L 3278602610219511 tedi/santi 3278082107820011
41
M. IJLAL ROSYID AL-GHIFARI 2018-09-18 L 3273171809180002 entoh/tuti 3273170602800001
42
M. MAQIL 2020-09-01 L 327808010920001 Ecep/yenyen 3278081008870009
43
M.ALDI 2018-04-09 L 3278600904180000 BUDI 327808
44
M.ALIY 2020-03-29 L 3278082903200003 Irpan/rima 3278081909890005
45
M.AZHAR 2019-11-02 L 3278080211190002 ade 3278080202890008
46
M.FAIZ ALBI MUBARAQ 2019-06-29 L 3278082906190002 nanang 3278081503840010
47
M.RASYID 2019-06-22 L 3278082206190002 DENIS 3278080406950009
48
M.RAZKA NUR SALIM 2019-08-11 L 3278081108190003 ANWAR SALIM 320627010940007
49
M.WILDAN 2019-12-09 L 3278080912190005 UJANG 3278080401890003
50
M.ZAHID 2018-07-02 L 2171100207180060 TISNA 2171102801840004
51
MEISA NURSYIFA 2019-05-18 P 3278085905190011 YUDI 3278032911800006
52
MUHAMMAD AGAM AULIAN 2022-05-08 L 3278600805225385 wawan/sakila 3278086912030002
53
MUHAMMAD ARSYA ARIFIN 2021-05-21 L 3278082105210001 erwin/sumiati 3278081406930006
54
NADIRA 2021-05-14 P 3278605405213752 Yana 3278071106970003
55
NADIVA KAIFIA RAFIQAH 2021-06-15 P 3278085506210001 ahmad/rohimah 3278080703790010
56
NAIRA 2020-08-09 P 3278084908200014 ASEP 3278082510770005
57
NASYWA ZAYBA RAFIFAH 2022-12-06 P 3278084612220001 Opik/jihan 3278081707930008
58
NAZIVA 2018-07-01 P 3278084107180001 ARIF 3278082304860006
59
NIDA NUR RINA 2023-01-24 P 3278086401230002 Irin/irna 3278080308930010
60
NIZAR 2019-11-15 L 3278081511190004 SUMARNA 3278012211820008
61
NOAH 2020-04-07 L 3278080704200008 FAIZ 37808
62
NOVAL 2019-11-09 L 3278080911190002 HERYANTO 3278082702850009
63
NOVITA 2019-11-09 P 3278084911190001 HERYANTO 3278082702850009
64
QALESYA 2019-09-10 P 3278085009190002 WILDAN 3273240708950004
65
QIANA 2020-09-19 P 3278085909200002 DEKA/DERINA 3278086710010011
66
RAFASHA 2021-05-27 L 3278602705219856 gungun/sri 3278050105790005
67
RAMADHANI PUTRI 2018-05-26 P 3278086605180001 YUDHA 3206240701870001
68
RATIH ALFIANI 2022-12-28 P 3278606812225348 Aa rasyid/nina 3278082909970006
69
RAYA PUTRA JOHANSYAH 2019-08-28 L 3278082808190002 EGI/AAT 3278072512920003
70
REVAN ARKANA PAMUNGKAS 2022-09-21 L 3278082109220001 Jajang/elly 3278081010830016
71
REYNALDI ARGA SAPUTRA 2022-01-24 L 3278082401220002 dede riswan/ai pipih 3278081406930006
72
RIANI MUTIA AZZAIRA 2020-01-14 P 3278085401200012 AGUS 3278083105870002
73
SAHLA 2020-05-30 P 3278087005200001 SUTISNA 3278010907820007
74
SANDRA ADIFA 2022-02-25 P 3278606502228002 ASEP/AI SUMIATI 3278081403800015
75
SYABIL NUR ASSHIDDIQ 2022-01-20 L 3278082001220001 LELI JAYADI/SITI MULYANI 3207112306890001
76
SYAFIRA 2020-09-26 P 3278086609200003 MULYANA 3278081609980001
77
UWAIS ABDULLAH 2020-06-28 L 3278082806200009 KOKO 3278011303790013
78
YUSUF HAIDAR AL-FARIZQI 2021-07-08 L 3278081501210003 M.ISMAIL/TINA 3217091006920013
79
ZAINI 2022-03-12 L 3278601203227055 Koko/rani 3278011303790013
80
ZENIA ZAKIYYAH AMANI 2021-11-10 P 3278085012210002 dede hendri/siti 3278082007790015
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
panyarang 087823792075
PANYARANG 0
PANYARANG KIDUL 0
Panyarang 089678582858
PANYARANG 085800300742
PANYARANG 085222325546
PANYARANG KIDUL 0
PANYARANG KIDUL 085770384897
PANYARANG 082318901750
PANYARANG 085281269368
Panyarang 081911696617
PANYARANG 081901946284
PANYARANG 085348781168
MANGKUBUMI 087823792075
PANYARANG KIDUL 0
Panyarang 081227378546
Panyarang 081227378546
PANYARANG KIDUL 0
PANYARANG 083167314411
Panyarang kidul 085222740704
panyarang 0895361341551
panyarang 082122313289
MANGKUBUMI 087823792075
panyarang kidul 0
PANYARANG KIDUL 0
PANYARANG 082353287422
Panyarang 089636628877
PANYARANG 087823792075
PANYARANG KIDUL 0
PANYARANG KIDUL 0
PANYARANG 085222005011
PANYARANG 085222005011
PANYARANG 089650718949
PANYARANG 0
PANYARANG KIDUL 0
PANYARANG KIDUL 0
PANYARANG 082118324788
PANYARANG 081930586383
panyarang 085928021892
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABDUL ROHMAN 2019-05-09 L 3278080905190003 DADAN 3206080401810001
2
ABIZAR 2021-02-07 L 3278600702215841 HERI 327808
3
ADIVA MAULIDA 2018-11-10 P 3278085011180003 ADI SUMARYADI 3278081411870006
4
AHSAN 2018-08-26 L 3278082608180003 MAMAN 327808
5
AILA SHAKAELA ZANITA 2018-12-31 P 3278097112180001
6
AINAYYA 2019-05-13 P 3278085305190001 AGUN 3278031106930005
7
AISAH SITI MARDIYANA 2022-11-19 P 3278085911220003 dadan 3206080401810001
8
AKILA 2021-09-10 P 327808500921002 HASAN 3214050303760006
9
ALESHA 2018-04-10 P 3278605004182406 hasan 327808
10
ALGHIFARI RAFFASYA 2018-12-01 L 3278080112180004 RIZAL ANSORI 3278073112890001
11
ARSHAKA HABIB AL FARIZI 2022-10-29 L 3278082910220001 undang 3278081208820014
12
ARSYA ADITYA PRATAMA 2021-07-30 L 3278083007210002 dede 3278072908920003
13
ARYA ARSHAKA FERDIANSYAH 2022-09-09 L 3278080909220001 fendi 3278082402790007
14
ARYA MUHAMMAD 2019-10-21 L 3278082110190000 ENDANG 3206160211780002
15
AZHKA ELVAN RAFISQI 2020-06-21 L 3278082106200001 IRFAN 3278080202950005
16
AZKAR 2020-04-02 L 3278080204200010 DEDI 3278080311800004
17
AZZAM MAULANA 2021-06-04 L 3278080406210004 ADI 3278081411870006
18
DAFFA ARYA 2018-10-27 L 3278082710180001 ANDI JAYA 3278081409910012
19
DIRHAM 2021-04-16 L 3278081604210002 YOSEP 3278062506900003
20
FAJRI PADHIL 2018-07-03 L 3278080307180001 YAYAT AHMAD 3278081505770007
21
FALISA UMROTUL AZIZAH 2022-02-15 P 3278085502220001 IFAN 3278081203930005
22
FARIZ MUHAMMAD 2019-12-23 L 3278082312190000 TAUFIQ RAHMAN 3278051312800002
23
GHINA SA\'BAN RAHMANI 2022-03-11 P 3278085103220001 eri rosdiana 3278082505850013
24
HAFIZ 2018-07-11 L 3278081107180002 DANI 3278080711780007
25
HIBAN ABDUL MATIN 2021-05-08 L 3278080805210003 HILMAN 327808
26
KAFKA KURNIAWAN 2018-08-27 L 3278082708180010 GITO 3278081401820006
27
KAISAR 2020-12-18 L 3278601812208035 JAJANG 327808
28
KHALISA HILYA 2021-06-03 P 3278084306210002 rian 327808
29
KHAYLA OKTAVIANI 2018-10-20 P 3278086001180001 YOGE TUBAGUS 3217071510980007
30
KIARA ZEA ALMAHYRA 2022-08-05 P 3278074058220002 didan
31
LUCKY SAPUTRA 2019-03-07 L 3278080703190001 HOERUMAN 3278082706720002
32
M.RAKHSAN 2018-04-28 L 3278082804180003 YASIR 3278080410770005
33
MAHREEN 2020-09-25 P 3278086509200001 DEVI 327808
34
MECCA 2020-07-24 P 3278086407200006 MAMAN 3278080504790011
35
MUHAMMAD DANIAL SAUQY 2020-09-23 L 3278082309200002 DICKY 327808
36
MUHAMMAD FARZAN 2018-04-09 L 3278080904180004 ALI 3278081712790008
37
MUHAMMAD JABAR TRI GUNA 2018-09-26 L 3278082609180002 MAMUN 3278081007760008
38
MUHAMMAD MULKI HAIDAR MUBAROK 2021-12-22 L 3278082212210003 ACEP SAEPUDIN 3278082301990003
39
MUHAMMAD MUNTAZ 2018-08-21 L 3278082108180004 ROHMAN ARIFIN 3278051709900004
40 MUHAMMAD RAFASYA ZAYYID
RAMADHAN 2022-04-27 L 3278082704220003 wawan 3278081702810001
41
MUHAMMAD SYAKIR 2020-09-04 L 3278080409200001 IWAN 327808
42
MUHAMMMAD GHIBRANI 2021-09-10 L 3278082903210001 ABDUL ARIF 3278082406930010
43
NABILA DUROTUN NAFISAH 2020-06-22 P 3278086206200000 AZAM 327808
44
NAIRA SHABILLA FAUZIAH 2021-07-25 P 3278086507210001 akbar 3278081301920012
45
NURUL HUMAIRA 2019-07-09 P 3278084907190000 NURUL HILMI 3278081910870007
46
PUTRI AISHABIRA LISTIANTI 2021-07-18 P 3278085807210002 LUTFI 3278082508970007
47
PUTRI ALYA 2019-07-03 P 3278084307190006 DIAN TAUFIK 3278081204920005
48
RAFA 2022-03-24 L 3278602403227918 ajat 327808
49
RASYID 2022-03-03 L 3278080303220001 andi 327808
50
RATU BEBY 2018-12-22 P 3278086212180003 AGUNG 3278082803890004
51
RAYYANZA HAIDAR ALFARIZQI 2022-09-22 L 3278082209220002 agung 3278082803890004
52
RISMA NURJANAH 2019-01-17 P 3278085701190005 KUSNADI 3278081112750009
53
RIZKY PRATAMA 2020-12-25 L 3278082512200002 UJANG 327808
54
SILKI RAHMANIAH 2021-10-02 P 3278084210210003 dede dian 327808
55
SYARIFATUR RAINA 2019-04-07 L 3278080704190010 APIP 3278080704810005
56
WAFA 2020-02-20 P 3278086002200000 AZIS 327808
57
ZIAD 2022-06-14 L 3278600705229849 TANJIL 327808
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
LIUNGGUNUNG 087823792075
liunggunung 081802186286
Liunggunung 085321508351
liunggunung 081381090236
liunggunung 081949995705
LIUNG GUNUNG 085223030441
LIUNGGUNUNG 085280577456
LIUNGGUNUNG 0
LIUNGGUNUNG 08213894979
MANGKUBUMI 087823792075
LIUNG GUNUNG 0
MANGKUBUMI 087823792075
LIUNG GUNUNG 0
LIUNGGUNUNG 0
LIUNG GUNUNG 082
MANGKUBUMI 087823792075
liunggunung 083135286140
LIUNGGUNUNG 0
liunggunung 081572104634
LIUNGGUNUNG 085158815051
liunggunung 087737423882
liunggunung 082
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABDULLAH ZAID AL HAQ 2020-11-24 L 3278082411201234 HUMAM 327808
2
ABIZAR 2018-12-21 L 3278082112180002 ERIS 3278080202940006
3
AHMAD ALI SYARIFUDIN 2020-07-09 L 3211020907200001 Apud saripudin 3211022207970006
4
AHMAD NUR F 2019-03-03 L 3278083103190003 FARID 3278080511880006
5
AL FAAZ MUBAROK 2021-06-06 L 3278080606210001 LUTHFI 3278082306830007
6
ANNISA 2018-11-09 P 3278084911180001 ENCEP 3278080206940006
7
AQILA ULFA RAMADHANI 2020-05-19 P 3278084905200008 YANA 327808
8
ATTHYA SHAQEENA GAMANTRA 2019-05-17 P 3278085705190001 Panji gamantara 3278080201860007
9
BAGEA R SAGARA 2022-09-09 P 3278604909225088 Febry ramdani 32072202970004
10
BAYANAKA JAKHI KALANDRA 2022-01-27 L 3278082701221234 DWIKY 3275160507940011
11
CANDRA 2019-01-15 L 3207330712140001 IMAN 3207334711930004
12
FAEYZA FAIRUS NURFALAH 2021-08-14 L 3278081408210001 NURUL FALAH 3278081104910006
13
FAZHIRA NINDI AULIA 2023-01-11 P 3278085101230001 GUN-GUN 3206030502030005
14
GIBRAN 2019-04-18 L 3278081804191234 OBOD 32708
15
HABIBIL KOLBI 2018-04-26 L 3278082604180005 YUDI 327808040800010
16
HANIF 2021-04-21 L 3278082104210004 ARMAN 3207021805790002
17
HISYAM 2018-11-25 L 3278082011180004 ARMAN 3207021805790002
18
IRFA HAFIDZAH NUR MUTMAINNAH 2020-05-29 P 3278086905200080 DIAN 3278080306830008
19
KAILA 2019-04-18 P 3278085804190000 ABUD 3278080710740014
20
KHALISA SALSABILA SETIAWAN 2022-04-02 P 3278084204220001 ASEP SETIAWAN 3278082109890002
21
KINARA 2020-02-28 P 3278086802201234 ARDI BASYARI 3278082310910001
22
M REYNAND KEENANDRA 2022-11-07 L 3278080711220002 Supriatna 3278081907840005
23
M.AHYARAYAN 2019-04-24 L 3278082004190003 NURMANSYAH 3206022910880001
24
M.BAGAS 2019-07-22 L 3216102207190010 ALDI 3216091712990006
25
M.BAGUS 2019-07-22 L 3216102207190020 ALDI 3216091712990006
26
M.RIZIQ AL GHAZALI 2021-07-28 L 3278082807211234 YAMIN 3278080303890007
27
M.ZABIR ASHIDIQ 2022-08-15 L 3278081508220002 Humam 3278080612970005
28
MUHAMMAD ALIF SYAPUTRA 2022-09-08 L 3278600809229782 Pudin 3278082701790001
29
MUHAMMAD AZKAN ARROFI 2022-02-09 L 3278080902220002 Ade yana / lestari 3278045104980005
30
MUHAMMAD RASYID 2022-06-21 L 3278602106224452 Irham 3278080510930001
31
NAFASA DZIKRIYA RAMADHANI 2020-04-30 P 3278087004200010 DENI 3276061207760013
32
NASYA ANAYA PUTRI 2022-12-01 P 3278604112221376 RISKI Indriawan 3207013101970002
33
NAVIZHA IRIYANI PUTRI 2018-08-05 P 3278094508180003 ADE YANA /LESTARI 3278045104980005
34
NOUREEN MIKAYLA 2019-11-30 P 3278087011190001 FIRMAN 3278091502930003
35
PAIJAN 2020-12-06 L 3278080612208776 AMINULLOH 3278080104780012
36
RAFKI AULIAN 2019-07-15 L 3278081507190001 ABDUL ADIS 3278081508840014
37
RAKHA 2021-04-06 L 3278080604210002 FAIZAL 3278020708780019
38
RAYNA ALESHA 2019-08-08 P 3278084808190002 IWAN 3278080808800011
39
RIAZ RAQILLA PERMANA 2021-08-02 L 3278080208210001 Rini rusdiani 3278065201940003
40
SALMA 2019-07-15 P 3278085507190000 NURUL ISMA 3278081104910006
41
SAMUDRA MALIK ALBADAR 2022-06-16 L 3278081606220003 GUMILAR 327801312020014
42
SAZWAN 2020-06-02 L 3278080206201234 DADANG 327808
43
SITI MALA 2019-12-01 P 3278084112190001 SAEPUL 3278012107870007
44
SYAQILA 2019-08-24 P 3278086408190002 AGUS 3278080701800013
45
SYAQILLA ALMAHYRA PUTRI DEANDRA 2021-03-27 P 3278086703210001 Dea 3278085709920005
46
TASYA SRI DWICAHYANI 2020-02-05 P 3278084502200008 TEDI 3278082402880001
47
WAFA SYANUM 2019-07-23 P 3278086307190003 IRWAN 3278082809800005
48
YUMNA 2018-06-03 P 3278024306180000 FURKON 3278020410800004
49
ZEED IBRAHIM 2019-08-31 L 3278083108190003 SYARIP 3278080104880005
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
PATAHUNAN 0
PATAHUNAN 085223030441
PATAHUNAN 085798454451
PERBU 0
PERBU 082317642230
SIRNASARI 0
Sirnasari 082290849122
WARUNG 0
PATAHUNAN 085223030441
PATAHUNAN 0
PATAHUNAN 087875333819
SIRNASARI 0
PERBU 087823792075
PATAHUNAN 0
PATAHUNAN 085223030441
PERBU 0
PATAHUNAN 08551989354
PERBU 08213894979
PATAHUNAN 085219236987
Patahunan 089603924511
PATUHANAN 085223030441
SIRNASARI 0
SIRNASARI 0
SIRNASARI 0
Mangkubumi 089515567986
Perbu 082321686149
Perbu 089602301072
Sirnasari 082213894979
SIRNASARI 0
Perbu 085846832551
PERBU 089602301072
PATAHUNAN 085223030441
PERBU 0
PERBU 085327521232
SIRNASARI 0
PERBU 082321958910
PATAHUNAN 085223030441
PATAHUNAN 087884996531
PERBU 0
JL SWAKA 0
PATAHUNAN 0
PERBU 085223030441
MANGKUBUMI 087823792075
PATAHUNAN 085280401048
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABISHA SABITA JURI 2022-06-03 P 3278084306221234 ASEP 327808
2
ADITIA RIZKI NUGRAHA 2022-06-20 L 3278602006223787 MAMAN 327808
3
AIZA KHAWLA 2019-01-17 P 3278085701190002 PIPIN 3278082105690002
4
AL MAIKA 2018-10-19 P 3278085910180005 MAULDAN 3278081708840017
5
ALBY ABRISAM 2021-05-29 L 3278082905211234 MANSUR 32
6
ANASYA ADRENA SHAILA 2020-10-23 P 3278086310201234 KIN KIN 3278082611930004
7
ARKALA SHAQEEL 2020-06-14 L 3278081406200008 RYAN 327808
8
ARSHAKA 2018-05-11 L 3278081105180002 ASEP 327808
9
CITRA 2020-12-01 P 3278084112201234 HENDRA 3278081212730024
10
DINDA KIRANA 2020-02-29 P 3278086902200002 SIDQI 3278080105900008
11
FAISAL LATIF 2021-01-04 L 3278081611070017 maman 3278081710800001
12
JESLYN 2019-08-06 P 3278084608190001 DEDI 3278080509930016
13
KAYLA ALMIRA 2020-06-17 P 3278085706200003 RANDI 3278081005870014
14
KIREIA 2018-07-06 P 3278084606180003 ASEP 3278082601840001
15
KYRGYZ BINAR KENZA 2021-01-04 P 3278084401210001 dede kurnia 3278081705840007
16
M.ANDRA 2021-01-08 L 3278080801210004 andi 32
17
M.GIBRAN 2019-06-20 L 3278082006190002 DODI SURYATIMAH 3278082107810017
18
M.NABHAN 2018-12-09 L 3278080912180000 YAYAT 3278080808770007
19
M.NAZRIL 2018-08-04 L 3278080408180004 GIRI 3278080607800013
20
M.RAVA 2020-01-24 L 3278082401200001 NASRUDIN 3278081212890006
21
M.RAZZAN AL HANAN 2021-11-14 L 3278081411210001 YUNAN 32
22
M.SYAFIK FAIZ 2021-02-09 L 3278080902210004 HENDRI 3278080605860003
23
MOZZALUNA SWARNA REKHA 2023-02-15 P 3278605502236378 Ade Riko
24
MUHAMMAD ZIDAN MUBAROK 2022-07-01 L 3278080107221234 UUS 327808
25
NABILA AISYAH 2020-10-24 P 3278086410200001 andri 3278080312910007
26
NADHIRA NUR KHUMAIRA 2023-01-01 P 3278604101232462 Erwin 3206052107950003
27
NADIRA 2019-02-06 P 3278084602190001 INDRA 3278081807842698
28
NAZHALEYA ATHAYA MYSHA 2022-12-07 P 3278604712223373 Agga Atma dwinata 3278082511980009
29
NOVIANI 2018-11-17 P 3278085711180002 HILMAN 3278080808820012
30
RAYYA 2018-10-02 P 3278084210180001 YUNAN 3278081308820014
31
RAYYANKA KHALIF NADHIRIZKI 2023-02-05 L 3278600502232647 ipti ramdani 3278092512000002
32
RIZAL ATAMIMI 2019-03-02 L 3278080203190002 DANI 3278080503800006
33
ROBYANSAH 2020-10-27 L 3278082710200001 UCA 3278082712840026
34
SEANINO 2022-01-03 L 3278080301221234 IMAN YAMAN
35
SEPTI MAHARANI 2021-09-15 P 3278085509210002 DENDI 32
36
SHANUM BYANCA GUMELAR 2022-12-24 P 3278606412229597 Kiki gumelar 3278080202010015
37
SHERIL 2019-01-15 P 3278085501190002 TONO 3278080409820012
38
SILFARA 2021-05-06 P 3278084605211234 SANDI 327808
39
SYAFA 2019-10-11 P 3278085110190000 JANA 3278082802760004
40
SYAKILA PUTRI 2020-10-07 P 3278084710201235 RONI 3278082402930001
41
TEVANO 2022-01-09 L 3278080901221234 DEDI 32
42
THEO FANIA THALITA 2022-09-08 P 3278604809222025 Satori 3301062806860003
43
YUMNA SYARA HAFIZAH 2021-07-29 P 3278086907210001 AGUS 32
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
SUKAMEKAR 085223255367
SUKAMEKAR 085223255367
SUKAMEKAR 085221154320
SUKAMEKAR 085223251367
SUKAMEKAR 0
SUKAGENAH 085316768226
SUKAMEKAR 085293965404
MANGKUBUMI 087823792075
SUKAMEKAR 085223255367
SUKAMEKAR 085723451700
sukamekar 087828803337
SUKAMEKAR 085722738014
SUKAGENAH 0
SUKAMEKAR 081912881169
sukamekar 0
sukamekar 0
SUKAGENAH 085223458584
SUKAMEKAR 085222395713
SUKAMEKAR 082126973651
SUKAMEKAR 082317208246
SUKAMEKAR 0
SUKAMEKAR 085223255367
sukamekar 085223255367
SUKAMEKAR 085223255367
sukagenah 085320403107
sukamekar 085223255367
SUKAMEKAR 085220062767
Sukamekar 081224740565
SUKAMEKAR 085223255367
SUKAMEKAR 089514478387
sukamekar 085223255367
SUKAMEKAR 0895362403400
SUKAMEKAR 082311226005
SUKAMEKAR 085289477003
SUKAMEKAR 0
sukamekar 085223255367
SUKAMEKAR 082315882402
SUKAMEKAR 085223255367
SUKAMEKAR 083826161267
SUKAGENAH 087809392362
SUKAMEKAR 0
Sukamekar 085320479209
SUKAMEKAR 0
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABIL SIDQI 2021-08-01 L 3278080108211234 ARIF 32
2
ABIZAR 2018-07-26 L 3278082607180008 MULYADI 327808
3
ABRISAM 2018-11-27 L 3278082711180008 HERU 3206241905750007
4
ADEVA 2018-11-04 P 3278084411181234 H.UCU 327808
5
AFFIQ 2018-05-01 L 3278080105180009 PUJA 327808
6
AIYRA 2019-05-27 P 3278086705190008 DIKI 327808
7
AL BARA 2020-10-19 L 3278081910200003 RIYAN 3278082208900007
8
AL GAISAHAN 2020-10-18 L 3278081810200000 RIZA 3278082504900005
9
ALEA NADIRA 2020-12-14 L 3278085404200008 ARIF 3278081402850002
10
ALISHA 2021-06-27 P 3278086706210001 MULYADI 3278052911850001
11
ALNAIRA 2019-10-18 P 3278085810190008 HENDI 327808
12
ALZIAN 2020-07-16 L 3278601607201823 tito ardiyanata 3278040209870010
13
ANAHITA 2022-08-19 P 3278035908220003 TRI HANSDOKO 3278081108830004
14
ARSHI 2019-04-09 P 3278084904190003 TEDI 3278082406820005
15
ARSYILA 2022-10-04 P 3278604410229207 m. hilman fauzi 3278041704900003
16
BANAFASHA 2022-02-15 P 3273025502220002 AZIZ ISNA FERTONI 3313083008910002
17
CHAVIA MECCA 2020-05-17 P 3278605705206047 bian tiara 327805210290001
18
DAMAR 2018-06-08 L 3278040806180002 dr.RIKI 3278041101850009
19
EKA PRASETIA 2022-11-09 L 3278080911220001 yudi wira buana 3278082705780003
20
FADHILAH 2020-12-14 P 3278605412208569 PEBRI 3278022012940005
21
FAHRIL 2020-06-19 L 3278081906200008 FADLI 327808
22
FATMA 2023-02-09 P 3278604902234323 ana 32780803840006
23
GAURA 2019-07-24 P 3278606407192553 HENDY 3278082906800006
24
HAFISA 2022-03-03 P 3278084303220001 Saepuloh
25
IMTIYAZ 2021-06-19 P 3278085906210002 SARKIM 3278082508840008
26
JENAIRA 2021-09-02 P 3278084209211234 Arif 3278084612930004
27
JULIANE 2021-06-19 P 3278605906218169 untung santosa 3278083010840008
28
KAIVAN 2020-12-12 L 3278081212200005 SANDY 3273022311920001
29
KANZA 2019-07-09 P 3278084907190008 ANDI 327808
30
KESA 2019-11-11 P 3278085111190008 MULYA 327808
31
KHALID 2020-07-19 L 3278601907203293 tri hansdoko 3278081108830004
32
KHAYRI GHAISAN 2020-05-09 L 3274030905201234 dery septriawan 3210130209810042
33
LIA 2019-09-09 P 3278084909190000 EMAN 327808
34
M ELFATA CORRADEO 2019-09-07 L 3278600709194393 TEGAR SEPTIANDI 3305120309920002
35
M ENZO RAYHAN PRTAMA 2021-02-12 L 327808110222001 rio regi prtama cipta 3278083108910006
36
M. ARKA 2021-11-18 L 3278601811216627 m. noval syaban 3278010701960011
37
M.ALZAM 2020-06-02 L 3278080206200008 UUS 327808
38
M.RAIYAN 2020-02-26 L 3278082602200002 ARIF 327808
39
M.ZIANDRA 2019-05-04 L 3278080405190001 GUNGUN 3278080409820011
40
MAHDUM 2019-08-12 L 3278081208190000 PEPI 3278052508800005
41
MIKAYLA 2021-03-23 P 3278066303210001 JIHAN ABDUL 306021309930004
42
NAFIS 2019-05-15 L 3278081505190007 ARIF 3278081702890010
43
PRAMA 2018-11-06 L 3278080611180000 RIDWAN 327808
44
PRIBADI A 2022-07-03 L 3278600307221666 HENDRA 1802162507940001
45
RAFASYA 2020-01-05 L 327804050120001 drg tendi 3278040209870010
46
RAFI 2018-10-12 L 3278081210180000 PEPI 327808
47
RAISHA AQIELA 2019-05-01 P 3278084105190008 ASEP 3278081203790012
48
REVA 2020-03-09 P 3278084903200003 ELIN 3278086309940003
49
REVANDRA 2021-12-10 L 3278081012211234 TANTAN 32
50
RIANI 2022-03-08 P 3278604803223908 Hilman
51
RY ARCELIO 2021-12-06 L 3278080612210004 rendi oktavian 3278083010840008
52
SABIRA 2019-07-17 P 3278085707190001 satria 327808
53
SABIYA VALEEQA 2020-12-29 P 3208176912200003 Iing supriatna 3201212802820004
54
SABIYAN PUTRA 2020-12-23 L 3208178912200001 RISKIYA 3201212802820004
55
SALMA 2020-07-25 P 3273256507200001 nurul ikhwan 3604221507930006
56
SELMA ALIVIA K 2022-12-09 P 3278604912221571 dani ramadani 3278020804900011
57
SYABIAN PUTRA 2019-02-10 L 3278081002190001 RIZKIA 3206341204790005
58
WAQAS 2018-11-27 L 3278082711180002 TRI HANSDOKO 3278081108830004
59
YUMMA 2020-09-15 P 3278085509200003 ISAM 327808050900007
60
ZAMZAM 2018-08-26 L 3278602608188785 Dede yayat 327808411790003
61
ZAYN ALFARIZI 2022-10-07 L 3278600710229767 edih 3278082410830009
62
ZAYYIN 2021-05-18 L 3278081805211234 RANDI 32
63
ZUNAIRA 2022-06-12 P 3278605206228115 DEDEN PERMANA 3206030606950008
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
Babakan jati 0
ANDALUSIA 085223030441
ANDALUSIA 085223030441
ANDALUSIA `0
ANDALUSIA 085223030441
BABAKAN JATI 0
BABAKAN JATI 0
Babakan jati 0
BABAKAN JATI 0
BABAKAN JATI 0
ANDALUSIA 0
BABAKAN JATI 0
BABAKAN JATI 0
BABAKAN JATI 0
BABAKAN JATI 0
ANDALUSIA 085223030441
ANDALUSIA 0
BABAKAN JATI 0
BABAKAN JATI 0
ANDALUSIA 0
ANDALUSIA 0
ANDALUSIA 0
ANDALUSIA 085223030441
BABAKAN JATI 0
BABAKAN JATI 0
babakan jati 0
Andalusia..alaves 0822400561660
ANDALUSIA 081312414401
BABAKAN JATI 0
BABAKAN JATI 0
BABAKAN JATI 0
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABINAYA ALEXI 2020-10-22 L 3278082210200001 DONI 3278082910910003
2
ADILA ZULEIKA 2020-12-19 P 3278085912200001 WAWAN 3206241207850002
3
ADZRA NADHIFA 2018-08-24 L 3278082408180002 HANHAN 3278081609870006
4
AFIFA FATIMA 2021-08-06 P 3278084608211234 RONI 32
5
AFTA HALWA 2020-06-22 P 3278086206200001 AAT 3278082304810002
6
AISYA FADILA RAMADHANI 2018-06-06 P 3278084606180002 IRPAN 3278060112880011
7
AISYA SAIRA 2020-09-25 P 3278082509200000 SUPRIATNA 327808
8
AISYAH TIYAS DRASTIANA 2021-10-16 P 3278085610210002 AANG 3278010303800007
9
ALIFIYA SAFANIYA 2021-04-01 P 3278084104211234 IRWAN 32
10
ALISHA KHANZA 2019-05-27 P 3278086705190000 YANGYANG 327808
11
AMELIA PUTRI NURAZIZAH 2022-09-17 P 3278085709220001 DARMANTO 3301162604900001
12
ANDINI SHAQUEENA 2020-10-15 P 3278081510200002 REDI 3207060602900002
13
ARETHA TAHANUF HAMKA 2022-05-08 P 3278084805221234 ALWAF TAHANUF 3278082404900005
14
ARGA AQSABIAN 2022-06-12 L 3278081206221234 emin muhaemin
15
ARKHA MUHAMMAD FEBRIANA 2022-02-06 L 3278080602221234 IYUS 32
16
ARRASYA KAYLA HANIFA 2021-12-04 P 3278084412210001 HENDRA 32
17
ARSENA XHAQUEENA AFANDI 2022-02-14 P 3278085402221234 ADI 32
18
ARSHAKA EL AZZAM 2021-09-17 L 3278081709211234 DADI 3278082302870005
19
ARSHAKA VIRENDRA S 2020-10-14 L 3278081410200003 ENDE R 3278083005900006
20
ARSY RAHMANIA 2020-08-04 P 3278084408200002 OBAN 3278082003870008
21
ARSYAKA 2020-08-21 L 3278082108200000 JAFAR 327808
22
ARTANABIL 2019-04-19 L 3278081904190002 NANANG 3278081602790006
23
ARUMI SYAFA HUMAIRA 2021-07-21 P 3278086107211234 EGI 32
24
ARVIN ALVARO 2020-05-11 L 3278081105200010 AGUY 3278080904820005
25
AZKILA QINARA 2020-06-15 P 3278085506200000 TATA 3278082209810003
26
BILAL HAFIDZ ALHANAN 2021-10-08 L 3278080810210001 FAZAR 3278081612950006
27
CELSYA GISKA SYAHPUTRI 2023-01-02 P 3278084201230001 RIDWAN 3206191011950001
28
DALIA MUTYARA 2021-11-16 P 3278085611211234 IRFAN 32
29
DAVIAN 2019-07-29 L 3278082907190000 FUJI 327808
30
DELISTA AULIA PUTRI 2020-04-09 P 3278014904200010 MUSLIM 3206121202880004
31
DELSHAD NUR RAHMAN 2020-11-06 L 3278080611200002 arif 3210040510860001
32
DENARA SHAQUEENA HUMAIRA 2018-05-03 P 3278084305180002 YANTO 3278080305830007
33
FADIA AZIZAH 2019-08-18 P 3278085808190000 KIKI 327808
34
FAHIMA 2020-08-29 P 3278086908200004 M.AZIS 3278082912960007
35
FATIHA DARA 2019-05-11 P 3278085105190004 ARIP 3278091202950003
36
FITRA 2020-05-24 L 3278082405200000 - 327808
37
GEHAN 2022-03-24 L 3278082403221234 ERIS
38
GILANG ADITYA 2021-05-10 L 3278081002210006 IJANG 3278081602870007
39
HAFSA 2018-10-25 P 3206356510180003 IIH 327808
40
INDIRA 2018-10-21 P 3278086110180005 WILDAN 3203072304780008
41
KAYLA CARISSA AQUEENA 2018-09-19 P 3278085809180005 dini 3278045211910011
42
KEYSA INAYA A 2019-03-25 P 3205086503190001 IRWAN 3278080305830005
43
KEYSA JUNNAH PUSPASARI 2021-06-08 P 3278084806210004 sani nursamsi 3278081910950002
44
KHALISA AISYA RUJHAN 2020-03-19 P 3278085903200002 ADIN 3278081408850009
45
KUMARA 2019-08-07 P 3278084708190003 AANG 327808
46
LANIKA PUTRI FADILA 2018-07-10 P 3278065007185421 AJAT 3278063103850014
47
M.ALVARENDRA RAZKA 2020-04-11 L 3278081104200002 DADAN 3278082412800009
48
M.BARA 2019-01-08 L 3278080801190002 ENDE 3278083005900006
49
M.MUMTAZ ARROPI 2019-03-16 L 3278081603190001 WAHID 3278082608870003
50
M.RIZKI PRATAMA 2020-08-17 L 3278011708200010 RIZAL 3278081605990005
51
MISEL SHARA ADZKIYA 2022-09-20 P 3278086009220001 AGUNG 3278082704920007
52
MOCH.ADRIAN F 2020-10-29 L 3278082910200004 LATIF 3278081406920004
53
MUHAMAD AL AZAMI DINULHAK 2021-01-15 L 3278081501210001 ADI 3278051704950001
54
MUHAMMAD ALMAS AZRAQI 2022-02-16 L 3278081602221234 NANANG 32
55
MUHAMMAD ALVINO RAMADHAN 2022-04-27 L 3278082704220002 ucu
56
MUHAMMAD ARJUN 2021-06-12 L 3278081206211223 MAMAN 32
57
MUHAMMAD ARSYA 2021-01-18 L 3278081801211234 nuryamin 32
58
MUHAMMAD AZKA ROFIK MUBAROK 2022-11-15 L 3278601511222017 RIAN 327808
59
MUHAMMAD DEVIN 2021-09-24 L 3278082409211234 IWAN 32
60
MUHAMMAD HIBBAN MUQTAFI 2022-05-28 L 3278082805220001 cecep
61
MUTIARA SAYYIDA NURRAHMAN 2022-08-31 P 3278017108220002 RAHMAN 3278011405940008
62
NAFA 2020-01-04 P 3278084401200000 BUDI 327808
63
NASHWA ALINA HUMAIRA 2020-06-15 P 3208085506200003 YONO 3207062811820003
64
NAYRA AQILA NAFISHA 2023-01-21 P 3278086101230001 MUSLIM 3206121202880004
65
NAZEERA LAKEISYA 2022-01-28 P 3278086801221234 azhar joharudin 3278081410910014
66
NAZIHA ADREENA 2018-04-12 P 1871015204180004 WIBI 1902011308880005
67
QINARA 2019-08-05 P 3278084508190001 TAUFIK 3278080609840014
68
RAFFASYA DANISH PURNAMA 2018-12-27 L 3278082712180003 SAMMY 3278032307920002
69
RAIDA ZAIN NIRVANA 2019-10-12 P 3206245210190002 JENI JAENAL AP 3206132309930001
70
RAIZUL HAQQI 2021-04-26 L 3278082604211234 AGI 32
71
RAKA ELVANO 2021-04-11 L 3278081104210001 RIKI 3278050703850002
72
RAMZAN AHMADOVIC KADIROV 2022-10-23 L 3278602310222890 DIAN 327808
73
RAYYANZA ARVI IBRAHIM ASSAJID 2022-01-24 L 3278082401221234 WIBI 1902011308880005
74
RIZKIA HANIFA YUMNA 2021-11-11 P 3278085111210001 OLIH 3278080206840007
75
SABDA NUR MUHAMMAD 2021-10-16 L 3278081610210004 NURSAMSI 32
76
SAFFANA NASHA FAWZI 2021-06-27 P 3278086706211223 CHEPI 32
77
SAFIRA NUR APRILIA 2018-04-26 P 3278086604180002 USEP 3278080906850009
78
SAMY AHMAD ABDILLAH 2022-11-06 L 3278600611227280 SARAH 327808
79
SELBY 2022-03-15 P 3278085503221234 DENI 327808
80
SHAHIRAN ZAYN ATHALLAH 2022-07-03 L 3278080307221234 IRFAN HUSNI MUBAROK 3278060112880011
81
SITI YULIANTI 2018-03-31 P 3278607103180000 ADE 327808
82
SYAQILA AIRA PUTRI HENDANA 2021-06-11 P 3278085106211233 YUDI H 32
83
VEGA MUSLIM AL RASYID 2020-12-31 L 3278083112200001 AMIN 3278082108900004
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
SAMBONG GIRANG 0
MANGKUBUMI 082240417339
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
MANGKUBUMI 087823792075
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
SAMBONG GIRANG 0
KP. BARU KONTRAKAN BOS IMAT SAMBONG
GIRANG 082216706805
Sambong girang 0
MANGKUBUMI 087823792075
SAMBONG GIRANG 0
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABIZAR SUKMA FARHANDIKA 2021-01-24 L 3278082402210002 Andreas 3278081408940008
2
ADIBA 2019-03-25 P 3278086503190003 Mumu 3278082107840008
3
AKHTAR FARZAN 2019-11-22 L 3278082211190001 ENTRI 3206190806930001
4
ALFIANI 2020-10-16 P 3278085610200001 IMAM 3278000304860002
5
ARSYA 2022-02-23 L 320605 Dede baya 3206055003950004
6
DILARA 2020-12-29 P 3278086812200001 Wawan 3278051207880009
7
ELPAN 2019-01-28 L 3278082801190009 ASEP 3278081901930011
8
FAREL 2020-11-05 L 327808051120 Cici 3278086706050002
9
HANIN 2021-09-06 P 3278604609214084 Denu 3278080502940009
10
HENDRIK 2021-07-08 L 327808080721 Elis 3278085202830001
11
IRSYAD 2019-12-12 L 3278081212190003 Diki 3278080110950008
12
KINANTI 2022-07-01 P 3278084107220001 RIAN 3603171705920006
13
M RIZKI SETIAWAN 2020-09-04 L 3278080409200002 Wawan 3278050409670002
14
M.WILDAN 2019-10-08 L 3278080810190002 ASEP 3206130803840002
15
NADIA HUMAIRA PUTRI 2022-04-17 P 3278085704220001 Dian hermawan 3278106204820001
16
NAUFAL SYIHAB 2018-06-04 L 3278080406180002 ADE 3278081609710012
17
NISA 2018-11-02 P 3278084211180000 ACENG 3278081611800009
18
NIZAM 2021-08-30 L 3278053008210005 Ali 3278050411890004
19
RAFFA 2021-07-21 L 3278082007210004 IMAM 3278082006940007
20
RAISA NUR RACHMAN 2019-05-27 P 3278086705190003 ZAMZAM NURJAMIL 3278081504840018
21
RAJENDRA SATYA RAZZANI 2020-07-24 L 3278082407200000 HENDRA 327808
22
SAKIL ALGHAISAN 2022-06-28 L 320617280622 Febri 3206172802910002
23
SYAHIDA MUTHIA PURNAMA 2020-04-02 P 3278084507200004 Azis 3278081111980010
24
SYAKIR 2021-12-05 L 3278600512219896 Azis 3278081111960010
25
TSANIA 2018-06-24 P 3278086406180002 ENDANG 3278081404760005
26
ZAHRA NUR AULIA 2018-08-30 P 3278087008180002 JAELANI 3278081903820011
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
Ciponyo 082133192085
Ciponyo 081394299299
CIPONYO 085223030441
CIPONYO 083208420810
Ciponyo 082213894979
Ciponyo 083208420810
CIPONYO 085223030441
Ciponyo 082213894979
Ciponyo 08213894979
Ciponyo 082213894979
Ciponyo 081394299299
CIPONYO 081394299299
Ciponyo 085223399391
CIPONYO 085223030441
Ciponyo 085713675420
CIPONYO 085223030441
CIPONYO 085223030441
Ciponyo 085223399391
CIPONYO 083208420810
CIPONYO 0
CIPONYO 0
Ciponyo 081394299299
Ciponyo 082133192085
Ciponyo 085223399391
CIPONYO 085223030441
CIPONYO 085223030441
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABRISAM JABARUDIN 2020-01-10 L 3278081001200002 AHMAD 3278030806870003
2
ADIBA KHADEEJA BTARI 2022-06-26 P 3278026606220001 Ardian Fauzi pahma 3278021401910007
3
ADZKIYA ZAHRA 2019-11-14 P 3278015411190002 DIKDIK FUAD 3278011205910005
4
AKHTAR ALFAREZI 2020-10-25 L 3278082510201235 - 32
5
ALISHA HUMAIRA SYABANI 2021-01-19 P 3278085902210001 ACHMAD ASYAMSI SYABAN 3206182703890002
6
ALULA LUBNA 2018-11-15 P 3207015511180001 ERIK 3206222012900001
7
ALUNA MALIKA 2020-04-08 P 3278084804201234 AGUNG 3278080902930002
8
ANDHIRA EMBUN 2019-11-28 P 3278086811190008 AGUS 3315042808850008
9
ANFA AL HAITAMI 2020-06-20 L 3278052006200001 TONI 3278052012830005
10
ANGGIA HUSNA RAMADHAN 2021-02-04 P 3278084402210001 ENJANG AJRUL RAMADHAN 3206160102970002
11
ANNAYSA ADZKIYA 2019-06-30 P 3278087006190002 DERI F 328012102850002
12
AQILLA KHAIRINA 2020-07-30 P 3278027007200001 PERI 3278021812850011
13
ARKA BHADRIKA RASENDRIA 2018-05-20 L 3278062005180001 YUSUP 3278010905900006
14
ARSAKHA ALVARENDRA 2019-12-22 L 3278072212190001 ENJANG ABDUL 3278072812940001
15
ARSAKHA KAELAN 2019-11-18 L 3278081811190001 LUKMAN 3278022706940005
16
ARSYAD NAUVAL 2019-11-13 L 3278081311190003 LATIF RAHMAN 3206010402940004
17
ASHEEQA 2020-11-06 P 3278604611209034 Winda 0000
18
ATHARRAZKA ZAYYAN A 2022-07-18 L 3278011807220001 DIK DIK FUAD ASIDIK 3278011205910005
19
AURORA NAADHIRA 2020-05-09 P 3278084905200001 YOGA 3207321909920004
20
DARREN 2020-10-01 L 0110207955 FITRI 0
21
DASTAN MUHAMMAD 2020-07-03 L 3278080307200001 HENDRA 3278012504860005
22
DHEFIN FAYYAD 2020-08-02 L 3278080208200003 DIKI 3278052911910004
23
DZAKY M GHIFFARY 2021-05-03 L 3278080305211234 RAJA 3206322306880002
24
ELSHARAWI AHMAD 2018-07-08 L 3278010807180002 IKBAL AHMAD 3278030409930004
25
EZHAR 2021-10-01 L 0110214905 ESTI 0
26
FAEYZA 2019-07-22 L 3278082207190001 FIRMANSYAH 3278080211920003
27
FAIREL ATHARIZ 2020-11-09 L 3278080911201254 DENI 3207312308820001
28
FIRDAN ADITYA MAULANA 2019-12-13 L 3278081312190002 DANI NURDIAN 3278012912870009
29
GAOUZAN MUFASA 2018-09-25 L 3278082509190004 SALMAN 3278010310950001
30
HAFSHAH PRAMIDITA NUGRAHA 2019-01-24 P 3208216401190001 Didit Aditya Nugraha 3208101602870004
31
HAFSYA HAZIYA 2020-08-25 P 3278086508201234 RUJALI 3207010507880002
32
HUSNA NURMAHYA 2018-04-03 P 3278084304180001 erdi purnama 3278061605920012
33
INARA SAFAIRA 2019-11-23 P 3278086311190002 MD AGUS 3278060905920012
34
JIHAN AZIZAH 2020-06-15 P 3278085506200003 NANAR NAORI 3206160107810144
35
KAFA BILLAHI FAUZI 2021-08-04 L 3278080408210003 IHSAN FAUZI 3278080301910008
36 KELVIN SATYA PRADANA PUTRA
MAOLANA 2021-04-21 L 3205142104210002 Agus Rahmat Maolana 3205142108950001
37
KIRANIA KHAIRUNNISA 2022-10-10 P 3278085010220003 ANDRA RIAN MULYANA 3206041210920004
38
M BILAL A 2019-05-10 L 3278031005190001 ROBY 3278032601940003
39
MALIKA 2021-12-01 P 3278084112211234 LUTFI 32
40
MALIKA 2019-01-20 P 6001192675 KOMALA 0
41
MOCH AL GIFARI QAHTAN 2020-11-11 L 3278081111201235 MOCH ALAMSYAH 3278031807160002
42
MOCH GHAISAN ALFARIZKY 2019-06-19 L 3278081906190002 MOCH ILHAM 3278031210910005
43
MUHAMMAD ALFAREZI 2019-12-19 L 3278021912190013 M.GUNTUR 3278081004950001
44
MUHAMMAD HYUGA 2021-05-17 L 3278081705211234 YOGA 14170605940001
45
MUHAMMAD KEENANDRA AL HAITSAM 2021-05-05 L 3278080505210001 AYIN ALFIANI 3206035104930001
46
NABILA AISYAH M 2019-05-10 P 3278085005190002 ZAMALUDIN A 3171071701931001
47
NINDITA AYU 2019-05-17 P 3278015705190002 ANDI 3310053012850002
48
PARFAIZ TRIAZFAR ARASEN 2022-05-05 L 3278010505220002 DEDEN KUSNENDAR 3207033001810001
49
PRISHA N.H 2021-11-25 P 3278086511211234 HENDRIK 327808
50
PUTRI GENDIS 2020-04-16 P 3278085604200002 EKA 3278082101950015
51
QUTHBI 2019-02-01 L 3278080102191234 MEGA 32
52
RABIZA NUR MAULIDA 2018-12-13 P 3278015312180001 Taupik jibril 3278012207820003
53
RAFKHA KEANU ARRASYID 2020-01-07 L 3278080701200002 MAMAN 3278010206790002
54
RANIA R 2021-09-01 P 3278084109211234 ERDI 32
55
RAYA HUMAIRAH 2018-12-21 P 3206126112180001 SYAHRUL FAHRI 3206120117880097
56
SHAKILA 2019-11-10 P 3278085011190004 VIKI 3206194204910002
57
SYAKILA MAHIRA PRATAMA 2022-06-04 P 3278604406221697 Ami meyla 0
58
SYAMSA ZAIDAN 2019-12-26 L 3278082612190003 SYAMSUL 3279012508900001
59
ZASKIA ZIDNI PUTRI AZIZAH 2021-11-14 P 3206265411210004 HAPID ABDUL AJIZ 3206281202960004
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
D'VILLAGE 0
D'VILAGE 0
PERUM D VILLAGE 0
PERUMAHAN D'VILLAGE RESIDENCE BLOK A19 KEL.
MANGKUBUMI 085213383791
PERUM D VILLAGE 0
PERUM D'VILLAGE 0
D'VILLAGE 0
PERUMAHAN D'VILLAGE RESIDENCE BLOK B20 KEL.
MANGKUBUMI +6281914945002
D'VILLAGE 0
D'VILLAGE 0
D'VILLAGE 0
D'VILLAGE 0
D'VILLAGE 0
MANGKUBUMI 0
PERUM D VILLAGE 0
PERUMAHAN D'VILLAGE RESIDENCE BLOK H11 KEL.
MANGKUBUMI 0
PERUM D VILLAGE 0
D'VILLAGE 0
PERUM D VILLAGE 0
PERUM D'VILLAGE 0
d'village 0
D'VILLAGE 085221863332
D'VILLAGE 0
PERUMAHAN D'VILLAGE RESIDENCE BLOK A18 KEL.
MANGKUBUMI 085287470700
PERUM D VILLAGE 0
PERUM D VILLAGE 0
D'VILLAGE 0
D'VILLAGE 0
PERUM D'VILLAGE 0
D'VILLAGE 0
Perumahan D'Village Residence Blok B26 Kel.
Mangkubumi 082130180123
PERUM D VILLAGE B6 0
D'VILLAGE 085323207682
D'VILLAGE 0
D'VILLAGE 0
D'VILLAGE 0
PERUMAHAN D'VILLAGE RESIDENCE BLOK B12 KEL.
MANGKUBUMI 083801891101
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ABYAN GILANG 2020-09-27 L 3278082709200004 WILDAN 3278091507840011
2
ADAM 2021-07-03 L 3278080307210001 MOMON 3278080706760008
3
AKHTA FAUZAN WIJAYA 2020-10-18 L 3278601810201557 Dede hasan 327808230480001
4
ALBY SHAKA 2021-10-19 L 3278081910210001 ANNISA 3278080611980003
5
ALVIN 2020-06-02 L 3278080206200001 SANDI 3278102909890001
6
ANJANI MUFIA 2020-11-13 P 3278085311200001 AKBAR 3216091407970002
7
AYESHA 2020-02-20 P 327808600220000 GINANJAR 327808
8
AYSILA 2018-04-06 P 3278084604180002 RISA 327808
9
AZQILA ZIYA NAZHEEFA 2022-10-27 P 3278086710220001 sandi 3278102909890001
10
BILQIS HUMAIRA 2022-06-17 P 3278605706224765 hartanto 3206184107850246
11
CIPTA ALDEBARAN 2021-02-04 L 3278082302210003 ANDI BELI 3278081906750009
12
DZIL FAIZ AZHIM 2021-01-23 L 3278602301214905 Nurdin 3278080801860018
13
FAEYZA 2018-08-08 L 3278080808180002 MUGNI 3278020612910001
14
GENDIS SYAQUEENA 2021-09-28 L 3278086809210003 YOGI 3278080704940016
15
GILANG 2021-04-05 L 3278080504210001 JAJANG 3278080610830001
16
KAIFA SANARI 2021-11-06 L 3278084611210003 SANSAN 3278021201950018
17
KAYLA NADHIFA 2021-02-04 P 3278084402201254 DADAN 327808
18
KIREINA SAHLA 2022-04-07 P 3278084704220001 ZAMZAM 3278086310980009
19
M AFZAL 2021-09-13 L 3278081309210003 DENI 3206392005870001
20
M ARFAN 2020-08-11 L 3278081108201223 OLIH 327808
21
M FAWAZ 2021-07-18 L 3278081807210001 EDIN ALI NURDIN 327808703790013
22
M NOUVRI MILANO 2021-11-03 L 3278080311210002 FAJAR 3278081405930003
23
M SAYYID 2019-08-07 L 3278080706190004 ERNA 3278081404910011
24
M.FADHIL 2018-08-28 L 3248082908180002 IMAN 3278081404760008
25
M.NAUFAL 2018-10-08 L 3278080810180003 CECEP 3278010103940012
26
M.ZAKI ALFATIH 2019-05-16 L 3278081605190003 HELMI 3278080804840005
27
MIKHAYLA 2019-12-07 P 3278084712190004 ANANG 3278091506920001
28
MISHAL 2019-11-25 P 327808651190001 SHOFWAN 3278081301870007
29
NADHIRA SEVINA 2018-09-18 P 3278085809180004 SUTISNA 3278080410820008
30
NADIRA 2020-05-09 P 3278084905200000 DIKI 327808
31
NAUFALIN ALESHA 2019-06-29 P 3278086906190001 DIAN 3278081005780007
32
RAJA WISTARA SYABANI FAUZI 2022-05-27 L 3278082705220002 MIFTAH FAUZI AL ANSORI Z 3278032512980001
33
RANDIKA 2018-07-04 L 3278080407180001 JAJANG 3278081801810001
34
REFIFA CLEMIRA KARIMA 2022-08-08 P 3278604808225786 YOGI 327808
35
REFINA ALFIRA 2022-04-27 L 3206256704220001 FIRMANSYAH 3206020408940003
36
REZA 2019-12-28 L 3278082812190001 restu 3278080802990007
37
SUCI 2019-05-13 L 3204115305190005 DADANG 3204110502030004
38
ZAHRAN NURFAHRI 2018-12-07 L 3278080712180001 ERPIN 3278082604800003
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
CIKALANG 0
BURUJUL 082213434218
BURUJUL 082127923128
BURUJUL 0
SITU BEDOG 0
CIKALANG 0
MANGKUBUMI 087823792075
burujul 085352519187
BURUJUL 082213434218
Cikalang 082213434218
BURUJUL 0
SITU BEDOG 082
BURUJUL 085352519187
CIKALANG 082
CIKALANG 0
BURUJUL 082
BURUJUL 0
BURUJUL 082
BURUJUL 0
BURUJUL 0
BURUJUL 0
CIKALANG 0
SITU BEDOG 0
BURUJUL 082213434218
CIKALANG 0
BURUJUL 0
CIKALANG 0
CIKALANG 085607629833
CIKALANG 0
BURUJUL 082
BURUJUL 082
BURUJUL 082
BURUJUL 0
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ADAM MIFTAH 2019-05-17 L 3278081705190010 ISHAK 327808
2
AKSARA LANGIT 2020-10-02 L 3278080210201235 ZEZEN 327808
3
ALIF MOHAMAD S 2021-03-14 L 3278081403210002 CECEP 327808
4
ALMIRA ZIA 2019-11-29 P 3278086911190000 ANANG 327808
5
ARSILA 2021-04-22 P 3278606204219686 DEDEN 327808
6
ARSYA FATAN A 2021-08-25 L 3278602508218936 Astri 3278086806970008
7
AYRA SHIRLY 2021-03-01 P 3278084103210001 ANGGA 327808
8
AZKA MUHAMAD M 2022-06-15 L 3278081506221223 RONI 3204080407820013
9
FAHIRA 2019-03-01 P 3278034103190002 SONI 327808
10
FARADILLAH SYAKAILA 2019-11-07 P 3278084711190000 ASEP 327808
11
FAWAZ 2022-07-11 L 3278081107221234 ASEP 327808
12
FAZRIN KHOIRUL I 2018-11-24 L 3206824111180004 RENI 3206085408860001
13
FIRDA A 2018-06-02 P 3278084206180000 DIDIN 327808500475
14
HAYFA AZALIA 2020-07-22 P 3278086207200001 WILDAN 3278081111930014
15
JERRY M ALFARIZI 2021-07-22 L 3278082207210001 JODI 327808
16
KEISYA AL MEERA 2019-07-16 P 3278085607190003 FERRY 327808
17
LULU ALHAWARI 2018-12-08 P 3278084812180000 ZENZEN 327808
18
M ALGHOZALI 2020-09-18 L 3278081809201235 U FAHMI 327808
19
M.ZIAD RAMADHAN 2020-05-11 L 3278081105200008 ANDI 327808
20
MAULIDYA HIFZA K 2021-10-30 P 3278607010217303 LUKMAN 327808
21
MELVIANO DANENDRA 2022-06-20 L 3278082006220002 AHMAD 3278081004880007
22
MOH.ALBI HAIKAL 2019-07-25 L 3278082507190000 A.ROHIM 327808
23
MUSA KAZIM 2018-05-12 L 3278081205180000 AJID 327808571091
24
PUTRI TRESNA 2022-07-22 P 3278086207221234 NANDA 327808
25
QHALIKA 2022-04-30 P 3278087004221234 EDI 327808
26
QIANDRA APRILIA N 2018-04-16 P 3278105604180002 GANJAR 327808
27
RAFARDHAN 2021-11-16 L 3278601611216910 SANDI 327808
28
RAFFA GHIFARI 2020-09-04 L 3278080409201255 ZENZEN 327808
29
REINA 2022-02-04 P 3278604402227210 UJANG 327808
30
RISA ARINDA 2019-06-14 P 3278085405190001 ARIS 327808
31
SATRIA ADITIYA 2020-06-30 L 3278082906200001 BUDI 327808
32
SENJA SHAQUINA 2019-08-04 P 3278084408190001 RIO 327808
33
SIFA KAMALIYAH 2019-10-21 P 3278086110190000 ELI 327808
34
SYAHNA RASYA 2019-04-23 P 3278086304190000 JHONI 327808
35
SYAID 2022-01-10 L 3278601001228455 SANTI 327808
36
TIARA 2018-05-18 P 3278085805180000 ROSITA 327808
37
TIARA ZAHRASYLA 2021-10-11 P 3278085110210001 JAJANG 327808
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
POJOK 087823792075
POJOK 0
PERUM KACAPI 0
PERUM KACAPI 0
Pojok 08157047886
POJOK 0
POJOK 087823792075
POJOK 085294718794
POJOK 087823792075
POJOK 089695531404
POJOK 0
POJOK 087823792075
POJOK 087823792075
POJOK 0
POJOK 0
POJOK 0
POJOK 087823792075
POJOK 087823792075
POJOK 085294718794
pojok 085294718794
POJOK 0
POJOK 0
POJOK 087823792075
POJOK 0
POJOK 087823792075
POJOK 087823792075
POJOK 087823792075
POJOK 0
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ADIA RIZKI WIJAYA 2021-04-09 L 3278080904210003 ANDRI 3278080606850006
2
AFWAN ALGIFARI 2019-10-01 L 3278080110190008 IWAN 327808
3
ALBIRRU 2021-02-23 L 3278082302211234 IQBAL 3278081105950008
4
ALMEERA 2018-04-10 P 3278085004180001 M.IQBAL 3278081105950008
5
AQEELA KHAIFANI ZETA 2021-01-28 P 3278086801210002 IPAN
6 P
AQILA MISHA SHAFANA 2022-10-04 3278084410220003 Yulianti 3278086307950003
7
ARSHAKA ELVANO RIDWAN 2021-12-07 L 3278080712210001 AGUS 3278081608890008
8
ARSYAD 2020-02-06 L 3278080602200014 DIKI 32780
9
AZURA 2019-11-09 P 3278084911190008 NANDAR 327808
10
DJENNNAIRA MECCA NUR ALAMSYAH 2021-08-17 P 3278095708210001 ALQI 3278020905910007
11
DRYAN AZKA 2019-07-31 L 3278083107190001 DERIS 3206264107920007
12
FAJAR HIDAYATULLAH 2019-06-22 L 3278082206190040 HENDRA 3278080112790006
13
FELISHA FAIRUZAH NUR KARIM 2022-05-21 P 3278086105221234 YUSUF KARIM 3278081107820009
14
GHAFIN ALFARIZI 2021-05-11 L 3206321105210002 DEDE
15
HIKMAL 2018-05-30 L 3278083005180006 SANSAN 3278081101850003
16
KEYSA PUTRI 2020-01-04 P 3278084401200005 UJANG 3202271210900007
17
KHALISA ALMAHYRA PUTRI PRATAMA 2022-03-01 P 3278084103220003 INDRA 3278082108940011
18
LASTRI 2020-07-15 P 3278085507201234 IMAT 327808
19
MEYRAMDHANISA 2019-05-24 P 3278086405190002 ASEP 3278080909870006
20
MOH.ALFATH 2018-05-01 L 3278080105180001 MAMAT 3278081311820009
21
MUHAMAD ABIZAR IBRAHIM 2021-11-26 L 3278082611210001 NGATMIN 3311052510780006
22
MUHAMAD FAUZAN MUNANDAR 2020-06-08 L 3278010806200003 ARIF 3278011806960006
23
MUHAMAD FIRZA RAMADAN 2018-06-09 L 3278080906180003 RAJA 3278081208610008
24
MUHAMAD GIBRAN ALFARIZI 2020-09-09 L 3278080909202234 UNDANG GUNADI 3278081703800009
25
MUHAMMAD ALVI SIDIQ 2019-03-25 L 3278082503190020 MAMAT 3278081606600001
26
MUHAMMAD DEAN RAMADANI 2021-03-19 L 3278081903210001 ANDI FIRMANSYAH 3278081005880014
27
MUHAMMAD RAKHAA YUSUF 2019-03-27 L 3278082703190003 DIAN LESMANA 3278081704940011
28
NANDITHA RIZKI 2018-12-01 P 3278084112180001 RIZKI BAYU 3278020808940009
29
RAPASYA 2018-11-02 L 3278080211180005 ROBI 327808
30
RAVINDRA ELZIO RAMDANI 2022-05-14 L 3278081405220001 ifan 3278082105850014
31
RIYAD GHAIZAN KURNIAWAN 2022-08-04 L 3278080408220001 YANA KURNIAWAN 3278012703850004
32
RIZKY ALMAARIF 2019-10-08 L 3278080810190001 SAMSUL 3278082709890006
33
SAFARAZ AFKAR 2018-05-18 L 3278081805180002 FAJAR MUSLIMIN 3278081306860014
34
SAHRIL MUHAMAD YUSUF 2020-11-03 L 3278080311200001 DANI AHMAD
35
SITI NURFAUZIYYAH 2022-02-20 P 3278086002220002 MAMAN 3175062009710010
36
TIARA AFIRA 2018-08-02 P 3278084208180002 ARIP 3278080401880005
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
SAMBONG ASEM 0
SAMBONG ASEM 0
SAMBONG ASEM 0
SAMBONG ASEM 0
SAMBONG ASEM 0
SAMBONG ASEM 0
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ADIB NUR 2018-12-08 L 3278080812180001 ANAS 327808
2
ADREENA CARABELLA 2019-10-23 P 3278086310190002 andri yana 3206291007920003
3
ADRESIA HAYATUL 2019-02-15 P 3278085502190003 YOSEP WAHYUDIN 3278080705170012
4
ADZKIA YUMNA 2021-07-05 P 3278084507210002 FATWA 3278083005940003
5
ADZRA 2020-11-09 L 3278080911201234 BAIS 327808
6
AKHIRA DAMANTHIA 2021-06-24 P 3278086406210003 arif rahman 3278082708790003
7
AL GHIFARI 2019-04-27 L 3278082704190001 YUDHI PERMANA 3278081010790009
8
ALESA RAYINA 2021-03-17 P 320624573210001 SOLEH 3206240203760005
9
ALFI 2018-12-16 L 3278081612180010 GANI 327808
10
ALMER AZZIKRA PUTRA SURYADI 2021-08-16 L 348080608210001 yudi suryadi 3204321809790007
11
ALTHAFFATHUL MUBNI 2018-06-08 L 3278601305225227 ANGGI 327808300890004
12
APIPAH SALMA 2021-04-14 P 3278085404210001 WAWAN 3278081622650005
13
ARJUNA RIZA WIBOWO 2019-02-11 L 3278081102190002 FAUZAN 3278081807150020
14
ARUMI 2021-03-12 P 3278084021800001 PIAN 3278081911870005
15
ARUMI YASMINA ZADA 2022-08-22 P 3278086208220002 ALDO KHOLIL PERMANA 3278040807970010
16
AZKADINA NURAZIZA 2020-11-10 P 3278085011200002 vian alfiansyah 3278084110490011
17
CAHAYA AYESHA 2020-09-26 P 3278086609200005 yadi taswadi 3278080810800009
18
D. AHTAR FAZAL AL WAHID 2020-09-17 L 3278081709200004 ENCEP 3278080410930020
19
DAMIA IMRAH BAHIRAH 2020-05-10 P 3278085005200005 DANI 3278080202760003
20
DINARA KHAIRA 2019-04-24 P 3278086404190002 RUDIANA 3278083003750002
21
DIVA PUTRI HANIPA 2021-11-14 P 3278085411210001 ATANG 3278080607780014
22
FAREL YOGIA 2020-12-03 L 3278080312200005 BAGJA 3278082512850002
23
FAUZAN RAMADHANI 2020-05-03 L 3278080305200001 DEDE IKDUL FARID 3278081909790017
24
FAYAD ABDUL HALIM 2020-09-22 L 3278082209200002 APAN EPENDI 3278081709830011
25
FIKYAR ABQORRY 2018-07-25 L 3278082507180006 ILHAM HUSNI 3278082612910006
26
GAITSA MAHIRA PUTRI 2018-10-06 P 3278084610180001 ABDUL ROJAK 3278080707880015
27
GIANA 2022-07-18 P 5807221885 SAEFULLOH 327808
28
HALIMAH 2019-10-09 P 3278080910190013 GANJAR 3278081103870020
29
JIHAN SAKINA 2021-11-23 L 3278602311219714 ARBI 3278081802910014
30
KEEVA CHAFIKA ATHALIA 2022-08-27 P 3278086708220001 adi arif hidayat 320221111960002
31
KIRANIA 2019-07-17 P 3278605707192227 resto 327808
32
M AKMAL 2018-04-01 L 3278080104180000 FAJAR 327808
33
M ALBIAN SYAH 2022-06-12 L 3278601206229473 RONI 327808
34
MAHIRA 2021-06-14 P 3278085406210002 APIP 320102261890001
35
MAHIRA AFRAH 2018-06-20 P 3278086206180002 DIANI 3278010701940001
36
MISHA 2019-08-05 P 3278084508190000 ANDRI 3278081007810005
37
MUBARIK AHMAD 2021-08-10 L 3278601008211932 dindin 327808
38
MUHAMAD ARKAM REZADIN 2020-08-31 L 3278083108200005 ENCENG 3278082705810008
39
MUHAMAD FAKHRI 2020-03-14 L 3278081443200001 IIR IRAWAN 3278021001920016
40
MUHAMAD SAHLA ALFARIZKI 2020-02-27 L 3278082702200003 DIAN HERDIANA 3278080701940001
41
MUHAMAD UWAIS 2019-01-06 L 3278080601190004 UWAN LUKMANUL 3204281404890016
42
N.HUMAIRA ZAINI ZAHIA 2020-03-03 P 3278084303200008 ATO SUGIANTO 3278081002780008
43
NABILA SEPTA AZZAHRA 2020-09-28 P 3278086809200001 ADE HENDRIANA 3278081509950017
44
NAZIRA PUTRI 2018-07-13 P 3278085307180010 ABDUL AZIZ 3278082205180005
45
NAZRIL ALFATIH 2018-05-25 L 3278081505180001 DINI ARDIANSYAH 3278081702870006
46
PADLAN PRATAMA 2019-02-23 L 3278082302190001 RIZKI 3278082210970001
47
PUTRI SALSABILA 2020-04-15 P 3278085504200001 PATUROHMAN 3278081807850011
48
RADEYA PUTRA 2020-05-31 P 3278083105200003 TEGUH 3217092501960012
49
RENDI PRIMA 2018-06-24 L 327808240618003 AGIH KUSWANDI 3278082810820013
50
SABIYA ALMAHERA 2019-01-30 P 3278087001190001 ADE RAHMAN 3278052409850002
51
SALMA ARSILA 2018-11-19 P 3278085911180002 TATANG SEPTIAN 3278082202840005
52
SAPIRA RASIKA 2018-07-20 P 3278088101180002 KAHADRIK 3278082411860005
53
SHAHEER SAZAD P 2019-04-28 L 3278082804190002 RESA 3278080209940005
54
SHAHRAZ QORRI AINA 2021-05-19 P 3278605905216014 andri yana 3206291007920003
55
SHAREESA RAMADHAN 2018-05-24 P 3278086405180000 GILANG 327808
56
TISYA KASILA 2020-11-03 P 3278084311201234 PERI KADAPI 327808
57
UWAIS RASIKH ILMI 2020-06-06 L 3278080605200005 BILI AGUSTIAN 3278082508800001
58
WAFDA 2018-10-22 P 3278606210187095 ato 327808
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
CIBATUR 087823792075
cibatur 082
MEKARWANGI 087823792075
CIBATUR WETAN 0
MANGKUBUMI 0
cibatur 082
MEKARWANGI 087823792075
MEKARWANGI 082
CIBATUR 087823792075
mekarwangi 082
CIBATUR 082
CIBATUR 081221213696
CIBATUR KULON 0
CIBATUR 082
mekarwangi 0
cibatur 082
CIBATUR 0
MEKARWANGI 087823792075
CIBATUR KULON 0
MEKARWANGI 085314778025
MEKARWANGI 081323141082
MEKARWANGI 087823792075
MEKARWANGI 085222232258
CIBATUR 082
MEKARWANGI 0
mekarwangi 082
cibatur 082
MANGKUBUMI 087823792075
CIBATUR 087823792075
cibatur 082
MANGKUBUMI 085607720504
MEKARWANGI 082115038586
MEKARWANGI 08990857284
CIBATUR 087823792075
CIBATUR 0
MANGKUBUMI 0
MEKARWANGI 087823792075
CIBATUR 0
CIBATUR 085174241564
CIBATUR 0
MEKARWANGI 089535526624
CIBATUR 087823792075
MEKARWANGI 0087823792075
CIBATUR 087823792075
MEKARWANGI 085832311992
cibatur 082
CIBATUR 087823792075
MANGKUBUMI 0
CIBATUR 085723696021
cibatur 082
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ADIBA HUMAIRA 2021-05-29 P 3278086905214321 IRMA 3278085805910017
2
ADZRIEL RAFIK S 2021-01-29 L 3278082901211235 SURYANA 327808
3
AFKAR MAQIL HAFIZHAN 2019-11-03 L 3278080311190007 IMAN 3278081309920006
4
AHMED DEVAN 2019-12-20 L 3278082012190000 ENDE YANDI 327808
5
AISHWA NAHLA KIRANA 2021-11-20 P 3278086011210002 HERI 32
6
AISYAH NAIRA 2020-07-03 P 3278084307200004 ZULFIKAR 3278081404890005
7
ALITHA AGHNIA 2019-04-07 P 3278084704190003 AGUS 3278080808690005
8
ALMEERA AZZAHRA 2019-09-16 P 3278085609190001 WENDI 3278081105880007
9
ANNASYA KHANZA S 2018-04-11 P 3278085104180001 Yusup 3278082809890006
10
ARLIN 2021-06-14 P 3278085406211234 IWAN 3278081608850016
11
ARSYLA SELVIANA 2021-08-20 P 3278086008210001 HELLA 32
12
AYRA NURHAFIZATUNNISA 2019-01-09 P 3278084901190001 SUHENDAR 3278082909830005
13
AYRA PUTRI 2019-07-23 P 3278096307190007 NIZAR 3278081011960015
14
AZWAR NURFARIZI 2018-12-28 L 3278082812180003 YAYAN 3278083001890001
15
DANIYAL AKMAL ALFARIZQI 2021-11-21 L 3278082111210001 Mimih 32
16
ELFANIA 2018-07-27 P 3278086707180001 HERI 3278081008880005
17
FADHEELA AULIA 2019-03-05 P 3278084503190002 YANDI 3278082010850005
18
FATIMAH A 2018-12-13 P 3278085312180005 PRASTIKO 3214121802920001
19
FAZILA HAFIZHATULJANNAH 2018-08-08 P 3278084808180006 WAWAY 3206371501820001
20
GIEFAHRI 2018-05-01 L 3278600105180000 EGI 327808
21
HADWAN 2021-03-31 L 3278603103211771 irwan 327808
22
HAFIDA NURUL ADZKIYA 2021-10-23 P 3278086310210001 ELAN 32
23
KAHFI ALBIRU 2018-09-27 L 3278082709180003 IMAM 3278080903920001
24
KAHLA SHANUM ALMAHYRA 2022-07-11 L 3278601107222020 imam 327808
25
M.AKBAR AL BUKHORI 2018-10-26 L 3278082610180001 YAYAT 3278081202810018
26
M.ALI AKBAR 2018-04-22 L 3278602204180000 BUDI 327808
27
M.ASADULLOH 2019-06-30 L 3278083006190002 M.ABDUL 3278023105930007
28
M.DAFFA MAULANA 2019-11-23 L 3278082311920003 IWAN 3278081110790008
29
M.GHAISAN 2019-07-12 L 3278081207190000 AGUS TOMI 3278081108840007
30
M.HADYAN ALFAREZ 2021-08-29 L 3278082908210001 FINDI 3278084508960007
31
M.RASYA 2018-05-28 L 3278082805180002 APEP 327808150610013
32
M.SHAKEEL AULIAN 2020-01-05 L 3278080501200000 DIAN 3278032412940003
33
M.SYAKHI MAKARIM 2021-04-13 L 3278081304210001 AI TETI 3278085904840002
34
MUHAMMAD ALVAN JANVAR 2022-01-22 L 3278082201221234 JAJANG 32
35
MUHAMMAD EMIR ABDURRASYID 2022-02-20 L 3278082002221234 RUBIYANTO 32
36
MUHAMMAD ROJAB 2022-02-28 L 3278082802221234 CECEP S 32
37
NAIRA APRILIA 2019-04-04 P 3278014404190002 IWAN 3278081608850016
38
NAURA NUR AZIZAH 2022-08-16 L 3278085608220001 hendri 327808
39
NAURA ZULAIKHA 2020-06-25 P 3278086506200001 AGUS 3278080501900010
40
NAURA \'ADHIMATUS SYAHRA 2020-03-05 P 327808550320002 WAHYU 327808
41
NAYA NUR INSANI 2019-01-16 P 3278085601190004 SANI 3278081712940005
42
NAYLA SYAKILA A 2018-10-16 P 3278085610180004 HELMI 3206312101860001
43
NURUL HANA 2018-07-16 P 3278085607180003 IRPAN 3278083110810004
44
OXANA MALIKA AMIN 2019-05-04 P 3278084405190001 ADE DENI 3278020606870016
45
QIANA NAFEEZA 2021-08-01 P 3278084108211234 ANIS 3278086212940001
46
RADELA RIZKIANI PUTRI 2021-08-25 P 3278086508210002 RISWANDI 32
47
RASYID LUCKY 2021-09-26 L 3278082609210002 YANDI 32
48
SALVIA AULIA 2018-08-25 P 3278086508180001 TAOPIK 3278082104800004
49
SILMI TAZKIYA 2020-06-03 P 3278084306200000 ASEP 327808
50
SYAFIRA AULIA 2019-10-23 P 3278086310190001 ARIP 3278081910910003
51
TIARA PUTRI 2019-05-16 P 3278085605190005 IWAN 3278081701890008
52
WIJDAN DZUL H 2021-01-15 L 3278081901210004 YULI 3278084708780005
53
ZAHIRA DELISHA 2018-09-15 P 3278085509180002 M.ILYAS 3278081004800011
TOTAL
Jumlah vial dibawa
Jumlah vial dipakai
Jumlah vial rusak Jumlah Vial Sisa
Jumlah Vial nOPV
UBPIN POLIO
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
PARUNGANTEN 0
SINDANGSARI 089514579353
PARUNGANTEN TONGGOH 0
MEKARSARI 0895704658068
SINDANGSARI 085323071060
MEKARSARI 085261499116
Kp. Sindangsari -
PARUNGANTEN KIDUL 0
SINDANGSARI 081929580410
PARUNGANTEN TONGGOH 085223030441
PARUNGANTEN KIDUL 0
PARUNGANTEN KIDUL 0
PARUNGANTEN 085320863684
SINDANGASIH 0
PARUNGANTEN TONGGOH 0
MANGKUBUMI 087823792075
parunganten 082
PARUNGANTEN TONGGOH 0
SINDANGSARI 0
PARUNGANTEN 085210616893
MANGKUBUMI 87823792075
SINDANGSARI 085211633723
PARUNGANTEN 082315731633
SINDANGSARI 089658093968
MANGKUBUMI 087823792075
SINDANGASIH 0
PARUNGANTEN 0
SINDANGSARI 0
SINDANGSARI 0
SINDANG ASIH 0
parunganten 081914946424
SINDANGSARI 085351516001
PARUNGANTEN TONGGOH 0
PARUNGANTEN TONGGOH 0
SINDANG ASIH 0
SINDANGSARI 082214041871
MEKARSARI 081995393200
SINDANGSARI 0
Parunganten 0
SINDANGSRI 0
MANGKUBUMI 0
PARUNGANTEN 0
PARUNGANTEN KIDUL 0
SINDANGSARI O87771892387
SINDANGASIH 081572244901
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ADZKIA 2022-02-04 P 3278604402222263 HERI 3278080508820017
2
AFZAL ATHILLAH 2021-08-06 L 3278600608219753 radit 3278081505830005
3
ALESYA PUTRI 2019-09-21 P 3278086109190001 BAYU 3278080811890004
4
ALMAIRA 2021-02-15 P 3278085502210003 ESYA 3278080505920011
5
ANNASYA ADREENA 2020-01-28 P 3278086801200002 U.ALI 3278080502760008
6
ARSYAD 2018-05-14 L 3278081405180004 DEDE 3278080212890003
7
ARSYILA HAPSARI NUGRAHA 2022-10-21 P 3278086110220002 Ega Nugraha 3278080507930001
8
AYRA ALNAIRA 2020-01-28 P 3278086801200200 U ALI 3278080502760008
9
AZHAM 2020-04-26 L 3278082604200002 ENTIS 3278081710760001
10
AZMYA 2021-12-25 P 3278086512210001 ANIS 3278081211940005
11
BAHAR KURNIA SIDIK PUTRA 2022-04-11 L 3278081104221234 ANWAR SIDIK
12
BELA NURMALA 2018-07-17 P 3278085707180000 OLIH 327808
13
DANIAL AL FATIH 2019-08-30 L 3278083008190004 RUDI 3278080906930008
14
EDZIN DZEKO AL 2018-10-10 L 3278083010180002 aep 3278082312880001
15
FATIAN 2020-03-05 L 3278080503201234 AGUS 327808121274002
16
GILANG 2018-07-02 L 3278082306180001 SUTISNA 3277030710860023
17
IRISH SALSABILA 2021-07-21 P 3278606107211554 trisna 3278081007960012
18
KAISAN 2018-05-09 L 3278080905180002 ADIN 3278082004680003
19
KAKA BINTANG 2018-08-25 P 3278082508180003 HENHEN 32780850920008
20
KAMILA 2020-04-04 P 3278084404200012 KAMAL 3278082912900008
21
KAMILA PUTRI ANJANI 2022-01-11 P 3278085101220001 SANDI 3278080406870006
22
KHALIFAH LUKMAN 2021-07-11 L 3278081107210002 RAHMAT 327327190590001
23
M. ARHAN FEBRI P 2022-02-04 L 3278600402229959 JAPAR 3278081110910004
24
M. ASHFI PUTRA RAMADHAN 2022-11-24 L 3278082411220002 Anggi ramadhan 3278082301960011
25
M.ABIZAR 2021-07-05 L 3278600507214481 edi 3278050106930003
26
M.ATHARAZKA 2021-05-10 L 3278081005210001 ILYAS 3278080701960008
27
M.DIRHAM 2020-01-20 L 3278082210860005 AI HINDA 3278082210860005
28
M.HAFIZ 2018-04-27 L 3278082704180004 HERMAN 3174052309850009
29
M.ILHAM NABAWI 2018-09-02 L 3278600209180000 YADI 3278085403780007
30
M.PAUNDRA 2019-10-07 L 3278080608190011 SESEP 327808
31
MUHAMMAD ALBARR ALFARIZQI 2019-07-21 L 3278082107190002 RONI PURNAMA 3278081910780001
32
MUTIA 2020-10-15 P 3278085510200001 DEDI 3278081212740026
33
NAUVAL 2019-02-27 L 3278082702190003 ALI ROSID 3278083105970003
34
NIDA AMELIA LESTARI 2022-05-28 P 3278086805220001 NURUL 3206164405920001
35
NIKEISH ABGASAN DHYA TORNADO 2021-12-07 L 3278600712218806 TENDI 3278081203880011
36
NISYA 2020-05-18 P 3278085805200003 AGUNG 1801081411830003
37
QIANA PUTRI NURDIANA 2022-07-04 P 3278084407220001 ARIP
38
RAYANDRA 2019-06-30 L 3278083006190003 ARIF 3278082003940007
39
RIAN 2018-11-20 L 3278082011180003 ANNAS 3278083010930001
40
SABIT 2019-09-23 L 3278082309190005 ANDI PRAJA 327808
41
SALMA SEPTIAN 2021-09-11 P 3278085109210001 ASEP 3278081207870007
42
SALSA 2019-12-10 P 3278085012190004 IWAN 3278082109860005
43
SITI ASSIFA NURULYANTI 2022-09-05 P 3278084509220001 HENDRA 3278080306820010
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
SAMBONG MANGKUBUMI 0
sambong mangkubumi 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
sambong mangkubumi 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
SAMBONG MANGKUBUMI 0
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
AFZAL 2020-01-15 L 3278081501200008 AAN 327808
2
AIDAN 2021-03-21 L 3278082103210003 SOPYAN 3278082103870005
3
AISYAH 2018-08-15 P 3278085506180001 RUHIMAT 3278081903860016
4
AISYAH DARA KUSUMAH 2021-11-03 P 3278084311211234 BAYU 32
5
AISYWA ZEA NAURA 2021-10-18 P 3278085810211234 WAHYUDIN 3211010108870007
6
AIZA 2018-08-24 P 3278086408180000 DEDE W 3211010108870007
7
ALEEVA SHIDQIA 2021-07-09 P 3278082603190010 HARI 3278082805870007
8
ALESHA SALSABILA 2020-07-14 P 3278085407200000 INDRA 327808
9
ALESHIA PUTRI 2018-09-03 P 3278084309180002 NIWA 3207151511860001
10
ALKHALFI ZIKRI 2021-03-26 L 3278081506200008 ASEP 3278012807890005
11
ALTHAF ASSAJAD 2019-09-06 L 3278080609190003 JERI 327808
12
ALULA 2018-06-20 P 3278086006180001 - 3278084901870005
13
AMANDA 2020-04-02 P 3206324204200001 RUDI 3206320404850005
14
ANASYA ZAHRA YUDA MAHIRA 2023-02-07 P 3278084702230001 HILDA/BAYU 3278024707890012
15
ANDARA 2020-07-25 P 3278081709190010 DERIS 3278081202940015
16
ARSYI 2018-04-14 P 3278085404180003 HILMAN 3278082108850005
17
ARUMI NASYA RAZETA 2020-02-01 P 3278084102200003 SUMARNA 3278086211500005
18
ATTAYA SHAQEENA 2019-05-17 P 3278085705190004 PANJI 327808
19
AUDI UMAIZA PARVEEN 2021-12-16 P 3278085612211333 MAULANA 3278086408890005
20
AURORA KAYYISA 2020-02-20 P 3278086002200008 MAULANA 327808
21
BANGKIT 2019-09-03 L 3278080309190003 FAJAR 327808
22
BARRAN RAMDHANI 2020-05-12 L 3278081205200008 BAYU 327808
23
BILQIS 2018-04-20 P 3278086004180001 DARIP/RISMAWATI 3278031506820015
24
CANTIKA 2018-05-20 P 3278086005180000 FAJAR 327808
25
CHELSEA MALIK ALFARANO 2021-09-28 P 3279026809210002 MARTARANO 3279026310900003
26
DAWIYA 2018-07-04 P 3278084407180001 SOMA 3278082405840006
27
DILLA F 2018-12-19 P 3278085912180002 NANDANG 3278086405960003
28
EL JIBRIL 2018-06-27 L 3278082706180010 DIKI 327808
29
FAIZ 2019-12-31 L 3278083112190000 - -
30
FAIZAR 2018-07-06 L 3278080607180002 CANDRA 3278082708980007
31
GATHAN 2019-12-31 L 3278083112190008 FAHROZI 327808
32
HAMKA M GHAZAN MUSTHAFA 2022-06-13 L 3278081306221234 IRFAN 327808
33
HANIFA ALSABA KANEISHIA 2021-08-23 P 3278086308210001 TAUFIK 3278082012960010
34
HAURA ZAHY 2020-05-18 P 3278085805200008 WILDAN 327808
35
HUMAIRA 2018-06-10 P 3278085006180003 BURHAN 3278081208850005
36
IDHAM 2018-05-15 L 3278081505180006 AJI 3278082609850005
37
ILHAM 2020-01-28 L 3278082801200011 dudung 327808
38
IZAN 2019-03-08 L 3278083001190002 YUDI 3278084307820014
39
KHARISMA PUTRI 2021-01-10 P 3278085001211213 HARI 3278085602810007
40
KINARA 2021-11-05 P 3278084511211234 DENI 32
41
M ADNAN 2020-10-08 L 0810207521 YUSUF 3203011202860006
42
M ARGAZA AQSABIAN 2022-07-23 L 3278082307221234 RESA 327808
43
M.AYASH 2021-02-19 L 3278081902211234 JAENUDIN 3278082606810010
44
M.DANIEL 2021-12-17 L 3278601712212999 Eka/mahwi 327808
45
M.MIRZA HANIF 2020-05-12 L 3278081205200000 HASAN 327808
46
M.MUSTAUJIB TSANA 2020-03-11 L 3278081103200000 DHANI 327808
47
M.RIZA RAMDANI 2022-01-24 L 3278082401224321 DENI 32
48
M.SALAH 2019-06-19 L 3278081906190004 ANDRI 327808
49
M.ZIDNI 2019-01-21 L 3278082101190010 HUSNI 3206206705020004
50
MELVIN 2019-04-14 L 3278081404190001 AAN 3173035105800004
51
MIRA 2019-05-09 P 3278084905190002 ADI 3278081009890009
52
MUHAMMAD KHAIZAN ARSYAD 2022-08-03 L 3278080308221234 AJI 3278082609850005
53
NADIVA NAUROJUL 2020-07-18 P 3278085807200000 OPIK 327808
54
NASYITA SAYEDA 2021-07-03 P 3278084307210001 BAMBANG 3272012012770010
55
RAMZAN FAAIQ 2019-07-18 L 3278081807190003 hari 3278082805870007
56
RAZBIAN 2018-07-07 L 3278080707180001 DIAN 327808
57
RAZKA 2019-07-19 P 3278084907190001 KAMAL 327808
58
RIAD FEBRIANSYAH 2020-02-15 L 3278081502200008 RENDI 327808
59
RIZKY ABDILLAH 2019-05-04 L 3278080405190002 IPIK 327808
60
SABIL 2018-11-09 L 3278080911180001 ROSTAMI 3278086812890004
61
SABIRA 2018-06-05 P 3278084506180001 AYEP 3278082512850005
62
SALIM IBADUROHMAN 2019-11-18 L 3278081811190003 SARIF 3278084108900012
63
SIDQIA SABIANI 2020-04-10 P 3278085004200000 DIDIN 327808
64
SYAFIYA PUTRI ZAINAL 2023-02-01 P 3278604102232707 Wina/ejen 3278086209920004
65
ZAIHA 2019-08-27 P 3278086708190003 AJI 3278082609850005
66
ZEA ALMAIRA MALEA 2021-10-02 P 3278604210217815 Hadi 3278083006840011
Jumlah vial dibawa
Jumlah vial dipakai
Jumlah vial rusak Jumlah Vial Sisa
Jumlah Vial nOPV
UBPIN POLIO
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
GUNUNG KONDANG 0
GUNUNG KONDANG 0
MANGKUBUMI 087823792075
GUNUNG KONDANG 0
LABUHAN BULAN 0
GUNUNG KONDANG 0
LABUHAN BULAN 0
GUNUNG KONDANG 0
GUNUNG KONDANG 0
LABUHAN BULAN 085223130322
LABUHAN BULAN 0
MANGKUBUMI 087823792075
MANGKUBUMI 087823792075
MANGKUBUMI 087823792075
GUNUNG KONDANG 0
GUNUNG KONDANG 0
GUNUNG KONDANG 0
LABUHAN BULAN 0
GUNUNG KONDANG 0
GUNUNG KONDANG 0
GUNUNG KONDANG 0
GUNUNG KONDANG 0
LABUHAN BULAN 0
Kp gn kondang 081390299696
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
AHMAD NURUL ANWAR 2021-05-30 L 3278083005210002 HADORI 3526170610930001
2
AIZA 2018-05-05 P 3278084505180020 ALAN 327808
3
ALESHA KINARA 2021-05-29 P 3278086905211234 KUSDINAR 32
4
ALEYA MIQAILA 2020-09-26 P 3278086609200002 AMIN 320630240890001
5
ALLEA DINAYA 2022-03-03 P 3278084303220004 Ejen 3278080508780023
6
ALMAGIKA 2018-07-27 L 3278082707180003 ROBI 3278080509760008
7
ALUNA 2019-10-13 P 3278085310190000 YOGI 327808
8
ALZENA 2018-04-13 P 3278605304180000 ROBI 327808
9
ARDHANI 2020-06-03 L 3278080306200000 M.YASIR 327808
10
ARRESA 2018-06-18 P 3278085806180003 OPI 3278012502730001
11
ARSHAN 2020-06-23 L 327808230620000 TEDI 327808
12
ARSYLA QIANA AZZAHRA 2019-07-10 P 3278085007190002 Muhammad iyos yossie 3278081310890009
13
ATQIYA NAFISAJ 2020-05-28 P 3278086805200002 Jamal 3278082202910007
14
ATTAR 2018-04-29 L 3278082904180003 DANI 327808
15
BILQIS KHANSA AULIA 2020-10-27 P 327808671020002 Acem m 3278081806820007
16
CEISYA 2019-11-03 P 3278084311190004 AGUS 3278081007880001
17
CHEVA 2018-05-11 L 3278081105180023 DENI 327808
18
DIVA ALMAHIRA RAMADHANI 2021-04-20 P 3278086004210001 Ficqi 3278082008850012
19
ERIZAL 2021-12-07 L 3278600712215167 tn 327808
20
FATAN ALFARZI QABEL NURSAMSI 2019-10-26 L 3278082610190004 Riki 3278010770587000
21
FEBRIAN 2020-02-07 L 3278080702200000 SANI 327808
22
FIRAZ RAMDHAN XABIRU 2018-05-17 L 3278081705180004 IMAM 327808
23
IRSHAN MAULANA YUSUF 2022-06-22 L 3278082206220001 Tedi 3278052405860001
24
JALWA F MARWAH 2020-02-07 P 327808070220 Resna 3278021503890004
25
KANZA 2019-12-12 P 3278085112190001 ALAN 32
26
LUQMAN 2021-12-05 L 3278080512210001 Metha 327808
27
M FIKRI 2019-02-14 L 3278081405190004 Acem m 3278081806820007
28
MIRZA AIMAN 2019-06-15 L 3278081506190001 DADANG 327808
29
MUHAMAD DHAFIN 2018-11-16 L 3278081611180002 TEDI 3278082101840002
30
MUHAMAD RAFA 2018-06-18 L 3278080906180030 ASEP 3278081809790004
31
MUHAMAD RAFLI 2019-04-20 L 3278082004190004 FAHMI 3278080303810014
32
MUHAMAD YASIR 2019-12-26 L 3278082612190000 DODI 327808
33
MUHAMMAD DIKRA ADIFTA 2020-12-08 L 3278080812201235 YAYA 327808
34
MUHAMMAD EZAR RA 2022-01-17 L 3278601701212426 ABDUL ROHMAN 3206310308870001
35
NAMIRATU 2018-12-23 P 3278086312180001 HISNI 3278080503880012
36
NAURA 2018-08-05 P 327808450818001 Aep yanto 3278080306840010
37
NAZIRA 2018-10-27 P 3278086710180002 ACEP 3278080304880008
38
RAFISQY 2021-06-22 L 3278602206212615 CEP IRWAN 327808
39
RAHIMA 2019-01-25 P 3278086501190000 EPEN 327808
40
RAIFHATHAN 2022-08-31 L 327808310822 Yanti 3278081807850012
41
RAKA ARSHAD 2020-04-11 L 3278081104200005 HENDRIK 327808
42
RASYID 2019-06-28 L 3278082806190002 YANI 3278080208850007
43
RIGELANDRA 2020-02-24 L 3278082402200000 ADITIYA 327808
44
RISMAN 2018-10-14 L 3278081410180001 ADE 3278083107800002
45
SAFANA 2022-02-09 P 3278604902227065 tatan 327808
46
SAILA ANASYA SYAKIRA 2021-06-10 P 3278085006210004 MINNA 3278071808910003
47
SANAYA 2022-02-09 P 3278604902229352 tatan 327808
48
SHAKI 2021-12-02 L 3278600212216104 ajo 327808
49
UMAR SHIDQI 2020-04-20 L 3278082004200010 ROBI 327808
50
VIONI SUPARTIKA 2018-06-30 P 3206277006180001 Yuspagionaka 3201010810810017
51
ZEHAN MUHAMMAD 2021-02-28 L 3278602802218045 IWAN 327808
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
KARANGKAEITAN 082213894979
BABAKAN 0
KARANG KAWITAN 0
KARANG KAWITAM 0
MANGKUBUMI 087823792075
KARANG KAWITAN 0
BABAKAN 0
Nyalindung 085318585168
Nyalindung 082133192085
KARANG KAWITAN 0
Karangkawitan 082213894979
KARANG KAWITAN 0
MANGKUBUMI 087823792075
Karangkawitan 081394299299
karang layung 0
KarangkaWitan 082133192085
KARANGKAWITAN 082213894979
Karangkawitan 081324433553
Karangkawitan 081394299299
Karangkawitan 082133192085
Karangkawitan 082133192085
NYALINDUNG 0
KARANG KAWITAN 0
BABAKAN 0
KARANG KAWITAN 0
KARANG KAWITAN 0
KARANG LAYUNG 0
NYALINDUNG 081394299299
KARANG KAWITAN 082240982792
Karangkawitan 082213894979
KARANG KAWITAN 0
KARANG LAYUNG 0
NYALINDUNG 0
Karangkawitan 085223399391
BABAKAN 0
KARANG KAWITAN 0
KARANG KAWITAN 0
nyalindung 0
nyalindung 0
karang layung 0
Karang kawitan -
KARANG KAWITAN 0
0
FORMAT PENCATATAN HASIL PELAYANAN SUBPIN POLIO
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
ARETA 2020-10-07 P 3278084710201123 YAHYA 327808
2
ARRASYAD NAKKA 2020-04-25 L 3278082504200050 NEGA 3278032306880010
3
ARSILA AURA 2018-05-17 P 3278605705189406 wulAN 327808
4
ARUNA ARSYILA 2020-12-20 P 3278086012201234 ANHAR 327808
5
ASHRAF ALIF 2021-05-14 L 3278081405210001 Arinal 3278080406910006
6
AYUNINDYA 2019-07-20 P 3278086007190003 EGI 3206152010880004
7
AZKIA 2018-05-28 P 3206326805180003 DANI 3278082307840001
8
EL BARRA M R 2022-01-29 L 3278082901221234 FATUR
9
ELZEIN ATTHALA A 2022-02-02 L 3278600202229063 GANI 327808
10
FARID 2019-07-11 L 3278081107191234 FATUR
11
JOEL PASARIBU 2018-06-20 L 3278602006180000 HENDRA 327808
12
KAMILA 2022-06-23 P 3278606306221036 327808
13
LUTFI 2021-11-23 L 3278602311211849 M. HASAN
14
M. ENZO 2022-02-11 L 3278601102222235 RIO 327808
15
M. WAFIK 2021-09-29 L 3278082909211223 WIDI 32
16
M.ARSA 2020-05-01 L 3278080105200000 RINAL 327808
17
M.NAZWAN 2018-09-14 L 3278081409180010 MIFTAH 3278081506850013
18
MAEZURA GIEENA 2022-09-14 P 3278605409228060 TAUFIK 327808
19
NARENDRA ABIMANYU 2020-05-06 L 3278080605200000 MUMU 327808
20
NAYARA 2018-11-20 P 3206142011180020 BAMBANG 3206140101850042
21
PUTRI 2021-07-07 P 3278084707211234 NANAN 327808
22
PUTRI ARHSILLA FAHAD 2020-02-12 P 3278085202200003 RIDWAN 327808
23
RAGA 2021-06-09 L 3278080906211234 RULI
24
REZFAN SA 2018-04-27 L 3278602704180000 DENIS 327808
25
RIEN PANCA 2022-06-01 L 3278080106221234 biner 3278082602740001
26
SABINE GREESA NR 2022-01-29 P 3278606901224671 SOFY NURDIANA
27
SALMAN 2018-09-04 L 3278080409181234 RIDWAN
28
SHIREEN ZEA A 2020-04-27 P 3278606704207657 NENDEN 327808
29
YASMIN 2022-09-15 P 3278605509224520 IMBAR 327808
30
YAZIEED P 2019-10-03 L 3278600310196538 IMBAR
31
YUMNA 2022-05-04 P 3278084405221234 AYAH
TOTAL
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
PERUM ABN 0
PERUM ABN 0
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
Jenis
No. Nama Anak Tgl lahir Umur Kelamin NIK Nama orang tua NIK Orang Tua
(L/P)
a b c d e f g h
1
AISYAH ADINDA NUR HAFIDZAH 2020-08-11 P 3207025108200001 MAWARDIANSYAH 3278081906940005
2
AKMAL MUHAMMAD NUR ZAIN 2022-03-24 L 3278082403220002 Tarmizi/nurwati 3312120608790003
3
AL-GHEFARIN IZQIAN HADI 2022-12-03 L 3278600312226803 Alwan /Natia 3204144311960006
4
ALDIN ARSYAD MUHSIN 2020-02-14 L 3278081402200002 Wahab/dena 3206041106830002
5
ALESHA 2021-04-10 P 3278085004210002 ROBY 3278081504950005
6
ALESHA GHANIYYAH 2019-07-31 P 3278087107190009 DIKKY 3278011604880004
7
ALEXA DEAMORA S 2020-09-23 P 3278016309200001 WAN KRISTOFER 1571011808920041
8
ALFANISA SHAFIQA HIDAYAT 2022-11-15 P 3278605511222320 Robbi/novva 3278084607960005
9
ALUDRA RUMAISH ADINSTY 2022-06-29 P 3278086906220003 DWIJOKO/DIAN 3278080406810009
10
AMR ADZKARI 2019-12-09 L 3278080912190002 RAI 3278081411870008
11
ANINDYA PUTRI RAMADHANI 2021-05-10 P 3278085005210001 ANWAR 3278081303850016
12
AQEELA CHAYRA FAUZIAH 2020-12-31 P 3278087112201234 AGUSTIA 3206305410910002
13
AQILLA 2018-09-17 P 3278085709180001 FERI 3278081204830017
14
ARSHAKA HAYKAL A 2021-02-27 L 3278082702110001 AZHAR 3278032310930001
15
ARSYA KIRANA 2019-12-06 P 3278084612190002 IRVAN 3278084907880001
16
ARVINNA 2018-07-30 P 3278087007180003 ARIS 3273180105770010
17
ASSABQI PUTRA KUSUMA 2021-02-22 L 3278082202210002 ANGGA 3278062910930006
18
ASSIDQI PUTRA KUSUMA 2021-02-22 L 3278082202210003 Angga/annisa 3278062910930006
19
ATARIZ 2019-10-26 L 3278082610190002 TOTO 3208221002880001
20
AYRA MUHSIN RAMADHANI 2018-05-23 P 3278086305180003 WAHAB 3206041106830002
21
AZKIA NUR FADILAH 2021-05-20 P 3278086005210001 FERI 3278081204830017
22
AZZALEA SAQUEENA SAFWAH 2021-11-10 P 3278085011210003 JENAL 3278032409770009
23
AZZARA ARUNIKA KAFIYYA 2022-10-31 P 3278607110227061 Yufi/yaneu 3278080409920010
24
AZZURA RENJANA SAFIYYA 2022-10-31 P 3278607110221186 Yufi/yaneu 327808040992001
25
DANIELA 2019-06-07 P 3278084706190002 DONNY 3278081409830009
26
DZAKIRA TALITA AZZAHRA 2021-10-04 P 3278084410210003 AUGUST 3278010408900001
27
FAIREL FARZANA 2021-03-22 L 3278082203210003 GUGUM 3278081303890010
28
FAIZA AYUDIA RAJABI 2022-02-10 P 3278081002224012 Dani/elya 3278060712850008
29
FARRAH ATHASYA MUHARRAMI 2020-08-27 P 3278086708200003 NANDANG 3278082012820007
30
FATHYA 2019-02-15 P 3278085502190004 LELI 3278080704850012
31
GAISAN RAFASYA HAFIZ 2022-11-25 L 3278602511223396 Yayan /yeni 3278086708810005
32
GINAN ADITYA ALFAREZ 2018-09-25 L 3275072509180002 Alna 3275075609860010
33
HAIRA RAMADHANI AMRA 2018-06-02 P 3278084206180003 JUJUN 3278081407890008
34
IBRAHIM ZAYYAN 2019-09-20 L 3278082009190002 ARI 3278030204900001
35
ISMAIL ZAYYAN RAMDHANI 2022-01-22 L 327808 ARI 3278030204900001
36
KARISYA 2019-07-17 P 3278085706190003 ERI 3278082011680008
37
KAZUMI FAZEELA PUTRI 2022-03-28 P 3278086803220003 AHMAD DZAKI/HESTI 3278082003820018
38
KHAIRUNA HAYYIN NURFALAH 2022-06-27 P 3278086706221234 Andy/kokom 3278082609840010
39
KIRANA AMIRAH 2018-06-07 P 3278084706180001 ACEP 3278011612860007
40
M.ABYAN 2018-10-27 L 3278082710180003 YAMIN 3278081803910005
41
M.AKHTAR ZIDAN 2019-07-31 L 3278083107190006 ZAFAR 3278080604940007
42
MUHAMAD KHALEED TSAQIF 2020-12-10 L 3278081012200003 M.IRHAM 3207010810950003
43
MUHAMMAD ALDIANSYAH 2021-03-02 L 3278080203210001 M.HENDRIANSYAH 3278082306890008
44
MUHAMMAD AZIL FAUZI 2021-06-17 L 3278081706210002 RIDWAN 3206271101790004
45
MUHAMMAD ILMAN RADHIKA 2021-06-24 L 3278082406210003 RONNY 0
46
MUHAMMAD RADEYA WIJAYA 2020-10-28 L 3278082810200001 ANGGI 3278082808940006
47
MUHAMMAD RAYYAN ABDILAH 2021-10-13 L 3278081310210001 YOSIE 3207060608920001
48
MUHAMMAD RIZKI FAZRUN 2021-06-28 L 3278082806210003 TARWIAN 3278010708840007
49
NAJMA ALLEA 2019-06-19 P 3278085906190001 JAJANG 3206010101880014
50
NALENDRA 2019-11-04 L 3278080411190001 M.NURYANA 7171020210840003
51
NAURA 2018-10-05 P 3278084510180003 PANJI 3278042010890006
52
NAYYARA ALFATHUNISA 2021-03-18 P 3278085803210002 WAWAN 3278042608850006
53
NISKALA RAZZA PERMADI 2021-11-09 L 0911216511 ANDI-ANNISA 3278085601960005
54
NIZLAN MUHAMMAD 2020-07-28 L 3278082807200003 AHMAD 3278081607760014
55
PUTRI 2019-05-29 P 3748086906190001 CECEP 3278081107830006
56
QAISYAN MUHAMMAD IRFAN 2020-02-21 L 3278082102200005 ACEP 3278011612860007
57
QUEENARA ADZKIA 2019-08-15 P 3278085508190001 INDRA 3205220210910003
58
RAFKA SHAQUILE ZHAFRAN 2020-02-21 L 3278082102200000 FERY 3278081204830017
59
RAKANA GANESHA ABDARIY 2020-12-27 L 3278082712201234 AGUNG 3278081405960003
60
RASYID 2018-08-02 L 3278600208180000 IRFAN 3278084907880007
61
RASYID IHSAN KAMIL 2021-06-15 L 3278081506210001 ERI 3278030809790001
62
RAYYA ZIYA ZULINA 2021-02-19 P 3278085902211234 DANI 3207140109890001
63
RIDHAN JAYA 2019-10-02 L 3278080210190004 DANI 3207140109890001
64
RIZKY MUHARRAM 2022-08-07 L 0708225396 SUSI/HENDRA HARYADI 3278085503880007
65
SAKHI 2019-03-11 L 3278081103190001 SONI 3278080705730001
66
SHAFARAZ 2019-12-31 L 3278083112190001 ARIP 3278080201950004
67
SHANNON 2019-03-22 P 3278086203190002 M.ROFI 3208220608930002
68
SHANUM AHZA RUMAISHA 2022-08-24 P 32786064084201 RIKHA 3278032312780003
69
SHAQUEENA HUMAIRA 2020-12-09 P 3278084912200001 ARI 3278081306800001
70
SILAS RADEEVA GAUTAMA 2022-12-03 L 3278600312223236 Sony/ignatia 3404106411910001
71
SYAKILA 2018-07-30 P 3278080708170001 IWAN 3278081205820009
72
SYAKIR ANKARIAN NURFALAH 2020-04-14 L 3278081404200003 KOKOM 3278082609840010
73
VAREN ALBIRU MIQDAM 2022-09-10 L 3278601009222047 Rizwan/merry 3278084205920009
74
ZAID ADZKARI 2019-12-09 L 3278080912190003 RAI 3278081410850003
Nama petugas :
Puskesmas :
Kabupaten :
Dosis 1 Dosis 2
Alamat No.Hp Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
i j k l m n o
MANGKUBUMI 082240121499
MANGKUBUMI 081214151540
PERUM SGI 0
MANGKUBUMI 087823792075
MANGKUBUMI 087823792075
0