FORMAT PENCATATAN HASIL IMUNISASI LANJUTAN PADA ANAK USIA SEKOLAH DI UNIT PELAYANAN

KABUPATEN/KOTA : Kab. Serang

PUSKESMAS : UPT Kibin
SEKOLAH : SDN GARUNG
TAHUN : 2023
Tanggal Imunisasi
No. Nama NIK Anak Tanggal Lahir Nama Orang Tua NIK Orang Tua Kelas Campak DT (kelas Td (Kelas Td (kelas HPV (Kelas
Rubella 1) 2) 5) 5)
(kelas 1)
1 Adelia 1809044601170001 2017-01-06 Muhaimin 1
2 Adila Agustin Riyadi 3211015608160003 2016-08-16 Taryadi 1
3 Aditya Ripki 3604162011150003 2015-11-20 Kutub 1
4 Ahmad Nazril Pradipta 3604240903170001 2017-03-09 Fajar Yulianto 1
5 Alesha Mikhayla Azahra 3213045708160001 2016-08-17 Cipto Suharna 1
6 Alwati Putri Lestari 3604166506160003 2016-06-25 Aklan 1
7 Amanda Putri 3604166212160001 2016-12-22 Ahmad 1
8 Anggun Azzahra 3603126003170002 2017-03-20 Aldian 1
9 Annisa 3604166809160002 2016-09-28 Saepi 1
10 Annisa Salsabila 3604165207160002 2016-07-12 H. Junaedi 1
11 Aqila Septiany Winanda 1301046009160002 2016-09-20 Anriko Winanda 1
12 Aqila Syakeera 3604165907160001 2016-07-19 Ahmad Sopian 1
13 Ardiyan 3604162909160002 2016-09-29 Rapi 1
14 Argani Raya Satrio 3328140301170005 2017-01-03 Didi Satrio 1
15 Arif 3604162008150002 2015-08-20 Gapur 1
16 Arsil 3604161611160003 2016-11-16 Andi Sata 1
17 Arsyla Fanessa 3604164905170002 2017-05-09 Erik Sairi 1
18 Asep Hidayatullah 3604162005170001 2017-05-20 Huba 1
19 Aurora Dhifa Giovanni 1807136611160001 2016-11-26 Agus Budiyanto 1
20 Ayu Indah 3604166001170001 2017-01-20 Saiman 1
21 Azahra Nur Aleeya 3604164709160002 2016-09-07 Ajum Gunawan 1
22 Azalea Khaliqa Ramadhani 3604315706170001 2017-06-17 Gan Gan Ginanjar 1
23 Azka Arvianingrum Ramadani 3172046806160007 2016-06-28 Arief Muharom 1
24 Azkiyatunufus 3604164305170001 2017-05-03 H. As'ari 1
25 Bilal Abdul Saputra 3604161404160001 2016-04-14 Ajat 1
26 Cahaya Putri 3205364111160001 2016-11-01 Asep Somantri 1
27 Carisa Atiqa Putri 1802086808160001 2016-08-28 Burhan 1
28 Cika Sintia Dewi 3604164708160001 2016-08-07 Joni 1
29 DAFA ALKADAFI 1602231710160001 2016-10-17 Havis 1
30 Echa Mey Salsabila 3604164305160002 2016-05-03 Cahya Nurdiana 1
31 Erwin Maulana 3604112804160005 2016-04-28 Muhdisin 1
32 Fatin Kiraina Azwa 1371056402160001 2016-02-24 Dardi Torial 1
33 Fayola Keisha Zahra 1801094605160001 2016-05-06 Joni Saputra 1
34 Frayuda 3604162402170001 2017-02-24 Gufu Rokhim 1
35 Gio Ardyansah 3604162103170002 2017-03-21 Ari Espriyanto 1
36 Hafiz Al Farizi 3604160507160001 2016-07-05 Umar 1
37 Hanifah Azzahra 3604165807160002 2016-07-18 Muhamad Hasani 1
38 Ihsan Alfatih 3604153101170003 2017-01-31 Marjuki 1
39 Jaenal Abidin 3604160601170005 2017-01-06 Kaswad 1
40 Jahra Nur Azizah 1801075902170002 2017-02-19 Muhammad Sadikin 1
41 Jamaludin 3604161208160003 2016-08-12 Ahmad 1
42 Jepri 3604161808160004 2016-08-18 Aspan 1
43 Kartika Aulia Putri 3604165301170003 2017-01-13 Karim 1
44 Kayyisa Putri Nugroho 3604114707160001 2016-07-07 Soni Nugroho, A. Md 1
45 Khairul 3604160205170001 2017-05-02 Saryadi 1
46 Lutfi Alansyah 3604161305170002 2017-05-13 Imam Setyadi 1
47 Maryam El Azizah 3604165710160001 2016-10-17 Sa'iludin 1
48 Mochamad Chaidir Alwi 3202360208160002 2016-08-02 Erwan Irawan 1
49 Muhamad Alby Kurniawan 1807123005160002 2016-05-30 Andika Kurniawan 1
50 Muhamad Alfin 3604171201170001 2017-01-12 Sarbani 1
51 Muhamad Ali Aditya Hidayatullah 3604172207160001 2016-07-22 Muslim Hidayatullah 1
52 Muhamad Aprijal 3604160105170001 2017-05-01 Markam 1
53 Muhamad Fauzan 3604162704170005 2017-04-27 Harto 1
54 Muhamad Husen Ibnu Yusup 3604162610150001 2015-10-26 Yusup 1
55 Muhamad Iqbal 3604160202170001 2017-02-02 H. Sapari 1
56 Muhamad Jawahirul Ma'ani 3604162306170001 2017-06-23 Suryadi 1
57 Muhamad Kanan Al Fajri 3604160410160001 2016-10-04 Muhamad Adi Santoso 1
58 Muhamad Pahmiudin 3604160301170001 2017-01-03 Sumitra 1
59 Muhamad Rendi Saputra 3604160812160002 2016-12-08 Dimas Sapitra 1
60 Muhamad Syiroz 3604160605170002 2017-05-06 Saridam 1
61 Muhamad Taufik 3604162710160002 2016-10-27 Haerudin 1
62 Muhamad Zulfiyadi 3604161710150002 2015-10-17 Mahmudi 1
63 Muhammad Ali 3329130609160003 2016-09-06 Silvan Agus Safari 1
64 Muhammad Fahri 1809011808160001 2016-08-18 Ahmad Najiyullah 1
65 Muhammad Rafif Fariansyah 3604162906170002 2017-06-29 Muhamad Fari 1
66 Muhti 3604162004160002 2016-04-20 Cecep Supriatna 1
67 Murnah 3604165604170001 2017-04-16 Mulud 1
68 Mutiara Awanah 3604165301170002 2017-01-13 Muhadi Alini 1
69 Nabil Fayad Ramadhan 3604160606170001 2017-06-06 Juber 1
 70 Nabila Kamilatunissa 3604165508180002 2016-08-15 Mudrikah 1
71 Narudin 3604160706170001 2017-06-07 Karta 1
72 Nasir 3604162305160004 2016-05-23 Sahroni 1
73 Nur Aulia Asifa 3604164206160001 2016-08-02 Ali 1
74 Putri Anggraeni 3604245107160001 2016-07-11 Madyuti 1
75 Raditya Maulana Yusuf 3673012202170005 2017-02-22 A. Sairi 1
76 Rafa Aska Putra 3604162208160001 2016-08-22 Saepi 1
77 Raka Marlino 3314060806160001 2016-06-08 Riko Setiyawan 1
78 Rania Aisha Rani 3604166712160002 2016-12-27 Sutarjo 1
79 Rantimah 3604165703170002 2017-03-17 Rapudin 1
80 Rati Sulastri 3604166012160002 2016-12-20 Rosyid 1
81 Raysa Agustia Arafah 1801096509160001 2016-09-25 Baheram Saputra 1
82 Rezky Ramadhan 3214110207160002 2016-07-02 Iyep Saripudin 1
83 Ripiansyah Fawaz 3604131003170001 2017-03-10 Murtala 1
84 Riyan 3604160211160001 2016-11-02 Aca 1
85 Rohimah 3604166903170002 2017-03-29 Supardi 1
86 Ryana Putri Medita 1608045902170001 2017-02-19 Medi Yanto 1
87 Sa'abira 3604166207160002 2016-07-22 Wari 1
88 Sabrina 3604166207160001 2016-07-22 Wari 1
89 Safira Fenny Hasanah 3604166608160001 2016-08-26 Khairun Azmi 1
90 Sahrini 3604165008160003 2016-08-10 Sarmani 1
91 Sayyida Maulina Az Zahra 3529195212160001 2016-12-12 Sunaryo 1
92 Shakila Nurhasanah 3604164611160001 2016-11-06 Kasan 1
93 Sifaul Aulia 3604296407160002 2016-07-24 Abdul Halim 1
94 Silahwati 3604166406160002 2016-06-24 Pendi 1
95 Siti Aisah 3604166205160002 2016-05-12 Sakiman 1
96 Siti Aura Felina 3604165201160002 2016-01-12 Agus 1
97 Siti Nurani Lesmana 3604164807160002 2016-07-08 Dede Lesmana 1
98 Siti Rohimah 3604165810160002 2016-10-18 Rasman 1
99 Siti Sa'diyyah 3604165705170002 2017-05-17 Amir 1
100 Widya Setiawati 3604164105150001 2015-05-01 Rosihin 1
101 Yandi Hermawan 3604160811160003 2016-11-08 Hermawan 1
102 Yuna Eka Putri 3604165605170001 2017-05-16 Yono 1
103 Abdurohman 3604161708140002 2014-08-17 Rustam Suhartono 2
104 Adibah Al Marini 3604166007150001 2015-07-20 Abdul Kayi 2
105 ADILA AZZAHRA 3673016308150001 2015-08-23 Yayan Sutisna 2
106 Adinda Ayudia Uzwah 3604166911150003 2015-11-29 Isep Riki Rismantoro 2
107 Afiqa Bilqis Villosca 3604166707150001 2015-07-27 Chris Septian Villosca 2
108 Ahmad Al Gozali 3604163101160001 2016-01-31 M. Thoyib Supriyanto 2
109 Akila Naila Putri 3318144904160001 2016-04-09 Asmadi 2
110 Alesha Nayla Zahra 3604195012150001 2015-12-10 Wawan Hermawan 2
111 Alesha Yakub 3604165403160002 2016-03-14 Ahmad Tawil 2
112 Alifiandra Azhari 1801063008150002 2015-08-30 Ariansyah 2
113 Aliya Anggita 1803101631215000 2015-12-23 Sadar 2
114 Aliyah Putri 3604164905150002 2015-05-09 Santa 2
115 Andinatasia 3604065306160002 2016-06-13 Andi Baskara 2
116 Anindha Bella Rachmadani 3604095806150001 2015-06-18 M Yudi Rahmadani 2
117 Anindya Syakirah Ramadhani 3520066506160001 2016-06-25 Kusnanto Taofik Widodo 2
118 Annisa Sovia Rahman 3275074201160001 2016-01-02 Arahman Putra SKB 2
119 Aripin 3604165502160003 2016-02-15 Sukri 2
120 Arsya Abdul Mubarok 1801091002160001 2016-02-10 Hardian Saputra 2
121 Asyifa Naila Muhdi 3604226504160002 2016-04-25 Dede Muhdi 2
122 Bagas Alfatih 3604162805160002 2016-05-28 Misnan 2
123 Bella Puspita 3604164406150002 2015-06-04 Bendi 2
124 Cahaya Salsabila 3673015501160006 2016-01-15 Cahyana 2
125 Danish Pratama 3603060102160001 2016-02-01 Budiono 2
126 Danu Muhammad Rizky 3604161604150001 2015-04-16 Dadang 2
127 Epriansyah Muhammad Wijaya 3604160810150001 2015-10-08 Eprianto 2
128 Firli Rahmansyah 3604162608150003 2015-08-26 Petdi Yusman 2
129 Firman Waes Al Qorni 3604162411150001 2015-11-24 Sapei 2
130 Gilang Alfajri 1801061204160001 2016-04-12 Syahroni 2
131 Gilang Putra Ramadhan 1802050307150001 2015-07-03 Teguh Riyanto 2
132 Hadiyansyah 1801091503160001 2016-03-15 Bustami 2
133 Hamdani 3604161911150004 2016-11-19 Iman 2
134 Ikbal Al-Rajab 1611022304150001 2015-04-23 Wawan Kusmono 2
135 Jihan Okta Saputri 3671025810150003 2015-10-18 Sungkowo Aji 2
136 Khaeriyah Hafifah 3604165611150002 2015-11-16 Khaelani 2
137 Khalilah Nur Azizah 3604164408150001 2015-08-04 Komarudin 2
138 Makhayla Almeera Khansa 3672085406160003 2016-06-14 Iwan Kuswanto 2
139 Maulana Sabillilah 1803061209150001 2015-09-12 Made Putra 2
140 Mikhailah 3604167009150001 2015-09-30 Masuri 2
141 Muhamad Aji 3604161509150002 2015-09-15 Solikin 2
142 Muhamad Albi Alfarizqi 3604331310150001 2015-10-13 Asmail 2
143 Muhamad Aldi Apandi 3604161608150003 2015-08-16 Abdul Kadir 2
144 Muhamad Aldi Pratama 1608142011150001 2015-11-20 Heriadi 2
145 Muhamad Dhafa 3604091710140001 2014-10-17 Darmin Sujana 2
146 Muhamad Dzacky 3604162804160004 2016-04-28 Encep Noh 2
147 Muhamad Fakhrurrozi 3604162310150001 2015-10-23 Achmadin 2
148 Muhamad Gausil Abror 3604161306150001 2015-06-13 Supandi 2
149 MUHAMAD LUKMAN ALI 3604162608150005 2015-08-26 Sarmani 2
150 Muhamad Nasrudhin 3604162004160001 2016-04-20 Kasmin 2
151 Muhamad Nazhirul Asrofi 3604162909150004 2015-09-29 Saripudin 2
152 Muhamad Tazki Ramadan 3201192406150002 2015-06-24 Irwan Sutisna 2
153 Muhammad Fathuroji 3172030604160005 2016-04-06 Salim Hamidi Sopyan 2
154 Muhammad Fauzan Falih 3604171610150004 2015-10-16 Ahmad Suhaimi 2
155 Muhammad Gentar Ramadhan 3604060907150003 2015-07-09 Tani 2
156 Muhammad IKhsan Rasid 3604162311160001 2016-11-23 Sajum 2
157 Muhammad Iqbal 3604162003160001 2016-03-20 Budi 2
158 Muhammad Irwansyah 3604160403160003 2016-03-04 Senen 2
159 Munawar Syaputra 3604342610150001 2015-10-26 Abdul Gani 2
160 Nur Fadilah Ramadania 3604166306160002 2016-06-23 Untung Winarko Imam 2
161 Nuraeni 3604166508150001 2015-08-25 Mardi 2
162 Nurhafidzoh 3601345811150003 2015-11-18 A. Sapullah 2
163 Putri Andini Larasakti 3604354706150001 2015-06-07 P Angga J.S 2
164 Radithya Rizal Alfarishi 1301041108150001 2015-08-11 Emrizal 2
165 Rafif Ahza Prasetya 3310071011150001 2015-11-10 Rohmat Eka Prasetya 2
166 Rafli Alkholifi Zikri 3673032001160002 2016-01-20 Syahriansyah 2
167 Raif Arfa Maulana 3604161908150001 2015-08-19 Adi Supriyatna 2
168 Rasi'ah 3604165301160003 2016-01-13 Rasiman 2
169 Risky Putra Komara 3604160403160001 2016-03-04 Ady Prayogo 2
170 Rizki Mulyadi 3604230505150003 2015-05-05 Basri 2
171 Rohmah 3604167107150003 2015-07-31 Rosuli 2
172 Rosyid 3604162007150001 2015-07-20 Nurbasa 2
173 Saadah 3604164401160002 2016-01-04 Said 2
174 Safiariani Zulmi 3671055401150006 2015-01-14 Fajar Hairul Zulmi 2
175 Salahudin Al Ayyubi 3604152109150002 2015-09-21 Syaiful 2
176 Samroni 3604161612150005 2015-12-16 Rosyid 2
177 Sapta Hadi 1807010809140001 2014-09-08 Zainal Abidin 2
178 Satria Pratama 3604162607150001 2015-07-26 Bayu Bastian 2
179 Silvia Agustina Safitri 3604165308150001 2015-08-13 Sarim 2
180 Sintiya Novi Yanti 3603175811150005 2015-11-18 Suhaili 2
181 Siti Afipatun Nazwa 3604166903160002 2016-03-29 Holil 2
182 Siti Nuraisah 3604166807150003 2015-07-28 Saripudin 2
183 Sukma 3604162104160003 2016-04-21 Buang 2
184 Syafira Nuraini 3604166809150001 2015-09-28 Tajudin 2
185 Agam Jati Mulya 3601242305120004 2012-05-23 Sukri 5
186 Fathan Shafwan Jafar 3604293006120001 2012-06-30 Abdul Halim 5
187 Rifki Erfan Saputra 1802240303120000 2012-03-03 Kuswanto 5
Mengetahui Tanggal/Bulan/Tahun
Kepala Sekolah
PETUGAS

TTD
INDAR YUNARI, S. Pd
NIP. 19660101 200003 2 005 (…....................)