Jenis

NO No. Tiket Dosis 1 No. Tiket Dosis 2 NIK Nama Penerima Vaksin Kelam Pekerjaan*
in

1 INVALID 3328013112600285 DAMUN L LANSIA

2 P-FJFVKYDY 3328014211590004 MURNI P LANSIA
3 P-GNMBXHR0 3328012202740003 SUTARMAN L UMUM
4 S-33AC86B8 3328010409590001 DUL GHONI L LANSIA
5 P-WJ0K2I3H 3328016107830003 ROMSIATUN MULYANI P UMUM
6 P-WJ0QWBYL 3328012809820002 WUTUH P UMUM
7 P-WJ11365G 3328110107900091 MOH. KOMARUDIN L UMUM
8 P-WJ1BYLYM 3328013112640022 MUHIM L UMUM
9 S-CFC4AA65 3328013112580123 KASID L LANSIA
10 P-WIZJ3R0E 3329160309770003 WARMAN L UMUM
11 P-WIZ813AI 3328012202710004 AGUS WAHID L UMUM
12 P-WJ45KNWB 3328010107500095 KASRO L LANSIA
13 P-WJ4F6LOD 3328014407980006 YULIA NUR KHOTIMAH P UMUM
14 P-WJ4O040Y 3328012712820005 JOKO SETYO PRAMUDYO L UMUM
15 P-WIYZ28KE 3328015506780012 HERMI YUNIARTI P UMUM
16 P-HEQOJGMU 3328012205780005 TASWID L UMUM
17 P-FQUUD39F 3328012807960002 MINTO HARYANTO L UMUM
18 P-WIYEDLPO 3328011709920002 MOH. HERU SETIAWAN L UMUM
19 P-WJ31ZU1G 3328010302090001 RAFA SATRIA NUGRAHA L UMUM
20 Y-0131W1DT 3328015106930005 KUSRINI P UMUM
21 P-WJ3XKNGP 3328010410090004 ILHAM MELVIN L REMAJA
22 P-JQX6R7L7 3328011208010003 KIRMANSYAH L UMUM
23 P-JJ4M94U9 3328010107340007 SARNO L LANSIA
24 P-IGXWCEEW 3328016001980011 RISKA DAMAYANTI P UMUM
25 P-HUVZMXST 3578290912090002 AHMAD NURIE ZAM-ZAMI L REMAJA
26 S-CBD3CFA2 3175036110410001 SUTINAH P LANSIA
27 S-637E2D2B 3328017112600257 DASRI P LANSIA
28 S-F06C4D28 3328014107300028 CASEM P LANSIA
29 P-GAS5IO1L 3328010303010005 AJI MUHAMMAD AGUNG L UMUM
30 P-GVRTHQ06 3328017012510003 RAITAH P LANSIA
31 S-810879F0 3328011307600001 JANUDIN L LANSIA
32 P-HLSOWPVZ 3328010708780002 ROSIDIN L UMUM
33 S-0CA28AF9 3328012904580002 MAKDORI L LANSIA
34 P-IM6BGIXZ 3328016206800005 IKE RAHMAWATI P UMUM
35 P-J25GHEG5 3328012404760005 KUSNANDAR L UMUM
36 P-K015JS42 3328011508910009 SUHARYANTO L UMUM
SINOVAC
 ALAMAT

TANGGAL LAHIR Kelompok

Umur
UMUR JENIS FASKES NAMA FASKES KECAMATAN KODE DESA
KECAMATAN

12/21/1960 63 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT

11/2/1959 64 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
2/22/1974 49 46-59 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
9/4/1959 64 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
7/4/1983 40 31-45 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
9/28/1982 41 31-45 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
9/16/1990 33 31-45 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
12/31/1964 59 46-59 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
12/21/1958 65 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
9/3/1977 46 46-59 PUSKESMAS BALAPULANGKETANGGUNGAN 332916 KUBANGWUNGU
2/22/1971 52 46-59 PUSKESMAS BALAPULANG MARGASARI 332801 MARGASARI
7/1/1950 73 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
7/4/1998 25 18-30 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
1/27/1983 41 31-45 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
6/15/1978 45 46-59 PUSKESMAS BALAPULANG MARGASARI 332801 MARGASARI
6/14/1978 45 46-59 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
7/28/1996 27 18-30 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
9/17/1992 31 31-45 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
3/2/2009 14 12-17 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
6/11/1993 30 31-45 PUSKESMAS BALAPULANG PENJARINGAN 317201 PENJARINGAN
10/4/2009 14 12-17 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
8/12/2001 22 18-30 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
7/1/1934 89 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
1/20/1997 27 18-30 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
12/9/2009 14 12-17 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
10/21/1941 82 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
12/31/1960 63 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
7/1/1930 93 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
2/3/2001 23 18-30 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
12/30/1949 74 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
7/13/1960 63 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
8/7/1978 45 46-59 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
4/29/1958 65 >60 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
6/22/1980 43 31-45 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
4/24/1976 47 46-59 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
8/15/1991 32 31-45 PUSKESMAS BALAPULANG MARGASARI 332801 PAKULAUT
 Kepesertaan BPJS
AMAT (tulis 'Ya' pada kolom Dosis I
yang sesuai)
No. Hp
BPJS Non Nama/ Tanggal
KODE DESA RT RW BPJS Non Anggo Tanggal Jenis/ Pemberian
PBI PBI ta Screening Merek Vaksinasi
Vaksin***
5 1 081973073396 1/8/2022 PFIZER 1/8/2022
5 1 085702224133 1/8/2022 PFIZER 1/8/2022
1 2 085200262876 1/8/2022 PFIZER 1/8/2022
5 1 085742775443 1/8/2022 PFIZER 1/8/2022
1 1 085642219749 1/8/2022 PFIZER 1/8/2022
3 4 081818669296 1/8/2022 PFIZER 1/8/2022
6 1 083894442255 1/8/2022 PFIZER 1/8/2022
2 1 082327042102 1/8/2022 PFIZER 1/8/2022
7 2 08813818253 1/8/2022 PFIZER 1/8/2022
4 3 082320905990 1/8/2022 PFIZER 1/8/2022
1 9 082135339083 1/8/2022 PFIZER 1/8/2022
1 1 082324677991 1/8/2022 PFIZER 1/8/2022
5 1 085878263173 1/8/2022 PFIZER 1/8/2022
1 1 085642219749 1/8/2022 PFIZER 1/8/2022
1 9 085225655364 1/8/2022 PFIZER 1/8/2022
2 2 087734357551 1/8/2022 PFIZER 1/8/2022
1 2 085786130951 1/8/2022 PFIZER 1/8/2022
4 1 085326747724 1/8/2022 PFIZER 1/8/2022
5 1 085712225479 1/8/2022 PFIZER 1/8/2022
4 8 082134579430 1/8/2022 PFIZER 1/8/2022
3 1 083837073519 1/8/2022 PFIZER 1/8/2022
4 1 082327042102 1/8/2022 PFIZER 1/8/2022
5 1 083837073519 1/8/2022 PFIZER 1/8/2022
5 1 083861220557 1/8/2022 PFIZER 1/8/2022
5 1 085869979118 1/8/2022 PFIZER 1/8/2022
1 2 085725138487 1/8/2022 PFIZER 1/8/2022
1 2 083891022668 1/8/2022 PFIZER 1/8/2022
1 2 085717671869 1/8/2022 PFIZER 1/8/2022
1 2 085722765680 1/8/2022 PFIZER 1/8/2022
2 2 082327042102 1/8/2022 PFIZER 1/8/2022
1 2 081912794538 1/8/2022 PFIZER 1/8/2022
1 2 085640255804 1/8/2022 PFIZER 1/8/2022
4 1 087810095962 1/8/2022 PFIZER 1/8/2022
4 1 085713799523 1/8/2022 PFIZER 1/8/2022
4 1 0859126213329 1/8/2022 PFIZER 1/8/2022
5 1 083861220557 1/8/2022 PFIZER 1/8/2022
Dosis I Dosis 2
Keterangan
(Ditunda/Tidak
Nama/ Tanggal Diberikan/Lanjut)
No. Batch No. Serial Tanggal Jenis/Merek Pemberian No. Batch No. Serial
Screening Vaksin*** Vaksinasi

FK0723 LANJUT DOSIS I

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