KEMENTERIAN AGAMA REPUBLIK INDONESIA

UNIVERSITAS ISLAM NEGERI

SUNAN AMPEL SURABAYA
Jl. Jend. A. Yani 117 Surabaya 60237, Telp. (031) 8410298 Fax. (031) 8413300
Website : http://www.uinsby.ac.id/ Email : info@uinsby.ac.id

NOTA DINAS
Nomor : Pt- 1778/Un.07/01/R/BU/KP.08.1/07/2021

Yth : Terlampir
Dari : Rektor.
Sifat : Penting
Hal : Vaksin Covid 19 ke 2
Tanggal : 21 Juli 2021.

Assalamu’alaikum Wr. Wb.

Sehubungan dengan pelaksanaan vaksin covid 19 ke 2 UIN Sunan Ampel
Surabaya, dimohon kehadiran saudara pada:
Tanggal : 22 Juli 2021
Waktu : 10.00 s.d 11.00 WIB
Tempat : CIPUTRA WORLD MALL Jl. Mayjen Sungkono No. 89 Surabaya
Sebagai calon penerima vaksin covid 19 ke 2 ini, dimohon memperhatikan hal
sebagai berikut :
1. Kondisi sehat jasmani dan rohani
2. Sebaiknya sudah sarapan dari rumah
3. Jika Demam, batuk atau pilek pelaksanaan vaksin ditunda
4. Calon penerima vaksin akan discreening kesehatan, sebelum divaksin.
5. Calon penerima vaksin yang memiliki Riwayat sakit darah tinggi atau
penyakit lain, disarankan tetap hadir, akan divaksin apabila lolos screening
kesehatan.
6. Membawa fotocopy KTP, Sertifikat Vaksin 1 dan Alat tulis.
7. Mengisi form terlampir dan membawa saat vaksin.
8. Apabila karena Kesehatan, sehingga tidak diperbolehkan vaksin, harap
menghubungi no. 081335001731.
Demikian, atas perhatian dan kerjasamanya yang baik disampaikan terima
kasih. Semoga Allah SWT, Tuhan Yang Maha Kuasa, Maha Kasih dan Maha
Penyayang senantiasa melindungi kita semua.

Wassalamualaikum Wr.Wb.

An. Rektor
Kepala Biro Administrasi Umum,
Perencanaan dan Keuangan,

H. Rijalul Faqih

Tembusan:
1. Rektor;
2. Wakil Rektor Bidang AUPK;
Lampiran Nota Dinas
Nomor : Pt-1778/Un.07/01/R/BU/KP.08.1/07/2021
Tanggal : 21 Juli 2021

DATA PEGAWAI UINSA YANG SUDAH TERVAKSIN DOSIS 1

No NIK Nama Instansi

1 '3513152001780002 HUSNUL MUTTAQIN, TN UINSA
2 '3515060306800003 SYAIFUL RACHMAN, TN UINSA
3 '3578100912720004 IKHWAN PRIYANTONO, TN UINSA
4 '3515187001760001 MUTMAINAH, NY UINSA
5 '3578252702720001 RACHMAN HIDAJAT, TN UINSA
6 '3578095510700003 ZUMROTUL MUKAFFA, NY UINSA
7 '3578022005810001 RUSMANTO, TN UINSA
8 '3578065604950007 DEA AYUNI SEKARSARI, NN UINSA
9 '3515187110960002 NUR LAILI MAGHFIROH, SE, NN UINSA
10 '3578024204840003 AFRILIA SELFIANI, SE, NY UINSA
11 '3528110107890250 RACHBINI, TN UINSA
12 '3578040303760006 ARI PRIYANTO, S.PD.I, TN UINSA
13 '3578010706850001 ALFIAN NAUFAL, TN UINSA
14 '3525130404770002 MUSTHOFA, TN UINSA
15 '3506246310920001 INTAN RAHMAWATI, S.KOM, NY UINSA
16 '9208012407920002 JULANG ARYOWILOTO, TN UINSA
17 '3520100211840001 EKO WAHYU WIBOWO, TN UINSA
18 '5203023012820003 ZAKY ISMAIL, M.SI, NY UINSA
19 '3573034904910005 NUR LUTHFI HIDAYATULLAH, TN UINSA
20 '3578024612840001 IFFA WARDATUL MAWADDAH, S.SOS.I, NY UINSA
21 '3523175308780002 UMMU CHAIDAROH, NY UINSA
22 '1771036805830004 HENNY MERIZAWATI, S.S, NY UINSA
23 '3514115210820004 AQIDAH ISLAMIYAH, SE, NY UINSA
24 '3525122509790004 M MUHLASH, TN UINSA
25 '3515132910850001 AHMAD HIFDHUL ABROR, S.KOM, TN UINSA
26 '3578081104700001 HERY RUSMANTO, TN UINSA
27 '3525111704800021 MUHAMMAD ROZIKIN, TN UINSA
28 '3578262305790001 NUR HASIB, S.KOM, TN UINSA
29 '3578080305860005 KHUSNUL ARIFIN, TN UINSA
30 '3515132608780006 MIFTAKHUS SURUR, TN UINSA
31 '3515185208670008 MARIYANI, NY UINSA
32 '3578041705850010 JOKO LISWADI, TN UINSA
33 '3578021005810002 MOCHAMMAD FAJ`RUS SODIK, TN UINSA
34 '3514122907760002 DIPO KARTAYUANGGA, TN UINSA
35 '3515136510890003 ANNISA MALAZANI, NY UINSA
36 '3515140201670009 IDRI, M.AG, DR, PROF, H, TN UINSA
37 '3506036203920001 DIRGANTARI RUKMANA, NN UINSA
38 '3578201103750001 SUMADI, TN UINSA
39 '35241742049200002 ELVA IMELDATUR ROHMAH, M.H, NY UINSA
40 '3316052406850003 ABDUL HARIS FITRI ANTO, TN UINSA
41 '3578021502700006 DJOKO SISWOYO, S.H, M.M, TN UINSA
42 '3524222012560003 M. ZAYIN CHUDLORI, DRS, M.AG, H, TN UINSA
43 '3515183012580002 M. FAISHAL MUNIF, DRS, M.HUM, TN UINSA
44 '3578046606690003 NURUL FUADAH, NY UINSA
45 '3515182007670005 SULAIMAN, TN UINSA
46 '3515131112580001 FUAD ANWAR, M.SI, DRS, TN UINSA
47 '3515171503870003 IBNU MARDIYANTO, S.MN.SH, M.H, TN UINSA
48 '3519121010900003 DHANANG TRI SETYAWAN, TN UINSA
49 '3515182207730004 MUHAMMAD AUNU ROFIQ, TN UINSA
50 '3578261202660002 PRIYO HANDOKO, S.S, S.H, M.HUM, DR, TN UINSA
No NIK Nama Instansi
51 '3525017011800002 NASIHATUL LATIFAH, NY UINSA
52 '3517112302880004 ARIES FEBRIANTO, TN UINSA
53 '3506111405970001 MOH ILHAM HASBULLOH, SDR UINSA
54 '3578026706680002 NURHAYATI, NY UINSA
55 '3578103006780004 ANUNG YOGA ANINDHITA, SE, TN UINSA
56 '3513140210870003 HOLILUR ROHMAN, TN UINSA
57 '3578252212880002 NURUL QOMAR, TN UINSA
58 '3517210107750068 ACHMAD KEMAL RIZA S.AG, M.A, TN UINSA
59 '3578075507690003 MUTMAINAH, NY UINSA
60 '3578026901770005 ARIES HAMIDAH, NY UINSA
61 '3514121001560001 MUH FATHONI HASYIM, DRS, M.AG, TN UINSA
62 '3578181112680001 HABIB, DRS, TN UINSA
63 '3578200407660001 ABD SYAKUR, DR, M.AG, TN UINSA
64 '3578205604700001 MUFLIKHATUL KHOIROH, DRA, M.AG, NY UINSA
65 '3517091510640001 JEJE ABDUL ROZAQ, M.A, DRS, TN UINSA
66 '3515130611720002 ARIF JAMALUDIN MALIK, M.AG, TN UINSA
67 '3525152703690006 ABDULLAH CHANIF, TN UINSA
68 '3578225301720001 RADEN AYU SRI ARYANI ASTOETI, NY UINSA
69 '3578086306750002 UMI RODLIYAH, S.AG, M.HUM, NY UINSA
70 '3578060209910005 RIZKY SEPTIAN INDRAJID, SDR UINSA
71 '3578040406740010 CHOIRUL ANAM, TN UINSA
72 '3578172110710004 ABDUL BASITH JUNAIDY, M.AG, TN UINSA
73 '3515136509700002 SITI UMAYAH, NY UINSA
74 '3522085506720004 NUR AINI, NY UINSA
75 '3578215910770001 ZAHRAH FUDOLI, NY UINSA
76 '3514095410890002 NAILUL INAYAH, NY UINSA
77 '3517106709950004 ULUL ABDILLAH, NN UINSA
78 '3515081006760003 MOCH CHOLIL, TN UINSA
79 '3524262311780001 HARY SUPRIYATNO, S.AG, TN UINSA
80 '3515184110970001 DESIANA EKASARI PUTRI, NY UINSA
81 '3572024207920001 ANJANI PUTRI RETNANINGGALIH, DR, NY UINSA
82 '3515185604790003 NUR LAILATUL MUSYAFA`AH, NY UINSA
83 '3525012111880001 RUDHI HERMANTO, TN UINSA
84 '3515120811760004 RIBUT ADI WIJAYA, TN UINSA
85 '3515186409700003 ANIS FAJRIYAH, NY UINSA
86 '3502075007920002 AMIRA ORIBIA WANDA SASMITA, NY UINSA
87 '3578316010950001 IMROATUL MUFIDAH, NN UINSA
88 '3515185302930003 ISTOFATILLAILI DEVINTA, NY UINSA
89 '3513146512720001 SHOLEHAH, NY UINSA
90 '3578020304690003 MISNADI, TN UINSA
91 '3578044208670003 MUAYADATUL MASRURY, NY UINSA
92 '3513111104730002 MUSAYADI, TN UINSA
93 '3524102510740002 WAHID HADI PURNOMO, M.H, TN UINSA
94 '3515075707740001 TATIK INDAYATI, M.PD, NY UINSA
95 '3515182910680004 MUHAMAD AMIR, TN UINSA
96 '3314011410860001 BAHTIYAR RIFA`I, S.PD.I UINSA
97 '3515180511770009 NAFIS, S.PD.I, TN UINSA
98 '3515181404730008 MOKHAMAD HISAM, S.SOS, TN UINSA
99 '3522130911860001 RIZA MULTAZAM LUTHFY, TN UINSA
100 '3515161703680003 SUWIQNYO, TN UINSA
101 '3515134108800010 NURUL HIDAYAH, NY UINSA
102 '3578024104850001 RINI WAHYU NINGSIH, NY UINSA
103 '3578104902910004 HANI KHAULASARI, NY UINSA
No NIK Nama Instansi
104 '3578064506730001 YUNI ARRIFADAH, NY UINSA
105 '3518042401870002 ANA TONI ROBY CANDRA YUDA, TN UINSA
106 '3578254206760005 SAMIDAH NURMAYUNI, NY UINSA
107 '3578041004790010 JOKO SUSILO, TN UINSA
108 '3578056103690002 HUSNIYATUS SALAMAH ZAINIYATI, NY UINSA
109 '3578045906890005 TRI WAHYUNI BINTARTI, ST, M.SI, NY UINSA
110 '3578116603710002 NURUN NAFIATIEN, NY UINSA
111 '3510145006870006 BETTY SILFIA AYU UTAMI, NY UINSA
112 '3578021708650003 MUHAMMAD AGOES KAMTO, TN UINSA
113 '3505126907900001 BINTI SHOFIATUL JANNAH, NY UINSA
114 '3305131705890003 IKHSAN FATAH YASIN, TN UINSA
115 '3516120606630002 MUHAMMAD MANSYUR, TN UINSA
116 '3524171003780004 MUWAHID, TN UINSA
117 '3327096812890017 DESY INDARWATI, NY UINSA
118 '3510092104850013 LIAN FUAD, TN UINSA
119 '3578031011910003 MUHAMMAD JAZIL RIFQI, TN UINSA
120 '3578302207680001 NADLIR, TN UINSA
121 '3578231801700001 MOHAMMAD ARIF, TN UINSA
122 '3515131409720001 HANAFI, TN UINSA
123 '3578181603910002 MUHAMMAD IQBAL SURYA PRATIKTO, SDR UINSA
124 '3517030409870002 M MAULANA ASEGAF, TN UINSA
125 '3524252611890003 MOH FAIZUR ROHMAN, TN UINSA
126 '3523171611840006 M MUKHLISHIN, TN UINSA
127 '3578234901900001 MAZIYAH MAZZA BASYA, HJ, NY UINSA
128 '3310091203640002 ABD RACHMAN ASSEGAF, TN UINSA
129 '3515086805890008 RATNA ANGGRAINI ARIPRATIWI, NY UINSA
130 '3578020810650002 MOCH ROFIQ, TN UINSA
131 '3578212011700002 IMAM SYAFI`I, TN UINSA
132 '3573041004530002 DAMANHURI, TN UINSA
133 '3515172903720002 M SYAMSUL HUDA, TN UINSA
134 '3578215409840003 RIZKA SAFRIYANI, NY UINSA
135 '3515055002860001 HILDA IZZATI MADJID, NY UINSA
136 '3515076809780007 UMI HANIFAH, NY UINSA
137 '3518096807940002 HELMINA ARDYAN FITRI, NN UINSA
138 '7371113103900009 MUHAMMAD SYAHRU AHMAD S, TN UINSA
139 '9109014305930010 RISKA AYU SETIAWATI, NN UINSA
140 '3515060708910002 ABDULLAH KAFABIH, SDR UINSA
141 '3509090501810003 AKHMAD YUNAN ATHO`ILLAH, TN UINSA
142 '3578066805890007 NURUL LATHIFAH, NY UINSA
143 '3578174204700010 AFI LAYYINAH, NY UINSA
144 '3514222912890002 ACHMAD SAFIUDI R, SDR UINSA
145 '3515073003930004 MOCHAMMAD ILYAS JUNJUNAN, TN UINSA
146 '3513154108790003 ITA MUSARROFA, NY UINSA
147 '3514145609750002 AFIDA SAFRIANI, NY UINSA
148 '3578152106680004 MUHAMAD AHSAN, DR, IR, MM, TN UINSA
149 '3578105610710001 NOER ENDAH, NY UINSA
150 '7302025104730001 CHAIRATI SALEH UINSA
151 '3578042908720010 YAHYA AZIZ, S.AG, M.PD.I, TN UINSA
152 '3512022605790001 AHMAD FAUZI, TN UINSA
153 '3578024501680002 JUMIK INDAYANI, NY UINSA
154 '3578224607670001 ILUN MUALLIFAH, NY UINSA
155 '3276030111860001 ADI DAMANHURI, TN UINSA
156 '3578041012690010 BUDI SUTARTO, TN UINSA
157 '3517026504810001 ENDANG RETNANINGRUM, NN UINSA
No NIK Nama Instansi
158 '3578204304660001 MASNONI, NY UINSA
159 '3578174211900001 NURISSAIDAH ULINNUHA, NN UINSA
160 '352118480360002 HAPSARI WIJI UTAMI, NY UINSA
161 '3517104410760002 FITRIAH, NN UINSA
162 '3578060707740004 SOELISTYONO, TN UINSA
163 '3516135004680001 HANUN ASROHAH, NY UINSA
164 '3578066004820002 ABADIYAH DWI MAHANANI, NY UINSA
165 '3519065407870003 DIAN YULIATI, NY UINSA
166 '3525105502930007 ZAINATUL ILMIYAH, NN UINSA
167 '3578201408680003 MOCHAMAD LUKMAN, TN UINSA
168 '3525102910810001 MOH KHOLIS FATIHULLAH, TN UINSA
169 '3578041505770010 NURHADI, TN UINSA
170 '3578031901650002 ASMARI, TN UINSA
171 '3203034110880009 NINA INDRIANI, NN UINSA
172 '3576015811830002 SAIDATUD DHUHRIN, NY UINSA
173 '3578071510740002 MAS`UD, TN UINSA
174 '5103024412930001 MEGA AYU NINGTYAS, NN UINSA
175 '3525132602770013 ABDUN NASHIR, TN UINSA
176 '6103072406850003 MARLI CANDRA, TN UINSA
177 '3578026310850006 ANNA MUSLICHAH, NY UINSA
178 '3514091310730001 MOKHAMAD SYAIFUDIN, TN UINSA
179 '3515135312860002 RAHMA ULFA MAGHFIROH, NY UINSA
180 '3578022101760002 SANURI, TN UINSA
181 '3578264608720004 ANIS FARIDA, NY UINSA
182 '3578025408800004 NANIK AGUSTINI, NY UINSA
183 '3578066709770005 KHUSNUL INAYAH, SAG, NY UINSA
184 '3573041212670009 MOHAMAD SALIK, TN UINSA
185 '3578061706770009 ABDUL WAHID JUNAIDI, TN UINSA
186 '3515160412720002 MAHIR, TN UINSA
187 '3503115803900001 WAHYUNI FAJAR ARUM, NN UINSA
188 '3578025305770001 HETY IRMA SURYANI, NY UINSA
189 '3515184503750003 LILIK MASLAMAH, NY UINSA
190 '3523161811810001 AHMAD LUBAB, M.Si, TN UINSA
191 '3578024607680002 SHOFIYAH, NY UINSA
192 '3504120210870001 UPIK KHOIRUL ABIDIN, TN UINSA
193 '3578022112670003 ATIQ MOHAMMAD ROMDLON, TN UINSA
194 '3506100905850003 SYAFRUDDIN FAISAL THOHAR, M.Psi, TN UINSA
195 '3578182303810001 ZUDAN ROSYIDI, SS, MA, TN UINSA
196 '3578187005830004 MURNI FIDIYANTI, SS, MA, NY UINSA
197 '3515131307700005 KHOLIK, S.AG, TN UINSA
198 '3525034702740002 WIWIN LUQNA HUNAIDA, NY UINSA
199 '3524140701700004 HISBULLAH HUDA, TN UINSA
200 '3526095810760002 HOLILAH, M. SI, NY UINSA
201 '3522082706800007 MUHAMMAD NURIL HUDA, TN UINSA
202 '3578045803930001 TRISTY KARTIKA FI`AUNILLAH, NN UINSA
203 '3578225709850001 RIDHA AMALIYAH, S.IP, MBA, NN UINSA
204 '3524052412860001 HUSNI ABDILLAH, S.PD, M.PD, TN UINSA
205 '3578025012780004 NUR MACHILAH, NY UINSA
206 '35780245903670001 SRI HASTUTIK,DRA,HJ, NY UINSA
207 '3515081506690001 ABU FANANI, M.Pd, TN UINSA
208 '3515165208770004 SURYANI, DR, S.Ag, S.Psi, M.Si, NY UINSA
209 '3510155006920003 WIKA DIANITA UTAMI, M.Sc, NY UINSA
210 '3515162512760003 ALI MUSTOFA, S.Ag.M.Pd, TN UINSA
No NIK Nama Instansi
211 '3522092701870003 ARIS FANANI, M.Kom, TN UINSA
212 '3578016302950001 AJENG WIDYA PRAKASITA, NN UINSA
213 '3578226606870004 ASRI SAWIJI, ST, NN UINSA
214 '3515132108830001 AGUS PRASETYO KURNIAWAN, TN UINSA
215 '3517072805890007 SUHANDOKO, S.Pd, M.Pd, TN UINSA
216 '3578022701760001 MOCHAMMAD FAUZI, TN UINSA
217 '3578045802670003 RENI DWI ASTUTI WINARSIH, NY UINSA
218 '3578170208700005 AMAL TAUFIQ, S.Pd, M.Pd, TN UINSA
219 '1256162706880001 ARIE KRISTIAN, TN UINSA
220 '3578022807680003 CHOIRUL ANAM, TN UINSA
221 '3516132802820003 EDIKA AFERI, TN UINSA
222 '3506130901710001 UMAR SISWORO, TN UINSA
223 '3518032011850001 AHMAD LUTFI, TN UINSA
224 '3529191201880003 JUMA`, M.Hum, TN UINSA
225 '3578224110910001 ADE IRMA SURYANI LATING, NY UINSA
226 '3515142901680001 ALI WAFA, DRS, M.Ag, TN UINSA
227 '3515060706710001 ENDRATNO PILIH SWASONO, S.Pd, TN UINSA
228 '3517166908540001 JUWARIYAH DAHLAN, PROF, DR, NY UINSA
229 '3578214601780004 SITI CHOLIFAH, NY UINSA
230 '3524236903950002 I`IN NUR ZULAILI, NY UINSA
231 '3523192002770002 SIHABUDIN, M.Pd.I, TN UINSA
232 '3578132610880001 ACHMAD TEGUH WIBOWO, S.Kom, M.T, TN UINSA
233 '3578044601770010 NURUL CHAMIDAH, NY UINSA
234 '3504177008890001 EVA AGUSTINA, M.SI, NY UINSA
235 '3502172704860003 MUJIB RIDWAN, TN UINSA
236 '3374074105820005 DIAH NUGRAHENI SETYOWATI, RR, NY UINSA
237 '3508021702830004 ADITYA FEBRIANTO, TN UINSA
238 '3517061404840003 ACHMAD HANTOYO, TN UINSA
239 '3514131807890001 TAUFIQURROHMAN, M.Pd.I, TN UINSA
240 '3514140309730002 AMRULLAH, M.AG, TN UINSA
241 '3578202709770001 SAMSUDIN, TN UINSA
242 '3578040503670002 MOCHAMAD SAFI`I, TN UINSA
243 '3507160204790003 KUSNUL PRIANTO, TN UINSA
244 '3515164704800001 ANA BILQIS FAJARWATI, NY UINSA
245 '3515135304910003 MASNA HIKMAWATI, S.HUM, NY UINSA
246 '3515160712860001 BAGUS HARYO YUDONO, TN UINSA
247 '3525013011790001 SULANAM, TN UINSA
248 '3578042609680012 IMAM BUCHORI, SE, TN UINSA
249 '3528030710850002 MOH. ATIKURRAHMAN, TN UINSA
250 '3524222209930001 HERNANTO, SDR UINSA
251 '3515181003930007 RAMADHAN SYAH PUTRA, SDR UINSA
252 '3578042302850002 TEGUH PANOTOGOMO, TN UINSA
253 '3578180704750002 SYAIFUDDIN, R, S.Pd, M.Pd, TN UINSA
254 '3578024808830003 HERNIK FARISIA, NY UINSA
255 '3578302207730001 M. BAHRI MUSTOFA, M.Pd, TN UINSA
256 '3578031611730002 AL QUDUS NOVIANDRI EKO S, LC, TN UINSA
257 '3515124707780001 FARIDA SHOLIHAH AMALIYAH, NY UINSA
258 '3319022303840002 NOOR WAHYUDI, TN UINSA
259 '7307044307860004 JUHAENI, M.Pd.I, NY UINSA
260 '3578086005920005 ARIZA QURRATA A`YUN, NY UINSA
261 '3578021409760003 IMAM GOZALI, TN UINSA
262 '3525112304750002 MUHAMMAD SHODIQ, DR, H, S.Ag, M.Si, TN UINSA
263 '3525090911820002 CHOIRUL ANAM, TN UINSA
264 '3510201112850004 DEDY SUPRAYOGI, S.KM, M.KL, TN UINSA
No NIK Nama Instansi
265 '3523181401840002 AHMAD ROZIQIN, TN UINSA
266 '3578180808770001 ARIF AINUR ROFIQ, TN UINSA
267 '3524151210820002 ROZAQUL ARIF, TN UINSA
268 '3528043012750003 AHMAD KHAIRUL HAKIM, TN UINSA
269 '3512065805760002 YUSRIA NINGSIH, NY UINSA
270 '3577012206730002 PARDIANTO, S.Ag, M.Si, TN UINSA
271 '3277015903900008 VERA ARIDA, NN UINSA
272 '3516084406920001 YUNITA ARDILLA, NY UINSA
273 '3578025904780002 RIES DYAH FITRIYAH, DR, NY UINSA
274 '3526010404730006 ABU BAKAR, TN UINSA
275 '5203026504790001 UMI SALAMAH, NY UINSA
276 '3578086209760001 SOFFY BALGIES, NY UINSA
277 '3517180704690002 SYAMSUL MA`ARIF, TN UINSA
278 '3516134512780002 MAS`ADAH, NY UINSA
279 '3525031705790001 MOHAMAD THOHIR, TN UINSA
280 '3404076402790013 EFA SURIANI, NY UINSA
281 '3311126408890003 DIAN SARI MAISAROH, NY UINSA
282 '3312135805880002 MEILINA FITRI KUMALASARI, NY UINSA
283 '3578027001710002 ROFHANI, NY UINSA
284 '3578154612770005 FIRDAUS NUZULAH, NY UINSA
285 '3311034408870001 ESTRI KUSUMAWATI, NY UINSA
286 '3523160311750001 MUHAMMAD LATHOIF GHOZALI, TN UINSA
287 '3578236108780004 ISNA FISTIYANTI, NY UINSA
288 '3571021011870001 MOH KHOIRUL ANAM, TN UINSA
289 '3517125004940001 AFIFATUR ROHIMAH, NN UINSA
290 '3319060903930008 NUR ROMDLON MASLAHUL ADI, TN UINSA
291 '3518071707680001 KHARISUDIN, TN UINSA
292 '3578084606810011 LILIK RAHMAWATI, NY UINSA
293 '3573046609830004 LISANUL USWAH SADIEDA, NY UINSA
294 '3517135206760005 MUFLIHAH, NY UINSA
295 '3524226808890001 FIKRY ZAHRIA EMERALDIEN, NY UINSA
296 '3515162212760007 NYONG EKA TEGUH IMAN SANTOSA, TN UINSA
297 '3518101411920001 MUHAMMAD SYIFAUL MUNTAFI, TN UINSA
298 '3502176702830001 ARFIANI SYARIAH, ST, MT, NY UINSA
299 '3515072112550001 BURHAN DJAMALUDDIN, TN UINSA
300 '3515085711840002 ESTI NOVI ANDYARINI, NY UINSA
301 '3508054808830001 HASTANTI AGUSTIN RAHAYU, NY UINSA
302 '3578094106840003 NUR MAZIDAH, NY UINSA
303 '3311120509820003 HANAFI ADI PUTRANTO, TN UINSA
304 '3578274505680005 MUKHLISHAH A.M, DRA, NY UINSA
305 '3524151804820001 HARIS SHOFIYUDDIN, TN UINSA
306 '3515155404770003 SITI ASMIYAH, NY UINSA
307 '3516132201910001 MOH ILHAM, TN UINSA
308 '3525142903920002 WIGA ALIF VIOLANDO , SDR UINSA
309 '3578085611770005 S KHORRIYATUL KHOTIMAH, NY UINSA
310 '3525054301770001 SUTINI, S.PD, M.Si, NY UINSA
311 '3578084610780002 RAUDLOTUL JANNAH, NY UINSA
312 '3515132412650001 JUNAEDI, DRS, M.AG, TN UINSA
313 '3578245310910003 UMMY CHAIRIYAH, NY UINSA
314 '3515096809840003 SITI LAILIYAH, NY UINSA
315 '3502076102870001 IKA MUSTIKA, NY UINSA
316 '3578182002740001 M BAIHAQI, TN UINSA
317 '3328090507770001 MOH. NURFUADI, SDR UINSA
318 '3505036812830001 DEASY TANTRIANA, NY UINSA
No NIK Nama Instansi
319 '3524225703780001 RAKHMAWATI, NY UINSA
320 '3517085203740001 RIZMA FITHRI, NY UINSA
321 '3528045204760010 ITSNA SYAHADATUD DINURRIYAH, NY UINSA
322 '3310114308800005 RITA ERNAWATI, NY UINSA
323 '3522194208760001 ANDRIANI SAMSURI, NY UINSA
324 '3317046707930003 NIHLATUL FALASIFAH, NN UINSA
325 '3576016503900002 RIZKI RAHMADINI NURIKA, NN UINSA
326 '3514125812570001 LILIEK CHANNA AW, NY UINSA
327 '3515186705790012 YUNIAR FARIDA, NY UINSA
328 '3578020205720004 CHUMAIDI, S.PD.I, TN UINSA
329 '3578022408620001 HAMIM ROSYIDI, TN UINSA
330 '3578245206780001 AINUN SYARIFAH,S.PDI, NY UINSA
331 '3515076205620001 NURLAILAH, NY UINSA
332 '7371136501820011 SRI HIDAYATI L, NY UINSA
333 '3573043009910004 M FAHMI AUFAR ASYRAF, TN UINSA
334 '3517134904730005 MUKHOIYAROH, NY UINSA
335 '3576025704870002 LINDA PRASETYANING WIDAYANTI, NY UINSA
336 '3578200210630001 MUHID, TN UINSA
337 '3515072706770001 ACHMAD ROOM FITRIANTO, TN UINSA
338 '3515072903830004 PRIYO EKO MARTHA HIDAYAT, TN UINSA
339 '3578231304740003 RISTANTO BUDI UTOMO, TN UINSA
340 '3578080705660002 ABDULLAH UBED, TN UINSA
341 '3515116202810001 IRUL HIDAYATI, NY UINSA
342 '3578052603760001 ARDIANSYAH RAFIKA, TN UINSA
343 '3578164103770006 SITI AZIZAH, NY UINSA
344 '7571033010770001 MUSTOFA , TN UINSA
345 '3578025107800003 IKA YULIASTUTIK, NY UINSA
346 '3578041202570010 MUSTOFA HUDA, TN UINSA
347 '3515131907810004 ABDULLAH MAHFUDZ NAZAL, TN UINSA
348 '3578011101760001 M BIKIN TORIN, TN UINSA
349 '3578144405770003 IZZA ERSIFA, NY UINSA
350 '3374114410850001 OKTAVI ELOK HAPSARI, NY UINSA
351 '3515145309820001 ADE AMELIA AMIR, NY UINSA
352 '3578095308760003 SITI MUSFIQOH, NY UINSA
353 '3524155010910006 SITI KAMILATUS SAIDAH, NY UINSA
354 '3515021306720003 SUTOPO, TN UINSA
355 '3525104804840003 MARLIN APRILIYANTI, NY UINSA
356 '3576025105760004 TATIK MUKHOYYAROH, NY UINSA
357 '3515142509690001 MOHAMMAD KURJUM, DR, M.Ag, H, TN UINSA
358 '3319076109880003 RIZKI ENDI SEPTIYANI, NN UINSA
359 '3524180806690003 KHOTIB, TN UINSA
360 '3526045601880002 JIPHIE GILIA INDRIYANI, NY UINSA
361 '3511192004880002 SAIFUL BAHRI, TN UINSA
362 '3524180206710001 ALI NURDIN, TN UINSA
363 '3525122009890001 HASAN MAHFUDH, M.Hum, TN UINSA
364 '3509166912890002 SITI TATMAINUL QULUB, NY UINSA
365 '3578074802690001 FERYANI UMI ROSIDAH, S.AG, M.FIL.I, NY UINSA
366 '3578021705730003 MUHAMMAD FAUZI, TN UINSA
367 '3578201205700001 ACHMAD ZAINI, TN UINSA
368 '3578046503670002 PUDJI RAHMAWATI, DRA, NY UINSA
369 '1501055811810002 NOVERMA, NY UINSA
370 '3328090102810014 TAHRUDIN, SDR UINSA
371 '3519142809760002 SALIM, SDR UINSA
372 '3515034608900001 HANIK FAIZAH, Si, M.Si, NY UINSA
No NIK Nama Instansi
373 '3524252112860001 SAIKU ROKHIM, M.KKK, TN UINSA
374 '3515071405820001 AUN FALESTIEN FALETEHAN, TN UINSA
375 '3578095711820003 MAULUDIYAH, NY UINSA
376 '3515162111730004 LUKMAN FAHMI, DR, M.PD, TN UINSA
377 '3214137011840002 IDA MUNFARIDA, NY UINSA
378 '3578241604760001 BUDI ICHWAYUDI, TN UINSA
379 '3578044211710010 KHOIRUL UMAMI, NY UINSA
380 '3578202909710001 YUSUF, TN UINSA
381 '1871052406830003 RAHMAD JUNAIDI, TN UINSA
382 '3527090507620004 UMAR FARUQ, DRS, TN UINSA
383 '3578066301760004 IDA ROCHMAWATI, NY UINSA
384 '3525020611800001 PUPUT PUJIONO, TN UINSA
385 '3578050903680002 RUDY AL HANA, TN UINSA
386 '3526135806880005 LATIFAH ANWAR, NY UINSA
387 '3522152104820011 MUHAMMAD AFDILLAH, TN UINSA
388 '3522123003790001 ARIF MANSYURI, TN UINSA
389 '3523060405790002 MUCHAMMAD HELMI UMAM, S.Ag, M.Hum, TN UINSA
390 '3515181811830009 ADVAN NAVIS ZUBAIDI, TN UINSA
391 '3578040507730007 SUYIKNO, TN UINSA
392 '3578044311770005 LAILI BARIROH, NY UINSA
393 '3525051912840001 FATHONIZ ZAKKA, TN UINSA
394 '3515131509810002 MUKHAMMAD ZAMZAMI, TN UINSA
395 '3515100409850001 BAKHRUL HUDA, M.E.I, TN UINSA
396 '3578262402760001 MUHAMMAD GHUFRON, TN UINSA
397 '3526012704870004 NAUFAL CHOLILY, M.Th.I, TN UINSA
398 '3515182108730005 LUKMAN HAKIM, TN UINSA
399 '3515131506650016 CHOLIL, Drs, MPd I, TN UINSA
400 '3515065401780003 NIKMAH HADIATI SALISAH, NY UINSA
401 '3526091608930001 SAMSUL ARIFIN, TN UINSA
402 '3515130807700001 AMIN TOHARI S.AG, M.Si, TN UINSA
 SURAT PERSETUJUAN / PENOLAKAN MEDIS KHUSUS (INFORM CONCERN)

Saya yang bertanda tangan di bawah ini :

NIK : ............................................................ Umur : (L/P)
Nama : .......................................................................................................
Alamat : .......................................................................................................
Telp : .......................................................................................................
Dengan ini menyatakan *SETUJU / *MENOLAK untuk dilakukan Tindakan Medis berupa Penyuntikan
Vaksin Covid-19 dengan 2x pemberian sesuai interval.
Surabaya, 2021
Alasan Menolak : Yang membuat pernyataan,

(_____________________)

KARTU KENDALI PELAYANAN VAKSINASI COVID-19 KITIR VAKSINASI

SKRINING
No Pemeriksaan Hasil Tindak Lanjut No. Eticket :
1 Suhu Suhu > 37,5 0C vaksinasi ditunda
sampai sasaran sembuh ................................
2 Tekanan Darah Jika >180/110 mmHg pengukuran
tekanan darah diulang 5 (lima) Hasil Skrining : (centang)
sampai 10 (sepuluh) menit
kemudian. Jika masih tinggi maka a. Divaksin ( )
vaksinasi ditunda sampai terkontrol
Pertanyaan Ya Tidak b. Ditunda ( )
1 Pertanyaan untuk vaksinasi ke-1 Jika Ya: vaksinasi
Apakah Anda memiliki riwayat alergi diberikan di Rumah Sakit Nama Petugas Meja 2 :
berat seperti sesak napas, bengkak dan
urtikaria seluruh badan? ....................................
2 Apakah Anda sedang hamil Jika sedang hamil
vaksinasi ditunda sampai melahirkan TTD Petugas Meja 2 :
3 Apakah Anda mengidap Jika Ya, maka vaksinasi ditunda jika
penyakit autoimun seperti sedang dalam kondisi akut ...................................
asma, lupus. atau belum terkendali
4 Apakah Anda sedang mendapat Jika Ya: vaksinasi
pengobatan untuk gangguan ditunda dan dirujuk
Nama Vaksin : ...............
pembekuan darah, kelainan darah,
defisiensi imun dan penerima produk No. Batch : ....................
darah/transfusi?
5 Apakah Anda sedang mendapat Jika Ya: vaksinasi
pengobatan immunosupressant ditunda dan dirujuk
seperti kortikosteroid dan Nama Vaksinator :
kemoterapi?
6 Apakah Anda memiliki penyakit Jika Ya: vaksinasi ...........................................
jantung berat dalam keadaan sesak? ditunda dan dirujuk
Pertanyaan Nomor 7 dilanjutkan apabila terdapat penilaian kelemahan fisik pada
sasaran vaksinasi TTD Vaksinator:
7 Pertanyaan tambahan bagi sasaran Jika terdapat 3 atau lebih
...........................................
lansia (≥60 tahun): jawaban Ya maka vaksin
1. Apakah Anda mengalami kesulitan tidak dapat diberikan
untuk naik 10 anak tangga?
2. Apakah Anda sering merasa
kelelahan?
3. Apakah Anda memiliki paling
sedikit 5 dari 11 penyakit
(Hipertensi, diabetes, kanker,
penyakit paru kronis, serangan
jantung, gagal jantung kongestif,
nyeri dada, asma, nyeri sendi,
stroke dan penyakit ginjal)?
4. Apakah Anda mengalami kesulitan
berjalan kira-kira 100 sampai 200
m?
5 Apakah Anda mengalami
penurunan berat badan yang
bermakna dalam setahun terakhir?