FIX - VAKSINASI Start SEPT 2021

FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19
TINGKAT PUSKESMAS
Nama Puskesmas/Jejaring : JANTI

Kabupaten/Kota : MALANG
Provinsi : JAWA TIMUR
Dosis I Dosis 2
Umur Keterangan
No NIK Nama Penerima Vaksin L/P Alamat No. Hp Merek Vaksin Tanggal Tanggal
Pemberian No. Batch Pemberian No. Batch
Vaksinasi Vaksinasi
1 ASTRAZENECA K004A
2 ASTRAZENECA K004A
3 ASTRAZENECA K004A
4 ASTRAZENECA K004A
5 ASTRAZENECA K004A
6 ASTRAZENECA K004A
7 ASTRAZENECA K004A
8 ASTRAZENECA K004A
9 ASTRAZENECA K004A
10 ASTRAZENECA K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi

TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
3 35730412038000003 HENDAR SUMARDIANTO L 80 JL.JANTI SELATAN VIII-9 05/06 08991070077 ASTRAZENECA 21/09/2021 K004A
4 35730355504910009 MARISSA NOR FITRIA P 80 JL.KEPUH UTARA GG MANDALA A/38 06/04 081233664938 ASTRAZENECA 21/09/2021 K004A
5 3573042303520004 SUKARLI L 79 JL.RAYA KEPUH No.45 07/04 085334889933 ASTRAZENECA 21/09/2021 K004A
6 3573042808770011 RUDIANTO L 79 JL.KLAYATAN III/22 08/02 - ASTRAZENECA 21/09/2021 K004A
7 3573046812590002 SUPARMI P 75 JL.KLAYATAN II-5 - ASTRAZENECA 21/09/2021 K004A
8 3573041409510001 WITOYO L 74 JL.KLAYATAN 2/33 03/04 - ASTRAZENECA 21/09/2021 K004A
9 3508053112990001 EDO SERLI ANDIKA L 73 JL.KLAYATAN III/46 13/02 081230847828 ASTRAZENECA 21/09/2021 K004A
10 3573042808030003 EXVEL RAY L 72 JL.KEPUH IX-9 09/05 081235890229 ASTRAZENECA 21/09/2021 K004A
11 3573041204800012 NUR KHOLIS L 71 JL.KLAYATAN I-10 01/04 089520813040 ASTRAZENECA 21/09/2021 K004A
12 3573046111590002 NURIATI P 71 JL.KLAYATAN I/47A 02/12 085755308244 ASTRAZENECA 21/09/2021 K004A
13 3573040505570004 RIONO L 71 JL.S.SUPRIYADI KEPUH II/12 01/15 - ASTRAZENECA 21/09/2021 K004A
14 3573045810890002 HENI NOVITA SARI P 71 JL.JANTI SEL GG.8/22 04/06 - ASTRAZENECA 21/09/2021 K004A
15 3573044807870007 RIZAH SETYAWATI P 70 JL.KLAYATAN II No.36A 13/12 085733338280 ASTRAZENECA 21/09/2021 K004A
16 3573045103630002 RIATIN P 70 JL.KEPUH IA-20 08/04 081249811913 ASTRAZENECA 21/09/2021 K004A
17 3573044310850006 ANIK MISTIANI P 70 JL.JANTI UTARA VI-1 05/09 085334199016 ASTRAZENECA 21/09/2021 K004A
18 3573046402570001 SUTEMI P 70 JL.JANTI UTARA V/11 03/09 081334242006 ASTRAZENECA 21/09/2021 K004A
19 3573044410720004 MUSLICHAH P 70 JL.KEPUH I/55 10/04 082337317015 ASTRAZENECA 21/09/2021 K004A
20 3573045602800003 SUPARTIK P 69 JL.KEPUH X-6 08/05 081252499330 ASTRAZENECA 21/09/2021 K004A
21 3573047112530030 ST.ROHANI P 69 JL.KEMANTREN I-8 06/03 - ASTRAZENECA 21/09/2021 K004A
22 3573046609920005 SEPTIAN RAHAYU KURNIAWATI P 69 JL.KEPUH I/54 10/04 - ASTRAZENECA 21/09/2021 K004A
23 3573040806620001 BAMBANG HERI SUMADI L 68 JL.KLAYATAN I-5B 01/04 081337529420 ASTRAZENECA 21/09/2021 K004A
24 3573010209560005 TEDDY HARIANTO L 68 JL.JANTI SELATAN 7/27 01/06 - ASTRAZENECA 21/09/2021 K004A
25 3573014808580013 YAYUK P 68 JL.JANTI UTARA VI-11 05/09 - ASTRAZENECA 21/09/2021 K004A
26 3573044206500001 ENDANG BIARTI P 68 JL.JANTI SELATAN VIII/14 05/06 081217743646 ASTRAZENECA 21/09/2021 K004A
27 3573041511620002 MUFTI SIGIT L 68 JL.KEPUH UTARA 17 04/04 085336355318 ASTRAZENECA 21/09/2021 K004A
28 3573041606760010 KASIONO L 68 JL.KEPUH UTARA GG MANDALA A/38 06/04 081233664938 ASTRAZENECA 21/09/2021 K004A
30 3573044501910001 ATIK PURWATI P 67 JL.KEMANTREN I/31 07/03 082232849959 ASTRAZENECA 21/09/2021 K004A
31 3573041201650007 ACHMAD HAMBALI L 67 JL. JANTI BARAT BLOK C/8 03/11 085765287718 ASTRAZENECA 21/09/2021 K004A
32 3573040403800003 HERI PURWANTO L 67 KLAYATAN IIIC/JL.ABDUL HAMID 30 04/02 - ASTRAZENECA 21/09/2021 K004A
33 3573044411610003 SRI HARTINI P 67 JL.KLAYATAN I/79 10/01 - ASTRAZENECA 21/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
34 3573040803550001 SIYONO L 67 JL.KLAYATAN III/34 12/02 085259058276 ASTRAZENECA 21/09/2021 K004A

35 35730405016100004 AKHMAD DANURI L 66 JL.JANTI BARAT C/2 03/11 0815555711250 ASTRAZENECA 21/09/2021 K004A
36 3573045401730001 SUSI SUKENTI P 66 JL.KEPUH IXA/17 06/05 082333151020 ASTRAZENECA 21/09/2021 K004A
37 3573041303730003 MARSONO L 66 JL.KLAYATAN II/42 10/12 081230592400 ASTRAZENECA 21/09/2021 K004A
38 3507070405910001 M BURHANUDIN L 65 JL.KEPUH X-12 085232664859 ASTRAZENECA 21/09/2021 K004A
39 3504057110920000 AYU WENDA INNEKE PUTRI P 65 JL.BERINGIN 53 04/09 082141692542 ASTRAZENECA 21/09/2021 K004A
40 3579030106820001 TONY SYAHRUL L 65 JL.KEPUH IV-30 02/05 089395152392 ASTRAZENECA 21/09/2021 K004A
41 3579036409870004 HERLINA SUTRISNOWATI P 65 JL.JANTI UTARA V/11 03/09 081334242006 ASTRAZENECA 21/09/2021 K004A
42 3573046810550002 SUMARMI P 65 JL.KEPUH I A/33 08/04 08815593826 ASTRAZENECA 21/09/2021 K004A
43 3524081703540001 ABDUL WAHID L 65 JL.SIMPANG KEPUH UTARA BLOK A/17 06/10 081235830281 ASTRAZENECA 21/09/2021 K004A
44 3573040702560005 SUGENG SUPRIYANTO L 64 JL.CEMARA No..66 01/01 085731335850 ASTRAZENECA 21/09/2021 K004A
45 3573044509550002 MASLIKHA P 64 JL.CEMARA No..66 01/01 081249791958 ASTRAZENECA 21/09/2021 K004A
46 3573044409580001 LILIK PURWANTINI P 64 JL.KLAYATAN II/19 02/01 085730480813 ASTRAZENECA 21/09/2021 K004A
47 3515185804700007 RA.ENDANG RETNOWATI P 64 JL.KEPUH IX-3 06/05 081249389070 ASTRAZENECA 21/09/2021 K004A
48 3573044303530003 MULYANI P 64 JL.KLAYATAN II-2 10/12 087781042770 ASTRAZENECA 21/09/2021 K004A
49 3573044406770001 RATIH HANDAYANI P 64 PERUM SUKUN PONDOK INDAH L/08 08/07 081242541240 ASTRAZENECA 21/09/2021 K004A
50 3573045407530004 NIAYAH P 64 JL.JANTI VI 04/09 085230747443 ASTRAZENECA 21/09/2021 K004A
51 3573042008410002 JASIN L 64 JL.RAYA KEPUH UTARA 39B 04/04 085336355318 ASTRAZENECA 21/09/2021 K004A
52 3573040705510002 MASDUKI L 64 JL.KEPUH I/55 10/04 - ASTRAZENECA 21/09/2021 K004A
53 33573043005650005 HADI PURWANTO L 64 JL.KLAYATAN III/22 02/02 81334692909 ASTRAZENECA 21/09/2021 K004A
54 3573044309760003 TITIK LUCKYANDARI P 63 JL.JANTI UTARA VIB-35 08/09 082245552249 ASTRAZENECA 21/09/2021 K004A
55 3573042007620006 MAMAN SURYAMAN L 63 JL.JANTI SELATAN 8/35 05/06 08998720420 ASTRAZENECA 21/09/2021 K004A
56 3573046006610005 SITI CHOTIJAH P 63 JL.KEBEN II BLOK C/32 08/11 081334316979 ASTRAZENECA 21/09/2021 K004A
57 3507241107760001 FIRMAN ARIFUDDIN L 63 JL.SIMPANG KEPUH UTARA BLOK A/17 06/10 081235830281 ASTRAZENECA 21/09/2021 K004A
58 3507182911740001 INDRA CAHYONO L 62 JL.KEMANTREN I GG PATTIMURA No.90 10/03 0852368177779 ASTRAZENECA 21/09/2021 K004A
59 357304650770003 SITI CHOTIMAH P 62 JL.KLAYATAN II-17 03/01 081252271159 ASTRAZENECA 21/09/2021 K004A
60 3573046310570001 ENDANG MUJIATI P 62 JL.KLAYATAN II/1 10/12 082140042448 ASTRAZENECA 21/09/2021 K004A
61 3573045604840007 SUCIATI P 62 JL.KLAYATAN III/22 02/02 081232375549 ASTRAZENECA 21/09/2021 K004A
62 3573040311890012 YUSUF ANDHIKA L 62 JL.KLAYATAN 1/29 03/12 085649962831 ASTRAZENECA 21/09/2021 K004A
63 35071809097900004 SOFYAN L 61 JL.KLAYATAN II-26 15/12 085856513983 ASTRAZENECA 21/09/2021 K004A
64 3573045207690003 RIYANAH P 61 JL.KLAYATAN III GG MELATI 10C 01/02 085748346377 ASTRAZENECA 21/09/2021 K004A
65 3573042110570002 SULISTYO HARDI L 61 JL.BERINGIN 53 04/09 082141692542 ASTRAZENECA 21/09/2021 K004A
66 3573045206720001 TITIK SUMIATI P 61 JL.JANTI BARAT BLOK C/18 03/11 - ASTRAZENECA 21/09/2021 K004A
67 3573041710750004 SUWANDI L 61 JL.JANTI SEL VII/58 02/06 081252690233 ASTRAZENECA 21/09/2021 K004A
68 3573041404690001 RIAMAN L 61 JL.KLAYATAN II/32 01/01 081234640918 ASTRAZENECA 21/09/2021 K004A
69 3573042805570001 SALUKI L 61 JL.KLAYATAN III/5A ASTRAZENECA 21/09/2021 K004A
70 3324095411840001 MUSAROFAH P 60 JL.KEPUH VII/31 05/05 081944989872 ASTRAZENECA 21/09/2021 K004A
71 3573044809630003 ENDANG PURNAMAWATI P 60 JL.KLAYATAN I-42A 02/12 087754601196 ASTRAZENECA 21/09/2021 K004A
72 3573045209420002 WARSIH P 60 JL.KLAYATAN I//12 01/04 081337529420 ASTRAZENECA 21/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
73 3573044510640004 SRI ENDAH RATNASARI P 60 JL.JANTI VI 04/09 085655656868 ASTRAZENECA 21/09/2021 K004A
74 3573042602980003 BAGAS ADI PRAKOSO L 60 SUKUN PONDOK INDAH BLOK C-6A 01/07 081216693597 ASTRAZENECA 21/09/2021 K004A
176 35730416608600007 SUNAARKO L 61 JL.KLAYATAN III-5A 082142936692 ASTRAZENECA 21/09/2021 K004A
197 3573044205590007 ENDANG TRI WULANSIH P 62 JL.KEPUH I/7 10/04 082141809960 ASTRAZENECA 21/09/2021 K004A
206 3573041808610008 DUMAIN L 60 JL. KEPUH UTARA 4/4 085103443996 ASTRAZENECA 21/09/2021 K004A
207 12.52.04.040561.0001 SARWIATO L 60 JL. JANTI BARAT 15/6 ASTRAZENECA 21/09/2021 K004A
1 3573042707650004 SAROZI L 83 JL.BRIGJEN SLAMET RIADI 01/01 085232148949 ASTRAZENECA 21/09/2021 K004A
2 3271021001960003 ALIP SULISTIO L 81 - 082330598425 ASTRAZENECA 21/09/2021 K004A
29 3507186209800002 CHOIRUL JUBAIDAH P 67 JL.SONOKEMBANG No..5 08179625940 ASTRAZENECA 21/09/2021 K004A
75 3573045612470001 KARTILAH P 60 JL.S.SUPRIADI GG.MASJID ABDULLAH 21 01/06 081517474590 ASTRAZENECA 21/09/2021 K004A
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
1 3573041206590006 MUZAMIL ISLAM ANURI L 62 IR RAIS XIV 11/4 087855532631 ASTRAZENECA 22/09/2021 K004A
2 3573044307600007 ISMININGSIH P 61 IR RAIS III 6/2 085794776673 ASTRAZENECA 22/09/2021 K004A
3 3573045603610007 MUSRINATUN P 60 IR RAIS IX 12/4 085804504412 ASTRAZENECA 22/09/2021 K004A
4 3573042109780010 HARIYONO L 43 SUKUN SIDOMULYO 4/7 088804922450 ASTRAZENECA 22/09/2021 K004A
5 3573044101670016 LILIS ANDRIYANI P 44 KASIN JAYA III/30 0882009491457 ASTRAZENECA 22/09/2021 K004A
6 3573045502540005 RUSMIATI P 67 TANJUNG PUTRA YUDHA 13/11 081216940380 ASTRAZENECA 22/09/2021 K004A
7 3573041501730005 SUPANDI L 48 KASIN JAYA III 8/1 085103425573 ASTRAZENECA 22/09/2021 K004A
8 3573044107440097 SUWARNI P 76 SUKUN SIDOMULYO 6/7 ASTRAZENECA 22/09/2021 K004A
9 3573041610810004 EDY PURWANTO L 39 PUTER DALAM UTARA 12/12 0895621112714 ASTRAZENECA 22/09/2021 K004A
10 3573041708570005 SUTRISNO L 63 MERGAN KERAMAT 3/11 087885386674 ASTRAZENECA 22/09/2021 K004A
11 3573041005550008 MOCH. KERTOSIN L 63 MERGAN SEKOLAHAN 6/6 081216678039 ASTRAZENECA 22/09/2021 K004A
12 3573045709600002 SUTIANI P 61 IR. RAIS IX 1/4 089526625050 ASTRAZENECA 22/09/2021 K004A
13 3573044708610006 SUGIATI P 60 TANJUNG PUTRA YUDHA 16/11 ASTRAZENECA 22/09/2021 K004A
14 3573040612580008 BASAR PAIMAN L 63 SIKATAN 5/8 082141310406 ASTRAZENECA 22/09/2021 K004A
15 3573040701590003 SARUAN L 62 TERUSAN MERGAN RAYA 10/11 082123107578 ASTRAZENECA 22/09/2021 K004A
16 3573045105020004 ROSALIA NINGSIH P 19 TANJUNG 3/13 0895630918668 ASTRAZENECA 22/09/2021 K004A
17 357304220660002 TONY ISWANTO L 35 IR. RAIS V 8/2 089655077615 ASTRAZENECA 22/09/2021 K004A
18 3573045508680009 KUSNUL KOTIMAH P 43 IR. RAIS V 8/2 089655077615 ASTRAZENECA 22/09/2021 K004A
19 3573042412800008 EKO APRIYANTO L 40 MERGAN RAYA VI 9/6 085850102780 ASTRAZENECA 22/09/2021 K004A
20 3573040912720005 JUPRI L 49 MERGAN KELURAHAN 5/11 082140532711 ASTRAZENECA 22/09/2021 K004A
21 3573045409830008 KRISTIARI P 38 PUTER DALAM UTARA 12/12 088992819515 ASTRAZENECA 22/09/2021 K004A
22 3573041307660003 BUANI L 55 RANGKOK SELATAN 3/12 085736838538 ASTRAZENECA 22/09/2021 K004A
23 3573044101800030 WARSIANI P 41 MERGAN RAYA VI 9/6 089644159265 ASTRAZENECA 22/09/2021 K004A
24 3573045808670005 PENI HANDAYATI L 54 IR. RAIS IX 5/4 081944825836 ASTRAZENECA 22/09/2021 K004A
25 3573045703810011 NUR WASITA P 40 GEMPOL 4/9 ASTRAZENECA 22/09/2021 K004A

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
26 3573045004740011 PUJI LESTARI P 47 TANJUNG PUTRA YUDHA 9/11 081615645001 ASTRAZENECA 22/09/2021 K004A
27 3573046908780008 ALTI LINANTI P 43 MERGAN KERAMAT 9/6 085755851575 ASTRAZENECA 22/09/2021 K004A
28 3573040307620004 ABDUL MAJID L 55 GEMPOL 2/10 0895613451847 ASTRAZENECA 22/09/2021 K004A
29 3573046610780002 LILIS SUMARNI P 42 TANJUNG PUTRA YUDHA 13/11 ASTRAZENECA 22/09/2021 K004A
30 3509191505730009 BUDI HARIYANTO L 48 PUTER TENGAH 8/12 081249739776 ASTRAZENECA 22/09/2021 K004A
31 3573040811790003 GUNARTO L 42 PUTER DALAM UTARA 12/12 08170515867 ASTRAZENECA 22/09/2021 K004A
32 3573044101560053 DAINAH P 64 IR. RAIS 1/2 081235918741 ASTRAZENECA 22/09/2021 K004A
33 3573044808490006 ANNY SUYANI P 75 MERGAN KELURAHAN 5/11 085711726184 ASTRAZENECA 22/09/2021 K004A
34 3573045206750010 YUNANIK P 46 MERGAN KELURAHAN 12/11 08533525399 ASTRAZENECA 22/09/2021 K004A

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
35 3573046104680007 RINA KUNTARWATI P 53 MERGAN LORI II 5/6 089677018268 ASTRAZENECA 22/09/2021 K004A
36 3573041210810002 DEDDY SETIAWAN L 40 MERGAN KRAMAT 9/6 089621204707 ASTRAZENECA 22/09/2021 K004A
37 3573044805880009 SOEKARSIH P 73 TERUSAN MERGAN RAYA 085859323639 ASTRAZENECA 22/09/2021 K004A
38 3573045212650008 ENDANG SRI UTAMI P 56 TANJUNG PUTRA YUDHA 9/11 0881026401006 ASTRAZENECA 22/09/2021 K004A
39 3573045007890004 NITA YULIA RACHMAWATI P 37 TANJUNG PUTRA YUDHA 9/11 081233416667 ASTRAZENECA 22/09/2021 K004A
40 3573042307020004 RICO HARI TRILAKSONO L 38 TERUSAN MERGAN RAYA 10/11 085856580421 ASTRAZENECA 22/09/2021 K004A
41 3573042801830007 DIDIK SUKARNO L 38 IR. RAIS 8/2 085856580421 ASTRAZENECA 22/09/2021 K004A
42 3573044810610001 SUMARMI P 60 KASIN JAYA 8/1 ASTRAZENECA 22/09/2021 K004A
43 3573046910000005 DIAN VITA LESTARI P 22 SUKUN SIDOMULYO 2/7 081574842165 ASTRAZENECA 22/09/2021 K004A
44 3573042710600001 HERI HADI SISWANTO L 60 IR. RAIS 9/4 0896870444928 ASTRAZENECA 22/09/2021 K004A
45 3573041904760006 KOMARUDDIN L 44 TANJUNG PUTRA YUDHA 7/11 ASTRAZENECA 22/09/2021 K004A
46 3573040506580004 KARIYADI L 63 TERUSAN TPY 3/13 083806883779 ASTRAZENECA 22/09/2021 K004A
47 3573046903710003 SARTI P 50 TERUSAN TPY 3/13 083111792656 ASTRAZENECA 22/09/2021 K004A
48 3573040701030003 IKRAR PUDJA PERSADA L 18 SUKUN SIDOMULYO 1/7 ASTRAZENECA 22/09/2021 K004A
49 3573045005870009 HARTIKA NINGSIH P 34 TANJUNG PUTRA YUDHA 14/11 089982871847 ASTRAZENECA 22/09/2021 K004A
50 3603312109620001 ROBERLY F. MANDEY L 59 TAMAN ADIYASA 082114251346 ASTRAZENECA 22/09/2021 K004A
51 3573041402770014 MUHAMAD SUSILO L 44 TANJUNG PUTRA YUDHA 14/11 0895620085628 ASTRAZENECA 22/09/2021 K004A
52 3573045405530002 SUKARTI P 67 IR. RAIS 1/5 ASTRAZENECA 22/09/2021 K004A
53 3573045706640002 MARSI'IN IIN KUSWIARTI P 56 TANJUNG PUTRA YUDHA 13/11 085103658361 ASTRAZENECA 22/09/2021 K004A
54 3573041308000002 RAHIM P 21 TANJUNGREJO 2/7 088231308245 ASTRAZENECA 22/09/2021 K004A
55 3506126503850010 INDRIANI P 36 IR. RAIS IX/329 082226558987 ASTRAZENECA 22/09/2021 K004A
56 3573041206680009 MUHADI L 53 TANJUNG PUTRA YUDHA VI 9/11 085257745856 ASTRAZENECA 22/09/2021 K004A
57 3573044612590003 SUKATMI P 62 IR. RAIS III 6/2 ASTRAZENECA 22/09/2021 K004A
58 3573042502460001 SOEPARNO L 75 MERGAN KELURAHAN 5/11 081945315939 ASTRAZENECA 22/09/2021 K004A
59 3573040903570006 DAMAN L 64 TERUSAN MERGAN RAYA 10/11 ASTRAZENECA 22/09/2021 K004A
60 3573046211840004 NOFI JUWITASARI P 37 JL.BINGKIL CIPTOMULYO 087853848477 ASTRAZENECA 22/09/2021 K004A
61 3573041001930004 SULISTYONO ABDILLAH L 28 SUKUN SIDOMULYO 5/7 083834314869 ASTRAZENECA 22/09/2021 K004A
62 3573047008950006 RITA DYA AYUNINGTYAS P 26 TATA SURYA INDAH DINOYO 083857153182 ASTRAZENECA 22/09/2021 K004A
63 3573042811610003 UNTUNG WITONO L 60 MERGAN KELURAHAN 12/11 081230321871 ASTRAZENECA 22/09/2021 K004A
64 3573040102420007 SUPARDI L 78 IR. RAIS 1/2 081239680396 ASTRAZENECA 22/09/2021 K004A
65 3573045304530001 ISTRIASIH P 67 IR. RAIS 1/2 081252621340 ASTRAZENECA 22/09/2021 K004A
66 3573040205580002 PAITO L 63 KASIN JAYA IV 12/1 085875387631 ASTRAZENECA 22/09/2021 K004A
67 3573040506680005 ABDUL KADIR L 52 IR. RAIS 5/3 081937980407 ASTRAZENECA 22/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
68 3573046505820015 SUNARIYANTI P 39 IR. RAIS 14/4 08973263948 ASTRAZENECA 22/09/2021 K004A
69 3573045210580005 DJUWARIYAH L 63 GEMPOL MARGA BHAKTI 5/10 081259622255 ASTRAZENECA 22/09/2021 K004A
70 3573045410990007 MARIA ANGELICA INDAH P 22 GEMPOL MARGA BHAKTI 5/10 089660669944 ASTRAZENECA 22/09/2021 K004A
71 3573042611730003 EDY PURNOMO L 48 KASIN JAYA III 5/1 089507142600 ASTRAZENECA 22/09/2021 K004A
72 3573044504550009 SITI FATIMAH P 65 KASIN JAYA III 6/1 081973249499 ASTRAZENECA 22/09/2021 K004A
73 3528100712950001 SAMSUL ARIFIN L 25 MERGAN LORI 7/6 081917617529 ASTRAZENECA 22/09/2021 K004A
74 3573042410620003 ACH. PARIONO L 60 KASIN JAYA I 1/1 ASTRAZENECA 22/09/2021 K004A
75 3573045405600001 RIATIN P 61 IR. RAIS IX 6/4 ASTRAZENECA 22/09/2021 K004A
76 3573044105620010 YATINI P 59 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A
77 3573046101620005 RIANTININGSIH P 59 SUKUN GEMPOL 17/9 ASTRAZENECA 22/09/2021 K004A
78 3573041311860001 ADITYA IMAWAN L 35 MERGAN VETERAN 1/11 081336805890 ASTRAZENECA 22/09/2021 K004A
79 3573040103610004 MUJIONO L 60 SUKUN SIDOMULYO 4/7 ASTRAZENECA 22/09/2021 K004A
80 3573041212610005 SUHADI L 60 PUTER DALAM UTARA 12/12 ASTRAZENECA 22/09/2021 K004A
81 3573044107450143 SUDILAH P 75 MERGAN MUSHOLLA 10/6 ASTRAZENECA 22/09/2021 K004A
82 3573043006650006 HERI SUPA'AT L 56 IR. RAIS 14/4 085604565133 ASTRAZENECA 22/09/2021 K004A
83 3573045208620005 SAMANI P 59 MERGAN LORI IIC 5/6 ASTRAZENECA 22/09/2021 K004A
84 3573040902020003 GIBRAN ISMAIL MSCHMUD L 19 MERGAN KERAMAT 3/11 082132362996 ASTRAZENECA 22/09/2021 K004A
85 3573047010650008 WINANINGSIH P 56 KAKAK TUA UTARA 2/12 0823342477228 ASTRAZENECA 22/09/2021 K004A
86 3573044101460020 SOERTINI P 75 KASIN JAYA 12/1 ASTRAZENECA 22/09/2021 K004A
87 3573045306810018 YUNI KRISTIANA P 39 PUTER DALAM UTARA 12/12 083832237801 ASTRAZENECA 22/09/2021 K004A
88 3573045409950001 SURTINI P 26 SUKUN GEMPOL 10/9 083848950050 ASTRAZENECA 22/09/2021 K004A
89 5108065710540002 LUCIA ETTY R P 67 PUTER SELATAN 9/12 082139693900 ASTRAZENECA 22/09/2021 K004A
90 3573042007410001 SUWARNO L 70 IR. RAIS IX 3/3 ASTRAZENECA 22/09/2021 K004A
91 3573040907740001 SUWITO L 47 PUTER DALAM TENGAH 11/12 0895384669870 ASTRAZENECA 22/09/2021 K004A
92 3573042808580006 ABD. ROCHIM L 63 IR. RAIS III 6/2 085736405800 ASTRAZENECA 22/09/2021 K004A
93 3573041705540005 PRASETYO HADI L 62 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A
94 3573040212640003 BUDIONO L 57 MERGAN SEKOLAHAN 6/6 082142196886 ASTRAZENECA 22/09/2021 K004A
95 3573046001570002 NURCAHYANINGSARI P 64 IR. RAIS XIV 11/4 082257106146 ASTRAZENECA 22/09/2021 K004A
96 3573040405610005 EKO SUPRIYONO L 60 TERUSAN MERGAN RAYA 10/11 ASTRAZENECA 22/09/2021 K004A
97 3573040603610007 BUANG SANTOSO L 69 SUKUN GEMPOL 10/9 083160395411 ASTRAZENECA 22/09/2021 K004A
98 3573052212820001 ANDRI CAHYONO L 39 TANJUNG 085649422751 ASTRAZENECA 22/09/2021 K004A
99 3573041111590004 KUSBAL 62 MERGAN KERAMAT 3/11 085648497757 ASTRAZENECA 22/09/2021 K004A
100 3573041806570003 MESELIM L 64 PUTER DALAM UTARA 12/12 088805746695 ASTRAZENECA 22/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
101 3573047112550039 SULASTRI P 66 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A
102 3573025307760003 RITA KRISUSANTI P 45 PROF YAMIN SUKOHARJO 085234266403 ASTRAZENECA 22/09/2021 K004A
103 3573044107620093 SUTIRAH P 59 SUKUN SIDOMULYO 6/7 082231529416 ASTRAZENECA 22/09/2021 K004A
104 3573045001890003 ITA PURWATISARI P 32 IR. RAIS IX 3/3 085745707783 ASTRAZENECA 22/09/2021 K004A
105 3573042104510004 BUADI L 69 TERUSAN MERGAN RAYA 10/11 081549449427 ASTRAZENECA 22/09/2021 K004A
106 3573046901850002 DEVI SULIASIH P 36 SUKUN SIDOMULYO 7/7 082228330159 ASTRAZENECA 22/09/2021 K004A
107 3573046512530003 SRI WIDJI KUSWANING H P 68 IR. RAIS 14/4 0895379161030 ASTRAZENECA 22/09/2021 K004A
108 3573044101610031 MARIATI P 60 SUKUN SIDOMULYO 6/7 085749400616 ASTRAZENECA 22/09/2021 K004A
109 3573041605720006 BAMBANG EDY HARIYANTO L 49 GEMPOL MARGA BHAKTI 7/10 081335709389 ASTRAZENECA 22/09/2021 K004A
110 3573041605750004 BUDIONO L 46 SUKUN SIDOMULYO 5/7 0895705866493 ASTRAZENECA 22/09/2021 K004A
111 3573042505430001 ANWAR L 78 MERGAN LORI II 5/6 ASTRAZENECA 22/09/2021 K004A
112 3573040112620001 SURI L 59 TERUSAN TPY 2/13 085604014426 ASTRAZENECA 22/09/2021 K004A
113 3573040608460001 WADI L 75 MERGAN LORI II 5/6 ASTRAZENECA 22/09/2021 K004A
114 3573044506540004 SUPARMI P 66 MERGAN LORI IIC 5/6 082140065816 ASTRAZENECA 22/09/2021 K004A
115 3573041808710001 AGUS HARIYANTO L 50 SUKUN SIDOMULYO 6/7 087879488032 ASTRAZENECA 22/09/2021 K004A
116 3573043112610024 RUMANDI L 60 KASIN JAYA 12/1 081234168191 ASTRAZENECA 22/09/2021 K004A
117 3573045312590001 YULIANI P 62 TANJUNG PUTRA YUDHA 16/11 08983481958 ASTRAZENECA 22/09/2021 K004A
118 3573040606020003 MOHAMMAD VIRGIAWAN S L 19 PUTER TENGAH 8/12 087851096836 ASTRAZENECA 22/09/2021 K004A
119 3508174804720004 PONIMA P 49 KASIN JAYA III 6/1 083113161635 ASTRAZENECA 22/09/2021 K004A
120 3573045206600006 SUWARTI P 61 KUNTUL 6/12 ASTRAZENECA 22/09/2021 K004A
121 3573044406700005 PONITI P 51 PUTER DALAM UTARA 12/12 081336811216 ASTRAZENECA 22/09/2021 K004A
122 3573040212530002 SUPARNO L 68 PUTER DALAM UTARA 12/12 ASTRAZENECA 22/09/2021 K004A
123 3573036605890003 LISTIYANINGRUM P 32 RANGKOK SELATAN 4/12 087853119813 ASTRAZENECA 22/09/2021 K004A
124 3573045212590010 SUNAYAH P 62 PUTER DALAM TENGAH 11/12 085854421912 ASTRAZENECA 22/09/2021 K004A
125 3573042311790003 RIZKY NOVIANTO L 42 MERGAN VETERAN 1/11 082136158242 ASTRAZENECA 22/09/2021 K004A
126 3573042508640004 BUDI ISMONO L 58 MERGAN LORI IIC 5/6 083853172280 ASTRAZENECA 22/09/2021 K004A
127 3573040411490002 SUGENG RIADI L 72 MERGAN KERAMAT 3/11 0895379107077 ASTRAZENECA 22/09/2021 K004A
128 3573046302570002 WIDYA MURTINI P 63 RANGKOK UTARA 5/12 089601669249 ASTRAZENECA 22/09/2021 K004A
129 3573041607540001 PONIRAN L 66 SUKUN SIDOMULYO 11/7 ASTRAZENECA 22/09/2021 K004A
130 3573042205550005 DRAI L 65 SUKUN SIDOMULYO 2/7 085904309295 ASTRAZENECA 22/09/2021 K004A
131 3573044905610002 SUHARTATIK P 59 IR. RAIS 1/2 085931564344 ASTRAZENECA 22/09/2021 K004A
132 3573045804580001 TUTIKANI P 63 KASIN JAYA 13/1 0881026832399 ASTRAZENECA 22/09/2021 K004A
133 3573041607610003 PAIDI AL MASHUDI L 60 KASIN JAYA I 1/1 ASTRAZENECA 22/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
134 3573045808520003 SEMI SUMIARSIH P 68 KASIN JAYA III 8/1 085784932194 ASTRAZENECA 22/09/2021 K004A
135 3573044705580005 MARYAM P 63 PUTER DALAM UTARA 12/12 ASTRAZENECA 22/09/2021 K004A
136 3573045001420001 MISRIKAH P 79 IR. RAIS IX 2/3 085646662880 ASTRAZENECA 22/09/2021 K004A
137 3573044706430002 SUMARTIYAH P78 IR. RAIS IX 3/3 08563526286 ASTRAZENECA 22/09/2021 K004A
138 3573046308620003 WANTINI P 59 SUKUN SIDOMULYO 8/7 088226071992 ASTRAZENECA 22/09/2021 K004A
139 3573040303530005 MISNAN L 67 MERGAN LORI II 5/6 0895604500802 ASTRAZENECA 22/09/2021 K004A
140 3573046001620004 CHOTIMAH P 59 MERGAN LORI II 5/6 ASTRAZENECA 22/09/2021 K004A
141 3573046005650013 INTANI MEI PUJI P 56 KASIN JAYA III 5/1 ASTRAZENECA 22/09/2021 K004A
142 3573043008670002 BUANG AGUNG BUDIONO L 54 KASIN JAYA IV 11/1 085100310816 ASTRAZENECA 22/09/2021 K004A
143 3573044803770006 SITI ROBIAH P 44 GEMPOL 4/9 085232509338 ASTRAZENECA 22/09/2021 K004A
144 3573054307820004 KASTIN WARTINI P 39 SUKUN GEMPOL 9/9 083832503371 ASTRAZENECA 22/09/2021 K004A
145 3573044907410001 SURIJATMI P 79 TERUSAN MERGAN RAYA 10/11 ASTRAZENECA 22/09/2021 K004A
146 3573046809460001 MUDAWATI P 75 TERUSAN MERGAN RAYA 8/11 085286878067 ASTRAZENECA 22/09/2021 K004A
147 3573044209590003 NUNUK HARWATI P 62 TERUSAN MERGAN RAYA 8/11 ASTRAZENECA 22/09/2021 K004A
148 3573042411970001 ANDI BAGUS WICAKSONO L 24 GEMPOL 4/9 087860618518 ASTRAZENECA 22/09/2021 K004A
149 3508102004620002 RASIYANTO L 59 TANJUNG PUTRA YUDHA 7/11 081249885180 ASTRAZENECA 22/09/2021 K004A
150 3573040504570003 SUPADI L 64 MERGAN LORI II 5/6 081252111200 ASTRAZENECA 22/09/2021 K004A
151 3573045907570001 SURIYANI P 64 MERGAN LORI II 5/6 081252111200 ASTRAZENECA 22/09/2021 K004A
152 3573045810590004 KATIYAH NURI P 62 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A
153 3507202111900002 MOCH MUHLIS L 31 NGASEM 089602656494 ASTRAZENECA 22/09/2021 K004A
154 3573041708620014 AGUS PURI SIYONO P 60 SUKUN SIDOMULYO 6/7 085706884552 ASTRAZENECA 22/09/2021 K004A
155 3573045212620011 SUTIAMI SAIDAH P 59 SUKUN SIDOMULYO 5/7 088805600955 ASTRAZENECA 22/09/2021 K004A
156 3573044503600004 MARIATI P 61 IR. RAIS IX 3/3 ASTRAZENECA 22/09/2021 K004A
157 3573041906610001 EDI SUROSO L 60 SUKUN SIDOMULYO 2/7 085951808141 ASTRAZENECA 22/09/2021 K004A
158 3573045007620002 SUNARSEH P 59 MERGAN RAYA V 8/6 085236339456 ASTRAZENECA 22/09/2021 K004A
159 3573042812570001 LUCIANUS SUKRI L 64 TANJUNG PUTRA YUDHA 7/11 ASTRAZENECA 22/09/2021 K004A
160 3573044105650006 IRAWATI P 56 IR. RAIS IX 3/3 081909055829 ASTRAZENECA 22/09/2021 K004A
161 3573046708620002 AMINAH P 59 IR. RAIS IX 3/3 ASTRAZENECA 22/09/2021 K004A
162 3573047112610029 SATUPAH P 60 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A
163 3573043112510026 PONIRAN L 69 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A
164 3573043112650012 MOCHAMAD ANWAR L 25 SUKUN SIDOMULYO 1/7 ASTRAZENECA 22/09/2021 K004A
165 3578125309860001 HANIK YUNAIDAH P 35 IR. RAIS 14/4 085548004086 ASTRAZENECA 22/09/2021 K004A
166 3573040802630002 HERU PRIYANTO L 58 MERGAN KERAMAT 9/6 087772866403 ASTRAZENECA 22/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
167 3573045111490002 MISRIAH P 72 TERUSAN MERGAN RAYA 4/11 081334800083 ASTRAZENECA 22/09/2021 K004A
168 3573056603020004 DEANDRA ORIZA SATIVA P 19 CANDI BADUT 083111841244 ASTRAZENECA 22/09/2021 K004A
169 3573044811610002 TRIASIH P 59 MERGAN LORI 8/6 089602626960 ASTRAZENECA 22/09/2021 K004A
170 3573041506470005 FATCHUR RACHMAN L 74 IR. RAIS IX 3/2 08999575100 ASTRAZENECA 22/09/2021 K004A
171 3573045004920003 NUR FITRIANI P 29 GEMPOL MARGA BHAKTI 5/10 083896263301 ASTRAZENECA 22/09/2021 K004A
172 3573041602890002 WOKO BAMBANG W L 32 GEMPOL MARGA BHAKTI 5/10 083830719047 ASTRAZENECA 22/09/2021 K004A
173 3573042612590001 SUYANTO L 62 SUKUN SIDOMULYO 2/7 085692039827 ASTRAZENECA 22/09/2021 K004A
174 3573041304550001 SUROSO L 66 GEMPOL 2/10 085336093958 ASTRAZENECA 22/09/2021 K004A
175 3573046806480001 NENENG SUHETI L 73 SIKATAN 5/8 081805105703 ASTRAZENECA 22/09/2021 K004A
176 3573022809550003 JAYADI L 65 KASIN JAYA III 6/1 ASTRAZENECA 22/09/2021 K004A
177 3573042508610002 SUMARSONO L 60 SUKUN GEMPOL 17/9 0895414645484 ASTRAZENECA 22/09/2021 K004A
178 3573047010740008 MISIYAH P 47 TANJUNG PUTRA YUDHA 16/11 083853426405 ASTRAZENECA 22/09/2021 K004A
179 5108066701830006 FRISCA SETYOWIDODO P 38 PUTER SELATAN 9/12 0817387446 ASTRAZENECA 22/09/2021 K004A
180 3573040108530010 SUTRISNO L 68 MERGAN LORI II 5/6 ASTRAZENECA 22/09/2021 K004A
181 3573044908620001 JUWARIYAH P 59 MERGAN KERAMAT 3/11 087757115871 ASTRAZENECA 22/09/2021 K004A
182 3573044606520004 MUSRINGAH P 69 TERUSAN MERGAN RAYA 10/11 ASTRAZENECA 22/09/2021 K004A
183 3573045508700008 JUASRI P 51 TANJUNG PUTRA YUDHA 16/11 08993770962 ASTRAZENECA 22/09/2021 K004A
184 3573044604580004 SATUMI P 63 TANJUNG PUTRA YUDHA 16/11 089516095614 ASTRAZENECA 22/09/2021 K004A
185 3573040101580029 SARNI SUYANTO P 63 TERUSAN MERGAN RAYA 10/11 081252616045 ASTRAZENECA 22/09/2021 K004A
186 3573040807480001 SUKARI L 73 KASIN JAYA 12/1 08134695159 ASTRAZENECA 22/09/2021 K004A
187 3573041210570003 SUGITO L 64 TANJUNG PUTRA YUDHA 13/11 ASTRAZENECA 22/09/2021 K004A
188 3573041902710006 JUPRIHANTO UTOMO L 49 IR RAIS XIV 11/4 082336932123 ASTRAZENECA 22/09/2021 K004A
189 3573042405550004 SAIFUL ARIFIN L 66 KASIN JAYA III 5/1 089509491724 ASTRAZENECA 22/09/2021 K004A
190 3573040104610005 BAMBANG SUHARDI L 59 TANJUNG PUTRA YUDHA 13/11 081336551245 ASTRAZENECA 22/09/2021 K004A
191 3522062406690002 ISMUJOKO L 52 KAKAK TUA UTARA 2/12 08525808556 ASTRAZENECA 22/09/2021 K004A
192 3573041212570009 SUGITO L 64 KASIN JAYA III 6/1 081233886183 ASTRAZENECA 22/09/2021 K004A
193 3573046206620001 SRI YUNARWATI P 59 KASIN JAYA III 6/1 081357694496 ASTRAZENECA 22/09/2021 K004A
194 3573042402800002 GIARTO WINDU L 41 KAKAK TUA UTARA 2/12 085733467785 ASTRAZENECA 22/09/2021 K004A
195 3573045802470001 ENNY YULIATI P 74 IR RAIS III 6/2 085855992613 ASTRAZENECA 22/09/2021 K004A
196 3573042311630001 NANANG ISMAJI L 58 MERGAN RAYA I 8/6 089602660944 ASTRAZENECA 22/09/2021 K004A
197 3573045507550009 LILIK UNTARI P 65 IR RAIS III 5/2 081228449171 ASTRAZENECA 22/09/2021 K004A
198 3573045405680006 DEWI LESTARI P 53 MERGAN KELURAHAN 12/11 082139698753 ASTRAZENECA 22/09/2021 K004A
199 3573041404960005 SUNARI L 25 SUKUN GEMPOL 9/9 083848642758 ASTRAZENECA 22/09/2021 K004A
200 3573040903950001 MOHAMMAD AFFI L 26 SUKUN GEMPOL 7/9 088217098864 ASTRAZENECA 22/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
201 3573032207600001 MAHFUD L 60 TERUSAN TPY 2/13 081555891308 ASTRAZENECA 22/09/2021 K004A
202 3573045811720005 SRI PUJI DYAH LESTARI P 49 SUKUN GEMPOL 2/9 087761699530 ASTRAZENECA 22/09/2021 K004A
203 3507215808930001 IRMA NURDIANSAH P 28 SUKUN GEMPOL 14/9 089520830040 ASTRAZENECA 22/09/2021 K004A
204 3510083110020001 MUHAMMAD SHOLEHUDIN M L 21 IR. RAIS 6/4 089649088920 ASTRAZENECA 22/09/2021 K004A
205 3573041811590001 RUWONO SANTOSO L 62 TANJUNG PUTRA YUDHA 8/11 0895413966296 ASTRAZENECA 22/09/2021 K004A
206 3573041011680004 ROFI'I L 53 IR. RAIS 3/5 082232884114 ASTRAZENECA 22/09/2021 K004A
207 3573044502710001 SUNAH P 50 MERGAN BARU 2/6 ASTRAZENECA 22/09/2021 K004A
208 3573045009520002 GEMI P 68 MERGAN KELURAHAN 12/11 081230195647 ASTRAZENECA 22/09/2021 K004A
209 3513121507880004 M. ANDIKA L 33 DUSUN PESISIR 088805675180 ASTRAZENECA 22/09/2021 K004A
210 3573041611680004 ANSORI L 53 MERGAN KELURAHAN 12/11 085335233399 ASTRAZENECA 22/09/2021 K004A
211 3573046511580001 SUPRAPTI P 63 IR. RAIS 4/5 083833555494 ASTRAZENECA 22/09/2021 K004A
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
No NIK Nama Penerima Vaksin L/P Alamat No. Hp Merek Vaksin
Tanggal Pemberian Tanggal Pemberian
No. Batch No. Batch
Vaksinasi Vaksinasi
1 3573044403830004 DIAS RINA NINGSIH P 38 JL. S. SUPRIADI/NGAGLIK GG 4A No. 149 081334410877 ASTRAZENECA 23/09/2021 K004A
2 3573046310730003 ASTUTIK P 48 JL. NGAGLIK IVA/168 082131910827 ASTRAZENECA 23/09/2021 K004A
3 3573044707580005 SATUKIT P 63 NGAGLIK IV B/224 081331510865 ASTRAZENECA 23/09/2021 K004A
4 3573042503550004 SUWADI L 66 JL. S. SUPRIADI VII/61 083175430847 ASTRAZENECA 23/09/2021 K004A
5 3573040303440004 PANI L 77 JL. S. SUPRIADI VII/33 08510000309 ASTRAZENECA 23/09/2021 K004A
6 3573044101570019 MUSRIPAH P 64 JL. NGAGLIK IV B/285 082133013552 ASTRAZENECA 23/09/2021 K004A
7 3573042605710006 ALFI SISWOYO L 50 JL. NGAGLIK IVB/210 081330911986 ASTRAZENECA 23/09/2021 K004A
8 3573043112510014 MUSTAKIM L 70 JL. S. SUPRIADI GG IV/53 082139504279 ASTRAZENECA 23/09/2021 K004A
9 3573042507840002 DEDY YULIANTO L 37 JL. S. SUPRIADI 5/37 082187158159 ASTRAZENECA 23/09/2021 K004A
10 3573040110760004 ADI SUHENDRA L 42 JL. NGAGLIK IV B/224 087721165261 ASTRAZENECA 23/09/2021 K004A
11 3514082807680003 ANTONIUS SUGENG WIDIANTO L 53 JL. PERTUKANGAN BARAT PURWOSARI 085645009775 ASTRAZENECA 23/09/2021 K004A
12 3573040404710005 MOCH SOLEH L 50 JL. S. SUPRIADI VII RT 6 RW 2 088805857869 ASTRAZENECA 23/09/2021 K004A
13 3573046401480001 SITI CHOSIAH P 73 JL. S. SUPRIADI 6/2337 085101164186 ASTRAZENECA 23/09/2021 K004A
14 3573041508450003 ASNANUK L 76 JL. S. SUPRIADI 6/2337 085101164186 ASTRAZENECA 23/09/2021 K004A
15 3573040106550003 SUNARTO L 66 JL. PARKIT SELATAN No.. 3 0895360595950 ASTRAZENECA 23/09/2021 K004A
16 3515084210720007 SRI MOELYANI P 49 JL. S. SUPRIADI IIB /23 085895702599 ASTRAZENECA 23/09/2021 K004A
17 3573046801610001 HARIYATI P 60 JL. S. SUPRIADI VII/36 081237911065 ASTRAZENECA 23/09/2021 K004A
18 3573044101660010 KATINI P 55 JL. S. SUPRIADI VII/45 088803235687 ASTRAZENECA 23/09/2021 K004A
19 3573044811760007 RINA CAHYANINGSIH P 45 JL. CAMAR No. 2 08123282540 ASTRAZENECA 23/09/2021 K004A
20 3573040703700003 ACHMAD JUMADIN L 50 JL. NGAGLIK II/308 087859471149 ASTRAZENECA 23/09/2021 K004A
21 3573041707700008 HUSAIN L 51 JL. CAMAR No. 2 08131171493 ASTRAZENECA 23/09/2021 K004A
22 3573041012600003 MOCHAMMAD SABAR L 60 JL. S. SUPRIADI IIA/40B ASTRAZENECA 23/09/2021 K004A
23 3573045704780007 SULASTRI P 43 JL. S. SUPRIADI RT 16 RW 6 087858840532 ASTRAZENECA 23/09/2021 K004A
24 3573041901670002 SUGENG RIADI L 44 JL. S. SUPRIYADI 2B/17 ASTRAZENECA 23/09/2021 K004A
25 3573042604680001 ARY HADIYANTO L 43 JL. NGAGLIK IVB/42 082332334286 ASTRAZENECA 23/09/2021 K004A
26 3573046404670002 SITI ELISTIA ERLIN P 50 JL. S. SUPRIADI IIA/42 081333289511 ASTRAZENECA 23/09/2021 K004A
27 3514144904700001 ANISA YUSNITA P 51 JL. SUPRIYADI RT 2 RW 6 081233520750 ASTRAZENECA 23/09/2021 K004A
28 3573041605600002 HARTOYO L 65 JL. S. SUPRIADI 2A/43A ASTRAZENECA 23/09/2021 K004A
29 3573047112480029 SULASTRI P 73 JL. JOHAN No.. 20 081235473876 ASTRAZENECA 23/09/2021 K004A
30 3573045212640005 SUPARTINI P 57 JL. KEPODANG 18 082132852054 ASTRAZENECA 23/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
No. Batch No. Batch
Vaksinasi Vaksinasi
31 3573045007650013 SUHARIATI P 66 JL. NGAGLIK IVB/37 087781042601 ASTRAZENECA 23/09/2021 K004A

32 3573040305860007 FERIK SUGIANTO L 35 JL. S. SUPRIADI IV NGAGLIK N 37 083853797435 ASTRAZENECA 23/09/2021 K004A
33 3514081708010001 GILANG MAHARDHIKA PRATAMA L 20 JL. PERTUKANGAN BARAT PURWOSARI 081554264757 ASTRAZENECA 23/09/2021 K004A
34 7371136901720005 LILIK SOEKRISTINI P 55 JL. ELANG No.. 7 081235789333 ASTRAZENECA 23/09/2021 K004A
35 3573044111570002 HARTUTIK P 64 JL. PARKIT SELATAN No.. 12 0895336923763 ASTRAZENECA 23/09/2021 K004A
36 3573044711620003 CICIK DYAH SEKAR WINARNI P 59 JL. PARKIT SELATAN No.. 3 089667543471 ASTRAZENECA 23/09/2021 K004A
37 3573046704670001 TRI KANTI HANDAYANI P 58 JL. S. SUPRIADI IIB/16 085785684741 ASTRAZENECA 23/09/2021 K004A
38 3573040912510005 NGADI L 69 JL. S. SUPRIADI IIB/27B 081334682630 ASTRAZENECA 23/09/2021 K004A
39 3507090104880003 YUDI EFENDI L 33 JL. PARKIT UTARA 30 083157960305 ASTRAZENECA 23/09/2021 K004A
40 3573040909540002 GUNAWAN L 66 JL. S. SUPRIADI 34 085796702373 ASTRAZENECA 23/09/2021 K004A
41 3573045803800006 ARIE RETNO SUSILAWATI P 41 JL. MERPATI UTARA No. 23 1/5 0895367025495 ASTRAZENECA 23/09/2021 K004A
42 3573042404710007 RAFIE L 50 JL. NGAGLIK IV B / 36 081918361090 ASTRAZENECA 23/09/2021 K004A
43 3573045208590006 SULASTRI P 74 JL. SUWARI UTARA No. 20 2/5 085790906511 ASTRAZENECA 23/09/2021 K004A
44 3573041410690005 AJI SUYOTO L 52 JL. SIMPANG SUKUN 22 085806367256 ASTRAZENECA 23/09/2021 K004A
45 3573042311570002 MANGGUNG YUWONO, DRS L 64 JL. MANYAR 85 16/8 082140646497 ASTRAZENECA 23/09/2021 K004A
46 3573044109030009 SITI NURFADILAH P 18 JL. S. SUPRIADI VII/15B 085765550213 ASTRAZENECA 23/09/2021 K004A
47 3573046708030003 CLARESTA QUEENA NURI P 18 JL. MENCO No..18 081945704579 ASTRAZENECA 23/09/2021 K004A
48 3573040807680005 SUKRI SETIYONO L 53 JL. S. SUPRIADI VII/15B 085765550213 ASTRAZENECA 23/09/2021 K004A
49 3573045208510003 RUMINI P 70 JL. SIMPANG SUKUN 085808300228 ASTRAZENECA 23/09/2021 K004A
50 3573044305620003 MOYA P 59 JL. NGAGLIK IVB/37 087764147211 ASTRAZENECA 23/09/2021 K004A
51 3573044607650002 LILIK ISMIATI P 55 JL. NGAGLIK 4B/586 087861642966 ASTRAZENECA 23/09/2021 K004A
52 3573040512640002 ABDUL MUNTOLIB L 57 JL. NGAGLIK 4B/586 087861642966 ASTRAZENECA 23/09/2021 K004A
53 3573020506610002 HASANUDIN L 60 JL. NGAGLIK IVB/37 087764147211 ASTRAZENECA 23/09/2021 K004A
54 3573046205960006 SITI MEILATUL AZIZA P 24 JL. NGAGLIK IVB/28 085963000181 ASTRAZENECA 23/09/2021 K004A
55 3573046405570001 SOEHARYATI P 64 JL. ELANG No.7 081235789333 ASTRAZENECA 23/09/2021 K004A
56 3573026909840001 SITI ANITA P 37 JL. NGAGLIK IV B/33 089601587379 ASTRAZENECA 23/09/2021 K004A
57 3573041408020003 RISKI DIAS INDRAYANTO L 18 JL. SIMPANG SUKUN 22 081556681699 ASTRAZENECA 23/09/2021 K004A
58 3573045904720004 HAYATIN P 49 JL. NGAGLIK IVB/22 KAMPUNG BARU 081918361090 ASTRAZENECA 23/09/2021 K004A
59 3573034701860007 RITA DIANA ZEZA P 34 JL. SIMPANG SUKUN TIMUR 085816621232 ASTRAZENECA 23/09/2021 K004A
60 3573040102830009 FAHRUR ROZI L 38 JL. KUTILANG BARAT 52 082334757280 ASTRAZENECA 23/09/2021 K004A
61 3573042706810004 AFIT SUYONO L 46 JL. SIMPANG SUKUN TIMUR 087859931136 ASTRAZENECA 23/09/2021 K004A
62 3573040901800002 ADI PRASTYO L 41 JL. S. SUPRIADI IIA/13 081803397639 ASTRAZENECA 23/09/2021 K004A
63 3573042507690002 AMAT BUDIONO L 52 JL. S. SUPRIADI IIE/26 082143698736 ASTRAZENECA 23/09/2021 K004A
64 8171024801800001 MAGDALENA H. MAKASENDA P 41 JL. S. SUPRIADI VI/2358 083834533337 ASTRAZENECA 23/09/2021 K004A
65 3573042401020002 FACHREZA ABDEEL ZACHARY L 19 JL. MERAK UTARA No.. 27 085782905710 ASTRAZENECA 23/09/2021 K004A
66 3573045505820005 PANCAWATI P 39 JL. NGAGLIK IVB/36 083834935302 ASTRAZENECA 23/09/2021 K004A
67 3573042812490002 SUPRAPTO L 72 JL. S. SUPRIYADI 34 E 088803364664 ASTRAZENECA 23/09/2021 K004A
68 3573034810780008 YENI RACHMAWATI P 43 PERUM BUMIAYU INDAH E-14 083848176987 ASTRAZENECA 23/09/2021 K004A
69 3573046201030002 LUCKY DWI LESTARI P 18 JL. S. SUPRIADI X/33 083832504145 ASTRAZENECA 23/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
No. Batch No. Batch
Vaksinasi Vaksinasi
70 3573044610400001 PONI P 81 JL. S. SUPRIYADI VIII/2432 082232750690 ASTRAZENECA 23/09/2021 K004A

71 3573044409700005 TITIK WIDAYATI P 50 JL. S. SUPRIYADI VII/15B 085765550213 ASTRAZENECA 23/09/2021 K004A
72 3573044712530001 SRI HARTINI P 67 JL. PRENJAK BARAT 38 087859616386 ASTRAZENECA 23/09/2021 K004A
73 3573045603020003 NUR WAFIQ AZIZAH P 19 JL. PRENJAK TIMUR No..35 085731663817 ASTRAZENECA 23/09/2021 K004A
74 3573046512480001 SUMIJATI P 72 JL. GELATIK LUAR No.. 2A 085234098051 ASTRAZENECA 23/09/2021 K004A
75 3573041212490007 SOEMARSONO L 71 JL. S. SUPRIYADI IX/35 081333154269 ASTRAZENECA 23/09/2021 K004A
76 3507301009740001 SUPRIANTO L 45 JL. NGAGLIK IVB/36 081237153038 ASTRAZENECA 23/09/2021 K004A
77 3573045708870008 WITIYAS AGUSTINA P 34 JL. KAKAK TUA SELATAN RT 15 RW 3 082139121357 ASTRAZENECA 23/09/2021 K004A
78 3573045712970003 NENI KURNIA P 24 JL. NGAGLIK IVB/30 088293100789 ASTRAZENECA 23/09/2021 K004A
79 3573041804770011 HADI KRISWANTO L 44 JL. S. SUPRIYADI X/21 083846370774 ASTRAZENECA 23/09/2021 K004A
80 3573040101580039 KASENO L 63 JL. S. SUPRIYADI X/10 088989715523 ASTRAZENECA 23/09/2021 K004A
81 3573036604810001 EMI LOLITASARI P 40 PERUM BUMIAYU INDAH E-14 089654007474 ASTRAZENECA 23/09/2021 K004A
82 3573042306700001 HARI WIDJAJA L 50 JL. MELIWIS TIMUR No. 29 08125232875 ASTRAZENECA 23/09/2021 K004A
83 3507215705830001 WIJI ASTUTIK P 37 DSN RECO 085872999505 ASTRAZENECA 23/09/2021 K004A
84 3573044912560005 LANI WIJAYA P 64 JL. KASIN JAYA III/20 ASTRAZENECA 23/09/2021 K004A
85 3573024705940001 YOMI PRATIWI PUTRI P 27 JL. S. SUPRIADI IIA/9 081216524402 ASTRAZENECA 23/09/2021 K004A
86 3573046408690005 NORMAH SARI P 52 JL. KUTILANG TIMUR No. 2 08125228584 ASTRAZENECA 23/09/2021 K004A
87 3573041812630001 MISNO L 58 JL. S. SUPRIADI V/16B 089613755574 ASTRAZENECA 23/09/2021 K004A
88 3573021602600001 PRIYONO L 60 JL. S. SUPRIADI IID/36 081315318130 ASTRAZENECA 23/09/2021 K004A
89 3573040608800008 IRWAN WAHYU HIDAYAT L 40 JL. MANYAR 12 085855600058 ASTRAZENECA 23/09/2021 K004A
90 3573042301810005 WARDIONO L 40 JL. S. SUPRIADI VI/2338 085791751299 ASTRAZENECA 23/09/2021 K004A
91 3573044201600003 WIWIK ASTUTIK P 61 JL. S. SUPRIYADI 2B/1A 087781385565 ASTRAZENECA 23/09/2021 K004A
92 3573044810690003 SUSIANA P 42 JL. S. SUPRIADI IIB/15B 085791156920 ASTRAZENECA 23/09/2021 K004A
93 3573041808690002 AGUS HARIYANTO L 52 JL. S. SUPRIADI X/19 083835142829 ASTRAZENECA 23/09/2021 K004A
94 3573045004680003 HARSASI P 53 JL. MELIWIS TIMUR 29 081945791968 ASTRAZENECA 23/09/2021 K004A
95 3573046210940001 LINA KUSHERAWATI P 27 JL. SIMPANG SUKUN TIMUR 083848586323 ASTRAZENECA 23/09/2021 K004A
96 3507246808800001 FITRI DEWANDINI P 40 JL. S. SUPRIYADI V/21 083848133960 ASTRAZENECA 23/09/2021 K004A
97 3573044701670002 SUPRI ARI WAHYUNI P 44 JL. S. SUPRIYADI IIB/62 083173122082 ASTRAZENECA 23/09/2021 K004A
98 3573041508620002 ALI SAUNUNU L 59 JL. SIMPANG SUKUN TIMUR 087877471113 ASTRAZENECA 23/09/2021 K004A
99 3573047003940003 MITA AYU RASWATI P 27 JL. S. SUPRIADI VII/61 083175430847 ASTRAZENECA 23/09/2021 K004A
100 3573046712750002 SUPRI AMBAR YUNANI P 46 JL. S. SUPRIYADI 2B/62 083111939189 ASTRAZENECA 23/09/2021 K004A
101 3507241009810002 ONE GIBION EFENDI L 41 JL. S. SUPRIADI V/21 081331760238 ASTRAZENECA 23/09/2021 K004A
102 3573046009820002 IKA SETYOWATI P 39 JL. S. SUPRIADI IIE/14 ASTRAZENECA 23/09/2021 K004A
103 3573041402010003 MAULANA MALIK HABIB L 20 JL. S. SUPRIADI VI/2263 085892187027 ASTRAZENECA 23/09/2021 K004A
104 3573042609640008 EKO MARDIONO L 57 JL. KEPODANG 26 089679546646 ASTRAZENECA 23/09/2021 K004A
105 35730406050200001 TITO LINGGA ZULKIFLI L 19 JL. S. SUPRIYADI IVII/61 08819562608 ASTRAZENECA 23/09/2021 K004A
106 3573041209460002 MULUD L 74 JL. NURI No. 23 ASTRAZENECA 23/09/2021 K004A
107 3573046903010003 ELVANNY YISKA PUTRI P 19 JL. NURI No. 5 087703240844 ASTRAZENECA 23/09/2021 K004A
108 3573045810970001 DINDA OKTAVIA TRI KUSUMA P 24 JL. SWARI SELATAN No. 2B 081252406972 ASTRAZENECA 23/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
No. Batch No. Batch
Vaksinasi Vaksinasi
109 3573045509850004 ERMINDA PUJIWIDYA LISTIANA P 36 JL. MERAK SELATAN No. 9 083847458626 ASTRAZENECA 23/09/2021 K004A
110 3573042302940002 ADHY WICAKSONO L 27 JL. CENDRAWASIH 17 081290486089 ASTRAZENECA 23/09/2021 K004A
111 3573044111730003 TRININGSIH P 48 JL. S. SUPRIADI VII/11A 085904293155 ASTRAZENECA 23/09/2021 K004A
112 3573044708970001 HANDINI ANGGRAENI SETIAWAN P 24 JL. S. SUPRIYADI IIB/23 08884086269 ASTRAZENECA 23/09/2021 K004A
113 3573046801680006 CHURRIYAH P 52 JL. NGAGLIK IVB/77 083835950645 ASTRAZENECA 23/09/2021 K004A
114 3573040611700003 SOLEH L 51 JL. S. SUPRIADI IIE No. 24 082230307187 ASTRAZENECA 23/09/2021 K004A
115 3573044301760004 ISNURIATI P 44 JL. KAKAK TUA SELATAN No. 2 089637902067 ASTRAZENECA 23/09/2021 K004A
116 3573047110000005 NUR TRI DIYAH P 21 JL. NGAGLIK IVB/77 085704040334 ASTRAZENECA 23/09/2021 K004A
117 3573040505840003 FARIZ MAULANA L 37 JL. S. SUPRIADI IX/65 082282282134 ASTRAZENECA 23/09/2021 K004A
118 3573044109650013 ENDAH SULASTRI P 56 JL. S. SUPRIYADI IIE/25 083129313934 ASTRAZENECA 23/09/2021 K004A
119 3573040612720001 KARIYONO L 49 JL. S. SUPRIYADI VII/59 08557262564 ASTRAZENECA 23/09/2021 K004A
120 3573041409820002 ARIF PRAYOGA L 39 JL. NGAGLIK IID/29 082233124100 ASTRAZENECA 23/09/2021 K004A
121 3573045407750002 MUDAWAMAH P 46 JL. S. SUPRIADI 154 085881631319 ASTRAZENECA 23/09/2021 K004A
122 3573041006000001 MOHAMMAD RISKI PRASETYO L 21 JL. NGAGLIK IID No. 40/564 089681565177 ASTRAZENECA 23/09/2021 K004A
123 3573040201810001 YANUAR SUPRIONO L 40 JL. ELANG 17 087857108886 ASTRAZENECA 23/09/2021 K004A
124 3573044909810004 ANITAWATI P 39 JL. S. SUPRIADI III/49 085719068272 ASTRAZENECA 23/09/2021 K004A
125 3573046404770008 ROHANI SULISTIANI P 44 JL. S. SUPRIADI NGAGLIK ES 31 082233427510 ASTRAZENECA 23/09/2021 K004A
126 3517216209970001 PUTRI FA'IQOH P 24 JL. S. SUPRIADI VII/15 085748108602 ASTRAZENECA 23/09/2021 K004A
127 3573045703840004 TRIANA SUSANTI P 37 JL. S. SUPRIADI 30 085648221363 ASTRAZENECA 23/09/2021 K004A
128 3573040104620002 RUBIMIN P 58 JL. PRENJAK BARAT 75 085642848700 ASTRAZENECA 23/09/2021 K004A
129 3573044910670003 SULIKAH P 44 JL. NGAGLIK IVB/76 08978999123 ASTRAZENECA 23/09/2021 K004A
130 3507310510030001 RAVAEL REXA OKTAVAN L 18 JL. S. SUPRIADI X/30 085791754866 ASTRAZENECA 23/09/2021 K004A
131 3573045711030001 WIDIA PUTRI NOVITASARI P 27 JL. S. SUPRIADI VII/11A 088803519598 ASTRAZENECA 23/09/2021 K004A
132 3573040404730001 SLAMET MARIYONO L 48 JL. S. SUPRIADI VII/11A 087869126403 ASTRAZENECA 23/09/2021 K004A
133 3573045912770001 SUPRAPTI P 44 JL. S. SUPRIADI VII/15 089516499961 ASTRAZENECA 23/09/2021 K004A
134 3573040809530003 HARIYANTO L 67 JL. NGAGLIK IVB/284 087716619821 ASTRAZENECA 23/09/2021 K004A
135 3573020701010001 MOCHAMMAD IRFANA HUDA L 20 JL. NGAGLIK IVB/1 081236950728 ASTRAZENECA 23/09/2021 K004A
136 3573046403510001 SITI MARIJAM P 70 JL. NGAGLIK 4B/248 082330759887 ASTRAZENECA 23/09/2021 K004A
137 3573040407890004 SLAMET RIYADI L 32 JL. S. SUPRIADI IXA/24C 085964141242 ASTRAZENECA 23/09/2021 K004A
138 3573044101540040 SUHARTI P 66 JL. S. SUPRIADI IXA/53 083898997778 ASTRAZENECA 23/09/2021 K004A
139 3573040707660002 MOCHAMMAD KHOLIQ L 55 JL. S. SUPRIADI VII/15 082120406315 ASTRAZENECA 23/09/2021 K004A
140 3518074205990006 DEWI FITRIAH P 25 JL. S. SUPRIADI V/45 081615005557 ASTRAZENECA 23/09/2021 K004A
141 3507246809890001 ANIS CHOIRIYAH P 31 JL. LARWO GG 7 085336099856 ASTRAZENECA 23/09/2021 K004A
142 3573045009780004 FITRI HANDAYANI P 42 JL. S. SUPRIADI GG 7/13B 083129946960 ASTRAZENECA 23/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
No. Batch No. Batch
Vaksinasi Vaksinasi
143 3573046811650003 LILIK SURYANI P 56 JL. S. SUPRIADI IV/23 081249885272 ASTRAZENECA 23/09/2021 K004A
144 3573045211630002 SRINAYU SETYANINGSIH P 58 JL. S. SUPRIADI VII/1 081233345661 ASTRAZENECA 23/09/2021 K004A
145 3573041501670003 SUGENG RIADI L 53 JL. S. SUPRIADI VI/2400 085100113733 ASTRAZENECA 23/09/2021 K004A
146 3573043107810005 PAMUNGKAS TRI HARDIKA L 39 JL. S. SUPRIADI NGAGLIK IV/176B 083834238686 ASTRAZENECA 23/09/2021 K004A
147 3573040609790016 DIDIEK ARIF BUDIANTO L 42 JL. S. SUPRIADI/NGAGLIK IV 176B 083165003311 ASTRAZENECA 23/09/2021 K004A
148 3573041203760004 FARID KURNIAWAN L 45 JL. MANYAR 12 081334577311 ASTRAZENECA 23/09/2021 K004A
149 3573046808660003 PIASIH P 54 JL. S. SUPRIYADI 2429 082334989833 ASTRAZENECA 23/09/2021 K004A
150 3573046310910001 RISKA LUSIANA P 21 JL. S. SUPRIADI VII/15B 0881036166018 ASTRAZENECA 23/09/2021 K004A
151 3573045608730003 SITI MASLICHAH P 48 JL. S. SUPRIADI VII//22 081217541282 ASTRAZENECA 23/09/2021 K004A
152 3573044401000008 ANIES VERANIA FABRILIA P 21 JL. S. SUPRIADI V/46B 089618211212 ASTRAZENECA 23/09/2021 K004A
153 3573046201900006 AYU NILMALASARI P 30 JL. S. SUPRIADI IXA/92A 082245356035 ASTRAZENECA 23/09/2021 K004A
154 3573040412890001 MOCHAMAD FAUZI L 31 JL. S. SUPRIADI VII/15B 085806348152 ASTRAZENECA 23/09/2021 K004A
155 3573040206990002 YUNIO MAGHRIZA L 22 JL. S. SUPRIADI VIII/2429/4 082334989833 ASTRAZENECA 23/09/2021 K004A
156 3573044911790004 AULIA SARI P 42 JL. NGAGLIK IV-B/204B 085648686699 ASTRAZENECA 23/09/2021 K004A
157 3507103009650006 ROHMAN SUDALI L 55 JL. S. SUPRIADI IIC/28 085330983703 ASTRAZENECA 23/09/2021 K004A
158 3573010808730001 NANANG HERI CAHYONO L 48 JL. JODIPAN WETAN 3C/7 081216302273 ASTRAZENECA 23/09/2021 K004A
159 3507210710030001 TALENTINO PUTRA BAGASKARA L 18 WAGIR 087782954457 ASTRAZENECA 23/09/2021 K004A
160 3573045008680009 KASIATI P 53 JL. S. SUPRIADI IX/93 081938423942 ASTRAZENECA 23/09/2021 K004A
161 3573040101530015 RASTAWI L 67 JL. NGAGLIK IIC/504 083834988388 ASTRAZENECA 23/09/2021 K004A
162 3573045202030004 ESA WAHYU MAGDALENA P 18 JL. SIMPANG SUKUN TIMUR 083115100676 ASTRAZENECA 23/09/2021 K004A
163 3573041005750006 MAHENDRA EKO SUWONO L 46 JL. S. SUPRIADI VII/13 083129946960 ASTRAZENECA 23/09/2021 K004A
164 3573044509850011 NUR CHOMARIYAH P 36 JL. S. SUPRIADI IXA/31 081336701352 ASTRAZENECA 23/09/2021 K004A
165 3573041512830002 TOMMY ANDIANUS L 37 JL. S. SUPRIADI 7/16 081234701053 ASTRAZENECA 23/09/2021 K004A
166 3573017007930001 YULIA WULANDARI P 28 JL. MUHARTO VI/9 083834742655 ASTRAZENECA 23/09/2021 K004A
167 3573046001570001 SUPRAPTI P 63 JL. S. SUPRIADI VII/15 082120406315 ASTRAZENECA 23/09/2021 K004A
168 3573041204630003 DJUMARI L 58 JL. S. SUPRIADI 2B/15B 085234210041 ASTRAZENECA 23/09/2021 K004A
169 3573040910640001 DRS. MUKAROM, MHUM L 57 JL. S. SUPRIADI IIB/17B 08123399948 ASTRAZENECA 23/09/2021 K004A
170 3573041902790006 WARDOYO L 42 JL. S. SUPRIADI IXA/92A 082232951035 ASTRAZENECA 23/09/2021 K004A
171 3573046112670001 UMI WIRASIH P 44 JL. S. SUPRIADI VI/31 ASTRAZENECA 23/09/2021 K004A
172 3573043008580001 SUPARNO L 63 JL. KEPODANG 18 082142563128 ASTRAZENECA 23/09/2021 K004A
173 3573042312640004 MUNIR YUNIARTO L 57 JL. S. SUPRIADI VI/31 ASTRAZENECA 23/09/2021 K004A
174 3578155404910003 RENI ARIANTI P 30 JL. MERAK SELATAN No. 12 083851031266 ASTRAZENECA 23/09/2021 K004A
175 3573044806530002 MAY HERAWATI P 68 JL. S. SUPRIADI VII/7 082139329822 ASTRAZENECA 23/09/2021 K004A
176 3514115603810003 DINA SUSANA P 39 JL. PRENJAK TIMUR 29 085649726601 ASTRAZENECA 23/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
No. Batch No. Batch
Vaksinasi Vaksinasi
177 3573046207850007 ERSINA WAHYU KUSUMANINGATI P 36 JL. SIMPANG SUKUN TIMUR 083833724809 ASTRAZENECA 23/09/2021 K004A
178 3573045010830007 ROKIDAH P 38 JL. S. SUPRIADI IXA/53 088226278515 ASTRAZENECA 23/09/2021 K004A
179 3573046501640003 SEMI KRISTIANI P 55 JL. S. SUPRIADI IIC/28 085330983703 ASTRAZENECA 23/09/2021 K004A
180 3573040106560001 SAIFUL ANWAR L 66 JL. GLATIK DALAM 11 ASTRAZENECA 23/09/2021 K004A
181 3575035610870004 IKA KURNIAWATI P 34 JL. S. SUPRIADI X/11 085704513187 ASTRAZENECA 23/09/2021 K004A
182 3573040310820004 JOKO ARIEF L 39 JL. S. SUPRIADI VII/14 085608162219 ASTRAZENECA 23/09/2021 K004A
183 3573044404520006 KASIYANI P 69 JL. S. SUPRIADI X/3 ASTRAZENECA 23/09/2021 K004A
184 3573046004590004 ENDAH WAHYUNINGRUM P 62 JL. PRENJAK BARAT 64 082245678110 ASTRAZENECA 23/09/2021 K004A
185 3573043112600026 NUROSO L 61 JL. SIMP. SUKUN TIMUR 082139310059 ASTRAZENECA 23/09/2021 K004A
186 3573045402790001 NURUL AINI P 41 JL. PARKIT SELATAN 24 083850560958 ASTRAZENECA 23/09/2021 K004A
187 3573041906740001 MAWAN JUNAEDIE L 45 JL. PARKIT SELATAN 24 083848088168 ASTRAZENECA 23/09/2021 K004A
188 3573046310860006 FRISKA ELLYANA FARIDAH P 35 JL. MERAK SELATAN 17 082132375828 ASTRAZENECA 23/09/2021 K004A
189 3573046903010001 CHARIEL CHANDRA SETYA LOVEREN P 20 JL. KUTILANG BARAT 23-25 085856772001 ASTRAZENECA 23/09/2021 K004A
190 3573041903670001 SIHADI HASTO PRANOWO L 54 JL. S. SUPRIADI X/9 08123261582 ASTRAZENECA 23/09/2021 K004A
191 3573020902820002 FERY HARWINNANTO L 39 JL. S. SUPRIADI III/49 085608570204 ASTRAZENECA 23/09/2021 K004A
192 3507982707830004 SLAMET YULIANTO L 38 JL. MERAK SELATAN 17 081333197727 ASTRAZENECA 23/09/2021 K004A
193 3573046002820007 CHUSNUL LAILIATI P 39 JL. PARKIT UTARA 34 083134736159 ASTRAZENECA 23/09/2021 K004A
194 3573046206630002 HARI SRI MULYATI P 64 JL. KUTILANG TIMUR 36 082225397608 ASTRAZENECA 23/09/2021 K004A
195 3573042007760006 YULIADI L 45 JL. SUWARI UTARA No. 62 0895359513799 ASTRAZENECA 23/09/2021 K004A
196 3573045009880003 NURUL PRASETYOWATI P 33 JL. GEMPOL MARGA BHAKTI 23 085101438845 ASTRAZENECA 23/09/2021 K004A
197 3573045303650006 NURKASANAH P 56 JL. GEMPOL MARGA BHAKTI 23 085101438845 ASTRAZENECA 23/09/2021 K004A
198 3573042712720004 WIDODO SUWARNO L 49 JL. PRENJAK BARAT 58 089507999288 ASTRAZENECA 23/09/2021 K004A
199 3572026706760005 SRI WAHYUNI P 45 JL. KAWI No.. 38 082229039299 ASTRAZENECA 23/09/2021 K004A
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
3 3573042606600004 RIANTO L 61 JL.KEMANTREN I/55 11/03 085794873436 ASTRAZENECA 24/09/2021 K004A

6 6302060107590202 AMAT L 63 JL.KEBEN II BLOK C KAV 4 08/11 081252692209 ASTRAZENECA 24/09/2021 K004A
34 3573041806590006 DJUHARI L 62 JL.KLAYATAN II/52 13/12 085100179444 ASTRAZENECA 24/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
39 3573040505530010 SAELAN L 68 JL.KLAYATAN II/51 13/12 085100179444 ASTRAZENECA 24/09/2021 K004A

43 3573043112570012 SUNARDI L 64 JL.JANTI VI/57 04/09 - ASTRAZENECA 24/09/2021 K004A
49 3573040112520010 SAID L 69 JL.KEMANTREN II/47 03/03 - ASTRAZENECA 24/09/2021 K004A
50 3573044603530003 SARPIAH P 68 JL.KLAYATAN I/21 03/12 081252651509 ASTRAZENECA 24/09/2021 K004A
55 3573044512340001 KAMIATI P 67 JL.KEMANTREN I/108 13/03 082138846924 ASTRAZENECA 24/09/2021 K004A
70 3573042504560002 WAJIB S L 65 JL.KEMANTREN II/JL.DANURI 52 05/03 089503087897 ASTRAZENECA 24/09/2021 K004A
71 3573040206540002 SUTRISNO HUSEN L 67 JL.RAYA KEPUH /1 02/05 081261561799 ASTRAZENECA 24/09/2021 K004A
80 6104035212570002 SRI MIATUN P 64 JL.KEMANTREN INO.31 06/03 085855149232 ASTRAZENECA 24/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
89 3573041507430002 SUKIMUN L 78 JL.KLAYATAN II/18 11/12 - ASTRAZENECA 24/09/2021 K004A

91 3573040701580002 SODIKIN L 63 BANDUNGREJOSARI 04/09 081907748949 ASTRAZENECA 24/09/2021 K004A
95 35730405055000003 BONIRAN L 71 JL.KLAYATAN II/73 13/12 082231529401 ASTRAZENECA 24/09/2021 K004A
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
31 3573036608950002 DILLA PRATIWI P 26 JANTI BARAT BLOK A PERUM PURI 081259171696 ASTRAZENECA 27/09/2021 K004A
NIRAWANA
144 3573046905680002 FATIMAH P 59 KLAYATAN III 2A 082132345600 ASTRAZENECA 27/09/2021 K004A
1 3573041510680002 RAHIM L 53 S SUPRIYADI X/8 083848070534 ASTRAZENECA 27/09/2021 K004A
2 3573044806760005 MAWARDA ANA DARMISWATIK P 36 S SUPRIYADI VI 085808927036 ASTRAZENECA 27/09/2021 K004A
3 3573041704800004 INOSENSIA HERTANTO L 31 S SUPRIADI IV 085335657855 ASTRAZENECA 27/09/2021 K004A
4 3573044104700008 SITI ROHAYEH P 51 SIMPANG SUKUN 085233738744 ASTRAZENECA 27/09/2021 K004A
5 3573041701720002 WIWIN SIGIT HERLAMBANG L 48 S SUPRIADI IV 085648043542 ASTRAZENECA 27/09/2021 K004A
6 3573042006560004 GREGORIUS RUDI REDIONO L 54 S SUPRIADI VIII 081286085758 ASTRAZENECA 27/09/2021 K004A
7 3573046706020009 ELORA AMANDIA PUTRI P 19 S SUPRIADI VIII 081286085758 ASTRAZENECA 27/09/2021 K004A
8 3573045004650003 SUSETIOWATI P 46 S SUPRIADI VI/23B 081252306221 ASTRAZENECA 27/09/2021 K004A
9 3573045503760010 NAHIDE P 45 S SUPRIADI VIII 085253833520 ASTRAZENECA 27/09/2021 K004A
10 3573046711680002 ERNI SUDARIYANI P 53 S SUPRIADI X/8 083848070534 ASTRAZENECA 27/09/2021 K004A
11 3573041010880006 DENNIS NANDA PERMANA L 32 S SUPRIADI VIB 081216092018 ASTRAZENECA 27/09/2021 K004A
12 3573047107980007 AGNES YULIANA CITRA P 23 S SUPRRIADI IX 08563496749 ASTRAZENECA 27/09/2021 K004A
13 3573041208840012 NUR CAHYADI L 36 S SUPRIADI VI 081234855932 ASTRAZENECA 27/09/2021 K004A
14 3573040906970003 MUHAMMAD AMIN ALKAUSAR L 24 SIMPANG SUKUN 081235443892 ASTRAZENECA 27/09/2021 K004A
15 3573041503860005 TRU BUDI MARTONO L 35 SIMPANG SUKUN 25 081617387884 ASTRAZENECA 27/09/2021 K004A
16 3573040303530004 ASTAMAN L 68 S SUPRIADI X/5 0877631281003 ASTRAZENECA 27/09/2021 K004A
17 3573042105550004 HARTANTO L 66 NGAGLIK IVA 088741007138 ASTRAZENECA 27/09/2021 K004A
18 3573042202650004 MUCHLIS EFENDY L 56 SIMPANG SUKUN 56 087759844123 ASTRAZENECA 27/09/2021 K004A
19 3671086403710002 TUTUT SUSRINI P 50 KP NAGRAK 085216703433 ASTRAZENECA 27/09/2021 K004A
20 3573042804990006 VICO SAVRIL SETYA YOGA L 22 S SUPRIADI X 21 08385942733 ASTRAZENECA 27/09/2021 K004A
21 3573047010960003 SONIA OKTA ANDI SAPUTRI P 24 S SUPRIADI 9A 083109270198 ASTRAZENECA 27/09/2021 K004A
22 3573040601550003 HARI SUCIPTO L 66 S SUPRIADI VI 087859994208 ASTRAZENECA 27/09/2021 K004A
23 3573046505520002 SUHARTI P 69 S SUPRIADI X 42 085645197220 ASTRAZENECA 27/09/2021 K004A
24 3573045909880002 VIDORA SANDI P 33 RAYA CANDI IIIA 082232888189 ASTRAZENECA 27/09/2021 K004A
25 3573044107830149 FENI RUSDIANA P 43 S SUPRIADI X 21 083846370774 ASTRAZENECA 27/09/2021 K004A
26 3573046003550003 SRIATI P 56 S SUPRIADI VI 2309 081234855932 ASTRAZENECA 27/09/2021 K004A
27 3573046011860084 TINI KUSWATI P 35 S SUPRIADI VI 2326A 081233435667 ASTRAZENECA 27/09/2021 K004A
28 3510065204600012 HARTINI P 61 DSN KRAJAN 08123382747 ASTRAZENECA 27/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
29 3573040508610002 MASHUDDIN L 60 S SUPRIADI IX 100 081233661925 ASTRAZENECA 27/09/2021 K004A
30 3573044202570001 DARMIATI P 64 S SUPRIADI IX 83 081217667210 ASTRAZENECA 27/09/2021 K004A
32 3573012604880003 SISMAWANTO L 33 NGAGLIK IVB 081916795493 ASTRAZENECA 27/09/2021 K004A
33 3573047011720002 RIBUT SUSANA P 49 S SUPRIADI VI 2351 085735257015 ASTRAZENECA 27/09/2021 K004A
34 3573041002560010 SUKARLIYANTO L 65 JANTI BARAT PADEPOKAN II 12 081336083338 ASTRAZENECA 27/09/2021 K004A
35 3573040709930001 MUHAMMAD MUCLIS L 28 NGAGLIK IVB 082217938939 ASTRAZENECA 27/09/2021 K004A
36 3573044401680003 SRI SUSANAH P 53 S SUPRIADI VI 2351 08954139650001 ASTRAZENECA 27/09/2021 K004A
37 3573044305720003 INDAH TJAHJOWATI P 49 S SUPRIADI 4 31 08179616563 ASTRAZENECA 27/09/2021 K004A
38 3573045708920006 SUSANTI P 29 NGAGLIK IVB 081916795493 ASTRAZENECA 27/09/2021 K004A
39 3573046204840008 RUBHIKA TANTI P 37 NGAGLIK IVB 210 081330911486 ASTRAZENECA 27/09/2021 K004A
40 3573046111730001 SUMAIYAH P 48 NGAGLIK II D 0859186088238 ASTRAZENECA 27/09/2021 K004A
41 3573041001700004 SUGIYAT L 51 NGAGLIK IID 551 0859186088238 ASTRAZENECA 27/09/2021 K004A
42 3573041307650002 SUPARDI L 56 JANTI BARAT PADEPOKAN 16 08123398552 ASTRAZENECA 27/09/2021 K004A
43 3507130608920003 ANDIK FAHRUDIN L 29 BROMO 081335055392 ASTRAZENECA 27/09/2021 K004A
44 3507231911700003 SUPARDI L 51 NGAGLIK IVB 621 087755041442 ASTRAZENECA 27/09/2021 K004A
45 3573040105710007 NUR YASIN L 30 S SUPRIADI VI 37 085101294373 ASTRAZENECA 27/09/2021 K004A
46 3573041601540003 KUSTANTYONO L 67 S SUPRIADI VI 36 085790706205 ASTRAZENECA 27/09/2021 K004A
47 3573047112750014 NUR AISYAH P 45 S SUPRIADI 6 2347 085105116744 ASTRAZENECA 27/09/2021 K004A
48 3573040112530005 RUSI L 58 NGAGLIK IV3 081131134624 ASTRAZENECA 27/09/2021 K004A
49 3573035504790002 FISTY DINA PRIHATIN P 42 S SUPRIADI X 2471 082132533303 ASTRAZENECA 27/09/2021 K004A
50 3573040904700005 MOCH WAKIDI L 51 S SUPRIADI 10 13 081252705494 ASTRAZENECA 27/09/2021 K004A
51 3573041010970004 DEDEN YOKE ZAINI L 24 NGAGLIK IVB 08971583422 ASTRAZENECA 27/09/2021 K004A
52 3573042808620001 ASUPRIYANTO L 59 SUPRIADI 04 081216731734 ASTRAZENECA 27/09/2021 K004A
53 3505065401000005 NATALIA P 21 NGAGLIK IVB 08988077409 ASTRAZENECA 27/09/2021 K004A
54 3573045803950003 ALMAIDAH VIVIANATA P 26 NGAGLIK II D 089697080237 ASTRAZENECA 27/09/2021 K004A
55 3573043112710005 ABDUL HADI L 49 NGAGLIK IID 13/01 089688335775 ASTRAZENECA 27/09/2021 K004A
56 3573045512780003 ZAINAP P 43 NGAGLIK IID 13/01 089688335775 ASTRAZENECA 27/09/2021 K004A
57 3573045511010007 NOVITA SARI P 19 S SUPRIADI IX 94 082233983006 ASTRAZENECA 27/09/2021 K004A
58 3573044305690005 DEWI WIRIYANTI P 52 S SUPRIADI IX 94 082233983006 ASTRAZENECA 27/09/2021 K004A
59 3573041911740003 SAM HAJI L 47 NGAGLIK IID 16 08780411614 ASTRAZENECA 27/09/2021 K004A
60 3573041306590001 SUYOTO L 62 NGAGLIK IVB 088237818356 ASTRAZENECA 27/09/2021 K004A
61 3573045001850013 MARGARETHA ANANCI KOLLANMO P 30 SUKUN VI 17B 085695112281 ASTRAZENECA 27/09/2021 K004A
62 3573040401510002 SUHARYO L 70 S SUPRIADI VIII 081334316255 ASTRAZENECA 27/09/2021 K004A
63 3573047108010006 ERIKA AGUSTINA P 21 S SUPRIADI IXA 081235719590 ASTRAZENECA 27/09/2021 K004A
64 3573041008860004 MUHAMMAD ARI L 53 NGAGLIK IVB 277 085732915550 ASTRAZENECA 27/09/2021 K004A
65 3573041101560001 SOEYOTO L 65 NGAGLIK IID 7 082257961450 ASTRAZENECA 27/09/2021 K004A
66 3507236112850002 NATALIA CHRISTANTI S P 36 NGAGLIK IVB 10B 087859540099 ASTRAZENECA 27/09/2021 K004A
67 3573044101600039 ISNAH P 61 NGAGLIK IID 087859966714 ASTRAZENECA 27/09/2021 K004A
68 3573044304650002 ISTIANI P 56 NGAGLIK IID ASTRAZENECA 27/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
69 3573031003660003 IZAK SOESILO L 55 SIMPANG JANTI BARAT IC 085330855227 ASTRAZENECA 27/09/2021 K004A
70 3573047112880015 KANTI NAYA SARI P 33 S SUPRIADI X 2489 085856611132 ASTRAZENECA 27/09/2021 K004A
71 3573046908970005 RESITA PUTRI AYUNINGRUM P 24 S SUPRIADI VIII 9 085830679792 ASTRAZENECA 27/09/2021 K004A
72 3573041212640004 RUSMINARDI L 57 S SUPRIADI VI 2351 081233664876 ASTRAZENECA 27/09/2021 K004A
73 3573046408960006 SUTSUGA DEBBY AULIA P 25 S SUPRIADI VI 2351 082232268924 ASTRAZENECA 27/09/2021 K004A
74 3573040710630001 SUPARDI L 58 S SUPRIADI IXA 081231216356 ASTRAZENECA 27/09/2021 K004A
75 3573041311020004 RAMADHAN GALANOV L 19 S SUPRIADI X 21 089696852634 ASTRAZENECA 27/09/2021 K004A
76 3573044312880009 HERLOVINA ANESTIA KOLLANMO P 33 SUKUN VI 17B 085855406386 ASTRAZENECA 27/09/2021 K004A
77 3573041701740002 JUADI JONI L 47 S SUPRIADI X 21 0895328499950 ASTRAZENECA 27/09/2021 K004A
78 3573041301830002 EDI PUSPITO L 38 S SUPRIADI CI 2297 0818536131 ASTRAZENECA 27/09/2021 K004A
79 3573042101710002 NUR WAKIT L 50 NGAGLIK IVB 504 085257478364 ASTRAZENECA 27/09/2021 K004A
80 3573047108820002 LINA KURNIAWATI P 39 JANTI BARAT PADEPOKAN 10 A 0895396147163 ASTRAZENECA 27/09/2021 K004A
81 3575033006750005 HANNAN L 44 JANTI BARAT PADEPOKAN 10A 082231298957 ASTRAZENECA 27/09/2021 K004A
82 3573044309860007 NUR KOIDAH P 35 S SUPRIADI X 087759917241 ASTRAZENECA 27/09/2021 K004A
83 3507122702640001 SOEKARTIANTO NANANG EFFENDI L 57 ROYAL JANTI RESIDENCE BLOK C 3 081232317398 ASTRAZENECA 27/09/2021 K004A
84 3573042008650005 SUSILO AGUS WARDOYO L 56 SIMPANG SUKUN TIMUR 08553225109 ASTRAZENECA 27/09/2021 K004A
85 2171035005739004 NUR KHASANAH P 48 S SUPRIADI VIII 2 08113666017 ASTRAZENECA 27/09/2021 K004A
86 2171036606979007 SARAH DAMAYANTI P 24 S SUPRIADI VIII 2 089653121452 ASTRAZENECA 27/09/2021 K004A
87 3504181602020001 MAHMUT ARIFIN L 20 SIMPANG JANTI BARAT II 081252254839 ASTRAZENECA 27/09/2021 K004A
88 3573046610000001 FARADILLA ANISA D P 21 S SUPRIADI VI 17 083115858139 ASTRAZENECA 27/09/2021 K004A
89 3573044406770003 MARIYATUN P 44 S SUPRIADI VI 17 083160395405 ASTRAZENECA 27/09/2021 K004A
90 3573040808520002 KAERUN L 69 S SUPRIADI VI 55 081334878576 ASTRAZENECA 27/09/2021 K004A
91 3573040507770008 MASNGUDI L 44 SIMPANG JANTI BARAT II 082139621259 ASTRAZENECA 27/09/2021 K004A
92 3573044301810003 DIAN FERLINA ROCHMAD P 39 SIMPANG JANTI BARAT II 085101434616 ASTRAZENECA 27/09/2021 K004A
93 3511114202910001 LUSINDA MUNIKA SARI P 30 S SUPRIADI IX 35 08814984090 ASTRAZENECA 27/09/2021 K004A
94 3573042410840009 RONI PRASETYO L 36 S SUPRIADI VI 2360 081334661984 ASTRAZENECA 27/09/2021 K004A
95 3573045907720003 SISMAWATI P 49 S SUPRIADI X 8 081917176189 ASTRAZENECA 27/09/2021 K004A
96 3573044108720003 LUSI SUNANTI P 49 NGAGLIK IVB 238 087863427456 ASTRAZENECA 27/09/2021 K004A
97 3573044106690006 SUDARMI P 66 S SUPRIADI VI 33 ASTRAZENECA 27/09/2021 K004A
98 3573050601800013 EKO BUDIARTO L 41 S SUPRIADI X 20 081334352286 ASTRAZENECA 27/09/2021 K004A
99 3573044706580002 ENDANG PAMULATSIH P 63 S SUPRIADI X 30 081283100691 ASTRAZENECA 27/09/2021 K004A
100 3573044104590001 NARTI P 62 SUPRIADI GG MASJID 29 081945383716 ASTRAZENECA 27/09/2021 K004A
101 3507336012770002 MUTISARI P 44 NGAGLIK IID 29 081252604712 ASTRAZENECA 27/09/2021 K004A
102 3573046512880007 EKA DEWI NATALIA P 33 SIMPANG SUKUN 44 085855257020 ASTRAZENECA 27/09/2021 K004A
103 3573042207800006 EKO HARIYANTO L 41 NGAGLIK IVB 242 085101401121 ASTRAZENECA 27/09/2021 K004A
104 3573044112620012 MUNTINI P 58 NGAGLIK IVB 602 ASTRAZENECA 27/09/2021 K004A
105 3573045006700006 MARLIK P 51 S SUPRIADI IXA 49 081357233791 ASTRAZENECA 27/09/2021 K004A
106 3573045510800011 DEWI HARIANI P 42 S SUPRIADI VI 16 085733858588 ASTRAZENECA 27/09/2021 K004A
107 3573044108770007 ENNY IRAWATI P 44 NGAGLIK IID 51 082257961450 ASTRAZENECA 27/09/2021 K004A
108 3573040304760003 TRIO ADRILIAN CAHYO L 45 S SUPRIADI VI 16 085733858588 ASTRAZENECA 27/09/2021 K004A
109 3573041903730004 YUSMAN L 48 S SUPRIADI NGAGLIK ES 69 08970625593 ASTRAZENECA 27/09/2021 K004A
110 3573045708810010 YUNARNI P 40 S SUPRIADI VI 2360 0895384660277 ASTRAZENECA 27/09/2021 K004A
111 3573044503800004 SUSIANI P 41 S SUPRIADI VIII 19 081390773427 ASTRAZENECA 27/09/2021 K004A
112 3573043009990003 MOCHAMMAD ALVIN L 21 S SUPRIADI VIII 19 081390773427 ASTRAZENECA 27/09/2021 K004A
113 3573043112580031 SUNAIM L 60 S SUPRIADI VI 37 ASTRAZENECA 27/09/2021 K004A
114 3573043005760004 SUYADI L 45 S SUPRIADI VIII 19 081390773427 ASTRAZENECA 27/09/2021 K004A
115 3573042307030003 EDWIN SAPUTRA L 18 NGAGLIK IVB 242 087873873556 ASTRAZENECA 27/09/2021 K004A
116 3573044406820006 DEWI LEGDANANINGSIH P 39 S SUPRIADI IX A 87 085719604919 ASTRAZENECA 27/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
117 3573041603820010 Ahmad HADI SANTOSO L 39 S SUPRIADI VII 13 087865831604 ASTRAZENECA 27/09/2021 K004A
118 3573044101740001 SITI ROHANA P 47 S SUPRIADI NGAGLIK ES 40 083130048646 ASTRAZENECA 27/09/2021 K004A
119 3573041107690002 BUDHI ANTORO L 52 S SUPRIADI NGAGLIK ES 39 E 081808015242 ASTRAZENECA 27/09/2021 K004A
120 3573044809770002 MIATI P 44 S SUPRIADI NGAGLIK ES 39 E 081808015242 ASTRAZENECA 27/09/2021 K004A
121 3507124501850001 WIWIN JUWANTI P 36 TERS MERGAN RAYA XIX 104 0881026956866 ASTRAZENECA 27/09/2021 K004A
122 3573041002690003 SYAIFUL ANHAR L 52 S SUPRIADI IX 71 082228342813 ASTRAZENECA 27/09/2021 K004A
123 3573040203000001 NANDA AJI PANGESTU SISWOYO L 21 S SUPRIADI X 16 081809587178 ASTRAZENECA 27/09/2021 K004A
124 3573045204880007 LILIS P 33 S SUPRIADI VI 23B 088237848519 ASTRAZENECA 27/09/2021 K004A
125 3573042802020003 DENY FEBRIANSYAH L 19 NGAGLIK IVB 222 081249233131 ASTRAZENECA 27/09/2021 K004A
126 3515080807810002 BAMBANG PURNOMO L 40 S SUPRIADI VI 2375 087712631224 ASTRAZENECA 27/09/2021 K004A
127 3573045508590001 MARIA GORETI DJUMIATUN P 62 S SUPRIADI X 39 082264447290 ASTRAZENECA 27/09/2021 K004A
128 3573042201980003 JANUAR RAMADHAN L 23 S SUPRIADI X 08176372904 ASTRAZENECA 27/09/2021 K004A
129 3573046508780002 HARTATIK PUJI ASTUTIK P 43 S SUPRIADI X 085732374075 ASTRAZENECA 27/09/2021 K004A
130 3573040206740001 PUJIONO L 47 S SUPRIADI 4/48 082132307687 ASTRAZENECA 27/09/2021 K004A
131 3573045701550003 SUKARSIH P 66 S SUPRIADI VIII 19 081390773427 ASTRAZENECA 27/09/2021 K004A
132 3573040703960013 RIZKY DARMAWAN L 25 S SUPRIADI X 0895335358377 ASTRAZENECA 27/09/2021 K004A
133 3573045809650003 ENDANG RAHAYU P 56 NGAGLIK IVB 0817787187 ASTRAZENECA 27/09/2021 K004A
134 3573040508990009 MUCH SULTHON H L 22 S SUPRIADI 2337 085236159795 ASTRAZENECA 27/09/2021 K004A
135 3573041811670001 SUPARDI L 64 S SUPRIADI VI 2337 085606154716 ASTRAZENECA 27/09/2021 K004A
136 3573041405660002 SRI TJAHJO WIDODO L 56 S SUPRIADI 4 31 081908162795 ASTRAZENECA 27/09/2021 K004A
137 3573044107540049 KARSINI P 67 S SUPRIADI VI 7 ASTRAZENECA 27/09/2021 K004A
138 3573045205840005 SUSMIATI P 37 JANTI BARAT PADEPOKAN I 14/04 0895325590065 ASTRAZENECA 27/09/2021 K004A
139 3579024805880001 ERLIN KRISWANTI P 33 S SUPRIADI IX 25 08815577405 ASTRAZENECA 27/09/2021 K004A
140 3573042208540003 ADI SUKIMUN L 67 NGAGLIK IID 7 08971591560 ASTRAZENECA 27/09/2021 K004A
141 3573043112470013 NGADI L 74 NGAGLIK IV A 201 087701532720 ASTRAZENECA 27/09/2021 K004A
142 3573041604740001 SUKOHADI L 47 S SUPRIADI VI 15 081348565896 ASTRAZENECA 27/09/2021 K004A
143 3507182903820005 BUDI WASONO L 39 JANTI BARAT PADEPOKAN I 089699260399 ASTRAZENECA 27/09/2021 K004A
145 3573042301950004 YEHEZKEIL AYATULLAH L 26 S SUPRIADI X 4 081357721568 ASTRAZENECA 27/09/2021 K004A
146 3573040902020001 RONI L 19 NGAGLIK IVB 087840510359 ASTRAZENECA 27/09/2021 K004A
147 3573044411780001 SRIANI P 43 S SUPRIADI IV 35 081232174986 ASTRAZENECA 27/09/2021 K004A
148 3573040101710031 MOCHAMMAD L 49 S SUPRIADI VI 27 082336696208 ASTRAZENECA 27/09/2021 K004A
149 3573041501700002 HARIS SUBAGYO L 51 S SUPRIADI VI 31 0895360426826 ASTRAZENECA 27/09/2021 K004A
150 3573040101720038 SUPRIONO L 49 S SUPRIADI 6 13 081233443288 ASTRAZENECA 27/09/2021 K004A
151 3507190104740002 HERI BUDIANTO L 47 PADEPOKAN JANTI BARAT 083831491138 ASTRAZENECA 27/09/2021 K004A
152 3573044810980001 INSIYA SARABILA ZARO P 23 S SUPRIADI IV 31 087826981589 ASTRAZENECA 27/09/2021 K004A
153 3573044405670004 MASLIKHAH P 54 S SUPRIADI 4 081216362770 ASTRAZENECA 27/09/2021 K004A
154 3573040803720002 HENDRA WICAKSONO L 49 S SUPRIADI VI 17 088804873334 ASTRAZENECA 27/09/2021 K004A
155 3573045509760009 YULIATI P 45 PADEPOKAN 1 JANTI BARAT 089515948586 ASTRAZENECA 27/09/2021 K004A
156 3573040906000004 MOECH NUR FIRMANSYAH L 21 S SUPRIADI 6/23 081246775278 ASTRAZENECA 27/09/2021 K004A
157 3573044605770010 URIFAN L 44 S SUPRIADI VI 081331865782 ASTRAZENECA 27/09/2021 K004A
158 3573042112800004 SUDARMAJI L 40 S SUPRIADI VI 20 081331866354 ASTRAZENECA 27/09/2021 K004A
159 3573046106730004 ASMA P 48 NGAGLIK 4B60 0859189638621 ASTRAZENECA 27/09/2021 K004A
160 3573042212680006 PUJI ARIONO L 53 S SUPRIADI 9A 180 085645052115 ASTRAZENECA 27/09/2021 K004A
161 3573046104840001 LIK ASIH P 38 JANTI BARAT PADEPOKAN 081234995864 ASTRAZENECA 27/09/2021 K004A
162 3573046509730004 SRI BUDI HARYANTI P 48 S SUPRIADI 6 13 081233443288 ASTRAZENECA 27/09/2021 K004A
163 3573044511720002 MISINAH P 48 S SUPRIADI 9A 80 082335079825 ASTRAZENECA 27/09/2021 K004A
164 3573041203750009 SUNARTO L 46 S SUPRIADI 6 08125236650 ASTRAZENECA 27/09/2021 K004A
165 3507072301860002 SULISWANTO L 35 S SUPRIADI VI 2 081357578187 ASTRAZENECA 27/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
166 3573042808600002 SANUSI KUSWANTO L 61 NGAGLIK IID 5 085732322894 ASTRAZENECA 27/09/2021 K004A
167 3573046212810009 DIAN SURYAWATI P 40 S SUPRIADI 6 2349 08125236650 ASTRAZENECA 27/09/2021 K004A
168 3573046604820003 DJUBING P 39 S SUPRIADI VI 2 081357578187 ASTRAZENECA 27/09/2021 K004A
169 3573045611780001 NURUL QOMARIAH P 43 S SUPRIADI VI 2265 082257696626 ASTRAZENECA 27/09/2021 K004A
170 3573045012680004 LILIK KOMARIAH P 53 SUPRIADI IX A 33 081316350726 ASTRAZENECA 27/09/2021 K004A
171 3573040508640003 ENDRI SULIATNO L 57 S SUPRIADI VI 35 081217577150 ASTRAZENECA 27/09/2021 K004A
172 3573040304020003 HAMADA CRISTAL OMEGA L 18 S SUPRIADI X 4 081357721568 ASTRAZENECA 27/09/2021 K004A
173 3573040604690003 KATIRAN L 52 SIMPANG SUKUN 02.04 085850263891 ASTRAZENECA 27/09/2021 K004A
174 3573040104980001 TUBAGUS ALFANSYAH L 23 S SUPRIADI VII / 7 081239080120 ASTRAZENECA 27/09/2021 K004A
175 3573041907670004 IMAM SAFII L 54 S SUPRIADI VI 2347 081998286837 ASTRAZENECA 27/09/2021 K004A
176 3573045612670005 SADINI P 54 NGAGLIK IVB 217 087780687678 ASTRAZENECA 27/09/2021 K004A
177 3573042912550002 BUDI SANTOSO L 66 GADAN GIII A 11 085755658327 ASTRAZENECA 27/09/2021 K004A
178 3573043001980003 IMAM RUDI SANTOSO L 23 NGAGLIK IVB 217 082229455460 ASTRAZENECA 27/09/2021 K004A
179 3573040111790005 EKO ATMOJO PUTRO L 41 S SUPRIADI 81 A 087856279179 ASTRAZENECA 27/09/2021 K004A
180 3573040102730003 ACHMAD ZAINUL FACHRUDDIN L 48 S SUPRIADI 2350 085103458583 ASTRAZENECA 27/09/2021 K004A
181 3573041103940003 ASTOMO L 27 NGAGLIK IVB 588 085335660770 ASTRAZENECA 27/09/2021 K004A
182 3573044207620006 SUKARTI P 59 NGAGLIK IVB 588 087703390621 ASTRAZENECA 27/09/2021 K004A
183 3573041807720009 AHMAD HASAN AMIRULLAH L 49 S SUPRIADI IX 50 08153563000 ASTRAZENECA 27/09/2021 K004A
184 3573042502810011 SUKARDIANTO L 40 S SUPRIADI VI 21 085647282663 ASTRAZENECA 27/09/2021 K004A
185 3573041105940005 RICKY CHOIRUL PUTRA L 27 S SUPRIADI VI 2342 081249456234 ASTRAZENECA 27/09/2021 K004A
186 3573040606970009 MUHAMMAD DENY LUTFI L 24 SIMPANG SUKUN 19 081808000299 ASTRAZENECA 27/09/2021 K004A
187 3573044101720006 JASMANI P 49 NGAGLIK IVB 273 087772894432 ASTRAZENECA 27/09/2021 K004A
188 3573041208780001 ARIF WIBISONO L 43 JANTI BARAT PADEPOKAN 14/4 0881026124365 ASTRAZENECA 27/09/2021 K004A
189 3573040905860005 YAFET KURNIAWAN L 35 SIMPANG SUKUN TIMUR 081322412061 ASTRAZENECA 27/09/2021 K004A
190 3573041502830001 SAIFUL ANWAR L 38 NGAGLIK IID 085784332166 ASTRAZENECA 27/09/2021 K004A
191 3505157007940003 AYUNAR P 27 RT.5 RW.8 SUKUN 081517677830 ASTRAZENECA 10/06/2021 CTMAV546 9/27/2021 K004A
192 3515132811880005 WAHYU NAFIER A L 33 PERUM GRAHA SAPTORAYA 081230065397 ASTRAZENECA 11/06/2021 CTMAV546 9/27/2021 K004A
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
1 3573025406940006 RATIH WDYA INTAN PAMUNGKAS P 27 JL. PUTER DALAM SELATAN 55 083848435329 ASTRA ZENECA 28/09/2021 K004A
2 3573031402840004 SULIONO L 37 JL. PUTER DALAM SELATAN 55 083114042915 ASTRA ZENECA 28/09/2021 K004A
3 3573040101650034 ASNAN L 60 JL. TANJUNG PUTRA YUDHA IV/68 083851743506 ASTRA ZENECA 28/09/2021 K004A
4 3573040504540004 MADEKUR L 67 JL. IR. RAIS III/13 6/2 08971592567 ASTRA ZENECA 28/09/2021 K004A
5 3573044503650013 SRI UTAMI P 56 JL. IR. RAIS III/13 6/2 08971592567 ASTRA ZENECA 28/09/2021 K004A
6 3573040101690021 MUNARUL L 52 JL. TANJUNG PUTRA YUDHA II 16/11 082145717091 ASTRA ZENECA 28/09/2021 K004A
7 3509116110850002 SITI USWATUN HASANAH P 36 DSN. SULAKDORO JEMBER 082119419020 ASTRA ZENECA 02/08/2021 D005A 9/28/2021 K004A SELESAI
8 3573035903980004 ARFIKA ROSALIA P 23 JL. TANJUNG PUTRA YUDHA II 16/11 081288032187 ASTRA ZENECA 28/09/2021 K004A
9 5271015004890003 ROYANI P 32 BTN. NELAYAN No..54 LING.KARANG PANAS 0881025585561 ASTRA ZENECA 02/08/2021 D005A 9/28/2021 K004A SELESAI
10 3522227004840004 SUPARMI P 37 DSN. PANASAN BUMIAYU 082139017813 ASTRA ZENECA 02/08/2021 D005A 9/28/2021 K004A SELESAI
11 3529117108780002 HANIYAH P 43 DSN. PESISIR, JAWA TIMUR 087884051415 ASTRA ZENECA 02/08/2021 D005A 9/28/2021 K004A SELESAI
12 3521105508960003 FANI PUTRI AGUSTINA P 24 JL. KELUD CK 087841692854 ASTRA ZENECA 02/08/2021 D005A 9/28/2021 K004A SELESAI
13 3573042311860007 YOHANES HARI SETYO NUGROHO L 35 JL. GEMPOL MARGA BHAKTI 29 082236939550 ASTRA ZENECA 28/09/2021 K004A
14 3573044712790003 KUSTINI P 42 JL. RANGKOK UTARA No. 15 085736020444 ASTRA ZENECA 28/09/2021 K004A
15 3573046709770010 KHUSNUL KHOTIMAH P 44 JL. TANJUNG PUTRA YUDHA II 16/11 0895396153906 ASTRA ZENECA 28/09/2021 K004A
16 3573040907720002 SAMSUL HADI L 49 JL. IR. RAIS IX/218 13/4 ASTRA ZENECA 28/09/2021 K004A
17 3573041912410002 UMAR L 88 JL. IR. RAIS III/40 C 085755544857 ASTRA ZENECA 28/09/2021 K004A
18 3573044203790002 SURYANI P 42 JL. SUKUN GEMPOL 17/9 08964005175 ASTRA ZENECA 28/09/2021 K004A
19 3573045704770009 PONITI P 44 JL. IR. RAIS XV/562 C 085646316618 ASTRA ZENECA 28/09/2021 K004A
20 3573040101860018 SUPRIANTO L 35 JL. PUTER UTARA 7/12 085338554447 ASTRA ZENECA 28/09/2021 K004A
21 3573044506830015 ASIH FIRDAUSIAH P 38 JL. KUNTUL No. 1 0881026253868 ASTRA ZENECA 28/09/2021 K004A
22 3573042212920003 RICCI WICAKSONO L 39 JL. IR. RAIS 14/1C 085331398250 ASTRA ZENECA 28/09/2021 K004A
23 3573046612790005 SRI RAHAYU P 42 JL. TANJUNG PUTRA YUDHA 2 0895396059825 ASTRA ZENECA 28/09/2021 K004A
24 3573041304650002 AGUS SUTIONO L 56 JL. IR. RAIS 14/37 081335231376 ASTRA ZENECA 28/09/2021 K004A
25 3173031507940003 HARI YULIANTO L 27 JL. GEMPOL MARGA BHAKTI 16 081217403548 ASTRA ZENECA 28/09/2021 K004A
26 3573042312750007 GANJAR HARDIANTO L 46 JL. SUKUN GEMPOL 17/9 089694005175 ASTRA ZENECA 28/09/2021 K004A
27 3573044104790010 SITI ALFIAH P 42 JL. KUNTUL No. 14 0881036429740 ASTRA ZENECA 28/09/2021 K004A
28 3573044101710025 SUNAIYAH P 50 JL. KUNTUL No. 7 081907234093 ASTRA ZENECA 28/09/2021 K004A
29 3573040101500042 NGADERI L 71 JL. KAKAKTUA SELATAN 18 - ASTRA ZENECA 28/09/2021 K004A
30 9105012007580002 HARIYANTO L 63 JL. PUTER DALAM SELATAN 53 083854019199 ASTRA ZENECA 28/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
31 3573012607840004 MOCHAMMAD ROJIQ L 37 JL. PUTER UTARA 2 081230797946 ASTRA ZENECA 28/09/2021 K004A
32 3573045210600014 V HARIATIN P 60 JL. GEMPOL MARGA BHAKTI 29 081230051165 ASTRA ZENECA 28/09/2021 K004A
33 3573040507770005 YULIANTO L 44 JL. SUKUN GEMPOL 17/9 089694005175 ASTRA ZENECA 28/09/2021 K004A
34 3573041508740005 BAMBANG AGUS NURIYANTO L 47 TANJUNGREJO 089530731855 ASTRA ZENECA 28/09/2021 K004A
35 3573044407540006 SIYAH P 67 JL. TANJUNG PUTRA YUDHA 4/61 0895339927652 ASTRA ZENECA 28/09/2021 K004A
36 3573044107670083 SUMINI P 56 JL. IR. RAIS 9/10 082332984096 ASTRA ZENECA 28/09/2021 K004A
37 3573041809740005 RIANTO L 47 JL. SUKUN GEMPOL 17/9 081336605836 ASTRA ZENECA 28/09/2021 K004A
38 3573042809810005 SARWIYONO L 39 JL. MERGAN SEKOLAHAN 3/86 085804226769 ASTRA ZENECA 28/09/2021 K004A
39 3573044510750002 SRI SUTIARI P 46 TANJUNGREJO 08976485642 ASTRA ZENECA 28/09/2021 K004A
40 3573041210950002 OKKY OKTARIAWAN L 25 GEMPOL MARGA BHAKTI 44 0895359613483 ASTRA ZENECA 28/09/2021 K004A
41 3573045910790004 RINI LESTYORINI P 42 JL. SUKUN GEMPOL 17/9 081336605836 ASTRA ZENECA 28/09/2021 K004A
42 3573050406820002 YUSWANDONO L 39 JL. MT. HARYONO XIV/1180 0895343003276 ASTRA ZENECA 28/09/2021 K004A
43 3573041211510005 SUDJADI L 70 JL. MERGAN RAYA V/718 085258280306 ASTRA ZENECA 28/09/2021 K004A
44 3507170804880005 DODIEK FERDIANSYAH L 41 PERUM ASABRI DUMPUL 081249599630 ASTRA ZENECA 28/09/2021 K004A
45 3573041104010007 BUSTOMY NUR ARDIANSYAH L 20 JL. PUTER DALAM UTARA No. 41 081382287124 ASTRA ZENECA 28/09/2021 K004A
46 3573041707580002 EDY CAHYONO L 63 JL. IR. RAIS 359 B 081235724700 ASTRA ZENECA 28/09/2021 K004A
47 3573041708720006 AGUS VAHYO PURNOMO L 49 JL. IR. RAIS 14/I 085855147291 ASTRA ZENECA 28/09/2021 K004A
48 3573050912800001 DIDIK YUWANTO L 40 JL. PUTER DALAM UTARA 23 081234026852 ASTRA ZENECA 28/09/2021 K004A
49 3573045206540005 TURIYANTI P 66 JL. IR. RAIS IX/110 082142309010 ASTRA ZENECA 28/09/2021 K004A
50 3573030706860003 IFAN ZIPRI L 35 LESANPURO XII 083117643942 ASTRA ZENECA 28/09/2021 K004A
51 3573044407630001 SUSIATI P 58 JL. RAWI SARI 2/5 081217929101 ASTRA ZENECA 28/09/2021 K004A
52 3573045803710001 SURYANI P 50 JL. MERGAN RAYA I/45 B 0815156323517 ASTRA ZENECA 28/09/2021 K004A
53 3573045910670002 HENNY IRAWATI P 52 JL. MERGAN RAYA No. 7 0895367098435 ASTRA ZENECA 28/09/2021 K004A
54 3573040101580023 DJANDJI YUDHIONO L 63 JL. KASIN JAYA V/15 082140042463 ASTRA ZENECA 28/09/2021 K004A
55 3573041501540009 MOESTAWI L 67 JL. KASIN JAYA 4 No. 4 08085755446466 ASTRA ZENECA 28/09/2021 K004A
56 3573042104750006 SYAMSUL ANAM L 46 JL. MERGAN MUSHOLLA 14-724 081230254497 ASTRA ZENECA 28/09/2021 K004A
57 3573040808880004 SYAIFUL ANWAR L 33 JL. KASIN JAYA 4 No. 1 085755446466 ASTRA ZENECA 28/09/2021 K004A
58 3573042304000009 FICKY SUGIANTO L 21 JL. GEMPOL MARGA BHAKTI 16 085850194355 ASTRA ZENECA 28/09/2021 K004A
59 3573041611930001 WAHYU ADI WIBOWO L 28 WAHYU ADI WIBOWO 085755794945 ASTRA ZENECA 28/09/2021 K004A
60 3507212409980001 ECKY RUSWANDI L 23 JL. RAWI SARI 4/5 085755794945 ASTRA ZENECA 28/09/2021 K004A
61 3573045012630005 NGATIPAH P 58 JL. MERGAN RAYA V/75 0815558210 ASTRA ZENECA 28/09/2021 K004A
62 3573044101810025 SITI WULANDARI P 40 JL. BANDULAN A/216 08986371710 ASTRA ZENECA 28/09/2021 K004A
63 3573046007750008 WIGATI SURYANI P 46 JL. MERGAN KELURAHAN BLOK D1-4A 082233266468 ASTRA ZENECA 28/09/2021 K004A
64 3573045107580005 MISINEM P 63 JL. MERGAN RAYA V/718 085258280306 ASTRA ZENECA 28/09/2021 K004A
65 3573040512790010 YOEDI KRISDIYANTO L 42 JL. BANDULAN A/216 08986371711 ASTRA ZENECA 28/09/2021 K004A
66 3573042504920007 RISTAK SWANDIFANI ADI SAPUTRA L 29 JL. MERGAN MUSHOLLA 719 081915925400 ASTRA ZENECA 28/09/2021 K004A
67 3573041202930009 RICHI SUBANDI L 28 JL. SIKATAN No. 26 083846592502 ASTRA ZENECA 28/09/2021 K004A
68 3573040306650002 PANJI L 56 JL. PUTER UTARA 35 085233167806 ASTRA ZENECA 28/09/2021 K004A
69 3573041504780009 LATIP L 43 JL. MERGAN KELURAHAN BLOK D1-7 08978271112 ASTRA ZENECA 28/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
70 3573042710940004 ASEP GUNAWAN L 27 JL. MERGAN MUSHOLLA 719 C 085771823117 ASTRA ZENECA 28/09/2021 K004A
71 3573040407790005 SUBBANASTAIN IRFA'UDIN L 42 JL. TANJUNG PUTRA YUDHA VI A/19 089652966372 ASTRA ZENECA 28/09/2021 K004A
72 3573045309980005 ALIFIA CAHYANING PRAMESTI P 23 JL. KUNTUL No. 14 082299158866 ASTRA ZENECA 28/09/2021 K004A
73 3573046110990002 YOLA MARATUS ZAHRO P 22 JL. SIKATAN No. 26 083846592502 ASTRA ZENECA 28/09/2021 K004A
74 3573045503850005 MELI SUGIARTI P 36 JL. IR. RAIS 566 087702517775 ASTRA ZENECA 28/09/2021 K004A
75 3573022405640003 BASOEKI RAHARJO, IR L 57 JL. MERGAN RAYA 1/50 081259090147 ASTRA ZENECA 28/09/2021 K004A
76 3573046910690007 SULIKATI P 52 JL. MERGAN MUSHOLLA 725 - ASTRA ZENECA 28/09/2021 K004A
77 3573046009900002 LIDI MANGGAR SUWANDANA P 31 JL. TANJUNG PUTRA YUDHA VI/30 0895634444200 ASTRA ZENECA 28/09/2021 K004A
78 3573044105740005 DAMAYANTI ASTUTIK P 47 JL. IR. RAIS 9 No. 180 A 0895396143197 ASTRA ZENECA 28/09/2021 K004A
79 3573046711870006 LIDI MAYANGSARI P 34 JL. MERGAN MUSHOLLA 722 085721286704 ASTRA ZENECA 28/09/2021 K004A
80 3573045006760015 SARI ANIK P 45 JL. IR. RAIS XII/2A 089520320060 ASTRA ZENECA 28/09/2021 K004A
81 3507186010940001 IRMA LAILATUL MUFIKI P 27 JL. RANGKOK UTARA No. 6 081906071326 ASTRA ZENECA 28/09/2021 K004A
82 3573045312980006 DEVIRA PUTRI ARI SUCI P 23 JL. IR. RAIS XII/2A 08974469747 ASTRA ZENECA 28/09/2021 K004A
83 3573045011850001 SULISTIANI P 36 JL. JUPRI 617 085706464076 ASTRA ZENECA 28/09/2021 K004A
84 3573042002990003 RIZQI RAHMAN L 22 JL. TANJUNG PUTRA YUDHA VI-A/34 '081249820024 ASTRA ZENECA 28/09/2021 K004A
85 3573046608830002 SRI WAHYUNI P 38 JL. ELANG No. 9 082328356968 ASTRA ZENECA 28/09/2021 K004A
86 3573042409690003 SULIYANTO L 52 JL. IR. RAISIX/292 085964226244 ASTRA ZENECA 28/09/2021 K004A
87 3573044405670007 ATIM HARIYANI L 54 TANJUNG PUTRA YUDHA 6/60 087831235260 ASTRA ZENECA 28/09/2021 K004A
88 3573041709820004 JAKIM L 39 JL. ELANG No. 9 082328356968 ASTRA ZENECA 28/09/2021 K004A
89 3573040101710032 AMIN ZULKIFLI L 50 JL. TANJUNG PUTRA YUDHA IV 13/11 089699962833 ASTRA ZENECA 28/09/2021 K004A
90 3507162711820002 MUJI RAHARJO L 39 JL. IR. RAIS IX/218 13/4 089649088931 ASTRA ZENECA 28/09/2021 K004A
91 3573043004810010 AGUNG SETIAWAN L 40 JL. IR. RAIS GG 3/15 0895366880260 ASTRA ZENECA 28/09/2021 K004A
92 3573046906810007 SRI SUNARSIH P 40 JL. SIKATAN No. 28 083129266105 ASTRA ZENECA 28/09/2021 K004A
93 3573014607790001 NURUL ACHIPIYAH P 42 GEMPOL MARGA BHAKTI 22 0895413978587 ASTRA ZENECA 28/09/2021 K004A
94 3573040709700003 KANTUN L 51 JL. TANJUNG PUTRA YUDHA VI B/19 08953951522 ASTRA ZENECA 28/09/2021 K004A
95 3573040505560006 SUPIRIN L 65 JL. SUKUN GEMPOL 17/9 085231001061 ASTRA ZENECA 28/09/2021 K004A
96 3573041011970002 YOGA ANDI PRATAMA L 24 JL. SUKUN GEMPOL 17/9 081944876005 ASTRA ZENECA 28/09/2021 K004A
97 3573027101000003 FITRI AMALIA LASMI PUTRI P 21 JL. MGR SUGIO PRANOTO II/37 A 0895362645175 CORONAVAC 28/09/2021 K004A
98 3573041103030002 ARYA YOGA FIRMANSYAH L 18 JL. KASIN JAYA III 6/1 087765910748 ASTRA ZENECA 28/09/2021 K004A
99 3573040107910073 HABIB L 30 JL. RANGKOK UTARA No. 6 081906071326 ASTRA ZENECA 28/09/2021 K004A
100 3573025107990002 VITA YULIA PUTRI P 22 JL. MGR SUGIO PRANOTO II/37 A 085692515293 ASTRA ZENECA 28/09/2021 K004A
101 3573041709950005 ACHMAD SOLEH L 26 JL. SUKUN GEMPOL 17/9 089605513692 ASTRA ZENECA 28/09/2021 K004A
102 3573045107940002 DEWA ATHFI ROCHMA P 27 JL. MERGAN LORI III/44 089602626960 ASTRA ZENECA 28/09/2021 K004A
103 3573042008470004 DULWACHID L 74 JL. IR. RAIS VIII/70 - ASTRA ZENECA 28/09/2021 K004A
104 3573044806720004 KARTINI P 49 JL. IR. RAIS III/38 - ASTRA ZENECA 28/09/2021 K004A
105 3573032512890002 FARIS IRAWAN L 32 JL. KOLONEL SUGIONO IX D/20 082144411891 ASTRA ZENECA 28/09/2021 K004A
106 3573041107620004 SUGENG HARIYONO L 59 JL. MERGAN RAYA XIX/5 082141242396 ASTRA ZENECA 28/09/2021 K004A
107 3573044811860008 LULUK SUGIANTI P 35 JL. MERGAN RAYA III/43 085856980543 ASTRA ZENECA 28/09/2021 K004A
108 3573046203720003 NETTY HERMAWATI P 49 JL. IR. RAIS XIV/1A 085697561336 ASTRA ZENECA 28/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
109 3573046601020008 AZIZAH FAISA PUTRI P 19 JL. IR. RAIS III/38 085812431298 ASTRA ZENECA 28/09/2021 K004A
110 3573041002390003 MOEDJIONO L 76 RT 1 RW 10 TANJUNGREJO 081334833724 ASTRA ZENECA 28/09/2021 K004A
111 3573042111780002 MOCHAMMAD SOLIHIN L 43 JL. PUTRA YUDHA 2 083830973586 ASTRA ZENECA 28/09/2021 K004A
112 3573045302800006 TAQWA MULIANA ANGGRAINI P 41 JL. IR. RAIS IX/276 08383598797 ASTRA ZENECA 28/09/2021 K004A
113 3573042810810006 LUKMAN HAKIM L 40 JL. IR. RAIS 558-A 08988995243 ASTRA ZENECA 28/09/2021 K004A
114 3573044910990002 JAUZAA AFIFA P 22 JL. IR. RAIS III/38 F 087855328815 ASTRA ZENECA 28/09/2021 K004A
115 3573050703790012 HAIDAR L 42 JL. IR. RAIS III/28 A 081937000068 ASTRA ZENECA 28/09/2021 K004A
116 3573041208760009 AGUS WAHYUDI L 45 JL. IR. RAIS IX/276 083848556960 ASTRA ZENECA 28/09/2021 K004A
117 3573045806530005 MISRIYATI P 68 JL. NGAGLIK II D/4 - ASTRA ZENECA 28/09/2021 K004A
118 3517120909930001 MUCHAMAD YASIN TRIO PRASETYO L 28 JL MERGAN RAYA III/30 081252416593 ASTRA ZENECA 28/09/2021 K004A
119 3573040401740005 MOH NADIR L 47 JL. KASIN JAYA V/19 08915606698 ASTRA ZENECA 28/09/2021 K004A
120 3573044609020006 MASYIATILLAH P 19 JL. KASIN JAYA V/19 - ASTRA ZENECA 28/09/2021 K004A
121 3573056608790007 HIKMA P 42 JL.IR.RAIS III/28A 081937111197 ASTRA ZENECA 28/09/2021 K004A
122 3573041412770001 SUBAGIO L 44 JL.MERGAN LORI 2C/27 081363254360 ASTRA ZENECA 28/09/2021 K004A
123 3528015610360002 NOOR MAIDAH P 35 JL.KASIN JAYA II/7 085954403755 ASTRA ZENECA 28/09/2021 K004A
124 3528011406820002 FADILI L 39 JL.KASIN JAYA II/7 087883659708 ASTRA ZENECA 28/09/2021 K004A
125 3573041008760007 SIGIT BAMBANG KUNCORO L 45 JL.KASIN JAYA II/54 082231410010 ASTRA ZENECA 28/09/2021 K004A
126 3573044706530002 RONI P 68 JL.MEGAN KERAMAT 51 085258458887 ASTRA ZENECA 28/09/2021 K004A
127 3522140509790001 CHOIRUL SISWANTO L 42 JL.IR.RAIS III/16 081290890557 ASTRA ZENECA 28/09/2021 K004A
128 3573044807750004 PUDJI LESTARI P 46 JL.IR.RAIS IX/142 085339124791 ASTRA ZENECA 28/09/2021 K004A
129 3573047009630005 SITI SOFIYAH P 58 JL.MERGAN KELAPA SAWIT 32 - ASTRA ZENECA 28/09/2021 K004A
130 3573041006820004 PUJIANTO L 39 JL.PUTER SELATAN 14 081331899452 ASTRA ZENECA 28/09/2021 K004A
131 3573034311840001 NOVYTA DHEWANTY P 37 JL.PUTER SELATAN 14 081331899452 ASTRA ZENECA 28/09/2021 K004A
132 3573042505600004 BUDIONO L 61 JL.KASIN JAYA IV/30 - ASTRA ZENECA 28/09/2021 K004A
133 3573045205780011 YULIATI P 43 JL.KASIN JAYA IV/26 088804867820 ASTRA ZENECA 28/09/2021 K004A
134 3573042106820001 FAJAR MARGA KUSDIANTOK L 39 JL.IR.RAIS IX/206 085904399060 ASTRA ZENECA 28/09/2021 K004A
135 3573040811480001 SUDJIJONO L 73 JL.MERGAN KERAMAT 51 08525845887 ASTRA ZENECA 28/09/2021 K004A
136 3573042103800005 RIZKI DJANATA L 41 JL.MERGAN KELURAHAN BLOK D1 - ASTRA ZENECA 28/09/2021 K004A
137 3573044309790007 SRI NURHAYATI P 42 JL.IR.RAIS 14 083832504370 ASTRA ZENECA 28/09/2021 K004A
138 3573045112820002 SUCI LAHYATI P 39 JL.MERGAN SEKOLAHAN 0895611998132 ASTRA ZENECA 28/09/2021 K004A
139 3573045403700002 NASIHAH P 51 JL.KASIN JAYA 4 No.21 08993897373 ASTRA ZENECA 28/09/2021 K004A
140 3573040810710003 MASKUR L 50 JL.KASIN JAYA 087773918392 ASTRA ZENECA 28/09/2021 K004A
141 3573042701620002 KABUL L 59 JL.KASIN JAYA IV/19 - ASTRA ZENECA 28/09/2021 K004A
142 3573044109530008 MISNATI P 68 JL.IR.RAIS IX/36 081215065317 ASTRA ZENECA 28/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
143 3573043112700023 SUPARDI L 51 JL.SUKUN GEMPOL 083849751192 ASTRA ZENECA 28/09/2021 K004A
144 3573031808870006 NURHADI L 34 BUMIAYU-KEDUNGKANDANG 0895333441165 ASTRA ZENECA 28/09/2021 K004A
145 3573042103600004 MISKAN L 61 TANJUNGREJO 4/5 - ASTRA ZENECA 28/09/2021 K004A
146 3573047101750001 HARIYATI P 46 JL.KASIN JAYA 2 No.6 081220372318 ASTRA ZENECA 28/09/2021 K004A
147 3507197112610003 BAWOK AMIRAWATI P 60 JL.KARANGJATI - ASTRA ZENECA 28/09/2021 K004A
148 3573044101550009 KADAR MANIK P 66 JL.SUKUN GEMPOL 14 - ASTRA ZENECA 28/09/2021 K004A
149 3573046706700003 SAROFAH P 51 JL.TANJUNGREJO 3/11 089680818366 ASTRA ZENECA 28/09/2021 K004A
150 3573034809750002 LEGINTEN P 46 JL.KAPRI 083117232125 ASTRA ZENECA 28/09/2021 K004A
151 3507266006720001 KUSMIATI P 49 DSN.KRAJAN-PUJON 21/10 - ASTRA ZENECA 28/09/2021 K004A
152 3573045203570003 SUMIATI P 64 JL.MERGAN KERAMAT 25 0895366449970 ASTRA ZENECA 28/09/2021 K004A
153 3573045810930004 SISKA MAHARANI P 28 JL.KASIN JAYA II/6 08993514953 ASTRA ZENECA 28/09/2021 K004A
154 3573031410020005 WAHYU PRASETYO L 19 JL.KAPRI 083111076071 ASTRA ZENECA 28/09/2021 K004A
155 3573044303820005 INDAH KURNIAWATI P 39 JL.MERGAN KERAMAT 19/25 085105455778 ASTRA ZENECA 28/09/2021 K004A
156 3573040809840003 IRWANTO L 37 JL.BARENG RAYA II/335E 081805010847 ASTRA ZENECA 28/09/2021 K004A
157 3573043005690003 IMAM SYAMSURI L 52 JL.IMAM SUJONO No.54 081238145846 ASTRA ZENECA 28/09/2021 K004A
158 3573047012650006 HERNANIK P 56 JL.SUKUN GEMPOL No.12 - ASTRA ZENECA 28/09/2021 K004A
159 3573045210850004 SITI MAIMUNAH P 36 JL.BARENG RAYA II/335 E 087750005950 ASTRA ZENECA 28/09/2021 K004A
160 3573046602690006 SITI RAKHMAWATI P 52 JL.IMAM SUJONO No..54 087832009601 ASTRA ZENECA 28/09/2021 K004A
161 3573046404670004 MARTINAH P 54 JL.GEMPOL No..3 081932782009 ASTRA ZENECA 28/09/2021 K004A
162 3573045005810009 MELANI P 40 JL.KASIN JAYA III/22 081336240060 ASTRA ZENECA 28/09/2021 K004A
163 3573045109660002 ANIK PRIATININGSIH P 55 JL.IR.RAIS IX/185 082229186142 ASTRA ZENECA 28/09/2021 K004A
164 3573021203670003 MAT SUMBRA L 54 JL.IR.RAIS IV/53 - ASTRA ZENECA 28/09/2021 K004A
165 3507195907950001 NISA'UL FAJRIYAH P 26 JL.KASIN JAYA III/5 089687049680 ASTRA ZENECA 28/09/2021 K004A
166 3573044706680001 NUNUK WIDAYATI P 53 JL.IR.RAIS XIV/7C 085738678920 ASTRA ZENECA 28/09/2021 K004A
167 3573044506650014 SUPIYAH P 56 JL.KASIN JAYA 4 089517990803 ASTRA ZENECA 28/09/2021 K004A
168 3573044503730004 PUJIATI P 48 JL.SUKUN GEMPOL - ASTRA ZENECA 28/09/2021 K004A
169 3573046503760006 NAFSIYAH P 45 JL.SUKUN GEMPOL No..20 083115205628 ASTRA ZENECA 28/09/2021 K004A
170 3573046812600002 RIYANI P 61 JL.SUKUN GEMPOL 36 08885528363 ASTRA ZENECA 28/09/2021 K004A
171 3573040610700002 MOCHAMAD SYARIFUDIN L 51 TANJUNGREJO 3/11 089692669250 ASTRA ZENECA 28/09/2021 K004A
172 3573012705800001 HIDAYAT L 41 JL.MUHARTO VIII/4 0851027350711 ASTRA ZENECA 28/09/2021 K004A
173 3573044407580002 SUWARNI P 63 JL.IR.RAIS 1/38 - ASTRA ZENECA 28/09/2021 K004A
174 3573046310800001 NUR AINI P 41 JL.KASIN JAYA 5/18 081909057774 ASTRA ZENECA 28/09/2021 K004A
175 3573046911660002 SRI MURNI ATININGSIH P 55 JL.NGAGLIK IIC/387 081934739550 ASTRA ZENECA 28/09/2021 K004A
176 3573021701770007 ALI MUKSIN L 44 JL.BARENG RAYA 288H 087763494448 ASTRA ZENECA 28/09/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
177 3573040506700002 SARIFUDDIN L 51 JL.IR.RAIS I/47B 087743300268 ASTRA ZENECA 28/09/2021 K004A
178 3573044602830003 MUTIAH P 48 JL.IR.RAIS I/47B 83832486768 ASTRA ZENECA 28/09/2021 K004A
179 3507210308850001 PURWANTORO L 37 DSN. JEMUNANG PANDANREJO WAGIR 081776729738 ASTRA ZENECA 28/09/2021 K004A
180
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
No NIK Nama Penerima Vaksin L/P Alamat No. Hp Merek Vaksin Tanggal
Tanggal Pemberian No. Batch Pemberian No. Batch
Vaksinasi Vaksinasi
1 3573045807750002 HENY PURWATININGSIH P 56 JL.JANTI SELATAN VII/23 01/06 089638253070 ASTRAZENECA 29/09/2021 K004A
2 3573044711550002 MASRIYAH P 66 JL.KLAYATAN III/62 09/02 082141277353 ASTRAZENECA 29/09/2021 K004A
3 3573046812660002 SUPIYAH P 55 JL.KLAYATAN II/29 15/12 082231227184 ASTRAZENECA 29/09/2021' K004A
4 3573045312720002 HERWIYATI P 49 JL.JANTI BARAT 1/21 01/08 081237417544 ASTRAZENECA 29/09/2021 K004A
5 3573042606600002 SUTOMO L 61 JL.KLAYATAN II/36 12/12 085890760936 ASTRAZENECA 29/09/2021 K004A
7 3573040805640001 SUWADJI L 57 JL.SIMPANG KEPUH 9C 04/10 08995687171 ASTRAZENECA 29/09/2021 K004A
8 3573042303770002 DJALI L 46 JL.DANURI KEMANTREN I No.3 06/03 0895634800005 ASTRAZENECA 29/09/2021 K004A
9 3573044503600002 BACHRIYAH P 61 JL.KLAYATAN 2/2 10/12 081336151865 ASTRAZENECA 29/09/2021 K004A
10 3573042208500001 SUHARI L 71 JL.KLAYATAN II/1 04/01 081231317400 ASTRAZENECA 29/09/2021 K004A
11 3573045209780002 ASTUTIK P 43 JL.DANURI KEMANTREN I No.3 06/03 085850873287 ASTRAZENECA 29/09/2021 K004A
12 3573044304730008 SARI RAHAYU P 48 JL.KEMANTREN I PATTIMURRA No.92 085850425139 ASTRAZENECA 29/09/2021 K004A
13 5315065212940001 BERNADITA DEWI P 27 JL.SIMPANG KEPUH 15 07/10 081246627582 ASTRAZENECA 29/09/2021 K004A
14 3573042912780009 HENGKI WIJAYADI L 43 JL.KEPUH III/22 01/05 085102306852 ASTRAZENECA 29/09/2021 K004A
15 357304103730013 SUWARDIANTO L 48 JL.KEMANTREN I PATTIMURRA No.92 085850425139 ASTRAZENECA 29/09/2021 K004A
16 3573042401840002 ERICK ARI INDRAWAN L 37 JL.SIMP KEPUH No.2 01/10 082132319328 ASTRAZENECA 29/09/2021 K004A
17 3573044711520001 SUMIATI P 69 JL.KEMANTREN I/21B 12/03 - ASTRAZENECA 29/09/2021 K004A
18 3507014207870002 EUIS YULIA MASYITHAH P 34 JL.KEMANTREN I/PATTIMURA 114 10/03 081249890530 ASTRAZENECA 29/09/2021 K004A
19 3573042904950003 SAPRIL GUNTUR PURNOMO L 26 JL.KLAYATAN I/56A 04/12 083841778995 ASTRAZENECA 29/09/2021 K004A
20 3573040408680002 KUS SUHARTO L 43 JL.KLAYATAN 2/74 13/12 082132324223 ASTRAZENECA 29/09/2021 K004A
22 3573046605720001 MEI LIANI P 49 JL.KEPUH X 08/05 082252186099 ASTRAZENECA 29/09/2021 K004A
24 3573045204030006 NADIVA APRILIA P 18 JL.KEMANTREN I 08/03 085607488894 ASTRAZENECA 29/09/2021 K004A
25 3573045703900003 KHUSNUL KHOTIMAH P 30 JL.KEMNATREN II/28 04/03 085749950980 ASTRAZENECA 29/09/2021 K004A
26 3573042601860003 SUPRIONO L 35 JL.KEMNATREN II/28 04/03 085749950980 ASTRAZENECA 29/09/2021 K004A
27 3573041108530001 SUKIMAN L 68 JL.KEPUH UTARA 33 04/04 082139646749 ASTRAZENECA 29/09/2021 K004A
28 3573045704770008 SULISTIYANI P 44 JL.KLAYATAN 1/31 06/01 089685416374 ASTRAZENECA 29/09/2021 K004A
30 357304490840009 DIAN FITRI P 37 JL.KEPUH III/16 01/05 081330920167 ASTRAZENECA 29/09/2021 K004A
31 3573042811750002 HERI WIDODO L 46 JL.KEMANTREN II 02/03 0815558888221 ASTRAZENECA 29/09/2021 K004A
32 3573042102020002 DANNY FEBRIANTO L 19 JL.KEMNATREN I/1 06/03 083863332917 ASTRAZENECA 29/09/2021 K004A
33 3573046404860009 DEWI AMALYAH P 35 JL.KEMNATREN II/17 081026575946 ASTRAZENECA 29/09/2021 K004A
35 3573045404570005 MASAMAH P 65 JL.KEMANTREN II/48 03/03 0881026575946 ASTRAZENECA 29/09/2021 K004A
Dosis I Dosis 2
No NIK Nama Penerima Vaksin L/P Umur Alamat No. Hp Merek Vaksin Keterangan
Tanggal Pemberian Tanggal
No. Batch Pemberian No. Batch
Vaksinasi
Vaksinasi
36 3573045209650010 JUWARIYAH P 47 JL.KLAYATAN 11/45 13/12 088989108983 ASTRAZENECA 29/09/2021 K004A

37 3573042210960001 TEDDY TRI MURDIANTO L 25 JL.SONO KEMBANG No..5 01/06 089506274202 ASTRAZENECA 29/09/2021 K004A
40 3573046302830002 KHOLIFAH P 38 JL.KLAYATAN III/20 001/002 081330234009 ASTRAZENECA 29/09/2021 K004A
41 3573040807750002 SUPRIYANTO L 46 JL.KLAYATAN II/43 085850347489 ASTRAZENECA 29/09/2021 K004A
42 3573046005640003 MISGIYANTI P 57 JL.S.SUPRIYADI GGMANDALA A-80 06/04 081232740453 ASTRAZENECA 29/09/2021 K004A
43 3573042408010006 AGUNG FERDIANSAH L 20 JL.KLAYATAN II 13/12 085730332381 ASTRAZENECA 29/09/2021 K004A
44 3573046007530001 SULAMI P 58 JL.KEPUH UTARA 33 04/04 082139646749 ASTRAZENECA 29/09/2021 K004A
45 3573041804590001 B.SULISMANTO L 52 PERUM SPI X/14 05/07 082234089000 ASTRAZENECA 29/09/2021 K004A
46 3573046706760003 TRI YUNIASIH P 45 JL.KEMNATREN II 02/03 083834669946 ASTRAZENECA 29/09/2021 K004A
47 3573046710830009 TRI LESTARI INDRIANI P 39 JL.KLAYATAN III /3D 02/02 085755178150 ASTRAZENECA 29/09/2021 K004A
48 3507024507920001 WIWIK WIDIANTI P 29 JL.KEMANTREN II GGJERUK-10 01/03 085230739970 ASTRAZENECA 29/09/2021 K004A
49 35730364050100005 ANUGRAH INTAN PUSPITA SARI P 22 JL.KEMANTREN I/15 11/03 085872686809 ASTRAZENECA 29/09/2021 K004A
50 3573041508690003 AGUS PRIYANTO L 52 JL.KEMANTREN I/I 06/03 083863332917 ASTRAZENECA 29/09/2021 K004A
51 3505124202790002 ANIK SETYOWATI P 42 PERUM SPI Q/4 07/07 081572676865 ASTRAZENECA 29/09/2021 K004A
52 3573040902990006 MOH.DWI LAKSONO L 22 JL.KLAYATAN I/40 01/12 083183562390 ASTRAZENECA 29/09/2021 K004A
53 3573044110950003 ETIKA TRI SAKTI P 26 JL.KEMANTREN I 06/03 08970404527 ASTRAZENECA 29/09/2021 K004A
54 3573045302670001 NANIK SUSELI P 54 JL.KLAYATAN II/36 12/12 085890760936 ASTRAZENECA 29/09/2021 K004A
55 3573041806010002 MOCHAMMAD RAFLI R L 20 JL.JANTI SELATAN VII/39 05/06 085230126715 ASTRAZENECA 29/09/2021 K004A
56 3573045106660003 SUYATI P 55 JL.KLAYATAN II/52 08787126479 ASTRAZENECA 29/09/2021 K004A
57 3507200912840002 PURWANTO L 36 JL.KLAYATAN III/6 02/02 082131182250 ASTRAZENECA 29/09/2021 K004A
58 3573044704780003 SUTANTI P 43 JL.KEMANTREN I/103 10/03 085704081288 ASTRAZENECA 29/09/2021 K004A
60 3573044902650007 SITI HALIMAH P 56 JL.KLAYATAN I/40 09/01 085645457395 ASTRAZENECA 29/09/2021 K004A
61 3573044211730001 SITI FATIMAH P 48 JL.KEMNATREN I/20 08/03 082257712810 ASTRAZENECA 29/09/2021 K004A
63 3573040806600001 MUDJIONO L 61 JL.KLAYATAN I/40A 09/01 085645457395 ASTRAZENECA 29/09/2021 K004A
64 3573045508760004 MASITA P 56 JL.KLAYATAN III 11/02 085607435855 ASTRAZENECA 29/09/2021 K004A
65 3573042708650001 SUGENG SUWARNO L 56 PERUM SPI S-14 04/07 083857210698 ASTRAZENECA 29/09/2021 K004A
66 3573042904660003 SUKADI L 55 JL.SIMP KEPUH UTARA A-30 08/10 085895428279 ASTRAZENECA 29/09/2021 K004A
68 3573046501990002 ASTI ROSALINA P 22 PERUM SPI S-14 04/07 083857210698 ASTRAZENECA 29/09/2021 K004A
69 3573041404020002 VIKY FERDIANSYAH L 19 PERUM SPI S-14 04/07 083857210698 ASTRAZENECA 29/09/2021 K004A
70 3573041701830001 SISWANTO L 38 JL.KEMANTREN I/7 11/03 085749011433 ASTRAZENECA 29/09/2021 K004A
71 3573042502570004 EDI SUJARWO L 64 JL.KEMNATREN I 06/03 08970404527 ASTRAZENECA 29/09/2021 K004A
72 3573041812800004 CHERI DONI T L 40 PERUM CITRA KEPUH RAYA A/17 06/10 085103583344 ASTRAZENECA 29/09/2021 K004A
73 3573042202670001 SUTIKNO L 45 JL.KEMNATREN I/63 11/03 085731709817 ASTRAZENECA 29/09/2021 K004A
74 3573041408800009 SUGIANTO L 41 JL.KLAYATAN I 06/12 089696750651 ASTRAZENECA 29/09/2021 K004A
75 3573040202020007 MOHAMMAD FEBRIANTO L 19 JL.KLAYATAN I/30 07/12 087843936516 ASTRAZENECA 29/09/2021 K004A
76 3573054708640007 ARI KURNIAWATI P 57 JL.BOUGENVILLE BAWAH No.24 01/09 085236937676 ASTRAZENECA 29/09/2021 K004A
78 3573042811920002 MOCH SYAIFUL RIJAL L 29 JL.KEPUH X/4 07/05 081330669752 ASTRAZENECA 29/09/2021 K004A
79 3507192403940002 TEGAR FITRA ADITYA L 27 JL.TEGALMULYO IINO7 YK 09/02 087871007440 ASTRAZENECA 29/09/2021 K004A
80 3573045907880002 DIANA SUSANTI DEVI P 33 JL.KLAYATAN II/65 13/12 081333893069 ASTRAZENECA 29/09/2021 K004A
Dosis I Dosis 2
Vaksinasi
Vaksinasi
81 3573042508830007 KARNO PUNGKAS GUSTIAR L 38 JL.KLAYATAN II/65 081333286869 ASTRAZENECA 29/09/2021 K004A
82 3573041905700002 MOH ZAHRI L 51 JL.KLAYATAN II/34 01/01 0851013678819 ASTRAZENECA 29/09/2021 K004A
84 3573044304750006 MARIANI P 46 JL.JANTI UTARA V/60 04/09 089652408237 ASTRAZENECA 29/09/2021 K004A
85 3573044106780006 YULI KRISNANI P 43 JL.KLAYATAN I/30 07/12 083112280823 ASTRAZENECA 29/09/2021 K004A
86 3507301506020003 MUCHLIS ALRIZKY AKBAR L 19 JL.KEPUH IV 02/05 082132299845 ASTRAZENECA 29/09/2021 K004A
87 3573041104850008 NUR IMANSA ROCHMAN L 36 JL.SIMP KEPUH 25 03/10 083831580261 ASTRAZENECA 29/09/2021 K004A
91 3573040505780002 MOHAMMAD RIZAL L 43 JL.KEMNATREN II/48 03/03 085100542907 ASTRAZENECA 29/09/2021 K004A
92 3573040808540002 WARSONO L 67 JL.KEMNATREN II/17 03/03 085100542907 ASTRAZENECA 29/09/2021 K004A
93 3573040901610003 EDDY PUDJI SANTOSO L 60 JL.KLAYATAN III/19B 10/02 081330788219 ASTRAZENECA 29/09/2021 K004A
94 3573040408840006 ROIS ISLAM L 37 JL.KEPUH VI/7 10/05 087705743631 ASTRAZENECA 29/09/2021 K004A
95 3573044311710004 MUNTIANI P 50 JL.KLAYATAN III 10/02 085803870333 ASTRAZENECA 29/09/2021 K004A
96 3573042206690003 SUHUD L 52 JL.KLAYATAN III 10/02 085704033807 ASTRAZENECA 29/09/2021 K004A
97 3573040607990008 ATIM GUNTUR RACHMAT L 22 JL.KLAYATAN I/12 08/01 081553363125 ASTRAZENECA 29/09/2021 K004A
98 3273175504900002 FITRIAH P 32 KOMP.BILABONG SOETA 5 07/08 081809075992 ASTRAZENECA 29/09/2021 K004A
99 3573045007620001 SANAH P 59 JL.SIMPANGH KEPUH 25 03/10 083848873260 ASTRAZENECA 29/09/2021 K004A
100 3573042905840009 CUCUK PRIBADI L 37 JL.KLAYATAN I/25 03/12 083114965978 ASTRAZENECA 29/09/2021 K004A
101 3573045305610001 SUSANTI P 62 JL.KLAYATAN II/13 083834303009 ASTRAZENECA 29/09/2021 K004A
102 3573045209890003 AUFA NUR AYU P 32 JL.SIMP KEPUH 25 03/10 083831396839 ASTRAZENECA 29/09/2021 K004A
103 3573047011820008 NOVITA HANDAYANI P 39 JL.KLAYATAN I 10/01 089664888877 ASTRAZENECA 29/09/2021 K004A
104 3573041609740009 MAMEK IMAM SANTOSO L 47 JL.S.SUPRIADI X/21 15/06 082331099897 ASTRAZENECA 29/09/2021 K004A
105 3573044711550001 SRI HARIYATI P 66 JL.KLAYATAN 3/21 A GG TERATAI 085100711336 ASTRAZENECA 29/09/2021 K004A
106 3573041608740009 AGHUS RIYANTO L 47 JL.KLAYATAN III/21A 05/02 085624063973 ASTRAZENECA 29/09/2021 K004A
19 3573025002860001 KHOIRUL NISA P 35 JL.KLAYATAN I/17 08/01 082230809067 ASTRAZENECA 29/09/2021 K004A
109 3573040310790005 AKHMAD HANDIK PRIYAWANTO L 42 JL.KLAYATAN III No.3D 02/02 085755178150 ASTRAZENECA 29/09/2021 K004A
110 35730420009630002 SUWANDI L 58 JL.KLAYATAN II/7 08/12 081336579209 ASTRAZENECA 29/09/2021 K004A
111 3573044301690002 YUNIK SISWATI P 52 JL.KLAYATAN II/71 15/12 087759662737 ASTRAZENECA 29/09/2021 K004A
114 3507054704910005 DWI SUSANTI P 30 JL.KEPUH UTARA BLOK A/21 087873720636 ASTRAZENECA 29/09/2021 K004A
115 35730412202780003 AGUS PUJIONO L 43 JL.KEPUH UTARA BLOK A/21 081944915261 ASTRAZENECA 29/09/2021 K004A
116 3573041307970001 MUCH ILHAM MUTTAQIN N L 24 JL.S.SUPRIADI VI/2337 07/06 081216162331 ASTRAZENECA 29/09/2021 K004A
117 3573042711800006 SALMAN FARIS L 41 JL.KLAYATAN III/14C 04/02 0895386271320 ASTRAZENECA 29/09/2021 K004A
118 3573040405430001 D RIJO PRIJANTO L 78 JL.KLAYATAN No.21 07/02 082232986668 ASTRAZENECA 29/09/2021 K004A
119 3573045509650003 SUNARMI P 56 JL.KLAYATAN II/69 15/12 0857082655746 ASTRAZENECA 29/09/2021 K004A
120 3573042601930002 HENDYK DWI PRASETYO ARIANTO L 28 JL.KLAYATAN II/13 04/01 081934645294 ASTRAZENECA 29/09/2021 K004A
121 3573046108680003 ANA ATIK WINANTI P 53 JL.SIMP KEPUH No..24 08/10 082332311532 ASTRAZENECA 29/09/2021 K004A
122 3573046103680003 SUMIATI P 53 JL.KLAYATAN I/24 06/12 081232890985 ASTRAZENECA 29/09/2021 K004A
123 3573042603630001 PURWADI L 58 JL.KLAYATAN I/24 06/12 085104660311 ASTRAZENECA 29/09/2021 K004A
124 3573045907020002 DIVA CHEFI NATASYA P 19 JL.KEMNATREN III/7 06/13 085731439642 ASTRAZENECA 29/09/2021 K004A
127 3573041506690001 ANTONIUS MIAJI L 52 JL.SIMP KEPUH No..24 08/10 085211448298 ASTRAZENECA 29/09/2021 K004A
128 3573042612630003 KUSDIANTO L 57 JL.RAYA KEPUH No.13 03/05 081918174323 ASTRAZENECA 29/09/2021 K004A
129 3573042408790001 DADANG HARI FITRIANSYAH L 42 JL.KEMANTREN 3/33 06/13 085645906796 ASTRAZENECA 29/09/2021 K004A
130 3573046802690003 SITI ROKHANI P 52 PERUM SPI Q-4 07/07 081555778778 ASTRAZENECA 29/09/2021 K004A
132 3573015801870006 ROBIATUL LAILI P 34 JL.JANTI SELATAN N01A 04/06 085790804527 ASTRAZENECA 29/09/2021 K004A
133 3573042209950003 ANDI WIDODO L 26 JL.KLAYATAN I/45 06/12 089523884558 ASTRAZENECA 27/07/2021 ABY1911 9/29/2021 K004A
134 3573044111360002 MISWATIN P 74 JL.SIMP.SUKUN TIMUR 38 081290180894 ASTRAZENECA 29/09/2021 K004A
135 3573041601820009 MOCHAMMAD MUKHLIS L 39 JL.KEBEN BLOK A-33A 05/11 085103099399 ASTRAZENECA 29/09/2021 K004A
139 3573042305770010 S.HARIONO L 44 JL.KLAYATAN 2 14-27 085100365645 ASTRAZENECA 29/09/2021 K004A
140 3573044703730007 SUTRIYANI P 48 JL.JANTI SELATAN 7/11 087761762545 ASTRAZENECA 9/29/2021 K004A
141 73710158029500001 DWI ANGGRAENI KUNTJORO P 26 PERUM SPI Z/07 06/07 082232983822 ASTRAZENECA 9/29/2021 K004A
Dosis I Dosis 2
Vaksinasi
Vaksinasi
6 3573046811920002 EKA NOVITA PRATIWI P 19 JL.SUKUN GEMPOL 13/09 08816932918 ASTRAZENECA 29/09/2021 K004A
21 3573041312670005 SUDARTO L 54 JL.SUKUN GEMPOL No. 46 03/09 083800667943 ASTRAZENECA 29/09/2021 K004A
23 3573046912690004 RINA HARIYANINGSIH P 52 JL.SUKUN GEMPOL No..46 03/09 083122818201 ASTRAZENECA 29/09/2021 K004A
29 3312072004810000 SUNARSO L 30 KARANGSONO KEBONAGUNG 083894167444 ASTRAZENECA 29/09/2021 K004A
34 3505171302660002 REKNO SUHADI L 55 DSN NGOLAKAN BLITAR 081234329010 ASTRAZENECA 29/09/2021 K004A
38 3573044403670005 TRI ES P 54 JL.PUTRA YUDHA 6A/48 15/11 082233812947 ASTRAZENECA 29/09/2021 K004A
39 3573046710000003 IKKE ASTRID DEWI P 21 JL.TANJUNG PYTRA YUDHA VI-A/43 15/11 081946176737 ASTRAZENECA 29/09/2021 K004A
59 3573045409030003 DINDA PINKA ELSA PUTRI P 18 JL.SUKUN GEMPOL 32 12/09 082139723140 ASTRAZENECA 29/09/2021 K004A
62 350714505830008 ROHMAWATI P 38 JL.MAKMUR 38 16/05 081946228822 ASTRAZENECA 29/09/2021 K004A
67 3507180101910031 NURUL HUDA L 30 KRAJAN 03/03 083857210698 ASTRAZENECA 29/09/2021 K004A
77 3573054203860006 DEVI SITHA PERTIWI P 35 JL.MERGAN SEKOLAHAN 44 06/06 085236937676 ASTRAZENECA 29/09/2021 K004A
83 5171041109800001 MESTO L 31 JL.KYAI SOFYAN YUSUF KO 0895335440863 ASTRAZENECA 29/09/2021 K004A
88 3507214612870002 REFI AFILIYAH P 34 JL.SUKUN GEMPOL 20 0882374080245 ASTRAZENECA 29/09/2021 K004A
89 2171031503890005 DANIEL HARTANTO L 32 KAMPUNG TEMBESI BENGKEL 085271179558 ASTRAZENECA 29/09/2021 K004A
90 2171074501910002 ANITA LESMANA P 30 KAMPUNG TEMBESI BENGKEL 081336604868 ASTRAZENECA 29/09/2021 K004A
107 3507195511720001 EMY SA'IDAH P 49 JL.KENDALISODO PAKISAJI 085732694644 ASTRAZENECA 29/09/2021 K004A
112 3573040607600002 SUHARDI L 61 JL.TANJUNG PYTRA YUDHA VI-A 15/11 087755659555 ASTRAZENECA 29/09/2021 K004A
113 357304610580002 HIDAYATI P 65 JL.MAWAR No.25 081233757667 ASTRAZENECA 29/09/2021 K004A
125 3507061406950001 GUS MOHDOR L 26 JDSN SBR SENGKARING 081336864256 ASTRAZENECA 29/09/2021 K004A
126 3573040404680008 SUPARNO L 53 JL.TANJUNG PUTRA YUDHA VIA/41 15/11 085236601569 ASTRAZENECA 29/09/2021 K004A
131 3573041612920006 ANGGA DIDA ARKADIAN L 29 JL.SUKUN SIDOMULYO 36 10/07 087720577133 ASTRAZENECA 29/09/2021 K004A
136 3573041610960004 MAULANA FIRMAN DWI L 27 JL.PUTER DALAM UTARA 40 12/12 083834711621 ASTRAZENECA 29/09/2021 K004A
137 3573030111650003 CHOTIB L 56 JL.KAPRI 19 05/04 0895331119502 ASTRAZENECA 29/09/2021 K004A
138 3507182511720001 DWI PATRIANTO L 48 JL.JEMBAWAN VI/3F-6 04/19 085755300949 ASTRAZENECA 29/09/2021 K004A
142 3573045411820004 CANDRA RIA Y P 39 JL.S.SUPRIADI IXA/22 07/04 085856902223 ASTRAZENECA 9/29/2021 K004A
143 3573045502760003 CICIK SUPRIYANTI P 45 S. SUPRIYADI ASTRAZENECA 29/09/2021 K004A
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
122 3573044612440001 SIAMI KUSMINI P 77 JL. KLAYATAN No. 21 082232986668 ASTRAZENECA 30/09/2021 K004A
124 3573046803510001 SULASTRI P 70 JL. SIMPANG JANTI BARAT II/22 081336087724 ASTRAZENECA 30/09/2021 K004A
2 3573040802410001 PONIMIN L 80 JL. PRENJAK TIMUR 43 081233709402 ASTRAZENECA 30/09/2021 K004A
8 3573046003540008 RETNOWATI P 67 JL. BIDO 11 081233341817 ASTRAZENECA 30/09/2021 K004A
9 3573044101500027 KUTSIPATIN P 71 JL. S. SUPRIADI X/7 - ASTRAZENECA 30/09/2021 K004A
12 3573045010580007 SUSIATI NANIK P 64 JL. BIDO 20 085101327344 ASTRAZENECA 30/09/2021 K004A
17 3573045512490003 TATTY SURYATI, HJ P 72 JL. PUNGLOR 15 081252136037 ASTRAZENECA 30/09/2021 K004A
Dosis I Dosis 2
Vaksinasi
Vaksinasi
37 3573040908560008 RUSWANDI L 65 JL. NGAGLIK IV B/27 089507377727 ASTRAZENECA 30/09/2021 K004A

40 3573047103600001 HJ. REFRIWATI, SE P 61 JL. S. SUPRIADI 24 0896217417910 ASTRAZENECA 30/09/2021 K004A
45 3573047112590023 SUHARTI P 62 JL. S. SUPRIADI VI/37 082336576054 ASTRAZENECA 30/09/2021 K004A
62 3573040111500001 BUWITO L 75 JL. PARKIT SELATAN 7 08121749539 ASTRAZENECA 30/09/2021 K004A
Dosis I Dosis 2
Vaksinasi
Vaksinasi
68 3573046602610002 PUDJIATI P 60 JL. PRENJAK TIMUR 41 0895397071979 ASTRAZENECA 30/09/2021 K004A

75 3573042004660001 SABAR L 66 JL. S. SUPRIADI II B / 16 0851023390099 ASTRAZENECA 30/09/2021 K004A
89 3573045312530001 LAMINI P 68 JL. SUWARI UTARA No.. 38 085755756786 ASTRAZENECA 30/09/2021 K004A
93 3573044805630006 SULASTRI P 68 JL. SUKUN GEMPOL 30 085233115644 ASTRAZENECA 30/09/2021 K004A
104 3573040710400001 SOEPARDI L 81 JL. S. SUPRIADI VI/2350 081945164114 ASTRAZENECA 30/09/2021 K004A
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
126 3573040806010006 MUHAMMAD FAJAR MAULUD L 20 JL.S.SUPRIADI VI/2276 02/06 082333131043 ASTRAZENECA
1 3515161912420000 ABDUL KARIM L 79 JL.TANJUNG PUTRA YUDHA B/6 07/11 081335592311 ASTRAZENECA 01/10/2021 K004A
2 3573040203540010 NGATENO L 67 JL.MERGAN KELURAHAN BLOK C-27 05/11 089630232204 ASTRAZENECA 01/10/2021 K004A
3 3515165103440001 MIATI SUNARYANI P 77 JL.TANJUNG PUTRA YUDHA B/6 07/11 081335592311 ASTRAZENECA 01/10/2021 K004A
4 3573040309850005 EKO SISWOYO L 36 JL.SUKUN SIDOMULYO 31 04/07 085855350122 ASTRAZENECA 01/10/2021 K004A
5 3573042103610001 MOCH AMIR L 60 JL.IR RAIS I/30 04/02 081352628702 ASTRAZENECA 01/10/2021 K004A
6 3507210607690013 ACHMAD ZAZULI L 62 SITIREJO TEMU 087700183947 ASTRAZENECA 01/10/2021 K004A
7 3573045307670006 SRI SULASMINI P 64 JL.KASIN JAYA V/15 13/01 082140042463 ASTRAZENECA 01/10/2021 K004A
8 3573040406780012 JONI PURWANTO L 43 JL.MERGAN LORI IIC/63 081233255604 ASTRAZENECA 01/10/2021 K004A
9 3573040411500004 DJUMAI L 71 JL.SUKUN GEMPOL 16 11/09 082231728120 ASTRAZENECA 01/10/2021 K004A
10 3573045508000001 ORELLA NATANIA P 21 JL.MERGAN VETERAN 5 01/11 098668965217 ASTRAZENECA 01/10/2021 K004A
11 3573040805640002 HARTONO L 57 JL.MERGAN KELURAHAN BLOK C-11 05/11 089613982216 ASTRAZENECA 01/10/2021 K004A
12 3573044203950003 KAMTI CAHYANI L 26 JL.TANJUNG PUTRA YUDHA II 16/11 089516095614 ASTRAZENECA 01/10/2021 K004A
13 3573042807740004 YULIONO L 47 JL.SUKUN SIDOMULYO 16 05/07 081332942660 ASTRAZENECA 01/10/2021 K004A
14 3573044501940003 TIAS L 27 JL.TANJUNG PUTRA YUDHA B 16/11 - ASTRAZENECA 01/10/2021 K004A
15 3573041512570001 SUJONO L 64 JL.SUKUN GEMPOL 14/09 081221324325 ASTRAZENECA 01/10/2021 K004A
16 3573046906640003 SUGIYEM P 57 JL.TANJUNG PUTRA YUDHA II 16/11 083848139203 ASTRAZENECA 01/10/2021 K004A
17 3573050805630001 AM.WAHYUDI NUGROHO L 58 JL.GEMPOL MARGA BHAKTI 25 05/10 082335284713 ASTRAZENECA 01/10/2021 K004A SELESAI
18 3573040102730009 WINARSO L 48 JL.TERS MERGAN RAYA 62 08/11 081249039560 ASTRAZENECA 6/24/2021 AZD1222 01/10/2021 K004A
19 3573046107650005 SULISTIANI P 56 JL.SUKUN GEMPOL 05/09 082143671726 ASTRAZENECA 01/10/2021 K004A
20 3514175508820003 ASRUFI P 53 JL.KASIN JAYA III/36 06/01 087712631037 ASTRAZENECA 01/10/2021 K004A
21 3573041510700010 MUK'ARI L 51 JL.SIKATAN No..24 05.08 082233272228 ASTRAZENECA 01/10/2021 K004A
22 3573041508830012 BAMBANG WAHYUDI L 38 JL.TANJUNG PUTRA YUDHA II/ 16/11 - ASTRAZENECA 01/10/2021 K004A
23 3573045011530002 SUBAIDAH P 68 JL.SUKUN GEMPOL 6 10/09 - ASTRAZENECA 01/10/2021 K004A
24 3573045306590001 ISTINAWATI P 62 JL.SUKUN GEMPOL 3 05/09 083823745261 ASTRAZENECA 01/10/2021 K004A
25 3573045708670005 IDA WIJAYANTI P 54 JL.MEERGAN LORI 60 11/06 0822228451246 ASTRAZENECA 01/10/2021 K004A
26 3573045202630007 PURWATI P 58 JL.SIKATAN No.8 05/08 089647948048 ASTRAZENECA 01/10/2021 K004A
27 3573041804600001 EDY PURWOKO L 60 JL.SUKUN GEMPOL No.14A 14/09 085103043680 ASTRAZENECA 01/10/2021 K004A
28 3573040101710050 SUGENG HARIADI L 50 JL.MERGAN SEKOLAHAN II/52D 06/06 082131537828 ASTRAZENECA 01/10/2021 K004A
29 3573040802660005 HERU PRABAWA L 55 JL.DALI UTARA 26 03/08 081357227274 ASTRAZENECA 01/10/2021 K004A
Dosis I Dosis 2
Vaksinasi
Vaksinasi
30 3573041406680008 SUYATNO L 53 JL.IR RAIS 9/39 03/03 082233699174 ASTRAZENECA 01/10/2021 K004A
31 3573045111650008 JUMANI L 56 JL.SUKUN SIDOMULYO - ASTRAZENECA 01/10/2021 K004A
32 3573045412590004 SRI NINGRUM P 62 JL.MERGAN VETERAN 9 01/11 - ASTRAZENECA 01/10/2021 K004A
33 3507274406980002 NUR AIDA AYU HANDINI P 23 DSN BENDOREJO 081933031383 ASTRAZENECA 01/10/2021 K004A
34 3573045810780002 SUSILA WARDANI P 43 JL.KASIN JAYA IV/25 12/01 082140961437 ASTRAZENECA 01/10/2021 K004A
35 3573047011720005 SRI ASTUTIK P 49 JL.MERGAN LORI IIC/57 05/06 083853172280 ASTRAZENECA 01/10/2021 K004A
36 3573041706010006 DYAS LAKSA KURNIA L 20 JL.SUKUN GEMPOL 14/09 0895366547845 ASTRAZENECA 01/10/2021 K004A
37 3573042404750008 DODIK L 46 JL.SUKUN GEMPOL No..17 05/09 085261607784 ASTRAZENECA 01/10/2021 K004A
38 3573041212770009 MOCH MANSUR L 44 JL.S.SUPRIADI IX/43 13/04 082142040004 ASTRAZENECA 01/10/2021 K004A
39 6472046512870009 YAYUK SETIOWATI P 34 JL.MERGAN RAYA III/25 08/06 085348970311 ASTRAZENECA 01/10/2021 K004A
40 3573040306650001 SUGENG L 56 JL.IR RAIS III/7A 03/02 - ASTRAZENECA 01/10/2021 K004A
41 3573041510730009 TRI MARGONO L 48 JL.TANJUNG PUTRA YUDHA VIA/25 15/11 - ASTRAZENECA 01/10/2021 K004A
42 3573045610600001 DWI YURITA P 41 JL.IR RAIS III/7A 03/02 - ASTRAZENECA 01/10/2021 K004A
43 3573045207620002 SOLIKAH P 56 JL.TANJUNG PUTRA YUDHA IV/68 083111200116 ASTRAZENECA 01/10/2021 K004A
44 3573041010720009 BUDIONO L 49 JL.TERS PUTRA YUDHA II 06/13 083845174224 ASTRAZENECA 01/10/2021 K004A
45 3573043112820013 SUWARNO L 39 JL.SIMPANG PUTRA YUDHA II 05/13 081216542015 ASTRAZENECA 01/10/2021 K004A
46 3573045905960003 ESTY DWI KHOIRUN NISA P 25 JL.JUPRI 61 03/06 085735031184 ASTRAZENECA 01/10/2021 K004A
47 3573046010880009 RESTY MULYANINGRUM P 33 JL.MERGAN VETERAN 01/11 089607050687 ASTRAZENECA 01/10/2021 K004A
48 3573041709480005 MUKIYIN L 73 JL.IR RAIS III/14 06/02 081916403585 ASTRAZENECA 01/10/2021 K004A
49 3573044107590005 HANA SETIAWAN P 62 JL.SIKATAN No.46 05/08 081234831313 ASTRAZENECA 01/10/2021 K004A
50 3573044501920009 GERRISA PUTRI KARTINI P 29 JL.MERGAN RAYA IV/37 03/06 089335417510 ASTRAZENECA 01/10/2021 K004A
51 3573024211650010 NAWATI EKA ISJIATI P 56 JL.KASIN JAYA III/36 06/01 083846428075 ASTRAZENECA 01/10/2021 K004A
52 3573044301500002 SRIANAH P 71 JL.IR RAIS III/14 06/02 081916403585 ASTRAZENECA 01/10/2021 K004A
53 3573040706620003 MOCHAMMAD RAWI L 59 JL.MERGAN KERAMAT 855A 03/11 087857109212 ASTRAZENECA 01/10/2021 K004A
54 3573045708710012 MANIAH P 50 JL.PUTRA YUDHA 6 13/11 087867596327 ASTRAZENECA 01/10/2021 K004A
55 3573046008800012 SUGIHARTINI P 41 JL.SUKUN GEMPOL 14/09 089693667733 ASTRAZENECA 01/10/2021 K004A
56 3573046404400002 SAMANI P 81 JL.KASIN JAYA V/55 13/01 081931884927 ASTRAZENECA 01/10/2021 K004A
57 3573044805700003 PAERAH P 50 JL.SUKUN GEMPOL 15/09 082244398534 ASTRAZENECA 01/10/2021 K004A
58 3573042602650005 SUHARIYANTO L 56 JL.KASIN JAYA 5NO.54B 13/01 081931884927 ASTRAZENECA 01/10/2021 K004A
59 3573046106600003 SUSIANI P 61 JL.TERS.MERGAN RAYA 814 03/11 082234239358 ASTRAZENECA 01/10/2021 K004A
60 3573045007710002 ANIK ENDANG RATNAWATI P 52 JL.IR RAIS GG9/43 03/03 081233126189 ASTRAZENECA 01/10/2021 K004A
61 3573041206660003 BUDIANTO L 56 JL.SIKATAN 17 05/08 085746321232 ASTRAZENECA 01/10/2021 K004A
62 3573041503650011 ATIM WAHYUDI L 56 JL.SIMPANG PUTRA YUDHA II 05/13 089653782903 ASTRAZENECA 01/10/2021 K004A
63 3573046606730002 SURATI P 48 JL.TANJUNG PUTRA YUDHA 6A/59 085231512692 ASTRAZENECA 01/10/2021 K004A
64 3573045104630005 MINARSIH P 58 JL.TANJUNG PUTRA YUDHA VIB/66 15/11 085964413417 ASTRAZENECA 01/10/2021 K004A
65 3271040207640009 SUWARNO L 57 JL.SUKUN SIDOMULYO 01/07 081233975884 ASTRAZENECA 01/10/2021 K004A
66 3573040101670020 AGUS SUTRISNO L 54 JL.PUTER DALAM UTARA 29 12/12 089686936339 ASTRAZENECA 01/10/2021 K004A
67 3523161202770001 ARIS SETYAWAN L 44 JL.MERGAN VETERAN 26 01/11 08980188187 ASTRAZENECA 01/10/2021 K004A
68 3573046912910001 NENI NURDIAH SUTRISNO P 30 JL.PUTER DALAM UTARA 29 12/12 089686936339 ASTRAZENECA 01/10/2021 K004A
Dosis I Dosis 2
Vaksinasi
Vaksinasi
69 3573045103480002 SARIPAH P 73 JL.IR RAIS GG.9 No..108 01/04 - ASTRAZENECA 01/10/2021 D005A
70 3573040101630025 BASUKI L 58 JL.SUKUN GEMPOL 13 12/09 - ASTRAZENECA 01/10/2021 K004A
71 3573044507740008 QOYIMAH P 47 JL.MERGAN KERAMAT XIX/808/5 03/11 081907945086 ASTRAZENECA 01/10/2021 K004A
72 3573045706730006 NINIK YUNIWARSIH P 48 JL.SUKUN GEMPOL 12/09 085100390832 ASTRAZENECA 01/10/2021 K004A
73 3573046306680004 KHOLILAH P 53 JL.ICHWAN RIDUWAN RAIS XIV/57 09/04 0895367098820 ASTRAZENECA 01/10/2021 D005A
74 3573041803620000 LALU HIHIN L 59 JL.IR RAIS 3/7A 03/02 089670992533 ASTRAZENECA 01/10/2021 D005A
75 3573042103920002 REDO SASMAYA L 29 JL.TERS.MERGAN RAYA 19/61 08/11 082140028240 ASTRAZENECA 01/10/2021
76 3573040101700046 RIFAI L 52 JL.KASIN JAYA III/100 04/01 081259177464 ASTRAZENECA 01/10/2021
77 3573040509510001 PAIDJAN L 70 JL.MERGAN KELURAHAN A-10 05/11 - ASTRAZENECA 01/10/2021
78 3573045210670003 FARKHIYAH P 54 JL.JUPRI 57/641 03/06 083129792407 ASTRAZENECA 01/10/2021
79 3573044101610052 MISIANAH P 60 JL.SUKUN GEMPOL 18 12/09 083835902449 ASTRAZENECA 01/10/2021
80 3573047112650014 KALSUMI P 56 JL.SUKUN SIDOMULYO 087863686571 ASTRAZENECA 01/10/2021
81 3573040903820002 SETYO TRISWANDIYANTO L 39 JL.IR RAIS IX/419 10/04 082264929275 ASTRAZENECA 01/10/2021
82 3573047009000011 ISMI NUR AZIZAH P 21 JL.RANGKOK SELATAN No.17 03/12 085736838538 ASTRAZENECA 01/10/2021
83 3573046612670003 SANIK YULIANI P 54 JL.MERGAN RAYA VI/51 03/06 081235438338 ASTRAZENECA 01/10/2021
84 3573042010860007 NGATIRI L 35 JL.MERGAN KERAMAT 15 03/11 089680337372 ASTRAZENECA 01/10/2021
85 3573044512650005 ENDANG CHUSNIAWATI P 56 JL.TERS MERGAN RAYA 16B 08/11 082336163502 ASTRAZENECA 01/10/2021
86 3573044912620003 NUR HAYATI P 59 JL.TANJUNG PUTRA YUDHA IV/12 13/11 0895367394986 ASTRAZENECA 01/10/2021
87 3573040909690011 SIONO L 52 JL.IR RAIS IX-151 03/04 087860977176 ASTRAZENECA 01/10/2021
88 35730442008670004 EVA JUNAIDAH P 54 JL.IR RAIS 14/41 09/04 08179653960 ASTRAZENECA 01/10/2021
89 3573040501610005 SUMARI L 60 JL.SUKUN GEMPOL 11/09 085855416197 ASTRAZENECA 01/10/2021
90 3573040101640018 ROCHMAD L 57 JL.IR RAIS IX/149 03/04 087860977176 ASTRAZENECA 01/10/2021
91 3573045105780005 DIAN MAETASARI P 43 JL.TERS.MERGAN RAYA XIX/19 10/11 081333220858 ASTRAZENECA 01/10/2021
92 3573044607570005 SUMIATI P 64 JL.SUKUN GEMPOL 4 10/09 081331709715 ASTRAZENECA 01/10/2021
93 3573044905810006 NURYATI P 40 JL.TERS MERGAN RAYA 10/11 0881036191214 ASTRAZENECA 01/10/2021
94 3573041810690006 RACHMAD SETIOBUDI L 52 JL.IR RAIS III/24 082113435951 ASTRAZENECA 01/10/2021
95 3573045212690009 MUJIATI P 52 JL.PUTER DALAM UTARA 12/12 083833302324 ASTRAZENECA
96 35730427087000005 PURNOMO L 51 JL.TERS MERGAN RAYA 10/11 089661071277 ASTRAZENECA
97 3573044108620037 KARTI P 59 JL.IR RAIS IX-496 081333671919 ASTRAZENECA
98 3573045808720008 LILIK AGUSTIN P 49 JL.TANJUNG PUTRA YUDHA 6/69 09/11 083851506751 ASTRAZENECA
99 3573044711760008 DWI ERNI NOVITA P 45 JL.TERS.MERGAN RAYA XIX/17 04/11 083848276166 ASTRAZENECA
100 3573046608640004 ANDAYANI P 57 JL.TERS.MERGAN RAYA GG.19/7 04/11 083831871714 ASTRAZENECA
101 3573046811980001 RISKA KOMALA SARI P 23 JL.PUTER SELATAN 09/12 081949585605 ASTRAZENECA
102 3573041010500006 SUMALI L 70 JL.JOHAN No.5 01/06 083834605563 ASTRAZENECA
103 3573040408690001 SAPTO HADI WIYONO L 52 JL.SUKUN SIDOMULYO 2 02/07 082231517675 ASTRAZENECA
104 3573043112680006 SOLIKIN L 53 JL.GEMPOL No..36 04/09 081335998630 ASTRAZENECA
105 3573040504690004 ACHMAT GATOT L 52 JL.KASIN JAYA 4/21 12/01 - ASTRAZENECA
106 3573042809740003 GIYATNO L 47 JL.KASIN JAYA I/29 01/01 085933111910 ASTRAZENECA
107 3573044811560003 SITI FATIMAH P 65 JL.TANJUNG PUTRA YUDHA VI/73A 09/11 082233720051 ASTRAZENECA
108 3573044109710003 NURUL HIDAYAH P 50 JL.SUKUN SIDOMULYO 03/07 083111709299 ASTRAZENECA
109 3573045409630001 JUMAIYAH P 58 JL.TERS.MERGAN RAYA 64 11/11 089533726227 ASTRAZENECA
110 3573041502690009 SUPRIYO ANGGODO L 52 JL.MERGAN KERAMAT 110 03/11 083834663940 ASTRAZENECA
111 3573047112690024 TUMINAH P 62 JL.GEMPOL 03/09 - ASTRAZENECA
112 3573040510380001 SOEPRIJONO ALWANIF L 83 JL.TANJUNGREJO 06/09 083194792604 ASTRAZENECA
113 3573042012940002 MOCHAMMAD CATUR SUTANTO L 27 JL.KASIN JAYA III/30 06/01 081334565775 ASTRAZENECA
114 3573041106690001 MUCHAMMAD MACHMUDI L 52 JL.IR RAIS XII/31B 04/05 0813577576344 ASTRAZENECA
115 3573042203670005 HEPY L 54 JL.IR RAIS XIV/41 09/04 087845283578 ASTRAZENECA
116 3573040505790004 RUDI SANTOSO L 52 JL.KASIN JAYA 3/37 06/01 081217792369 ASTRAZENECA
Dosis I Dosis 2
Vaksinasi
Vaksinasi
117 3573041102710003 SUJIONO L 50 JL.SUKUN SIDOMULYO 8 03/07 083111709299 ASTRAZENECA

118 3573045107770001 ULVA ANALIA P 44 JL.KASIN JAYA I/61 01/01 089670993458 ASTRAZENECA
119 3573045003750007 YUNI KRISTINA P 46 JL.IR RAIS XIV/420 14/04 081333151992 ASTRAZENECA
120 3573046303720001 FARHATUN NAIMAH P 49 JL.TANJUNG PUTRA YUDHA A/53B 07/11 08571155634 ASTRAZENECA
121 3573041406650006 MUJIONO L 56 JL.PUTER DALAM UTARA 12/12 081249571519 ASTRAZENECA
122 357302405930003 YOEL ADE FRIBADI L 29 JL.TANJUNG PUTRA YUDHA IV 13/11 081252693368 ASTRAZENECA
123 3573044411620002 TITIK SUHARTI P 59 JL.DALI UTARA 20 03/08 088989056371 ASTRAZENECA
124 3573045810990001 DESY WULANDARI P 22 JL.KASIN JAYA III/30 06/01 0882009491457 ASTRAZENECA
125 3573044202520006 RR ETTY ARINI P 69 JL.MERGAN RAYA VI/64-53 03/06 08123361548 ASTRAZENECA
127 3573040605760004 TEGUH PRASETYO L 45 JL.TERS MERGAN RAYA 67 08/11 085286878067 ASTRAZENECA
128 3573032202810002 SUGIANTO L 40 JL.SUKUN GEMPOL No..4 085719752756 ASTRAZENECA
129 3573044507470003 MUTINI P 74 JL.SUKUN SIDOMULYO 13 05/07 082331726350 ASTRAZENECA
130 3573046511550002 SUJIATIM P 66 JL.TERS,MERGAN RAYA GG.19/106 11/11 082233807675 ASTRAZENECA
131 3574040704860005 HARI MUHAMMAD ISRA L 35 JL.SUKUN SIDOMULYO 083849285960 ASTRAZENECA
132 3573036204670003 KUSMINI P 54 JL.KAPRI KEDUNGKADANG - ASTRAZENECA
133 3573046311690005 ANDIKA ANDRIANNA P 52 JL.TERS.MERGAN RAYA 62 08/11 081232335795 ASTRAZENECA
134 3573044503750008 ATIEK ANDRAWATI P 46 JL.TERS.MERGAN RAYA 62 08/11 081235908737 ASTRAZENECA
135 3573045011010005 REMA RATU BINTANG T P 20 JL.TERS MERGAN RAYA 62 08/11 087748232680 ASTRAZENECA
136 3573046010770006 MARYAM P 44 JL.TERS MERGAN RAYA 90 10/11 081249875460 ASTRAZENECA
137 3573045105810005 SULISTYOWATI P 40 JL.MERGAN LORI III/4-B 07/06 085231140380 ASTRAZENECA
138 3573046608580003 NURSIJATI P 63 JL.TERS.MERGAN RAYA 19/66 08/11 081252719889 ASTRAZENECA
139 3573011302940005 MOCHAMMAD RAMADHAN NUR WAHI L 27 JL.MERGAN KELURAHAN B/13 05/11 081330213766 ASTRAZENECA
140 3507115112740002 JUWARIYAH P 47 DUSUN KRAJAN 01/01 085855884779 ASTRAZENECA
141 3573040507650003 MOCH CHUSAIRI L 56 JL.IR RAIS I/57 04/02 085649758073 ASTRAZENECA
142 3573045210710004 ATIK SUPINI P 50 JL.TANJUNG PUTRA YUDHA 2 16/11 082155149697 ASTRAZENECA
143 3573046309680002 NGATINI P 53 JL.TERS MERGAN RAYA 19/51 085238031907 ASTRAZENECA
144 3573045710760005 YUYUN WININGSIH P 45 JL.SUKUN SIDOMULYO 16 05/07 082230665509 ASTRAZENECA
145 3573040609870002 MOCH MUSTOUFEK L 38 JL.SUKUN SIDOMULYO 02/07 083835978076 ASTRAZENECA
146 3573045708770005 DUCI KURNIATI P 44 JL.MERGAN LORI 3A/4A 07/06 08983484958 ASTRAZENECA
147 3573041505770007 PURWANTO L 44 JL.PUTER BAWAH DALAM SELATAN 57 10/12 083846592337 ASTRAZENECA
148 3573044308590003 MARLIYAH P 62 JL.TANJUNG PUTRA YUDHA 6A/61 15/11 - ASTRAZENECA
149 3573044208840006 SUHARTI P 37 JL.SUKUN GEMPOL 12/09 081223999432 ASTRAZENECA
150 3573041508590005 BOIMAN MUSADI L 62 JL.MERGAN KELURAHAN A/26 05/11 085738757689 ASTRAZENECA
151 3573047112760013 GIYEM P 45 JL.TANJUNGREJO 03/09 083846985671 ASTRAZENECA
152 3573043003800002 FREDDY WARDANA L 41 JL.IR RAIS IX/185 03/04 083874225230 ASTRAZENECA
153 3573045208820012 PURWANTI P 39 JLTERS MERGAN RAYA 19/108 11/11 0881026181424 ASTRAZENECA
154 3573041112630013 SAIMAN L 58 JL.TANJUNG PUTRA YUDHA 2 16/11 0895620089103 ASTRAZENECA
155 3573046212700002 SUTARTIK P 51 JL.TERS MERGAN RAYA 52B 10/11 081252462438 ASTRAZENECA
156 3573045004680002 SITI HOTIMAH P 53 JL.IR RAIS IX/361 12/04 085749508273 ASTRAZENECA
157 3514102208820001 AHMAD L 39 JL.TANJUNG PUTRA YUDHA VIA/39 15/11 081233137548 ASTRAZENECA
158 3573045603700005 SATIMAH P 51 JL.TERS MERGAN RAYA 115 11/11 081334558282 ASTRAZENECA
159 3573041510750006 SUGIANTO L 46 JL.IR RAIS IX/181 03/04 08884877247 ASTRAZENECA
160 3573042812600005 SUPRIYADI L 61 JL.IR RAIS IX/93 03/03 081252278029 ASTRAZENECA
161 3573046606840006 WIWIN HARTINI P 37 JL.TERS MERGAN RAYA 19/6 11/11 081332003891 ASTRAZENECA
162 3573045902430001 ELSITA MARKATI P 78 JL.IR RAIS VIII/12A 01/03 - ASTRAZENECA
163 3573047112660007 SUKARTUN P 55 JL.PUTER DALAM SELATAN 10/12 - ASTRAZENECA
164 35730402112880002 DODIK ERWINSYAH L 33 JL.SUKUN GEMPOL 14/09 0895390251388 ASTRAZENECA
165 3573042409980005 ACHMAD TRI KURNIAWAN L 33 JL.IR RAIS XIV/41 09/04 088228196746 ASTRAZENECA
Dosis I Dosis 2
Vaksinasi
Vaksinasi
166 3573042606660002 WIGNYO HARIYANTO L 55 JL.SRIGUNTING No.36 14/05 082147912369 ASTRAZENECA

167 3573041202560003 KUSWANDI L 65 JL.IR RAIS IX/274 07/04 087752364793 ASTRAZENECA
168 3573040101690013 NGATURI L 52 JL.SUKUN SIDOMULYO 17 05/P7 085785644205 ASTRAZENECA
169 3573042402980002 DICKY FEBRI WICAKSONO L 23 JL.SRIGUNTING No.36 14/05 082230487755 ASTRAZENECA
170 3573046507000006 DHEA AMALIA P 21 JL.IR RAIS IX 087752364793 ASTRAZENECA
171 35071955604950003 EKA WAHYUNI P 26 JL.MERGAN KERAMAT 15 03/11 089680337372 ASTRAZENECA
172 3573044112510003 NGATIPAH P 70 JL.SUKUN GEMPOL 26 089686944013 ASTRAZENECA
173 3573042909790007 DEDY KURNIAWAN L 42 JL.IR RAIS III/40D 082230745926 ASTRAZENECA
174 3573046908920002 RIBUT WANDIRA P 29 JL.SUKUN GEMPOL 083848543486 ASTRAZENECA
175 3573040510670004 PURDIANTO L 54 JL.SUKUN SIDOMULYO 2 081233662779 ASTRAZENECA
176 3573041005670008 SUGIANTO L 54 JL.TANJUNG PUTRA YUDHA IV/37 081334399732 ASTRAZENECA
177 357302531171021 LILIK RUSDIANTI P 50 JL.TANJUNG PUTRA YUDHA VI/51 - ASTRAZENECA
178 3573044501730001 CANDRAWATI P 42 JL.TANJUNG PUTRA YUDHA VI/40 - ASTRAZENECA
179 3573040504540003 SUNARLI L 67 JL.MERGAN LORI IIIA/4B 085231140380 ASTRAZENECA
180 3573046811820010 YUIDA ASTUTIK P 39 JL.SUKUN SIDOMULYO 085204117840 ASTRAZENECA
181 3573044404650004 MESENI P 56 JL.GEMPOL 34 - ASTRAZENECA
182 3573044804580003 MISNI P 63 JL.MERGAN LORI IIIA/4B 085231140380 ASTRAZENECA
183 3573044604610003 ENDANG SULASTRI P 60 JL.SUKUN GEMPOL 081803879762 ASTRAZENECA
184 3573046903520002 TUTIANI P 69 JL.GEMPOL MB 26 08993866446 ASTRAZENECA
185 3573044407710011 KARYA NINIK MULYATI P 50 JL.IR RAIS 9 -369 085100726659 ASTRAZENECA
186 3573046510670002 HARI HANDAYANI P 54 JL.IR RAIS 11/17 089638990809 ASTRAZENECA
187 3573040304650004 M ARSYAD EFFENDI L 56 JL.IR RAIS IX-35 081331276446 ASTRAZENECA
188 3573045305810005 SUPRIYATIN P 40 JL.SUKUN GEMPOL No..30 081231676114 ASTRAZENECA
189 3523164809840004 RINA HARTANTI N P 37 JL.WIJAYA KUSUMA IV 085716409326 ASTRAZENECA
190 35730444111640003 NINIT ANISAH P 67 JL.MEREGAN LORI I/23 089697034530 ASTRAZENECA
191 3573045504640005 MUJIATI P 57 JL.MERGAN KERAMAT 47 085105455778 ASTRAZENECA
192 3573045309780004 SRIYATIN P 43 JL.SUKUN GEMPOL 26B 082139019836 ASTRAZENECA
193 3573044507690012 TRI EKA SURYANI P 52 JL.TERS MERGAN RAYA 62 08/11 081217214455 ASTRAZENECA
194 3573042704820010 KASIONO L 39 JL.IR RAIS IX/184A 081334485626 ASTRAZENECA
195 3573045801860003 NANIK WIJAYANTHI P 35 JL.BANDULAN SIMPANG IF 085859184363 ASTRAZENECA
196 3573046810020002 SITI CHOLAIFAH P 19 JL.MERGAN BARU XXI/36 087851932293 ASTRAZENECA
197 3573044109720008 SUMARMI P 49 JL.PUTER DALAM SELATAN 10/12 - ASTRAZENECA
198 3573044809630009 DARMI P 58 JL.TANJUNG PUTRA YUDHA II/25 - ASTRAZENECA
199 357304230690003 BHAYANGKARA TIWO JAYA L 29 JL.PARKIT UTARA 41 082213339353 ASTRAZENECA
200 3573045611670003 SITI AMINAH P 54 JL.KASIN JAYA IV/30 085716409326 ASTRAZENECA
201 3573043112800014 ROFI'I L 41 JLSUKUN SIDOMULYO 083832503060 ASTRAZENECA
202 3573042903870005 WARIS L 34 JL.SUKUN SIDOMULYO 36 08924604913 ASTRAZENECA
203 3527136008680002 URWIYAH P 53 JL.SIMPANG PUTRA YUDHA 3 - ASTRAZENECA
204 3573045909680006 SUKESI P 53 JL.TERS MERGAN RAYA XIX/41 0895412583600 ASTRAZENECA
205 3573042301780002 ABDUL BAHAR L 43 JL.MERGAN KERAMAT 19/25 085232338337 ASTRAZENECA
206 3573045605610002 SUNARTI P 60 JL.MERGAN RAYA 19/108 0881026181424 ASTRAZENECA
207 3573040106900009 M IMAM JUNAIDI L 31 JL.JOHAN No.5 085234407245 ASTRAZENECA
208 3573045005760005 SITI HASMIYAH P 45 JL.MERGAN BARU GG 21/36 0878519332293 ASTRAZENECA
209 3573046409000005 ANIZZA TUZZAHROH P 21 JL.SUKUN SIDOMULYO 08885839900
210 3573040105000002 ANDIKA CHOIRUL M L 21 JL.TERS MERGAN RAYA 23 -
211
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
7 3573040602570001 SUPARMAN L 64 JL. KLAYATAN 1/24 085227046100 ASTRAZENECA 02/10/2021 K004A

56 3573044105610007 TRIANI P 60 JL. KEMANTREN II/24 081916619406 ASTRAZENECA 02/10/2021 K004A
92 3573043112490021 KATENI L 72 JL. KLAYATAN III/77 082334673508 ASTRAZENECA 02/10/2021 K004A
95 3573044202580002 WURYANINGSIH P 63 JL. KLAYATAN II/73 082257619374 ASTRAZENECA 02/10/2021 K004A
1 3573040210580003 SUHARDJONO L 63 JL. MERGAN MUSHOLA 66B 087858180070 ASTRAZENECA 02/10/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
10 3573045308610002 SRI YUNIATI P 60 JL. MERGAN MUSHOLA 66B 087859180070 ASTRAZENECA 02/10/2021 K004A
26 3573044211570001 WIWIK SURANIYAH P 64 JL. GEMPOL 17 083102616177 ASTRAZENECA 02/10/2021 K004A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
57 3504012412560001 SUTAMAN L 65 JL. S. SUPRIADI IX/KAV C-12 081335785244 ASTRAZENECA 02/10/2021 K004A
68 3174084101441001 SUPINI P 77 JL. NGAGLIK IVB/188 082139218053 ASTRAZENECA 02/10/2021 K004A
69 3573040907580002 SENAN L 63 JL. IR RAIS IX No. 399 089509491881 ASTRAZENECA 02/10/2021 K004A
87 3573040505600006 ABDUL RACHMAN L 61 JL. SIMPANG SUKUN No. 6 085101380751 ASTRAZENECA 02/10/2021 K004A
100 3573042103500002 KASIJAN L 71 JL. NGAGLIK IVB/197 085204141601 ASTRAZENECA 02/10/2021 K004A
104 3573022803550004 THIO HAN YANG L 66 JL. KEDONDONG 17 085853071171 ASTRAZENECA 02/10/2021 K004A
114 3507190708600002 SAMSUL HADI L 61 JL. SUKUN GEMPOL 082139022314 ASTRAZENECA 02/10/2021 K004A
127 3573044203570005 ANIK SUNARIYAH P 64 JL. MERGAN LORI IIB/21C 081703660377 ASTRAZENECA 02/10/2021 K004A
129 3573044505600003 MISLIKAH P 61 JL. IR RAIS IX/257 ASTRAZENECA 02/10/2021 K004A
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
1 3505171810890000 Arik Irayanto P 41 Jl. Klayatan II/24 85885667836 ASTRAZENECA 04/10/2021 D005A
26 3573041001630003 Sumardi L 58 Jl. Simpang Kepuh Utara 081249553709 ASTRAZENECA 04/10/2021 D005A
39 3573045611690003 Evi Susanti P 53 Jl. Kepuh IX/24 0895604563232 ASTRAZENECA 04/10/2021 D005A
59 3573045212740002 Endang Puji Ashari P 47 Jl. kemantren 2/59 085648708557 ASTRAZENECA 04/10/2021 D005A
67 357304037740002 Juwari L 47 Jl. kemantren 2/59 085648708557 ASTRAZENECA 04/10/2021 A1050
84 3573041710570002 Nasrhur Fuad L 64 Jl. Kemantren I ASTRAZENECA 05/09/2021 K004A 10/4/2021 A1050
107 3573046412910008 Woro Natalia Saputri P 30 Jl. Kepuh I/50 082136669861 ASTRAZENECA 04/10/2021 A1050
2 3573041611960008 Andika Setyawan L 25 Jl. Ters Tanjung Putra Yudha V E/28 083117414395 ASTRAZENECA 04/10/2021 D005A
3 3573041403020004 Didan Putra Armiando L 19 Jl. Sukun Gempol 17 083853199777 ASTRAZENECA 04/10/2021 D005A
4 3573040908820008 Agus Iriawan L 39 Jl. Simpang Putra Yudha II/32 085755633024' ASTRAZENECA 04/10/2021 D005A
5 3505212901980001 yanuar Fitrananda L 23 Blitar 082331473910 ASTRAZENECA 04/10/2021 D005A
6 3573040710730006 Achmad Zaini L 48 Jl. Ngaglik IIC/381 085767984733 ASTRAZENECA 04/10/2021 D005A
7 3573043101610001 Agus Haryono L 60 Jl. Ngaglik IiI C 085843841416 ASTRAZENECA 04/10/2021 D005A
8 3573042105960002 Jery Irawan L 25 Sukun Gempol 089515948034 ASTRAZENECA 04/10/2021 D005A
9 3573044811740010 Mi'ah P 47 Jl. Sukun Gempol No..17 085104357676 ASTRAZENECA 04/10/2021 D005A
10 3573042108750007 Agus Sasdiono L 46 Jl. Sukun Gempol marga bhakti 29 088805815539 ASTRAZENECA 04/10/2021 D005A
11 3573042208550001 Abd Rochim L 66 Jl. Sukun Gempol 088805815539 ASTRAZENECA 04/10/2021 D005A
12 3573042105840006 Tri Setyono L 37 Jl. Sukun Gempol 087759822389 ASTRAZENECA 04/10/2021 D005A
13 357304407990006 Dewi Chalifatus Zakdiyah P 22 Jl. Puter dalam Utara 36 A 087776246189 ASTRAZENECA 04/10/2021 D005A
14 3573045306890008 Cahyeni yuningsih P 32 Jl Puter dalam Utara 31 083143130754 ASTRAZENECA 04/10/2021 D005A
15 3573044212970004 Bella Nurafni P 24 Jl. Puter Dalam Utara 27 083852394215 ASTRAZENECA 04/10/2021 D005A
16 3507216803930003 Mardiana Setyawati P 28 Jl. Sukun Gempol 085850436858 ASTRAZENECA 04/10/2021 D005A
17 3507221701710006 Suwanah P 51 Jl. Puter Dalam Selatan 0857356684822 ASTRAZENECA 04/10/2021 D005A
18 3573045702740005 maryam pujiasih P 27 Jl. Sukun Gempol 16A 083854547822 ASTRAZENECA 04/10/2021 D005A
19 3573016208810004 Debby Anggraeni P 40 Jl. Ngaglik II/393 085755440855 ASTRAZENECA 04/10/2021 D005A
20 3573044107720069 Crecenta Siamah P 50 Gempol Marga Bhakti23 b ASTRAZENECA 04/10/2021 D005A
21 3573042503800001 Joko Sugiarto L 41 Jl. Sukun Gempol 085103057632 ASTRAZENECA 04/10/2021 D005A
22 3573042001790005 Antoko Supandri L 42 Jl. Suku Gempol 08998859539 ASTRAZENECA 04/10/2021 D005A
23 3573050602810002 Tamujji Pribowo L 40 Jl. Terusan Putra Yudha II 08194597914 ASTRAZENECA 04/10/2021 D005A
24 3573041707810007 Mahfud Arif L 40 Jl. Sukun Gempol 089528435731 ASTRAZENECA 04/10/2021 D005A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
25 3573022907950001 Muhammad Dicki L 26 Jl. Sukun Gempol 089513809431 ASTRAZENECA 04/10/2021 D005A
27 3573046303580003 Suwarni P 63 Jl. Sukun Gempol 088805815539 ASTRAZENECA 04/10/2021 D005A
28 3573044809870009 Susiati P 34 Jl. Simpang Tanjung 089679756688 ASTRAZENECA 04/10/2021 D005A
29 3573042308980002 Moh. Alfin kurniawan L 23 Jl. Tanjung Putra Yudha VIB/7 089668464928 ASTRAZENECA 04/10/2021 D005A
30 3573044703690003 Yeti Herawati P 62 Sukun 081334714011 ASTRAZENECA 04/10/2021 D005A
31 3573041203820011 Warna Andika L 39 Sukun Gempol N0.16 081332288458 ASTRAZENECA 04/10/2021 D005A
32 3573016707580002 Kristina Setya Rahayu P 63 Jl. S. Supriadi Ngaglik II/393 085855311930 ASTRAZENECA 04/10/2021 D005A
33 3573041709550002 Suyono L 66 Jl. Sukun Gempol 36 - ASTRAZENECA 04/10/2021 D005A
34 3573031206830005 Badriyah P 37 Jl. Sukun Gempol No.7 ASTRAZENECA 04/10/2021 D005A
35 3573047112510007 Misiati P 60 Jl. Gempol 15 081332288458 ASTRAZENECA 04/10/2021 D005A
36 3573046206820004 Riyani P 39 Jl. Gempol No.16 081332288458 ASTRAZENECA 04/10/2021 D005A
37 3573041506640004 Sukirno L 57 Jl. Puter Dalam Selatan 085706616588 ASTRAZENECA 04/10/2021 D005A
38 3573046304960006 Rika Mandasari P 26 Jl. Gempol 15 085710576076 ASTRAZENECA 04/10/2021 D005A
40 3573036002770007 Agnes Femi Artanti P 44 Perum Tidar View Kav. B10A 082334681977 ASTRAZENECA 04/10/2021 D005A
41 3573044108750001 Minayah P 46 Jl. Simpang Sukun 081259497176 ASTRAZENECA 04/10/2021 D005A
42 3573022306890006 Firdan Ardiansyah L 32 Jl. Ternate I/19 08884841262 ASTRAZENECA 04/10/2021 D005A
43 3573044101950006 Suryaning Eka Suci P 26 Jl. Simpang Sukun Timur 089655566751 ASTRAZENECA 04/10/2021 D005A
44 3507184810900002 Bertin P 31 Jl. Bandara Timika Blok C 08123153381 ASTRAZENECA 04/10/2021 D005A
45 3507181210890003 Lendra Cahya Nugraha L 32 Jl. Bandara Timika Blok C 081237153381 ASTRAZENECA 04/10/2021 D005A
46 3573046806800011 Rini Puji Lestari P 41 Gempol Marga Bhakti 13 082230917094 ASTRAZENECA 04/10/2021 D005A
47 3573041501850001 Muchlis Efendy L 36 Jl. Simpang Putra Yudha II/29 0878244504686 ASTRAZENECA 04/10/2021 D005A
48 3573041101860005 Heri Sudarmawan L 35 Jl. Sukun Gempol 31 085852832675 ASTRAZENECA 04/10/2021 D005A
49 3573045505900009 Fitra Rahmawati P 31 Jl. Sukun Gempol 31 085852832675 ASTRAZENECA 04/10/2021 D005A
50 3573046001890002 Ririn Fita Ekasari P 32 Jl. Terusa Putra Yudha Ii 0895397305537 ASTRAZENECA 04/10/2021 D005A
51 3507192309990002 Fani Ferdyansah L 22 Jl. Embong Turi 081226840883 ASTRAZENECA 04/10/2021 D005A
52 3573045604010002 Natasya Adella Mahothi P 20 Sukun Gempol No..8 0895035327966 ASTRAZENECA 04/10/2021 D005A
53 3573040908850003 Agus Junaedi L 36 Jl. Puter Dalam Utara 27 081217299458 ASTRAZENECA 04/10/2021 D005A
54 3573042511980005 Rayfando Tri Darmawan L 23 Jl. Gemek 13 083845153733 ASTRAZENECA 04/10/2021 D005A
55 3573042606740004 Samsul Mashuri L 47 Jl. Sukun Gempol No.30 081231676114 ASTRAZENECA 04/10/2021 D005A
56 35730412122590006 Wariadi L 62 Jl. Pelabuhan Tanjung Perak 081217524459 ASTRAZENECA 04/10/2021 D005A
57 3573036611870003 Ekka Sucristina P 34 Jl. Sukun Gempol 082129127874 ASTRAZENECA 04/10/2021 D005A
58 3507046311570001 Yatimah P 64 Jl. Sukun Gempol Bhakti Utara ASTRAZENECA 04/10/2021 D005A
60 3573046911790007 Enik Sri Mulyani P 42 Jl. Sri Gunting 36 083127169110 ASTRAZENECA 10/06/2021 CTMAV546 10/4/2021 D005A
61 3573042011790004 Heru marenda L 42 Jl. Sri Gunting 36 083898995219 ASTRAZENECA 10/06/2021 CTMAV546 10/4/2021 D005A
62 3573046508820009 Mujiati P 39 Jl. Simpang Putra Yudha II/48 085331866220 ASTRAZENECA 04/10/2021 D005A
63 3527100903890002 Abdullah L 32 Jl. Muharto V B 081231109226 ASTRAZENECA 04/10/2021 D005A
64 3573045805010001 Putri Anggraini Qoiriah P 26 Jl. Terusan Putra Yudha V A 082234518699 ASTRAZENECA 04/10/2021 A1050
65 3573042312760005 Luki Aliandri L 45 Jl. Puter Dalam Utara 33 081214010246 ASTRAZENECA 04/10/2021 A1050
66 3573042602520001 Sujadi L 69 Jl. S. Supriadi IXA/24 ASTRAZENECA 04/10/2021 D005A
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
68 3573040311960004 Agung Nofianto L 25 Jl. Putra Dalam Utara 085815716526 ASTRAZENECA 04/10/2021 D005A
69 3573041702010003 Rico Nurhermansah L 20 Sukun Gempol 0895331275895 ASTRAZENECA 04/10/2021 A1050
70 3507090612830003 Agung Pujiono L 38 Jl. Raya Talangsuko 082131170994 ASTRAZENECA 04/10/2021 A1050
71 3573041307790007 Teguh Harianto L 42 Jl. Terusan Tanjung Putra Yudha V A/44 085790831906 ASTRAZENECA 04/10/2021 A1050
72 3573041001550001 Saruwi L 66 Jl. Pelabuhan Tanjung Perak 082131170994 ASTRAZENECA 04/10/2021 A1050
73 3573041404610004 Eko Sudarmanto L 60 Jl. Pelabuhan Tanjung Perak 085719205702 ASTRAZENECA 04/10/2021 A1050
74 3507215207890006 Ika Sari Yulianti P 32 Dsn Mendalan Wetan 089629144424 ASTRAZENECA 04/10/2021 A1050
75 3573043005550001 Sunari L 66 Jl. Ters Tanjung Putra Yudha V E/28 081230967865 ASTRAZENECA 04/10/2021 A1050
76 3573042702990003 Catur Susilp Febrianto L 22 Jl. Puter Dalam Utara No.29 081515270694 ASTRAZENECA 04/10/2021 A1050
77 3573021711020005 Ihwan Maulana L 19 Tanjungrejo 0895367290652 ASTRAZENECA 04/10/2021 A1050
78 3573041106000004 Achmad Nur choirun L 21 Jl. Sukun Gempol 0895622732836 ASTRAZENECA 04/10/2021 A1050
79 3573044510960006 Lutfiatul Putri Ayuning Tyas P 25 Jl. Puter Dalam Utara 1 ASTRAZENECA 04/10/2021 A1050
80 3573042809760005 Moh Sahri L 45 Jl. Tanjjung Putra Yudha 6b 081945596589 ASTRAZENECA 04/10/2021 A1050
81 3573045509800017 Lilly Ferdi Handayani P 41 Gempol Marga Bhakti No.28 085706598780 ASTRAZENECA 04/10/2021 A1050
82 3507151111720002 Hary Novianto L 49 Jl Prenjak Barat N0.43 081336562020 ASTRAZENECA 04/10/2021 A1050
83 3507190210910001 Toni Exwan Fauji L 30 Jl. Puter Dalam Utara No.29 089686936339 ASTRAZENECA 04/10/2021 A1050
85 3573046003910002 Rany Puspandini P 30 Jl. S. Supriadi X/25 081235193588 ASTRAZENECA 04/10/2021 A1050
86 3573046907030002 Puspita Larasari P 18 Gempol 085706598780 ASTRAZENECA 04/10/2021 A1050
87 3507095710820002 Lin Wayan Diana P 39 Jl. Sukun Gempol 25 087754425805 ASTRAZENECA 04/10/2021 A1050
88 3573046302790003 Suryati P 47 Jl. Pelabuhan Tanjung Perak 0821311709994 ASTRAZENECA 04/10/2021 A1050
89 3573042303810004 Sudarmawan L 40 Jl. Tanjung Putra Yudha VI-B/2 089681255548 ASTRAZENECA 04/10/2021 A1050
90 3573045004810009 Ini'matus Sya'diyah P 40 Jl. S. Supriadi IX/ KAV 4 081249847950 ASTRAZENECA 04/10/2021 A1050
91 3573040606770012 Maulid Amin L 44 Jl. Gempol Margha Bhakti 12 085706837049 ASTRAZENECA 04/10/2021 A1050
92 3573041405000005 Diki Mey Saputra L 21 Jl. Tanjung Putra Yudha VIB/12 089681255548 ASTRAZENECA 04/10/2021 A1050
93 3573047009010006 Ferdianti Septian L 20 Jl. Gempol Marga Bhakti 085755970211 ASTRAZENECA 04/10/2021 A1050
94 3573042504870008 Sunari L 35 Jl. TPY VIB ASTRAZENECA 04/10/2021 A1050
95 3573044702730005 Sriani P 48 Jl. S. Supriadi II A/31 085755144633 ASTRAZENECA 04/10/2021 A1050
96 3507180803810002 Erwan Susanto L 46 Jl. Ters Tanjung Putra Yudha V E/24 083849372846 ASTRAZENECA 04/10/2021 A1050
97 3573044702970008 Della Arista Yuane P 24 Jl. Gempol Marga Bhakti 081235923413 ASTRAZENECA 04/10/2021 A1050
98 3573045604730008 Kartini P 48 Jl. Gempol Marga Bhakti 087865820708 ASTRAZENECA 04/10/2021 A1050
99 3573044810820008 Siti Zainab P 39 Jl. Tanjung Putra Yudha 6B 081945596589 ASTRAZENECA 04/10/2021 A1050
100 3576011210990001 Muchammad Ismail L 22 Kranggan Mojokerto RT4 RW4 089523867223 ASTRAZENECA 22/05/2021 CTMAV546 04/10/2021 A1050
101 3573045502950006 Anggita Octaviane P 26 Jl. Gempol Marga Bhakti No..16 081332435547 ASTRAZENECA 04/10/2021 A1050
102 3573047112510002 Sumiati P 70 Jl. Rangkok No..58 081259656606 ASTRAZENECA 04/10/2021 A1050
103 3573021311810003 Sugianto L 40 Jl. Ternate IvB 085100468109 ASTRAZENECA 04/10/2021 A1050
104 6102071001970012 Sy. Abd Hamid Al Kadri L 24 jl. Raya Peniraman 081329823898 ASTRAZENECA 04/10/2021 A1050
105 3573046509920004 Erma Desy Arianti P 29 Jl. Terusan Tanjung Putra Yudha V 089516543126 ASTRAZENECA 04/10/2021 A1050
106 3573052609930002 Yohe Tri Sutrisno L 28 Jl. Terusan Tanjung Putra Yudha V 089516543126 ASTRAZENECA 04/10/2021 A1050
108 3573047004970002 Vivi Ery Fiani P 24 Sukun 082136304110 ASTRAZENECA 04/10/2021 A1050
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
4 3573040306410001 SUHARLI L 80 JL. JANTI UTARA 27 CORONAVAC 05/10/2021 B202106069

5 3573041303530003 SODIKIN L 68 JL. BERINGIN 62 089655871955 CORONAVAC 05/10/2021 B202106069
7 3573044410570003 SUBAIYAH P 64 JL. BERINGIN IV/46 CORONAVAC 05/10/2021 B202106069
10 3573046502610001 SUSIATI P 60 JL. JANTI UTARA VIB/35 082245552249 CORONAVAC 05/10/2021 B202106069
12 3573045909460002 SUMAIYAH P 75 JL. JANTI IV/39 CORONAVAC 05/10/2021 B202106069
13 3573044810520004 NGATINI P 69 JL. JANTI VIA/9 CORONAVAC 05/10/2021 B202106069
14 3573047112590021 SRI BAWON P 62 JL KLLAYATAN 3/38 081336379716 CORONAVAC 05/10/2021 B202106069
15 3573042704540004 SUGIONO P 67 JL. KLAYATAN 3/36 085607584933 CORONAVAC 05/10/2021 B202106069
16 3573046104590011 SRI LESTARI P 62 JL. KLAYATAN 3/36 085607584933 CORONAVAC 05/10/2021 B202106069
17 3573044405530001 SRIWATI P 68 JL. JOHAR 081259606930 CORONAVAC 05/10/2021 B202106069
21 3573044806520001 WATINI P 69 JL. JANTI VA/32 082336466667 CORONAVAC 05/10/2021 B202106069
22 3573040101600009 SUYANTO L 61 BANDUNGREJOSARI RT 6 RW 9 CORONAVAC 05/10/2021 B202106069
27 3573046612590001 RUKIYAH P 62 JL. JANTI BERINGIN 31 RT 7 RW 9 CORONAVAC 05/10/2021 B202106069
33 3573041808960002 AGUS KURNIAWAN L 66 JL JANTI UTARA 10 RT 3 RW 9 083834945513 CORONAVAC 05/10/2021 B202106069
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
34 3573044310550001 HARTIK ASTUTIK P 66 RT 11 RW 12 CORONAVAC 05/10/2021 B202106069

36 3573040101580010 SLAMET HARIYADI L 63 JL. BERINGIN RT 2 RW 9 089668301034 CORONAVAC 05/10/2021 B202106069
37 3573046003560002 DAWUK RUKMINI P 65 JL BERINGIN 62 RT 7 RW 9 CORONAVAC 05/10/2021 B202106069
39 3573040101590002 MULYONO L 62 JL JOHAR 25 RT 7 RW 9 CORONAVAC 05/10/2021 B202106069
55 3573044710500001 MU'INAH P 71 JL. JANTI UTARA VI/34B RW 9 083834008911 CORONAVAC 05/10/2021 B202106069
56 3573045411550001 MUTMAINAH P 66 JL. JANTI UTARA IV/34A RW 9 083834008911 CORONAVAC 05/10/2021 B202106069
57 3573040701530001 SUKRIANTO L 68 JL. JANTI VI/54 RT 4 RW 9 08125253122 CORONAVAC 05/10/2021 B202106069
58 3573045106570001 SRIWATI P 64 JL. JANTI VI/54 RW 9 CORONAVAC 05/10/2021 B202106069
60 3573040701470001 JAENAB P 74 JL. JANTI UTARA VI RT 5 RW 9 CORONAVAC 05/10/2021 B202106069
65 3573046312580002 DJUMAIYAH P 63 JL. JANTI VA/42 RT 3 RW 9 CORONAVAC 05/10/2021 B202106069
69 3573045010600006 SUMINAH P 61 RT 11 RW 12 CORONAVAC 05/10/2021 B202106069
77 3573041208580003 SUGIANTO L 63 JL JANTI GG 4 RT 1 RW 9 0895331264329 CORONAVAC 05/10/2021 B202106069
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
80 3573040101540005 BOIMAN L 67 JL JANTI UTARA 6/25 RT 5 RW 9 087865865811 CORONAVAC 05/10/2021 B202106069

91 3573044205520001 NGATIAH P 69 JL BERINGIN JANTI RT 6 RW 9 082244161966 CORONAVAC 05/10/2021 B202106069
102 3573043112530023 WARI L 68 JL JANTI UTARA VI/56 RT 4 RW 9 CORONAVAC 05/10/2021 B202106069
104 3573045203610001 MASIYEM P 60 JL. JANTI UTARA 6 RT 5 RW 9 087865865811 CORONAVAC 05/10/2021 B202106069
107 3573045505540010 DJAENAB P 67 JL. JANTI TIMUR 52 RT 1 RW 9 081348565912 CORONAVAC 05/10/2021 B202106069
114 3573044512570002 PUDJIATI P 64 JL KLAYATAN I/56A RT 4 RW 12 083841778995 CORONAVAC 05/10/2021 B202106069
121 3573040406600002 SARIMAN L 61 JL JANTI VI/35 RT 2 RW 9 CORONAVAC 05/10/2021 B202106069
124 3573046202660003 MISIATIN P 66 JL JANTI UTARA GG 5A/33 RT 3 RW 9 CORONAVAC 05/10/2021 B202106069
137 3573044604520001 SEMI P 61 JL JANTI UTARA 41 RT 7 RW 9 081333013606 CORONAVAC 05/10/2021 B202106069
141 3573041909610001 DIDIET MOESO WIDJOYO L 60 JL JANTI SELATAN RT 2 RW 6 08815534307 CORONAVAC 05/10/2021 B202106069
144 3573042506540004 RIYONO L 67 JL KLAYATAN I/69 RT 4 RW 12 085234130200 CORONAVAC 05/10/2021 B202106069
152 3573041505540003 PAIMAN L 67 JL BERINGIN V RT 3 RW 9 CORONAVAC 05/10/2021 B202106069
158 3573040612590002 SUYATNO L 62 JL KEPUH 2 RT 1 RW 5 083837993461 CORONAVAC 05/10/2021 B202106069
162 3573041708600010 AGUS DIONO L 61 JL BERINGIN RT 6 RW 9 08123398429 CORONAVAC 05/10/2021 B202106069
167 3573044104560002 RIBKHA SUTILAH ASTUTI P 65 JL KLAYATAN I/59 RT 4 RW 12 085234130200 CORONAVAC 05/10/2021 B202106069
173 3573041004560002 TAKIM L 65 JL JANTI VIA RT 6 RW 9 CORONAVAC 05/10/2021 B202106069
176 3573045010570014 MUSMILAH P 64 JL SIMPANG KEPUH D 14 RT 1 RW 10 087859436132 CORONAVAC 05/10/2021 B202106069
180 3573045502560003 DJAMINI P 65 JL KLAYATAN 3 082223328954 CORONAVAC 05/10/2021 B202106069
183 3573041907650006 DJUWATI L 66 JL JANTI BARAT III/80 RT 5 RW 8 082233962457 CORONAVAC 05/10/2021 B202106069
186 3573040606460002 TRISNONYOTO L 75 JL KLAYATAN 3 RT 7 RW 2 CORONAVAC 05/10/2021 B202106069
187 3573042602580001 MOCH SLAMET PRASETYO L 63 JL KLAYATAN 1/5 RT 7 RW 12 082245675644 CORONAVAC 05/10/2021 B202106069
189 3573044708610004 DJUWANIK WIDAYANI P 60 JL KLAYATAN I/5 RT 7 RW 12 082245675644 CORONAVAC 05/10/2021 B202106069
208 3573040802550002 DJAIS L 66 JL JANTI RT 4 RW 8 083114966765 CORONAVAC 05/10/2021 B202106069
218 3573040102480002 PUJIONO L 73 JL KLAYATAN 2/6 RT 13 RW 12 085736079202 CORONAVAC 05/10/2021 B202106069
220 3573045001600001 RUKAYAH P 61 JL JANTI SELATAN VIII/56 081554742405 CORONAVAC 05/10/2021 B202106069
240 3573044212540002 SUNARTI P 67 JL KLAYATAN 2/14 RT 11 RW 12 CORONAVAC 05/10/2021 B202106069
257 3573044512600003 HJ MISBIATIN P 61 JL JANTI BARAT 17A RT 4 RW 8 087859067037 CORONAVAC 05/10/2021 B202106069
259 '3573041012560002 ASIR L 65 JL KLAYATAN 3/25D RT 10 RW 2 082100841630 CORONAVAC 05/10/2021 B202106069
277 3573044702510001 SAMINI P 70 JL KALYATAN 3 RT 8 RW 2 085101353667 CORONAVAC 05/10/2021 B202106069
287 3573041112580002 ALI MASHUDI L 63 JL JANTI SELATAN RT 4 RW 6 081247086922 CORONAVAC 05/10/2021 B202106069
295 3573041001610006 PAIDJAN L 60 JL KLAYATAN 1 RT 2 RW 12 083851147913 CORONAVAC 05/10/2021 B202106069
301 3372045707590009 SRI LESTARI NUR HAYATI P 62 JL KEPUH VI/34 RT 1 RW 5 085728017699 CORONAVAC 05/10/2021 B202106069
315 3573046505600006 SRI RAHAYU P 61 JL KEPUH VI/22 RT 10 RW 5 0895397162996 CORONAVAC 05/10/2021 B202106069
324 3573045509610003 RESTU SETYOWATI P 60 JL RAYA KEPUH X RT 7 RW 6 082336724914 CORONAVAC 05/10/2021 B202106069
327 3573043012550007 SUWARSONO L 66 JL RAYA KEPUH X RT 7 RW 5 082336724914 CORONAVAC 05/10/2021 B202106069
336 3573045106500001 SOENARSIH P 71 JL KLAYATAN 3 RT 5 RW 2 0821509335909 CORONAVAC 05/10/2021 B202106069
346 3573042201610001 HADI GATOT SUPRAPTO L 60 JL JANTI SELATAN RT 4 RW 6 085790865599 CORONAVAC 05/10/2021 B202106069
371 3573046404420002 EKO HARINI P 79 JL RAYA KEPUH RT 2 RW 5 081334703691 CORONAVAC 05/10/2021 B202106069
376 3573044910610001 BAWUK SUPRIHATIN P 60 SEPUM SPI W-7 RT 7 RW 7 087859959822 CORONAVAC 05/10/2021 B202106069
382 3573044101500021 RANTIYAH L 71 JL KEMANTREN RT 12 RW 3 081805020834 CORONAVAC 05/10/2021 B202106069
408 3573046308590001 BUAMAH P 62 KLAYATAN II 2/1 089515675362

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
413 1603051212500007 PONIMAN L 71 KEMANTREN GG 1 6/3 081358059922
417 3573043112540001 NGATMARI L 67 KLAYATAN 3 9/2 081336379716
466 3573041004420002 ROFII L 79 KLAYATAN III 081334877429

485 3573046001510002 SUHARTININGSIH P 70 KEPUH II 082140910250
54 3520164304440001 YAMINI P 77 JL. DAKUTAH 081252938855 CORONAVAC 05/10/2021 B202106069
193 3573020704540001 BAMBANG SETIAWAN L 67 JL KARIMUN JAWA 082334314020 CORONAVAC 05/10/2021 B202106069
273 3573034209600002 MARSI'IN P 61 JL. MUHARTO KEDUNGKANDANG 081913331680 CORONAVAC 05/10/2021 B202106069
498 3573054707340003 ROSNI P 89 SIMP. BOGOR 0811366958 10/5/2021 AB202106069
TINGKAT PUSKESMAS
ama Puskesmas/Jejaring : JANTI

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
239 3573044307520001 WARSI P 69 KEMANTREN I 10 0813535590690 CORONAVAC 06/10/2021 B202106069

275 3573047009570001 SUTIANI P 64 KLAYATAN II 40 085803717687 CORONAVAC 06/10/2021 B202106069
3 3573041805780005 MOHAMMAD SOLEH L 64 SIMPANG SUKUN 49 083821710952 CORONAVAC 06/10/2021 B202106069
4 3573041001560006 FX SUDIONO L 65 GEMPOL MARGA BAKTI 11 087759626332 CORONAVAC 06/10/2021 B202106069
12 3573044107380065 TUKIYEM P 83 PRENJAK TIMUR 10 CORONAVAC 06/10/2021 B202106069
17 3573047112540030 SRIATUN P 67 S SUPRIADI 6 2326A CORONAVAC 06/10/2021 B202106069
18 3573041905580004 SUPRIADI L 63 JALAK 3 082234822000 CORONAVAC 06/10/2021 B202106069
21 3573044107430049 RUBIAH P 78 JALAK 10 085850801458 CORONAVAC 06/10/2021 B202106069
24 3573044707530001 TUMINI P 68 JALAK 4 083134824771 CORONAVAC 06/10/2021 B202106069
28 3573045402460006 SUPIANI P 75 GLATIK LUAR No. 9 08563523043 CORONAVAC 06/10/2021 B202106069
31 3573040503500005 SUDJIO HADI L 71 SUWARI UTARA 32 081357019431 CORONAVAC 06/10/2021 B202106069
38 3573046011550002 MARGRIETJE R A P 66 KUTILANG BARAT 23-25 081555981777 CORONAVAC 06/10/2021 B202106069
40 3573045011480002 RIJAMI P 73 MANYAR 39 085107666667 CORONAVAC 06/10/2021 B202106069
42 3573944294439992 SULASMINI P 78 KUTILANG TIMUR 17 085735294898 CORONAVAC 06/10/2021 B202106069
45 3573045901550006 PUTMIWATI P 66 SUWARI UTARA 32 081357019431 CORONAVAC 06/10/2021 B202106069
56 3573044209610006 ENI ANDIWATI P 60 SRI GUNTNIG 78 085101770887 CORONAVAC 06/10/2021 B202106069
59 3573041006580006 SARMAN L 63 SIMPANG SUKUN 38 083831763615 CORONAVAC 06/10/2021 B202106069
64 3573042906360002 HARI PRATIKNO L 85 MURI No. 7 085655288983 CORONAVAC 06/10/2021 B202106069
69 3573046508590001 NINIK MARIANI P 62 S SUPRIADI X 2542 082229282872 CORONAVAC 06/10/2021 B202106069
73 3573046409580003 LILIK ROCHMAYATI P 63 S SUPRIADI IX 2I 081336579041 CORONAVAC 06/10/2021 B202106069
81 3573041010560002 ALI YUNUS L 65 NGAGLIK IVB 72 082230796631 CORONAVAC 06/10/2021 B202106069
87 3573042302540004 BAMBANG SUTEDJO L 67 MANYAR 73 085257433928 CORONAVAC 06/10/2021 B202106069
90 3573045401610001 ELMI MULYATI P 60 MANYAR 93 081931856336 CORONAVAC 06/10/2021 B202106069
93 3573046005500004 NGATINAH P 71 MERGAN MUSHOLLAH 085331697048 CORONAVAC 06/10/2021 B202106069
98 3573040111510002 MUJIMAN L 70 MANYAR 47 085257433928 CORONAVAC 06/10/2021 B202106069
113 3573044101520014 SULASI P 69 S SUPRIADI 7/5 083862563854 CORONAVAC 06/10/2021 B202106069
128 3573047010590004 SUTINA P 62 MERPATI 02 0817539516 CORONAVAC 06/10/2021 B202106069
137 3573044705570007 SUWARNI P 64 MERPATI 02 089508600348 CORONAVAC 06/10/2021 B202106069
140 3573040503590003 NURBUAT L 62 KUNTUL 16 089531904257 CORONAVAC 06/10/2021 B202106069
151 3573041304530001 SULISTYADI L 68 KAKAK TUA SELATAN 47 081233638050 CORONAVAC 06/10/2021 B202106069
168 3573011904570001 MUDJIONO L 64 S SUPRIADI VII 41 A 087851118831 CORONAVAC 06/10/2021 B202106069
177 3573041608460001 BAMBANG SUNARKO L 75 NGAGLIK 4 108 085875395800 CORONAVAC 06/10/2021 B202106069
179 3573045511540001 SRI HARTATIK P 67 S SUPRIADI IIC 20 085608704873 CORONAVAC 06/10/2021 B202106069
191 3573045010590009 SULIKAH P 62 MELIWIS TIMUR 22 081259662912 CORONAVAC 06/10/2021 B202106069
200 3573040101550038 SUGENG L 66 PUTER DALEM SELATAN 53 083854019199 CORONAVAC 06/10/2021 B202106069
204 3573040410550004 SUKIRMAN L 66 S SUPRIADI IIA 088805000909 CORONAVAC 06/10/2021 B202106069
206 3573040505460004 YAHYA JAYUS L 75 PRENJAK BARAT 46 087866760175 CORONAVAC 06/10/2021 B202106069
221 3573041809490001 WINARTO L 72 MENCO 27 083115822339 CORONAVAC 06/10/2021 B202106069
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
228 3573045912420001 LASIJEM P 79 NGAGLIK IV 89 085655449891 CORONAVAC 06/10/2021 B202106069

234 3573042005560002 SOERIYADI L 65 NGAGLIK II 304 081333164554 CORONAVAC 06/10/2021 B202106069
263 3573014405570005 NINIK MARIYATI P 64 TUNTANG II 081939188658 CORONAVAC 06/10/2021 B202106069
266 3573046203500002 SOEGIATININGSIH P 71 JALAK 5 08125286004 CORONAVAC 06/10/2021 B202106069
285 3573045301550003 ACH MUKTI P 66 MANYAR 27 0895366896645 CORONAVAC 06/10/2021 B202106069
288 3573046811430001 MASITAH P 78 KUTILANG TIMUR 36 081336503259 CORONAVAC 06/10/2021 B202106069
295 3573047112640011 SURATI P 67 S SUPRIADI VII 11 08980303776 CORONAVAC 06/10/2021 B202106069
298 3573047007580001 MUDJIATI P 63 S SUPRIADI X 38 083194209122 CORONAVAC 06/10/2021 B202106069
321 3573045003530005 SUDJIATI L 68 S SUPRIADI IX 18 081249011087 CORONAVAC 06/10/2021 B202106069
322 3573045504460003 SUHARMINTATI P 75 SUKUN 17/8 082177468008 CORONAVAC 06/10/2021 B202106069
326 3573041105580002 KASIONO L 63 SIMPANG SUKUNN 59 085526251706 CORONAVAC 06/10/2021 B202106069
336 3573045105570006 SOFIATIN P 64 S SUPRIADI 11 081233151523 CORONAVAC 06/10/2021 B202106069
341 3573040506510003 LUKMAN HAKIM L 70 S SUPRIADI 81B 085791261397 CORONAVAC 06/10/2021 B202106069
345 3573015902600005 MARTI P 64 S SUPRADI VII 41 083848382817 CORONAVAC 06/10/2021 B202106069
346 3573044101590047 TUKINI P 62 GEMPOL MARGA BHAKTI 6 085852148543 CORONAVAC 06/10/2021 B202106069
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
355 3573040401590001 IMRON SUMADI L 62 SUKUN SIDOMULYO 087701652333 CORONAVAC 06/10/2021 B202106069
371 3573040503520002 WIRATNO L 69 MELIWIS TIMUR 30 081259161725 CORONAVAC 06/10/2021 B202106069
375 3573024101450009 SITI MARIYAM P 76 SUWARI UTARA 40 08155025454 CORONAVAC 06/10/2021 B202106069
384 3573042712580004 MANGKU HARI MULYONO L 63 DERKUKU SELATAN 17 085234167357 CORONAVAC 06/10/2021 B202106069
389 3573040309540003 WAHYONO L 67 PUTER BAWAH DALAM SELATAN 57 081230790786 CORONAVAC 06/10/2021 B202106069
395 3573044109570005 YATMININGSIH P 64 PUTER BAWAH DALAM SELATAN 57 081230790786 CORONAVAC 06/10/2021 B202106069
399 3573043112610014 DJUWARI L 60 PUTER DALEM SELATAN 081283262076 CORONAVAC 06/10/2021 B202106069
414 3573045004570005 SUYATMI P 64 MELIWIS TIMUR 23 081233125242 CORONAVAC 06/10/2021 B202106069
665 3573045112590012 DAWAMAH P 61 IR. RAIS 9/4 085230019225 CORONAVAC 06/10/2021 B202106069
FORMAT PENCATATAN

No NIK Nama Penerima Vaksin L/P Umur
581 3573045312530002 SATU`AH PEREMPUAN 68

582 3573045906570001 SRIPATMINIATI PEREMPUAN 64
585 3573040101520014 SAMIUN LAKI_LAKI 69
586 3573044104590003 PONIPAH PEREMPUAN 62 TAHUN
587 3573040101520014 SAMIUN LAKI_LAKI 69
589 3573046712490001 NGATIPAH AL SUTIPAH PEREMPUAN 72
590 3573045906570001 SRIPATMINIATI PEREMPUAN 64
600 3573044708520001 SRI KARTINI PEREMPUAN 69
603 3573044102600003 MISTIN PEREMPUAN 61
606 3573044804580002 DJUMAATI PEREMPUAN 63
609 3573045510400001 WARSIYAH PEREMPUAN 81
611 3573042504610002 PONIDI LAKI_LAKI 60
613 3573044101460027 SULIKAH PEREMPUAN 75
614 3573044104590003 PONIPAH PEREMPUAN 62
629 3573044107570049 DJUMAINAH PEREMPUAN 64
641 3573040606550005 MOCHAMAD CHOSIM LAKI_LAKI 66
642 3573040905560006 DARMADI LAKI_LAKI 65
643 3573046703560002 SITI DJUWARIYAH PEREMPUAN 65
661 3573042504610002 PONIDI LAKI_LAKI 60
663 3573042112590002 WINARTO LAKI_LAKI 62
668 3573045609610004 SUHARTINI PEREMPUAN 60
676 3573044606610001 BA'INI PEREMPUAN 60
678 3573044101550016 EEM PEREMPUAN 66
687 3573045704610003 SUPI'ANI PEREMPUAN 60
713 3573042508580001 PRIYADI LAKI_LAKI 63
718 3573045212590004 MISNAH PEREMPUAN 62
732 357304804540001 M. SAID LAKI_LAKI 67
748 3573041502610002 DIDIK BAMBANG SUPRIYADI LAKI_LAKI 60
756 3573040808570002 MUSIRAN LAKI_LAKI 64
782 3573044101490051 RUMINAH PEREMPUAN 72
809 3573040409460001 DJOKO SUNJOTO BA LAKI_LAKI 75
817 3573042404610004 ASNAN LAKI_LAKI 60
833 3573046907590003 KASIATI PEREMPUAN 62TH
845 3573044405610004 SUMIATI PEREMPUAN 60
862 3510082404570003 SUHARTO LAKI_LAKI 64TH
876 3573037112570075 SUDJIKA LAKI_LAKI 64
884 3573046811600003 LILIK NURHAYATI PEREMPUAN 61
894 3516145210020001 KARTIKA DWI RAHMAWATI PEREMPUAN 61
895 3573045303540002 SUMIJAH PEREMPUAN 67
907 3573040301450001 SLAMET LAKI_LAKI 76
910 3573044101390017 TIANAH PEREMPUAN 82
915 3573044411610001 RUSMIATI PEREMPUAN 60
935 3573040504600005 SUPRAPTO LAKI_LAKI 61
944 3573042611510001 JUWARI LAKI_LAKI 70
949 3573041808500001 KOSIM LAKI_LAKI 71
956 3573044103570002 SOEPINI PEREMPUAN 64
957 3573045308590002 SUMARTI PEREMPUAN 62
963 3573044019560001 GINAH PEREMPUAN 65
964 3573045612500001 NEIK PUJOWATI LAKI_LAKI 71TH
967 3573044806510003 MARSINAH PEREMPUAN 70
968 3573040909470001 MU'ADJI LAKI_LAKI 74
970 3573041206570002 GUNARKO LAKI_LAKI 64
982 3573044101570031 KASIATI PEREMPUAN 64
1012 3573042410560001 DJOKO SOETOPYO LAKI_LAKI 71
1013 3573045610580003 MUINI PEREMPUAN 63 TAHUN
1018 3573045208560004 WIDJI LAKI_LAKI 62
1022 3573044810540005 ROCHMAN PEREMPUAN 67
1023 3573042909560001 DAI GEPENG LAKI_LAKI 69
1030 3573045201540002 WATINI PEREMPUAN 67
1046 3573044801580006 ENDANG CHASTIANI PEREMPUAN 63
1047 3573040406470001 H. M. SOEDJONO LAKI_LAKI 74
1049 3573045406610001 RIANI PEREMPUAN 60
1061 3573042302470002 SOETJJIPTO LAKI_LAKI 74
1063 3573044108580002 NUR HAYATI PEREMPUAN 63
1066 3573046209570002 SITI CHOIRIYAH PEREMPUAN 64
1069 3573044610530001 MARFI PEREMPUAN 68
1071 3573045409600003 SRI RAHAYU PEREMPUAN 61
1072 3573042412530002 H. EDDY RAHYONO LAKI_LAKI 68
3 3573041706550002 RIDWAN RAIS L 66
5 3573040406610008 ABDUS SALAM L 60
7 3578032607520001 USMAN L 69
11 3573047112490017 LILIK WALIKAH P 72
20 3573045912470002 FARIDAH NOERIDAJATI P 74
29 3573044609610005 TIYAMAH P 60
31 3573041201600002 SANIMAN L 61
34 3573041008590007 SAIMAN L 62
45 3573041005590007 TUBIASIS L 62
63 3573042004610001 ALI MUSTOFAH L 60
64 3573045010600007 SUSILOWATI P 61
68 3573041204560002 SUGIONO L 65
71 3573046606540002 WASNIATI P 67
84 3573040810500003 SULIONO L 71
91 3573040406500002 SUKINO KORNELIUS L 71
92 3573040504470001 JUMAIN L 74
105 3573040306340001 MOCH SAID L 82
112 3573040107470052 DASIMAN L 74
129 3573045007600005 KAMINI P 61
135 3573047112590033 WIJI P 62
144 3573044107580090 KRISTINAH P 63
145 3573040812440001 ASKUR L 77
152 3573040301570003 SUPRAYITNO L 64
154 3573047112560022 MUNIAH P 65
157 3573047112450036 RUTI P 76
169 3573041212520003 SALEH L 69
176 3573040101510015 SLAMET L 70
191 3573045004570006 YOHANNA KUSTIARSIH P 64
210 357304410520062 SIMAH P 69
226 3573044808590007 MISTIANAH P 62
227 3573046310600004 PONIYEM P 61
249 3573044803640002 SUSIATI P 67
262 3573046502610002 SIAMIN P 60
279 3573044807540003 THERESIA LILIK M P 67
286 3573040707570007 KOSNADI L 69
287 3173086506580005 NUNUK SUPRIYANI P 63
303 3573044905570003 MUDJIATI P 64
304 3573041011510004 BAKRI L 70
311 3573046412610003 ST CHOTIDJAH P 60
315 3573040412510001 KOESLAN L 70
324 3573040910590004 SUYONO L 62
330 3573047011590008 WASTITI P 62
333 3573040105540001 SUGENG L 67
334 3573011707600008 SUBAKIR L 61
335 3573045408560003 SUKARSIH P 65
346 357306808590008 ENDNAG DWI AMBARWATI P 62
355 3573041212540007 SUTRISNO L 67
359 3573026807570001 JULIASTUTY P 64
368 3216069803570004 HUSEN SUYONO L 64
373 3573045611550001 SU'AMI P 65
376 3573047009600001 SRI ATEM P 61
386 3573045207550002 KELINAH P 66
390 3573044101600034 SUPANI P 60
400 .3573045410570002 SUPRIANINGSIH P 64
404 3573040112440002 SUKIRMAN L 77
408 3573044101540058 SITI MAIMUNAH P 67
413 3573043112610029 DJAMIL EFENDI L 60
418 3573040602550004 IGNATIUS SUSIANTO L 66
428 3573041707590002 MOH. AFFANSY NR L 62
437 3573040309560005 SOEBANDI L 65
452 3573040804520001 YACOBUS YADI DJALAL L 69
453 3573046409610002 SUHARTATIK P 60
456 3573041608600005 WAHYUDI L 61
466 3573045112680005 SITI AMINAH P 63
474 3573040701560004 HARIAWAN, SE L 65
477 3573042303580004 HARIYONO L 63
481 3573044507580008 MARIYANI P 63
487 3573040608590004 SUNARKO L 62
488 3573041303530004 MARJONO L 68
492 3573041807800003 ARIFUL HUDIANTO L 61
493 3573047006460001 NUR SA ADAH P 75
502 3573040105570004 SUGIANTO L 64
513 3573043112610007 KAMINO L 60
518 3173080303550003 SUWITO KASTORI L 66
522 3573041011550005 SUGIANTO L 65
524 3573041011560003 SUYONO P 65
531 3573042510510002 WARIS L 70
534 35730471125110033 SURIP P 70
535 3573047112560020 SITI NGAISAH P 65
539 3573040603580001 HADI SUMARIYONO L 63
543 3573046006580005 MISRINI L 63
561 3573012007520004 BUDI MUNADJI L 69
565 3573052812570002 SUGENG L 64
961 3573044408810001 SUPATIMININGSIH PEREMPUAN 60
TINGKAT PUSKESMAS
Alamat No. Hp Merek

Vaksin
JL.KLAYATAN III/36 085XXXXXXXXX

JL. KLAYATAN III/51 RT. 013 RW.002 081334996551
JL. KLAYATAN III RT 8 RW 2
KLAYATAN GG.3/37 085236158889
JL.KLAYATAN III 08/02 08XXXXXXXXXX
JL.KLAYATAN III/22 06/02 082141412960
JL.KLAYATAN III/51 013/002 081334996551
JL.KLAYATAN III/13 BANDUNGREJOSARI SUKUN 087759779320
JL.KLAYATAN III / 39 BANDUNGREJOSARI SUKUN 081249797829
JL KLAYATAN III / 67 RT 09 RW 02 BANDUNGREJOSAR082232087077

JL.KLAYATAN 3/05 01/02 087737194549
JL. KLAYATAN III/26 BANDUNGREJOSARI SUKUN MALANG
JL.KLAYATAN III/37 09/02 085236158889
JL KLAYATAN III / 38 B RT 09 RW 02 BANDUNGREJOS 0896011877310
JL KLAYATAN III / 3C RT 02 RW 02 BANDUNGREJOSA 08000000000
JL.JANTI BARAT I NO.29 08XXXXXXXXXX
JL. KLAYATAN III/ BANDUNGREJOSARI SUKUN MALA 08XXXXXXXXXXXX
JL.KLAYATAN III/05 087737194549
JL KLAYATAN IIIC /7 081234060221
JL. KLAYATAN III/ BANDUNGREJOSARI SUKUN MALA
JL KLAYATAN II / 59 RT 14 RW 12 BANDUNGREJOSAR 085606130959
JL.KEMANTREN I/26 08XXXXXXXXXX
JL.KLAYYATAN II/27 08XXXXXXXXX
JL KLAYATAN III C / 19 RT 14 RW 02 BANDUNREJOSA 08000000000
JL KLAYATAN 3C RT 04 RW 02 BANDUNGREJOSARI S 089668427051
JL.KLAYATAN I/73 0895200800900
JL.KEMANTREN I/52 08813272018
JL KLAYATAN III GG MELATI 11B BANDUNGREJOSARI085748346377
JL.KLAYATA II/4 08XXXXXXXX
JL.KEMANTREN 1 RT.007 RW.003 080000000
JL. KLAYATAN II / 04 RT 2 RW 1 081234640924
J.KLAYATAN II RT.008 RW.012 081238643747
JL. KLAYATAN III 081234567891
JL. KLAYATAN II 085252427167
JL. KLAYATAN III / 22 RT 7 RW 2 08827926539
JL KLAYATAN II/11 KOTA MALANG 08563539275
KLAYATAN I/34 -
JL. KLAYATAN II -
JL. KEMANTREN 1 / 26 RT 8 RW 3
JL KEMANTREN III / 47 RT 04 RW 13 BANDUNGREJOS 085712938741
JL.KLAYATAN I/65 08XXXXXXX
JL.KLAYATAN I/65 085100337736
KLYATAN III/3C JL. ABDUL HAMID -
JL KLAYATAN I/19 KOTA MALANG
JLKEMANTREN III RT.001 RW.003 085100429106
JL. KLAYATAN III 81232736086
JL. KLAYATAN II/11, BANDUNGREJOSARI, SUKUN 08000
JL.KLAYATAN I/9 085104383010
JL. KLAYATAN III
JL. KLAYATAN II/30 RT.000/012 08179615226
JL. KLAYATAN 3 NO 12 081234058891
JL. KEMANTREN I 0895331280237
JL. KLAYATAN I -
08560815680
JL. KLYATAN II/11 RT.004/001 081232882586
JL. RAYA KEPUS 081334601201
JL. KLAYATAN II/2 RT.009/012 -
JL. KLAYATAN III/27 RT.003/002 081332929585
PERUM SUKU PONDOK INDAH BLOK 08XXXXXXXX
JL.KEBEN II BLOK C-25C 08XXXXXXXXX
JL. KLAYATAN II NO. 36A RT.013/012 -
JL. KLAYATAN III/33 RT.003/002 085735870510
JL. KLAYATAN III -
JL.IR RAIS IX/155 03/04 081803110325 SINOVAC
JL.IR RAIS V/1 07/02 085649848779 SINOVAC
JLIR RAIS 1/27 SINOVAC
JL.MERGAN MUSHOLLA A 728C SINOVAC
JL.TERS.MERGAN RAYA 083891440302 SINOVAC
JL.MERGAN KELURAHAN B/13 05/11 087712632064 SINOVAC
JL.TERS.MTJ PUTRA YUDHA VE/22 0813365000541 SINOVAC
JL.TERS TANJUNG PUTRA YUDHA VC/19 03/13 085748998797 SINOVAC
JL.SUKUN GEMPOL 14/09 081907410213 SINOVAC
JL.SUKUN GEMPOL No..24 085100609208 SINOVAC
JL.TERS.TPY VA/55 085157775881 SINOVAC
JL.SIKATAN 17 087753285171 SINOVAC
JL.SIKATAN 17 087753285171 SINOVAC
JL.MERGAN RAYA VI/45 09/06 089528431653 SINOVAC
JL.GEMPOL MB/8 08/10 082332999040 SINOVAC
JL.TERS.TPY 5A/63 04/13 085235888341 SINOVAC
JL.TANJUNG PUTRA YUDHA V/50 081334731012 SINOVAC
JL.GEMPOL 03/09 081883404062 SINOVAC
JL.TERRS TPY V/2A 04/13 085755142805 SINOVAC
JL.SUKUN SIDOMULYO 2 05/07 0817389307 SINOVAC
JL.IR RAIS 9/114 01/04 085652333545 SINOVAC
JL.IR RAIS 9/114 01/04 085652333545 SINOVAC
JL.MERGAN KERAMAT 815 03/11 082230006430 SINOVAC
JL.SUKUN SIDOMULYO 4 05/07 083815503690 SINOVAC
JL.TANJUNG PUTRA YUDHA V/34 14/11 0895801206141 SINOVAC
JL.SUKUN SIDOMULYO 8 087756668907 SINOVAC
JL.DALI SELATAN 38 08/08 082132612670 SINOVAC
JL.GEMPOL MB 4B 06/10 081392530099 SINOVAC
JL.MERGAN SEKOLAHAN NO64 06/06 0895383013575 SINOVAC
JL.MERGAN RAYA V/21 08/05 089523305242 SINOVAC
JL.SIKATANA 32 05/08 088217862588
JL.TANJUNG PUTRA YUDHA 6/15 A 09/11 083119791373
JL.IR RAIS IX/294 08/04 085964226244
JL.SUKUN GEMPOL 25 081249085925
JL.MERGAN KERAMAT 40 03/11 081334800083
JL.TERS.MERGAN RAYA 19/12 04/11 081317134331 SINOVAC
JL.ICHWAN RIDWAN RAIS IX/20 06/04 089515773067
JL.SUKUN GEMPOL 087712523993
JL.S.SUPRIADI VII/9 07/02 08311849998
JL.MERGAN RAYA I/42 08/06 082257289173
JL.MERGAN MUSHOLLA XIX/750 081233449688
JL.TERS TANJUNG PUTRA YUDHA VB/28 082139017414
JL.TERS TPY VB 03/18 0882139017414
JL.PERKUTUT UTARA 26 085101192269
JL.MERGAN RAYA 6/34 081333277433
JL.BARENG TENGAH V/813 02/03 081334733560
KP. TAMBUN 1/1 TAMBUN 083835939266 SINOVAC
JL. TERS. TANJUNG PUTRA YUDHA V A/41 089630440500 SINOVAC
JL. MERGAN MUSHOLA 21 083852022440 SINOVAC
JL. TERUSAN MERGAN RAYA 19/72 083848658198 SINOVAC
JL. SUKUN GEMPOL 17/9 082231356891 SINOVAC
JL. IR. RAIS I/57 087806365272 SINOVAC
JL. GEMPOL MARGA BHAKTI NO 1 085893602089 SINOVAC
JL. SUKUN GEMPOL 7/9 083175790250 SINOVAC
JL. JOHAN NO 8 1/8 0881036121713 SINOVAC
JL. SUKUN GEMPOL 1 081335333226 SINOVAC
JL. IR. RAIS 17 18 087765935101 SINOVAC
JL. MERGAN KERAMAT 089602661559 SINOVAC
JL. GEMPOL MARGA BHAKTI 4B 081392530099 SINOVAC
JL. IR. RAIS IX/313 082230186622 SINOVAC
JL. SUKUN GEMPOL 9 085100552060 SINOVAC
JL.. MERGAN VETERAN NO 23 081317615060 SINOVAC
JL. MERGAN KERAMAT NO 28 087856436604 SINOVAC
JL. IR. RAIS 1/1 082122619682 SINOVAC
JL. KAKAKTUA SELATAN 12 081334784048 SINOVAC
JL. PUETR DALAM TENGAH 30 087856436560 SINOVAC
JL. IR. RAIS IX 58 C 083133724187 SINOVAC
JL. IR. RAIS IX 083133724187 SINOVAC
JL. PUTER SELATAN 22 089539517302 SINOVAC
JL. TANJUNG PUTRA YUDHA VI B/66 081249677244 SINOVAC
JL. TERS. MERGAN RAYA 19/12 08131734331 SINOVAC
JL. BANDULAN BARU 165 082228811694 SINOVAC
SUKUN GEMPOL 8 085648136148 SINOVAC
JL. MERGAN XXI/20 - SINOVAC
SUKUN SIDOMULYO 7/7 08597827022 SINOVAC
JL. TANJUNG PUTRA YUDHA VI/29 081211945163 SINOVAC
JL. KASIN JAYA IV/34 081359106290 SINOVAC
JL. IR. RAIS IX/383-B 081540089070 SINOVAC
JL. LEBAKSARI 6/1 081231664025 SINOVAC
TEGALREJO
Dosis I Dosis 2
Keterangan
Vaksinasi No. Batch Vaksinasi No. Batch
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
9/6/2021 202107142K 10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
10/7/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
06/09/2021 2040714201 10/7/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
07/10/2021 24006821
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
68 3573041503580002 KUSMANADI L 63 KLAYATAN I 39 10/01 083112033365 CORONAVAC 08/10/2021 24006821

73 3318124911400001 BOINI P 80 S SUPRIADI XI 28 06/04 085161677181 CORONAVAC 08/10/2021 24006821
205 3573041008570008 LUKIS WORO AMAN L 64 JL. JANTI BARAT 11 082232810057 SINOVAC 08/10/2021 24006821
291 3573046104490001 Sulami PEREMPUAN 72 Jl. Simpang Kepuh No. 50 -
295 3573040101300025 SOEDJONO LAKI-LAKI 91 JL KEPUH VII/35, BANDUNGREJOSARI, SUK 085855258236
298 357304450880005 SITI MAESAROH PEREMPUAN 63 JL KEPUH X/42, BANDUNGREJOSARI, SUKUN081247374460
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
306 3573041507510006 WARIYADI LAKI-LAKI 70 JL. KEPUH VIII / 16 RT 5 RW 5 081233464327

309 3573040708580008 Yasin LAKI-LAKI 63 Jl KEPUH 10/33, BANDUNGREJOSARI, SUKU 081247374460
319 3573045204590005 SRIYAHMANI HARIATI PEREMPUAN 62 JL. RAYA KEPUH 73 RT 3 RW 5 08983418449
324 3573046611600001 SUKARTI PEREMPUAN 61 JL. KEPUH X / 081333279572
338 357304008560003 SUJONO LAKI-LAKI 65 JL. SIMPANG KEPUH NO. 33 C RT 4 RW 10 081334731012
341 3573042208560003 SUGIHARTONO LAKI-LAKI 65 JL. KEPUH IX / 7 G RT 9 RW 5 085258266726
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
351 3573045811500002 FAJARIAN PEREMPUAN 71 JL.RAYA KEPUH 10 NO. 2 081233579073

366 3573042303380001 MOEHADJI LAKI-LAKI 83 JL. RAYA KEPUH V B / 35 RT 3 RW 5 082145655500
367 3573044207490003 Srijatin PEREMPUAN 72 JL KEPUH IX-A/18, BANDUNGREJOSARI, SU 081233127964
368 3573041209600004 Supri Asrifak LAKI-LAKI 61 Jl. Raya Kepuh X/35 RT. 007/005 081259214663
385 3573040108580003 KUSMADI LAKI-LAKI 63 JL. SIMPANG KEPUH 38 -
388 3573041805470001 SUKAEMI LAKI-LAKI 74 BANDUNGREJOSARI SUKUN MALANG 0852355469124
389 3573043108590002 HARTONO LAKI-LAKI 62 J. JANTI SELATAN VII / 31 RT 3 RW 6 081252359475
393 3573044906450001 SARMINTEN PEREMPUAN 76 JL.KEPUH IX A/23 085755266388
394 3573043101480001 JONATAN LAKI-LAKI 73 JL. JANTI VIII / 04 RT 5 RW 6 085236887418
429 3573042006360003 SOEKARDI LAKI-LAKI 85 thn JL.KEPUH X/23 082132154177
430 3573044101610051 KASIATI PEREMPUAN 60 JL. KLAYATAN 1/40 085855883330
434
3573041604600003 SUNARKO LAKI-LAKI 61 JL. RAYA KEPUH 35 RT 4 RW 5 089515310903
438 3573042312590003 GATOT CAHYONO LAKI-LAKI 62 JL. KEPUH IX/ 11 A 082229341137
452 3573045508560006 MUSLICHAH RAHAYU PEREMPUAN 65 JL. KEPUH RT 10 RW 5 083129656114
476 3573040507550004 Nasuki LAKI-LAKI 66 Jl. Kepuh X/55 RT. 007/005 089580029671
486 3573040205560007 D.M COKRO NEGORO LAKI-LAKI 65 Bandungrejosari sukun malang 081555333660
490 3573046810610003 Suyatemi PEREMPUAN 60 Jl. Kepuh IX/13 RT. 009/005 085900085157
492 3573045209600010 ANIDA ANWAR PEREMPUAN 61 JL. SIMPANG KEPUH 13 B -
496 3573044709630006 Endah Widarti PEREMPUAN 68 Jl. Simpang Kepuh 15B RT. 004/010 -
498 3573046102610002 Sri Rahaju PEREMPUAN 60 JL SIMPANG KEPUH 26, BANDUNGREJOSARI0895384669868
500 3573040101470007 DJAMA'ALI LAKI-LAKI 74 JL. RAYA KEPUH X/ 25 085101427414
524 3573042508530003 SUNARI LAKI-LAKI 68 thn JL.KEPUH V B/33 087866738556
535 3573041002560004 BAMBANG RUKUNTONO LAKI-LAKI 65 JL. SIMPANG KEPUH NO. 60 RT 3 RW 10 08123268411
537 3573044605580007 NUNIK LESTARI RAHAYU PEREMPUAN 63 JL RAYA KEPUH 35 0895396101769
541 3573045110590001 IDAWIYAH PEREMPUAN 61 JL. KLAYATAN III/30C RT.06/02 -
545 3573041611550003 ZAINUL BACHRI L 66 JL/ KEBEN IA/7 089630028222
546 3573045805580005 SITI NGAISAH P 63 JL. KEBEN IA/ 7 085855343158
549 3573047009480002 ASI BEKTIARI P 73 JL. KEBEN II BLOK A/8A 081230304595
570 3573045501600005 MISTIANI P 61 JANTI BARAT 17 04/08 083848484319
576 3573044101470013 MARPUAH P 74 KEPUH 8 18 05/05
587 3573041301600001 SLAMET SALAMUN LAKI-LAKI 61 JL. RAYA KEPUH III/14
1 3573040101560012 SUGITO L 65 S SUPRIADI VI 2358 083120274906 CORONAVAC 08/10/2021 24006821
5 3573044402490001 YASMINAH P 72 S SUPRIADI X 26 17/06 081334725270 CORONAVAC 08/10/2021 24006821
6 3573034101320025 MISARAH P 89 GALTIK DALAM 5 08319479961 CORONAVAC 08/10/2021 24006821
8 3573046509580002 JUMAANI P 63 S SUPRIADI VIII 11 13/06 085932275573 CORONAVAC 08/10/2021 24006821
13 3573040811610004 ADI KAWURJAN L 66 S SUPRIADI VI 2373 10/06 CORONAVAC 08/10/2021 24006821
25 3573041201540006 ABDUL SUUD L 67 S SUPRIADI XI 32 06/04 082232798024 CORONAVAC 08/10/2021 24006821
40 3573044307600005 YULIATI KUSMIATI P 61 SUKUN GEMPOL 4 03/09 081233664062 CORONAVAC 08/10/2021 24006821
64 3573041109580004 PUJI HARTONO L 63 S SUPRIADI XI 7 06/04 085381116868 CORONAVAC 08/10/2021 24006821
81 3573045502600006 SEMI P 61 S SUPRIADI IV 5 05/06 082230246010 CORONAVAC 08/10/2021 24006821
83 3573045903500001 YOHANA PIATI P 71 SUKUN GEMPOL 15 CORONAVAC 08/10/2021 24006821
86 3573044101500001 TUMINEM P 71 S SUPRIADI IV 65 05/06 085330874271 CORONAVAC 08/10/2021 24006821
87 3573046910600001 WIJIYATI P 61 S SURPADI 6 2311 04/06 085704045028 CORONAVAC 08/10/2021 24006821
116 3573041912530001 MURDIONO L 68 S SUPRIADI VI 2379 10/06 081232018326
127 3573041208550004 SUTARTO L 66 S SUPRIADI 6 30 10/06
146 3573040901520001 ARIADI L 69 JL. S. SUPRIADI X/26 081249592454 SINOVAC 08/10/2021 24006821
150 3573045509420003 DIYAH P 79 JL. S. SUPRIADI IV/42 085231116823 SINOVAC 08/10/2021 24006821
153 3573042307610002 WASIS L 60 JL. S. SUPRIADI IV/58 083851047505 SINOVAC 08/10/2021 24006821
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
157 3507306801540001 TARINI P 67 DSN TULUNGREJO 081332904852 SINOVAC 08/10/2021 24006821

179 3573042008590004 DJULIONO L 62 JL. SIMPANG SUKUN 087869125536 SINOVAC 08/10/2021 24006821
188 3573041104610001 PAIMAN L 60 JL. S. SUPRIADI 083834936815 SINOVAC 08/10/2021 24006821
193 3573044411520004 WARSINI P 69 JL. S. SUPRIADI VIII/2423 082245908586 SINOVAC 08/10/2021 24006821
194 3573045410610001 ENDANG SRI UTAMI P 66 JL. S. SUPRIADI XI/7 085257823343 SINOVAC 08/10/2021 24006821
206 3573045206400003 LOEBERFIRMANARTI P 81 JL. S. SUPRIADI VI/2365 081336701119 SINOVAC 08/10/2021 24006821
207 3573045712430001 SUDARMI P 78 JL. S. SUPRIADI IV/62 085330874271 SINOVAC 08/10/2021 24006821
209 3573041302570004 MUCHTAR L 64 JL. S. SUPRIADI X/38 081913009522 SINOVAC 08/10/2021 24006821
212 3573046006590002 SRI SUKENI P 62 JL. S. SUPRIADI VI/2349 - SINOVAC 08/10/2021 24006821
214 3573041505580008 SAMADY L 63 JL. TERS. TANJUNG PUTRA YUDHA V BLOK E-29 08123353898 SINOVAC 08/10/2021 24006821
216 3573045005580011 ENDANG SETYAWATI UTAMI P 63 JL. TERS. TANJUNG PUTRA YUDHA V BLOK E-29 082131931258 SINOVAC 08/10/2021 24006821
218 3573045003590002 SITI ARIANI P 62 JL. S. SUPRIADIIV/4 082139499445 SINOVAC 08/10/2021 24006821
221 3573042807550002 ABD. ROCHIM L 66 JL. S. SUPRIADI VIII/2417-24 08533107569 SINOVAC 08/10/2021 24006821
230 3573044705550002 SUGIYOWATI P 66 JL. S. SUPRIADI VI/2349 - SINOVAC 08/10/2021 24006821
237 3573045710590004 ETI SULIANA P 62 JL. S. SUPRIADI IV/49 088289452807 SINOVAC 08/10/2021 24006821
257 3573044107590052 MISTIN P 62 JL. S. SUPRIADI X/15 082132257702 SINOVAC 08/10/2021 24006821
258 3573041105570002 ABDIL MALIK L 64 JL. S. SUPRIADI X/37 081333667683 SINOVAC 08/10/2021 24006821
269 3573041606550006 SUPRIADI L 66 JL. S. SUPRIADI X/34 083834226239 SINOVAC 08/10/2021 24006821
276 3573044802560001 SURITATIK P 65 JL. S. SUPRIADI 8/2420-18 083834226239 SINOVAC 08/10/2021 24006821
284 3573045404560005 SUDARIYAM P 65 JL. SUKUN GEMPOL 20 081555652021 SINOVAC 08/10/2021 24006821
346
3507194811540001 Rahajeng Mujilowati PEREMPUAN 67 Kebonagung 65, Pakisaji, Malang 081216155744
350
3573044612610004 Tumini PEREMPUAN 60 Jl. Kuntuk No. 21 RT. 000/012 081216737779
544 3573045408600001 SUMARMI P 61 GADANG VI/2 081703539395
569 3573044212600005 SRI HARTATIK P 61 S SUPRIADI IH 26 B 085230866885

582 3507215202540002 NGATINAH P 67 DSN TEMU 08/03 0895396101768
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
492 3573044808580010 SUYATI PEREMPUAN 71 JL. KLAYATAN I 22RT 1 RW 4 81333660274

498 3573044101580010 NURUL AINI PEREMPUAN 63 JL. KEMANTREN 3/53 RT.003/013
499 3573045206520010 SARTINI PEREMPUAN 69 JL. KLAYATAN II / 14 RT 15 RW 12 81357082551
500 3573045208580000 MAMIK PEREMPUAN 63 JL. KLYATAN II GG. MELATI 11 RT 1 RW 2 89505845100
505 3573045001550000 SUNARTI PEREMPUAN 66 JL. KLAYATAN II / 44 RT 14 RW 12 83845617701
525 3573043112580010 Hari Supadi LAKI_LAKI 63 Jl. Klayatan I/27 RT. 005/012 85101408702
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
531 3573045506610010 LILIK SUSILOWATI PEREMPUAN 60 JL. KEMANTREN II GG. JERUK NO. 05 RT.001/003 81916292445
532 3573044807600000 ELIATI PEREMPUAN 61 JL. KLAYATAN II / 30 RT 11RW 12 81231310277
536 3573044210580000 SUPRAPTI PEREMPUAN 63 KLAYATAN I/24B 82143321521
542 3573044508580010 KASIJ PEREMPUAN 63 JL. KLAYATAN III / 25 C RT 3 RW 2
567 357304020945002 Taseman LAKI_LAKI 76 Jl. klayatan 3 / 20 B RT 3 RW 2 811261052237
569 3573042808590000 BAMBANG SETIA BUDHI LAKI_LAKI 63 KLAYATAN II/54E 85755494719
572 3507214106590000 Sriani PEREMPUAN 62 Jl. Klayatan II / 49 RT 14 RW 12 8233524537
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
578 3573045004600000 Suwartiningsih PEREMPUAN 61 Jl. Klayatan II /60 B RT 14 RW 12 85745778561

581 3573040108530010 SUPAROH LAKI_LAKI 63 Jl. Kemantren I 82242612180
585 3573046908560000 DJUWANAH PEREMPUAN 65 KLAYATAN I/17 82142612180
589 3573045609580000 Trianah PEREMPUAN 63 Jl. Kemantren II gg. Jeruk 14 rt 1 rw 3 85851339486
594 3573041801560000 SUMAJI LAKI_LAKI 65 KLAYATAN III/53 81273354247
596 3573042606570000 Supangat LAKI_LAKI 64 Jl. Klayatan I/36 RT. 006/001 8986323552
598 3573040804540000 SOEBANDI LAKI_LAKI 67 KLAYATAN II/17 85716291489
599 3573041203590000 Sakur LAKI_LAKI 62 Jl. Klayatan I/21 RT. 005/012 82142612180
608 3573045407530000 RUKIYATI PEREMPUAN 68 KLAYATAN II/15A 81216867960
609 3573044711570000 Kasiyatun PEREMPUAN 64 Jl. Klayatan II 9 81232498890
610 3573047112550010 Kasih PEREMPUAN 66 Jl. Klayatan I/36 RT. 007/001 97859918693
611 3573043112570020 Surawi PEREMPUAN 64 Jl. Klayatan II 7 81230933324
612 3573040905520000 D. Yanto LAKI_LAKI 69 Jl. Klayatan II 22
614 3573045410590000 DJUMAIYAH PEREMPUAN 62 KEMANTREN II GG.JERUK NO.10 85604420844
616 3573044102610000 Asiati PEREMPUAN 60 Jl. Klayatan II/17 RT. 025/012 85259453039
620 3573040102600010 Kolik LAKI_LAKI 61 Jl. Klayatan II no. 42 a rt 14 rw 12 81252435822
621 3573040302610000 TUKIMAN LAKI_LAKI 60 KLAYATAN II/46 82338266232
629 3573042010550000 Sugito LAKI_LAKI 66 Jl. KlayatanII / 17 rt 15 rw 12 81359365515
635 3.573004590357E+016 Asiyah PEREMPUAN 64 Jl. Klayatan II / 35 rt 4 rw 1 82142612180
636 3573046001560000 Sumiati PEREMPUAN 65 Jl.klayatan 2 82123494746
638 3573046203370000 SARMI PEREMPUAN 84 KEMANTREN III PERUM MORSE REGENCY B.3 85785232452
641 3573044705320000 Lidya wagiyem PEREMPUAN 79 Jl. Klayatan II/9 RT. 008/012 81556729459
642 3573046808610000 SUNINGSIH PEREMPUAN 60 KEMANTREN II GG.JERUK NO.25 87859407447
653 3573045901650000 Lukitawati PEREMPUAN 66 Jl. Kemantren III gg. H. Agus Salim 74 rt 1 rw 13 85105181464
658 3573045111530000 Djami PEREMPUAN 67 Jl.kemantren gg 2/14 81555966219
661 3573042306610000 Budi karyadi LAKI_LAKI 60 Jl.klayatan 1/30 85100479663
662 3573042404480000 Mukiyar LAKI_LAKI 73 Jl.klayatan gg 1/02 82232321289
672 3573044411490000 Susmi PEREMPUAN 72 Jl. Klayatan II / 4 rt 14 rw 12 85815152126
676 3573044411600000 SRIATI PEREMPUAN 61 KLAYATAN II/27 85755773871
705 3573045011610000 NGATMINI PEREMPUAN 60 JL. KLAYATAN I/9 89523818009
706 3.57304440554E+016 Suprapti PEREMPUAN 67 Jl. Klayatan II /54 c rt 14 rw 12 85732508810
716 3573040907480000 M Tunggal LAKI_LAKI 73 Jl. Klayatan I/49 RT. 001/012
728 3573052608600990 Sunartak LAKI_LAKI 61 Jl. Klayatan III gg. Melsti 17 rt 1 rw 2 83849233525
731 3573040101500030 MISDI LAKI_LAKI 71 JL. KLAYATAN I/30 RT.001/012 8986323552
740 3573045807550010 ROMLAH PEREMPUAN 66 JL. S. SUPRIADI / KEPUH GG. I / 14 A
741 3573047107610000 Wartiningtiyas PEREMPUAN 60 Jl. Klayatan I/77 rt 4 rw 12 85843713144
750 3573040804600000 Sukri LAKI_LAKI 61 Jl. Klayatan II 46 rt 15 rw 12 881026066702
766 3573041609570000 MOCHAMMAD CHOIRUL LAKI_LAKI 64 JL.RAYA KEPUH X / 15 - 148 82230236149
768 3573041201540010 Irfan efendi LAKI_LAKI 67 Jl. Kemantren III/40 f rt 4 rw 13 82233777061
772 3573040512540000 SAKRI PEREMPUAN 67 JL. KLAYATAN I / 46 8986323552
775 3573045012560010 Lamah PEREMPUAN 65 Kepuh Gg.VI/32 83849096149
KEL.BANDUNGREJOSARI
781 357304130480003 SUPRIADI LAKI_LAKI 91 KEC.SUKUN 83846328191
795 3573044402600000 Sulistiyowati PEREMPUAN 62 Klayatan I/24C 81937626059
797 3573043004570000 Erwin samsono LAKI_LAKI 69 Jl. Klayatan I/40 rt 1 rw 12 8986323552
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
801 3573044603480000 KUSUMARTININGSIH PEREMPUAN 73 JL. KLAYATAN I / 42-27 82334530055

805 3573044201390000 Kusni PEREMPUAN 82 Perum Sukun Pondok Indah Blok BB-3 RT. 005/0 89560137236
808 3573041504610000 Sugeng Hariyanto LAKI_LAKI 60 Jl. Klayatan I/30 RT. 008/001 8125280147
811 3573040711610000 Djoko Sungkono LAKI_LAKI 60 Janti Selatan 7/44 85330346868
814 357301009490003 Supono LAKI_LAKI 72 Klayatan I/73B 71239857042
KEL.BANDUNGREJOSARI
820 3573045212570010 MARSIH PEREMPUAN 64 KEC.SUKUN 85326705504
829 3573044808500010 Sit Fatimah PEREMPUAN 71 Klayatan II/9 8986323552
849 3573040508590000 Sujoko LAKI_LAKI 62 Jl. Danuri 07 85100413590
857 3573040423590000 Affandi LAKI_LAKI 62 Jl. Klayatan III/49 rt 13 rw 2 85704368007
KEL.BANDUNGREJOSARI
867 5373045204610000 SRIANTI PEREMPUAN 60 KEC.SUKUN 895630919856
868 3573045005570010 Karminingsih PEREMPUAN 64 Jl. Klayatan II/23 rt 8 rw 12 82249108853
KEL.BANDUNGREJOSARI
871 3573046008590000 SUYATI PEREMPUAN 62 KEC.SUKUN 85646555873
KEL.BANDUNGREJOSARI
876 3573044101420020 SITI FATIMAH PEREMPUAN 73 KEC.SUKUN 85646555873
880 3573046505380000 Katiyem PEREMPUAN 83 Jl. Klayatan II/31 RT. 004/001 8986323552
890 3573040107550100 Djamari LAKI_LAKI 66 Perum SPI Blok BB-03 89562013226
894 3573045611560000 Fatimah PEREMPUAN 65 Klayatan III/23 82134306030
896 3573044102600010 Sudarsih PEREMPUAN 61 Klayatan III/46 81252225655
904 3573041909540000 Yasin LAKI_LAKI 67 Jl. Kemantren I/15 GG. Trunojo RT. 009/003 8986323552
908 3573041707590000 Rusdi Wahono LAKI_LAKI 62 Klayatan II/29
935 3573040304600000 Mulyadi LAKI_LAKI 61 Jl. Kemantren II/44 RT 4 RW 3 81212030408
941 3573047112470020 Suparmi PEREMPUAN 74 Jl. Klayatan I/14 RT 5 RW 1 85933993885
956 3573044009530000 Wasiyah PEREMPUAN 68 Jl. Klayatan I/33 RT 6 RW 12 85549070150
962 3573044101450020 Suyatin PEREMPUAN 76 Jl. Klayatan 2/30 RT 15 RW 12 89651014522
973 3573045709510000 Sri Soetjiati S PEREMPUAN 70 Klayatan I/1 81252720452
975 3573040304610000 Tjutjuk Sulaksono LAKI_LAKI 60 Perum Sukun Pondok Indah S-21C RT. 004/007 81335747131
986 3573045310500000 Suyati PEREMPUAN 71 Jl. Klayatan III /6A RT 3 RW 2 8980362903
994 3573041509390000 Rifai Parto LAKI_LAKI 82 Klayatan II/20 8986323552
1024 3573047112530010 Sumiati PEREMPUAN 68 Kemantren I/16 895335422586
KEL.BANDUNGREJOSARI
1033 3573042104380000 YAHMUN LAKI_LAKI 83 KEC.SUKUN 8986323552
1043 3573041011580010 Suwono LAKI_LAKI 63 Klayatan II 82264521457
1054 3573040108600010 FANARI SUYONO LAKI_LAKI 61 Bandungrejosari, sukun, malang 82142612180
1072 3573040902530000 Suratno LAKI_LAKI 68 Jl. Klayatan I/38 RT. 001/012 82330781523
1083 3573047001540010 Misi Yanik PEREMPUAN 67 Klayatan I/32
JL KLAYATAN II/2
1084 3573042712580000 BAMBANG SUROSO LAKI_LAKI 62 RT/RW 02/01 85859536449
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
1134 3573045006500002 HARI TUTININGSIH P 73 KLAYATAN II/37 08111930131
1135 3573042007380001 HARI POEDYASTOMO L 71 KLAYATAN II/37 08111930131
9 3573040509610007 SYAIFUL WACHID L 60 JL SIMP TPY 2/20 081333382075 SINOVAC B202106069
17 3573045909590005 SUPARTI P 62 JL IR RAIS 562 B RT 1 RW 6 082331988481 SINOVAC B202106069
20 3573044102410003 LASMANI P 80 JL IR RAIS IX/68 089687343378 SINOVAC B202106069
23 3573045312480002 SULASTRI P 73 JL IR RAIS 15/563 081259219889 SINOVAC B202106069
29 3573044808610007 RUMINAH P 60 JL MERGAN MUSHOLA NO 22 089653339340 SINOVAC B202106069
31 3573044606590006 SUTAMI P 62 JL SUKUN GEMPOL 4 08239029822 SINOVAC B202106069
35 3573044808540006 SULASTRI P 67 JL SUKUN GEMPOL RT 15 RW 9 082331985713 SINOVAC B202106069
39 3573045707610001 SITI CHALIMAH P 60 JL MERGAN MUSHOLA NO 46 0881024033623 SINOVAC B202106069
59 3573044803550003 RUKAYAH P 65 JL IR RAIS IX/257 089525016079 SINOVAC B202106069
77 3573044302590002 HJ MARIYAM P 62 JL IR RAIS IX/55 081334582000 SINOVAC B202106069
82 3573046605600002 RR. YOEL HARINDRATI P 61 JL IR RAIS IX/133 SINOVAC B202106069
87 3573040101570043 RAWAT L 64 JL SUKUN GEMPOL NO 30 083848597083 SINOVAC B202106069
88 3573040503520003 DJUMAIN L 69 JL IR RAIS IX/55 081334561521 SINOVAC B202106069
91 3573047112530028 SUTALMI P 68 JL IR RAIS IX/417 085339124791 SINOVAC B202106069
93 3573040606530005 MARIYONO L 68 JL SUKUN SIDOMULYO RT 6 RW 7 085749400616 SINOVAC B202106069
100 3573041504500001 SUHARTONO L 71 GADANG RAYA 315E 08999302262 SINOVAC ### B202106069
101 3573046505420002 KARTI P 79 JL TER TPY VA//45 SINOVAC B202106069
106 3573041506500001 KEMIN L 71 JL TPY 2 DALAM 081358823879 SINOVAC B202106069
108 3573046903580002 NANING SULISTYORINI P 63 JL GEMPOL MARGA BHKATI 20 0895334935132 SINOVAC B202106069
113 3573040903550004 BUDIANTORO L 66 JL KASIN JAYA V/77 SINOVAC B202106069
121 3573042207530002 H. UMAR SAID H L 68 JL PUTER TENGAH NO 21 081334581155 SINOVAC B202106069
126 3573045709560004 RIYATI P 65 JL IR RAIS 9/19 SINOVAC B202106069
132 3573040805540006 SUMARTO L 67 JL TRS TPY 5A/69 SINOVAC B202106069
139 3573047005580001 HARIYATI P 63 JL IR RAIS 1 NO 9B 081945358045 SINOVAC B202106069
141 3573045006590002 SUHARTINI P 62 JL SUKUN SIDOMULYO 12 0895359808089 SINOVAC B202106069
144 3573042906610001 SUGITO L 60 JL IR RAIS IX/321 08979679924 SINOVAC B202106069
151 3573044601520002 AMINI P 69 JL IR RAIS UX/147 085855539849 SINOVAC B202106069
169 3573047112600028 SUMIATI P 61 JL GEMPOL MARGA BHAKTI 13 081237110802 SINOVAC B202106069
173 3573046506590004 SURATIN P 62 JL KASIN JAYA IV/8 081235884816 SINOVAC B202106069
194 3573042005520003 MULYANTO L 69 JL SUKUN GEMPOL 08770767952 SINOVAC B202106069
209 3573042210530002 KUSDARMADJI L 68 JL MERGAN BARU XXI/28 089516012429 SINOVAC B202106069
214 3573044811520004 SANIK P 69 JL PUTER DALAM UTARA 24 083834775537 SINOVAC B202106069
229 3573040104550005 RUSMAT L 66 JL KLAYATAN GG 1 NO 55C 085738682909 SINOVAC B202106069

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
238 3573044112590005 SUTINI P 62 JL IR RAIS GG 3/18 SINOVAC B202106069
251 3573044108510012 WATINI P 70 JL GEMPOL MARGA BHAKTI 8 SINOVAC B202106069
253 3573040301530003 SATUK L 75 JL KASIN JAYA 4 NO 18 SINOVAC B202106069
255 3573046808560002 RUSMINI P 65 JL KASIN JAYA 4 NO 18 SINOVAC B202106069
256 3573044107510001 MARIANA P 70 JL MERGAN BARU XXI/58 081252306660 SINOVAC B202106069
262 3173036012540004 SUKARNI P 67 JL GEMPOL MARGA BHAKTI 16 083122068787 SINOVAC B202106069
263 3573047012600009 BADERIA P 61 JL TPY VIA/42 087755701882 SINOVAC B202106069
267 352703516610003 TUMI P 60 DSN LENTENG 087863424150 SINOVAC B202106069
271 357304060360003 SAMURI L 61 JL MERGAN BARU XX1/58 081252306660 SINOVAC B202106069
279 3573044101550044 SUNARTI P 65 JL IR RAIS IX/253 08954111331252 SINOVAC B202106069
289 3573040108570034 RIADI L 64 JL GEMPOL 24 081359564198 SINOVAC B202106069
293 357304945600001 AMINAH P 61 JL MERGAN KELURAHAN BLOK D1/4A 08125214041 SINOVAC B202106069
296 3573045004520002 DJUMANI P 69 JL MERGAN KELURAHAN C-7 08125242766 SINOVAC B202106069
310 3573041701470001 SLAMET ZAINURI L 74 JL IR RAIS IX/195 081944800133 SINOVAC B202106069
314 3573040109490004 SOLIKIN L 72 PUTER DALAM SELATAN 52 081231667288 SINOVAC B202106069
321 3573047009440002 MARDIKANINGSIH P 77 CUCAK ROWO 12 SUKUN 081328144038 SINOVAC B202106069
329 3507044405570004 JARWANING TYAS P 60 JL. SIMPANG PUTRA YUDHA II/20 081333382075 SINOVAC B202106069
330 3573044608540000 ERNA RETNOWATI P 67 JL. TPY 2/07 085770304470 SINOVAC B202106069
336 3573040305500004 HARJOKO L 71 JL. SUKUN GEMPOL 082331985713 SINOVAC B202106069
341 3573045401520000 SUMIHARTINI P 69 JL. IR RAIS 562 A 081334327232 SINOVAC B202106069
343 3573040404540002 SUHARIYADI L 67 JL. IR RAIS 9/150 085794753080 SINOVAC B202106069
348 3573040107420077 SAMIN L 89 GEMPOL MARGA BHAKTI 081334939979 SINOVAC B202106069
350 3573045011610008 SATRI P 65 JL. SUKUN SIDMULYO 8 085607361970 SINOVAC B202106069
352 3573046008580007 HARTATIK P 63 JL. SUKUN GEMPOL 083143199347 SINOVAC B202106069
354 3573042104510004 KIMIN L 70 JL. SUKUN GEMPOL 31 085706897012 SINOVAC B202106069
355 3573047112540005 SUTIYEM P 67 JL.SUKUN GEMPOL 31 085706897012 SINOVAC B202106069
360 3573045010590017 TUKIYEM P 62 JL. SUKUN SIDOMULYO 8 085607361970 SINOVAC B202106069
361 3507192812550001 UJANG TIBRONI L 66 JL. IR RAIS IX/206 082330178533 SINOVAC B202106069
374 3573044101590049 DASRI P 62 JL. SUKUN GEMPOL NO 30 SINOVAC B202106069 10/11/2021 B202106069
380 3573044906490004 KASIYATI P 72 JL. GEMPOL 53 081357920967 SINOVAC B202106069
382 3573044912510001 SITI CHALIMAH P 70 JL. IR RAIS IX/103 081234063588 SINOVAC B202106069
384 3573041501540008 SUGENG SANTOSO L 67 JL. IR RAIS XIV/362 082232736630 SINOVAC B202106069
390 3573046905590004 HARI SUKEMI P 62 JL. SIKATAN 25 083834757358 SINOVAC B202106069
392 3573045503450002 YAMANAH P 76 JL. SUKUN SIDOMULYO 089516232884 SINOVAC B202106069
393 3573040607580002 SUKENI ZAINUDDIN L 63 JL. SIKATAN 25 083834757358 SINOVAC B202106069

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
397 3573041809580003 MISDI L 63 GEMPOL MARGABHAKTI 10 081239393020 SINOVAC B202106069
399 3573042711500001 NURALI L 71 JL. IR RAIS IX/199 0895365924159 SINOVAC B202106069
405 3573045712600006 SULISTINAH P 61 JL. IR RAIS IX/260 0883848577184 SINOVAC B202106069
414 3573045205570003 SUMIATI P 64 JL. TRS TPY 5A NO 69 SINOVAC B202106069
416 3573040611560000 SUKADI L 65 JL. TPY VI A/2 082336848343 SINOVAC B202106069 10/11/2021 B202106069
424 3573046004610004 LISIATI P 61 JL. KASIN JAYA IV/4 081252628728 SINOVAC B202106069
426 3577214905610001 TITIK TRIANI P 60 DSN BUWEK RT 06 RW 04 082363502628 SINOVAC B202106069
434 3573042007530002 BAMBANG SUKARWARNO L 68 JL. IR RAIS IX/333 0818844357 SINOVAC B202106069
436 3573041207500004 SAYEM P 71 JL. IR RAIS IX/253 SINOVAC B202106069
439 3573045706580004 NGATINI P 63 JL. SUKUN GEMPOL NO 31 SINOVAC B202106069
443 3573044101550048 SRI BAWON P 66 JL. IR RAIS VII/71 087816386674 SINOVAC 11/10/2021 B202106069
444 3573041410610003 SUTOYO L 60 JL. GEMPOL 30 083117510939 SINOVAC B202106069
446 3573030610550002 PAITO L 65 JL. SATSUI TUBUN IV 083121607925 SINOVAC B202106069
455 3573040106380001 KASDU L 83 JL. SUKUN GEMPOL SINOVAC B202106069
465 3507045411510001 NANIK SUNAINI P 70 JL. SUKUN GEMPOL 082144127588 SINOVAC 11/10/2021 B202106069
467 3573047110610003 WINARTI P 60 JL. SUKUN GEMPOL 20 0881026909171 SINOVAC 11/10/2021 B202106069
468 3573044308380003 RATIN P 83 JL. IR RAIS IX/178 SINOVAC B202106069
469 3573045004550005 MAERAH P 62 JL. SUKUN SIDOMULYO 5 SINOVAC B202106069
474 3573044912560002 SITI MAISYAROH P 65 JL. GEMPOL MARGA BHAKTI 38 SINOVAC B202106069
477 3573043112610023 SLAMET L 60 JL. JOHAN NO 6 081331750785 SINOVAC B202106069
478 3573046711580001 AMINAH P 63 JL. TPY VI A 0895363532223 SINOVAC B202106069
487 3573041505480004 PAIMUN MUNIR L 73 JL. IR RAIS IX/253 08954111331252 SINOVAC B202106069
489 3573040610610007 GINO L 60 JL. SUKUN GEMPOL 30 085259474747 SINOVAC B202106069
493 3514124101600010 RAHAYU SUWARTININGSIH PEREMPUAN 61 PENANGGUNGAN GG. BERLIAN RT.002/027 81286532524
494 3514120707520000 ACHMAD RIFAI LAKI_LAKI 69 PENANGGUNGAN GG. BERLIAN RT 2 RW 27 82139914720
556 3507194101570000 WIWIK NURYATI PEREMPUAN 64 PERUM SARIMADU PERMAI II BLOK A1-3 85695142045
562 3.50719410157E+016 Wiwik Nuryati LAKI_LAKI 64 Perum Sarimadu Epermai II Blok A1-3 RT 11 RW 85695142045
563 3573041506390000 Yitno LAKI_LAKI 77 Jl. Krmantren I/Trunojoyo 26 8986323552
631 3572034705910000 Yuyun Ariati PEREMPUAN 70 Jl. Timor GG. II RT. 010/014 8125299722
709 3573045005600010 Sri Mulyati PEREMPUAN 61 Pelabuhan Ketapang 1 81906881096
841 3505042602540000 SUPARDJI LAKI_LAKI 67 DSN KAMPUNG TENGAH
909 3515164404460000 Yuliana Suyati PEREMPUAN 75 Jl. Kutilang Barat 63 rt 7 rw 8 82142623280
943 3573030507420000 Soedjono Roedijanto LAKI_LAKI 74 Jl. Kresno 28 82231957626
1018 3573042807600000 Purwono LAKI_LAKI 61 Jl. Kolonel Sugiono 10/55 RT 14 RW 1 82242819004
1090 3573036304610000 SUWARNI PEREMPUAN 60 JL MUHARTO VII B KOTALAMA, KEDUNGKANDA 81230282395
Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
1091 3507226505560000 RUBIATIN PEREMPUAN 65 Sumbersekar, Dau 85293739511

TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
17 3573044911570002 ARI ASTUTIK P 64 JL.S.SUPRIADI 87N03/04 083894490222 SINOVAC 7/9/2021 24003221 10/12/2021 B202106069
28 3573046504590001 SUGIYANTI P 62 JL.KEMANTREN III/12A 04/13 - SINOVAC
43 3573045004540005 SUMAIDAH P 64 JL.S.SUPRIADI 9/5 09/04 082257247370 SINOVAC 12/10/2021 B202106069
76 3573041701560003 HERI SUYONO L 65 JL.S.SUPRIADI IX/102 10/04 08155553305 SINOVAC 12/10/2021 B202106069
77 3573046410580001 ALFIATI P 63 JL.SUPRIADI 9A/31 09/04 085608920566 SINOVAC 12/10;/2021 B202106069
101 3573047112580028 SUMIATI P 63 JL.KLAYATAN I/47A 02/12 085755308244 SINOVAC 12/10/2021 B202106069
Dosis I Dosis 2
Vaksinasi
Vaksinasi
139 3573040308560001 ALI MUNAWAR L 65 JL.KLAYATAN III/6 11/02 081333269997 SINOVAC 12/10/2021 B202106069
18 3573044111400003 SITI FATIMAH P 81 JL.MANYAR 21 17/08 - SINOVAC 12/10/2021 B202106069
19 3507244107340001 ANIPAH P 87 PERUM ASABRI 1/11 06/13 RANDUAGUNG 081233901788 SINOVAC 12/10/2021 B202106069
21 3573044102490001 KARIYEM P 72 JL.S.SUPRIADI VI/2304 081333995255 SINOVAC
Dosis I Dosis 2
Vaksinasi
Vaksinasi
47 3573044304550008 PATIMAH P 66 JL.S.SUPRIADI X/16A 18/06 085649505721 SINOVAC 12/10/2021 B202106069

52 3573041209540005 SUKIRNO ABDUR ROCHIM L 67 JL.MANYAR TIMUR 31 17/08 082332980115 SINOVAC 12/10/2021 B202106069
53 3573044703600005 EMI MUJAYANTI P 61 JL.MANYAR TIMUR 31 17/08 082332980115 SINOVAC 12/10/2021 B202106069
54 3573044106480001 SRIAMAH P 73 JL.MANYAR 9 17/08 085259336283 SINOVAC 12/10/2021 B202106069
61 3573037012510002 LAILY NURAISIJAH P 70 JL.DANAU RANAU IV G1B/10 06/15 082139239977 SINOVAC 10/09/2021 24003521 10/12/2021 B202106069
67 3573027112430008 DJUWARIYAH P 78 JL.KPT PIERE TENDEAN IDE/29 08/10 085857258422 SINOVAC 12/10/2021 B202106069
72 3573040103570003 WAKIDI L 64 JL.SUPRIADI 9A/36 09/04 085608920566 SINOVAC 12/10/2021 B202106069
94 3573042406600004 ERIN TAMRIN L 61 JL.KAKAK TUA SEL 17 15/08 082301198787 SINOVAC 13/09/2021 2021081551 10/12/2021 B202106069
106 3573045306610002 SRI YUNI SUBANDIYAH P 60 JL.SRI GUNTING No..11 06/06 085101769734 SINOVAC 12/10/2021 B202106069
107 3573040405560003 A RACHMAN MULYADI L 65 JL.SRI GUNTING No..11 06/06 082331844443 SINOVAC 12/10/2021 B202106069
113 3573044101360003 SUPINAH P 84 JL.S.SUPRIADI No..6 2295 03/06 - SINOVAC 12/10/2021 B202106069
114 3573044510510005 LIEM DJIEN AIJ P 70 JL.S.SUPRIADI 63 08/02 085832500454 SINOVAC 12/10/2021 B202106069
135 35730422075500002 SUJITNO L 66 JL.S.SUPRIADI X/17 18/06 081333507488 SINOVAC 12/10/2021 B202106069
144 3573040502360002 GIMAN L 85 JL.SIMP PUTRA YUDHA II/15 06/13 081556648657 SINOVAC 12/10/2021 B202106069
147 3573040401450003 MUHAMMAD THOHA L 76 JL.S.SUPRIADI 14 01/06 085220112966 SINOVAC 12/10/2021 B202106069
173 3573046101580001 SUKINI P 63 JL.S.SUPRIADI VII/39 04/02 083130006150 SINOVAC
217 3573046005390003 SUDJIMAH L 80 S SUPRIADI X 4 16/06 15/09/2021 B202106069 10/13/2021 B202106069
219 3573042504560003 SUWITO L 65 S SUPRIADI X 7 16/06 087754425896 15/09/2021 B202106069 10/13/2021 B202106069
226 3573041501510003 SUGIANTORO L 70 MANYAR 89 16/08 15/09/2021 B202106069 10/13/2021 B202106069
227 3573044707530002 YULIATIRODE P 68 MANYAR 89 16/08 081945946996 15/09/2021 B202106069 10/13/2021 B202106069
TINGKAT PUSKESMAS

Dosis I Dosis 2
Umur Keterangan
Vaksinasi Vaksinasi
82 3573046308890004 ZALWA RANI AZIZAH P 32 JL. KLAYATAN III/35 082330059835 SINOVAC 14/10/2021 B202106069
98 3573044212900003 MOSTAFAVI AZ ZAHRO P 31 JL. KLAYATAN III/35 081329558582 SINOVAC 14/10/2021 B202106069
210 3573045304000001 SAFIRA EKTA FIRDAUSI P 21 JL. KLAYATANIII/ 29 085659670658 SINOVAC 14/10/2021 B202106069
230 3573041905870006 FANDI AHMAD L 34 JL. KLAYATAN III/36 RT/RW 12/2 082155637229 SINOVAC 14/10/2021 B202106069
237 3573046103650009 SITI MARHUMAH P 56 JL. KLAYATAN III/35 RT/RW 12/2 081329558582 SINOVAC 14/10/2021 B202106069
254 357303270879002 ARIL FERRY W L 42 JL. JANTI BARAT BLOK. A 07/06 081252262706 SINOVAC 14/10/2021 B202106069
1 3201045005030007 NADIA MAHARANI PUTRI P 17 JL. MERGAN VETERAN NO. 40 081334947260 SINOVAC 10/14/2021 B202106069
2 3528056103000008 MILAWATI P 21 DUSUN AMPERRE 085854412578 SINOVAC 14/10/2021 B202106069
3 3573040106010004 ALVIN MAULANA L 20 TANJUNG PUTRA YUDAH V/49 089602643404 SINOVAC 14/10/2021 B202106069
4 3573046311080001 NURIL GLADISYA ADIANI P 12 JL. SUKUN SIDOMULYO 089520530701 SINOVAC 14/10/2021 B202106069
5 3573040901710002 MOCH. IMAM SUMADI L 50 TANJUNG PUTRA YUDAH V/49 083848561607 SINOVAC 14/10/2021 B202106069
6 3573040307560002 SABAR L 65 JL. OUTER DALAM TENGAH 2 081336331340 SINOVAC 14/10/2021 B202106069
7 3508126504870002 SULASTRI P 22 JL. TANJUNG PUTRA YUDHA 081331859201 SINOVAC 14/10/2021 B202106069
8 3573045903990001 SUHARTINI P 22 JL. KASIN JAYA 4 083848731666 SINOVAC 14/10/2021 B202106069
9 3573045605720003 SOLICHAH P 49 JL. MERGAN KERAMAT No. 58C 081235766161 SINOVAC 14/10/2021 B202106069
10 3573040304740003 DIAN PRAMOSINTO L 47 JL. KASIN JAYA 2 08385947320 SINOVAC 14/10/2021 B202106069
11 3573045002000003 NAFISAH P 21 JL. I. R RAIS IX/46 0881036591030 SINOVAC 14/10/2021 B202106069
12 3573044107000037 DINIK P 25 JL. TANJUNG PUTRA YUDA V/83 0895630918673 SINOVAC 14/10/2021 B202106069
13 3573045803710005 DJAMILA P 50 JL. KELAPA SAWIT III/22 SINOVAC 14/10/2021 B202106069
14 3573040609860006 SAMSUL QOLIK L 35 JL. MAYJEN PANJAITAN XVII-A 082213138934 SINOVAC 14/10/2021 B202106069
15 3573030507050003 GIRHAN ALDRIAN LESMANA L 16 JL. DANAU TONDANO DALAM III 082228355080 SINOVAC 14/10/2021 B202106069
16 3573042011650003 BAMBANG L 56 JL. TANJUNG PUTRA YUDHA 4/58 085334414198 SINOVAC 14/10/2021 B202106069
17 3573021401790004 ARIS SUSANTO L 42 JL. KASIN JAYA IV/27 083834298013 SINOVAC 14/10/2021 B202106069
18 3573041707630003 MOCHAMAD SAID L 58 JL. TANJUNG PUTRA YUDHA 53 085107771066 SINOVAC 14/10/2021 B202106069
19 3573042112610002 NANO L 60 JL. SUKUN SIDOMULYO 088989710905 SINOVAC 14/10/2021 B202106069
20 3573044612800006 SUPRIYATIN P 41 JL. SUKUN GEMPOL NO. 4 085815600715 SINOVAC 14/10/2021 B202106069
21 3573044909700005 SITI ROBIKAH P 51 JL. TANJUNG PUTRA YUDHA 53 085107771066 SINOVAC 14/10/2021 B202106069
22 3573045307660002 YULI RIBAWANINGTIYAS P 55 JL. I.R RAIS 9 NO. 35/391 085790950653 SINOVAC 14/10/2021 B202106069
23 3573044112500007 MARKINI P 70 JL. RANGKOK SELATAN 15 085850681141 SINOVAC 14/10/2021 B202106069
24 3573046805900002 AMBAR WATI P 31 JL. JOHAN No. 21 0895395198717 SINOVAC 14/10/2021 B202106069
Dosis I Dosis 2
Vaksinasi
Vaksinasi
25 3573041003600003 MUDJIARTO L 61 JL. I.R RAIS V / 114A 085257434543 SINOVAC 14/10/2021 B202106069
26 3573045602080001 HAFIZHA CINTA AZ ZAHRA P 13 JL. S. SUPRIADI X/16 A 085649505721 SINOVAC 14/10/2021 B202106069
27 3573045908940001 SUZAN SAHR BANU ZAHRO P 27 JL. I. R RAIS V / 114 A 085257434543 SINOVAC 14/10/2021 B202106069
28 3573045011920005 RODHIATUS SAKDIA P 39 JL. TANJUNG PUTRA YUDHA 53 085804077092 SINOVAC 14/10/2021 B202106069
29 3573044101480017 SUPINAH P 73 JL. MERGAN LORI 601 B 081232324954 SINOVAC 14/10/2021 B202106069
30 3573041010600011 DJALI L 61 JL. SUKUN SIDOMULYO 081336700927 SINOVAC 14/10/2021 B202106069
31 3573041303770006 IMAM MASHURI L 44 JL. JUPRI 640 085236601466 SINOVAC 14/10/2021 B202106069
32 3573045904820003 SRI HARIATI P 39 JL. SUKUN GEMPOL 085749481751 SINOVAC 14/10/2021 B202106069
33 3573040508790001 SODIKIN L 42 JL. MERGAN SEKOLAHAN 64 085608351421 SINOVAC 14/10/2021 B202106069
34 3518090608910001 MUHAMMAD QOMARUDIN L 30 JL. TANJUNG PUTRA YUDHA 53 081555957579 SINOVAC 14/10/2021 B202106069
35 3573045507820004 SUCI WULANDARI P 39 JL. SUKUN GEMPOL 4 083856060272 SINOVAC 14/10/2021 B202106069
36 3573041206790002 DODIEK BENNY YUNIARTO L 42 JL. MERGAN VETERAN NO. 40 085649604902 SINOVAC 14/10/2021 B202106069
37 3573040807650002 S. SUNTORO L 56 MERGAN KRAMAT 085231863904 SINOVAC 14/10/2021 B202106069
38 3573046401030007 ROSYIDA AMALIA PUTRI P 18 JL. MEGAN RAYA V/55 089602627099 SINOVAC 14/10/2021 B202106069
39 3573044207880007 DEWI IRAWATI P 33 JL. SUKUN SIDOMULYO 089680813520 SINOVAC 14/10/2021 B202106069
40 3573045004740010 YANTI P 47 JL. DSUKUN GEMPOL 31 082230412416 SINOVAC 14/10/2021 B202106069
41 3573046411870002 ZAENAB P 34 JL. KOL SUGIONO IX B 085954373202 SINOVAC 14/10/2021 B202106069
42 3573044107630137 SULIK P 58 JL. SUKUN SIDOMULYO 12 081249867891 SINOVAC 14/10/2021 B202106069
43 3573040704520001 SUTAWI P 60 081249867893 SINOVAC 14/10/2021 B202106069
44 3509015805850001 JUARIYAH P 36 DUSUN KRAJAN II 081353249427 SINOVAC 14/10/2021 B202106069
45 3573040204770006 MACHMUD EFFENDI L 44 JL. MERGAN SEKOLAHAN 62 085707122161 SINOVAC 14/10/2021 B202106069
46 3573046312750004 ANI WAHYUTI P 46 JL. SUKUN GEMPOL 085951808073 SINOVAC 14/10/2021 B202106069
47 3573040902050002 M. HISYAM FEBRIAN EFFENDY L 16 JL. JAYASRANI 7A No. 09 087758198360 SINOVAC 14/10/2021 B202106069
48 3573042104740006 EDY SUHARIYANTO L 47 JL. TERUSAN MERGAN RAYA 19/35 085100471948 SINOVAC 14/10/2021 B202106069
49 3507093009810001 IVAN IRAWAN L 40 JL. I. R RAIS IX / 181 A 081217928075 SINOVAC 14/10/2021 B202106069
50 3573045410930002 VINA DIANSAH RATNA MANGGALIH P 28 JL. TERUSAN TANJUNG PUTRA YUDHA V E 0881026957736 SINOVAC 14/10/2021 B202106069
51 3573043112660010 PURWANTO L 55 GEMPOL MARGA BHAKTI 30 085854428680 SINOVAC 14/10/2021 B202106069
52 3573040602060002 MOCHAMMAD TAUFIQ HIDAYAT L 15 JL. TERUSAN MERGAN RAYA 19/35 08973030384 SINOVAC 14/10/2021 B202106069
53 3573054312540001 NAPSIYAH P 67 JL. SUKUN GEMPOL 081246559837 SINOVAC 14/10/2021 B202106069
54 3573046010570006 SUHARTI L 64 JL. RANGKOK SELATAN 56 089647101950 SINOVAC 14/10/2021 B202106069
55 3573040206030004 BIMA SYAHPUTRA L 18 JL. GEMPOL MARGA BHAKTI 16 085231314927 SINOVAC 14/10/2021 B202106069
56 3573041604040005 ALDI BAMBANG PRAKOSO L 17 JL. GEMPOL MARGA BHAKTI 089668310720 SINOVAC 14/10/2021 B202106069
57 3573044810950002 NYDIA PANGESTI HAPSARI P 26 JL. RANGKOK SELATAN 1 082232311681 SINOVAC 14/10/2021 B202106069
58 3573041505020001 DWI CANDRA PERMANA L 19 JL. TERUSAN MERGAN RAYA 19/45 087756665820 SINOVAC 14/10/2021 B202106069
59 3573041409720005 SAHRUDIN L 49 JL. TANJUNG PUTRA YUDHA 6/69 083835344507 SINOVAC 14/10/2021 B202106069
60 3573040101560025 RASIM L 65 JL. SUKUN SIDOMULYO 081237765856 SINOVAC 14/10/2021 B202106069
61 3573041702030004 ELSA ARDYANSYAH L 18 JL. I. R RAIS I/50 0833846446124 SINOVAC 14/10/2021 B202106069
62 3573041611070001 MUHAMMAD YASIR MIFBACH L 14 JL IR RAIS I/49 081230945059 SINOVAC 14/10/2021 B202106069
63 3573044609720002 SUWARNI P 49 JL IR RAIS I 083846446124 SINOVAC 14/10/2021 B202106069
Dosis I Dosis 2
Vaksinasi
Vaksinasi
64 3573041804780015 ACHMAD JUFRI L 43 JL IR RAIS 14/27 081247067244 SINOVAC 14/10/2021 B202106069

65 3573045403650005 NURIYAH P 56 JL TERS. TANJUNG PUTRA YUDHA V E/ 22 0895335418717 SINOVAC 14/10/2021 B202106069
66 3573042506520002 HARTONO L 68 JL. TERS TANJUNG PUTRA YUDHA V E/ 24 085895007705 SINOVAC 14/10/2021 B202106069
67 3573012610920004 HENDRI PRASETYO L 29 JL. LETJEN S. PARMAN III A/ 23 081232323057 SINOVAC 14/10/2021 B202106069
68 3214121303980003 ADITYA ANUGRAH L 23 JL. SUKUN GEMPOL No.27 0895634340708 SINOVAC 14/10/2021 B202106069
69 3573045503520001 SUMARMI P 69 JL. MERGAN VETERAN NO. 4 089509326027 SINOVAC 14/10/2021 B202106069
70 3573043105830007 DIDIK DWI NARKO L 34 JL. TANJUNG PUTRA YUDHA 1 083835789015 SINOVAC 14/10/2021 B202106069
71 3573045905420003 SUKATMINI P 79 JL. IR RAIS I/5 088235796352 SINOVAC 14/10/2021 B202106069
72 3573040802890004 AGWAN FEBRI YANTO L 32 JL. KAKAKTUA UTARA 30 082257482787 SINOVAC 14/10/2021 B202106069
73 3573042909010002 ABIMANYU ATMANEGARA L 20 JL. MERGAN LORI II A/ 6 B 08993901700 SINOVAC 14/10/2021 B202106069
74 3573043112650010 FIYANTONO L 56 JL. SUKUN SIDOMULYO 082838982141 SINOVAC 14/10/2021 B202106069
75 3509195804830005 NURMA YUNITA P 38 JL. MERGAN MUSHOLLA 719 A 082154617770 SINOVAC 14/10/2021 B202106069
76 3573046212820003 WAHYUNINGTYAS P 39 JL IR RAIS IX/257 085655881912 SINOVAC 14/10/2021 B202106069
77 3573042110570004 PARWOTO L 64 JL. IR RAIS IX/257 085649591883 SINOVAC 14/10/2021 B202106069
78 3573044903710002 MUSLIKAH P 50 JL TANJUNG PUTRA YUDHA 6A/34 085232742103 SINOVAC 14/10/2021 B202106069
79 3573041604790001 MOH. SAID L 42 JL. IR RAIS Gg IX / 191 A 081808453269 SINOVAC 14/10/2021 B202106069
80 3573044404810004 ISTIKOMAH P 40 JL. MERGAN MUSHOLLAH No. 33 087720841697 SINOVAC 14/10/2021 B202106069
81 3573042608040001 MOCH INDRA FARESA L 17 JL. KASIN JAYA IV/ 26 087758351910 SINOVAC 14/10/2021 B202106069
83 3573020208690004 LUKMAN NURHAKIM L 52 JL. IR RAIS VII/70 081223687445 SINOVAC 14/10/2021 B202106069
84 3573044104660005 RUPIATI P 56 JL. IR RAIS IX/191 A 082140664400 SINOVAC 14/10/2021 B202106069
85 3573041707030006 AKMAL SADDAM IRHAMNI L 18 JL IR RAIS V / 114 081335196622 SINOVAC 14/10/2021 B202106069
86 3573040302030002 MEGAN PUTRA KHUSIA ERWANTO L 18 JL. IR RAIS GG VII / 98 082235647292 SINOVAC 14/10/2021 B202106069
87 3573044301030001 ANYA LINGGAR CAHYANI P 18 SUKUN GEMPOL No. 32 085895147773 SINOVAC 14/10/2021 B202106069
88 3174107007670001 HARTINI P 54 JL. H. BUANG 6/7 087756663778 SINOVAC 14/10/2021 B202106069
89 3573040302630003 SAMIN L 58 JL. MERGAN BARU XXI 082331614033 SINOVAC 14/10/2021 B202106069
90 3573041106680006 TRISNO L 53 KALIMANGIR 001/011 081334351179 SINOVAC 14/10/2021 B202106069
91 3573040302930004 FEBBY ARDHIANTO L 28 JL. MERGAN LORI II A 082233467646 SINOVAC 14/10/2021 B202106069
92 3529241608050002 MOHAMMAD AKSAN TABRANI L 16 JL. BARENG TAMAN BUNGA No. 25 082332948055 SINOVAC 14/10/2021 B202106069
93 3573042310990002 RIZKY DWI ADJIE NUGROHO L 22 JL. MERGAN LORI II A 08993900907 SINOVAC 14/10/2021 B202106069
94 3507222605950001 HADI SUGIARTO L 26 DUSUN KLASEMAN 020/009 085755533120 SINOVAC 14/10/2021 B202106069
95 3573043003910007 ACHMAD SUTRISNO L 30 JL. SUKUN SIDOMULYO No. 6 089656236557 SINOVAC 14/10/2021 B202106069
96 3573044312980003 NOFIA HERAWATI P 23 DUSUN KLASEMAN 020/009 085755533120 SINOVAC 14/10/2021 B202106069
97 3573032707760006 KARYONO L 45 JL IR RAIS IX / 247 081228364855 SINOVAC 14/10/2021 B202106069
99 3573044303850009 IKA SUSANTYA NINGSIH P 36 JL. KASIN JAYA IV / 30 081358036932 SINOVAC 14/10/2021 B202106069
100 3573035310710001 SULASTRI P 50 JL DANAU SEMAYANG IV 089602665171 SINOVAC 14/10/2021 B202106069
101 3573044501840006 MAHRIYAH P 37 JL. KASIN JAYA II / 20 081217772278 SINOVAC 14/10/2021 B202106069
102 3573044407990009 AMINATUS SOLICHA P 22 JL. SUKUN SIDOMULYO 0895331276253 SINOVAC 14/10/2021 B202106069
103 3506131007770001 M AGUS L 44 JL. MERGAN LORI 085855460505 SINOVAC 14/10/2021 B202106069
104 3573040211660003 SAMITO L 55 JL. IR RAIS IX / 361 085704758227 SINOVAC 14/10/2021 B202106069
105 3573022811680001 H. ACHMADI L 53 JL. SARTONO SH No. 7 083848247883 SINOVAC 14/10/2021 B202106069
106 3573045207850002 DEFI SUYANTI P 36 JL. MERGAN SEKOLAHAN V / 60 082139696499 SINOVAC 14/10/2021 B202106069
107 3573041005650017 SUNYOTO L 56 JL. TANJUNG PUTRA YUDHA IV / 73 087784675324 SINOVAC 14/10/2021 B202106069
108 3573041309560002 AGUS PRIHANDOKO L 65 JL. KAKAKTUA UTARA 30 082257412034 SINOVAC 14/10/2021 B202106069
109 3507146302810003 MIFTAKHUL JANNAH P 40 JL. SIDODADI V 0895331276249 SINOVAC 14/10/2021 B202106069
110 3527134306640002 HJ. ST. SAOTUN P 57 JL. TERS PUTRA YUDHA V E / 12 081944861602 SINOVAC 14/10/2021 B202106069
111 FUDOLI L 32 081944861602 SINOVAC 14/10/2021 B202106069
112 3573044110090004 KHALISA FARRAS AZIZAH P 12 JL. GADANG TERMINAL 4 085100739391 SINOVAC 14/10/2021 B202106069
113 3573045711860003 SUMAROH LIA P 35 JL. TERUSAN TANJUNG PUTRA YUDHA V 0895411049223 SINOVAC 14/10/2021 B202106069
Dosis I Dosis 2
Vaksinasi
Vaksinasi
114 3507210909090002 AZRIEL GIBRAN PUTRA AGUSTIAN L 12 JL TERS. TANJUNG PUTRA YUDHA V C 089653093750 SINOVAC 14/10/2021 B202106069
115 3573040501450002 SUGIONO L 76 SINOVAC 14/10/2021 B202106069
116 3573045309770002 SUDARTI TITIK ERNAWATI P 44 JL. TANJUNG PUTRA VI A/15 089655237777 SINOVAC 14/10/2021 B202106069
117 3573041106060002 FHAJAR ILHAM NAZZAR L 15 JL. TANJUNG PUTRA YUDHA VI A 089655237777 SINOVAC 14/10/2021 B202106069
118 3212026506020002 REBECCA GABRIELLA TAMPUBOLON P 19 JL PARSOBURAN SIMP.3 08224118185 SINOVAC 14/10/2021 B202106069
119 3507286208730001 SUMIATI P 48 DUSUN TOYOMERTO 085855020292 SINOVAC 14/10/2021 B202106069
120 3573042105730003 MUKLIS L 48 JL. KASIN JAYA IV / 26 082141183939 SINOVAC 14/10/2021 B202106069
121 3573040406570003 SUBANDI L 64 JL. TANJUNG PUTRA YUDHA VI / 21 SINOVAC 14/10/2021 B202106069
122 3573041406970009 MUHAMAD PUTRA SUMANTO L 24 JL. SIMPANG PUTRA YUDHA II 087886596481 SINOVAC 14/10/2021 B202106069
123 3507240103780007 NURSALIM L 43 JL. SUKUN GEMPOL 081223999739 SINOVAC 14/10/2021 B202106069
124 3573041507560001 SAMSUL ICHWAN L 65 JL. IR RAIS I / 11 081334043136 SINOVAC 14/10/2021 B202106069
125 3573041007810005 TURMIDI L 40 JL. NGAGLIK IV B/ 32 081370010039 SINOVAC 14/10/2021 B202106069
126 3573046006890012 LUCKY DIAN ARISANDI P 32 JL. NGAGLIK IV B 0895331119735 SINOVAC 14/10/2021 B202106069
127 3573044602860007 EVIE SUSANTI P 35 JL. NGAGLIK IV B / 32 081332493975 SINOVAC 14/10/2021 B202106069
128 3573040107620057 SLAMET L 59 JL. TANJUNG PUTRA YUDHA V 0895331121662 SINOVAC 14/10/2021 B202106069
129 3573044711010003 HUSNIYAH P 46 JL. KASIN JAYA IV / 26 081216164121 SINOVAC 14/10/2021 B202106069
130 3573045103710005 KARIATI P 50 JL. PUTER DALAM SELATAN No. 64 082237735156 SINOVAC 14/10/2021 B202106069
131 3573044505720001 MARIA ULFA P 49 JL. KASIN JAYA 4 / 28 082141415825 SINOVAC 14/10/2021 B202106069
132 3573044502720006 ANJARWATI P 49 JL. TERUSAN MEGAN RAYA No. 61 085259036680 SINOVAC 14/10/2021 B202106069
133 3573044312980004 DESI FARIDA SETIOWATI P 23 JL. PANDANLANDUNG 089503309029 SINOVAC 14/10/2021 B202106069
134 3573047003910003 ADE NOVA MARITA P 30 JLN IR RAIS IX / 227 082333653391 SINOVAC 14/10/2021 B202106069
135 3573041107790003 MUHADI L 42 JL. SUKUN GEMPOL 1 081917781132 SINOVAC 14/10/2021 B202106069
136 3573044206690005 SUYATI P 52 JL. PUTER TENGAH 12 081249388332 SINOVAC 14/10/2021 B202106069
137 3573045103030007 NASTITI KARYA DEWI P 18 JL. TANJUNG PUTRA YDHA VI 081529951217 SINOVAC 14/10/2021 B202106069
138 3507285108060001 IKA AGPAFINATA NURASMIATI P 15 JL. SUKUN SIDOMULYO No. 9 083806850470 SINOVAC 14/10/2021 B202106069
139 3573046606010005 MAY RADHITIYA RISKI P 20 JL. MERGAN LORI II B 081233708997 SINOVAC 14/10/2021 B202106069
140 3578041701030002 FAHRUR ROZI L 18 JL. MERGAN MUSHOLLA No. 66 087719929145 SINOVAC 14/10/2021 B202106069
141 3573044902830002 FEBRINA MAYA PUSPITA P 38 TANJUNGREJO 08/11 085744343277 SINOVAC 14/10/2021 B202106069
142 ENDANG SUSILOWATI P 55 TANJUNGREJO 08123322041 SINOVAC 14/10/2021 B202106069
143 3573040402750000 ACHMAD SYAIFUDIN L 46 JL. KEBONSARI I H/19 081 SINOVAC 14/10/2021 B202106069
144 3573044510600000 SULIYANTI P JL. PUTER DALAM TENGAH 2 081249269002 SINOVAC 14/10/2021 B202106069
145 357304640762003 SUWARNAH p 59 jl. Ir rais ix/108 81333618703 SINOVAC 14/10/2021 B202106069
146 3201040310020004 MUHAMMAD BINTANG MAHAPUTRA L 19 JL. MERGAN VETERAN NO. 40 0889 96346627 SINOVAC 14/10/2021 B202106069
147 3573046205930006 CITRA DEWI PUTRI SURYONO P 27 MERGAN KELURAHAN BLOK C NO. 6 0813034009 SINOVAC 14/10/2021 B202106069
148 3573041305630002 HADI SUSILO L 58 JL. SUKUN GEMPOL 34 085334906861 SINOVAC 14/10/2021 B202106069
149 3573044709530004 SA'AMAH P 68 JL. MERGAN VETERAN 5 08998803115 SINOVAC 14/10/2021 B202106069
150 3573045001760006 MARBIYAH P 45 JL. KASIN JAYA II/24 0813117649642 SINOVAC 14/10/2021 B202106069
151 3573045709720002 SUMARMI NINGSIH P 49 JL. IR RAIS IX/48 0881036591030 SINOVAC 14/10/2021 B202106069
152 3505206406810002 SRI UTAMI P JL. PUTER DALAM UTARA 29 082139022152 SINOVAC 14/10/2021 B202106069
153 3573045006590004 SUPARLIN P 62 JL. TANJUNG PUTRA IV/73 SINOVAC 14/10/2021 B202106069
154 350520111040002 VIRMAN RAMADANI L 17 JL. PUTER UTARA 29 083893785966 SINOVAC 14/10/2021 B202106069
155 3573040512580003 MUDJIONO L 63 JL. SUKUN GEMPOL IV/3 082122616396 SINOVAC 14/10/2021 B202106069
156 3505200107730076 SUGIANTO L 48 JL. PUTER UTARA 29 082139022152 SINOVAC 14/10/2021 B202106069
157 35730401039500004 ADITYADAMARIS JORDAN DAVID L 26 JL. SUKUN GEMPOL 24C 08976306377 SINOVAC 14/10/2021 B202106069
158 3573045205780010 UMI WIDI LESTARI P 43 JL. SUKUN GEMPOL 14 08121746325 SINOVAC 14/10/2021 B202106069
159 3573040810080003 MAHFIROH AMAN ROGIM L 13 JL. MERGAN MUSHOLLA 716/11 A SINOVAC 14/10/2021 B202106069
160 3573045712650003 ERNI WINARTININGSIH P 56 JL. IR RAIS V/114 A 085257434543 SINOVAC 14/10/2021 B202106069
161 3573040712980002 AHMAD HANAFI L 23 JL. IR RAIS III/247A 089253527323 SINOVAC 14/10/2021 B202106069
Dosis I Dosis 2
Vaksinasi
Vaksinasi
162 3528064107930144 HOTIMAH P 28 JL. SUKUN SIDOMULYO 087881587003 SINOVAC 14/10/2021 B202106069
163 3515155401740001 RIATI P 47 JL. SUKUN SIDOMULYO 082140430920 SINOVAC 14/10/2021 B202106069
164 3573045507810000 YULI RAHMAWATI P 40 JL. MERGAN SEKOLAHAN/64 085608351421 SINOVAC 14/10/2021 B202106069
165 3573043112910002 NATANAEL YULIUS SAPUTRO L 30 JL. GEMPOL MERGAN BHAKTI 9 089660459456 SINOVAC 14/10/2021 B202106069
166 3573042605040003 SANDI PUTRA PAMUNGKAS L 17 GEMPOL MARGAN 9 089505786655 SINOVAC 14/10/2021 B202106069
167 3573041708970002 ACHMAD HAKIM L 24 JL. KASIN JAYA V/48 087869523788 SINOVAC 14/10/2021 B202106069
168 35730411730003 AGUS SUTRISNO L JL. TERUSAN MERGAN RAYA 081223291100 SINOVAC 9/16/2021 02108123H 14/10/2021 B202106069
169 3573046312680001 SITI ROMLAH P JL. SUKUN SIDOMULYO 088217435834 SINOVAC 14/10/2021 B202106069
170 3573045209960002 CHOIRIYAH P 25 JL. SUKUN SIDOMULYO 12 081233837606 SINOVAC 14/10/2021 B202106069
171 3573040305810000 RENI SUSILO L 40 JL. SUKUN GEMPOL 08706061006 SINOVAC 14/10/2021 B202106069
172 3573044403670003 SUTIANI P 54 JL. MERGAN KELURAHAN D/41 081242519486 SINOVAC 14/10/2021 B202106069
173 3573041804910003 FIKE ADIFASA L 30 JL SIMPANG PUTRA YUDHA II/58 087872909496 SINOVAC 14/10/2021 B202106069
174 3578086004000011 NIKITA FORTUNA SURYANINGSIH P 21 PUCANG ADI 3/15 085746908992 SINOVAC 14/10/2021 B202106069
175 3573040702760011 YUWONO L 45 JL. SUKUN GEMPOL 17/09 089653685589 SINOVAC 14/10/2021 B202106069
176 357303220240002 RATEMAT ABOE L 81 JL. TANJUNG PUTRA I 07/11 081331273105 SINOVAC 14/10/2021 B202106069
177 3573041502930002 WIKE BAMBANG ARDIANSYAH L 28 JL. GEMPOL MERGAN BHAKTI 5/10 089668310720 SINOVAC 14/10/2021 B202106069
178 3528054403840001 SITI AISYAH P 37 JL. SUKUN SIDOMULYO 11/07 087786730934 SINOVAC 14/10/2021 B202106069
179 3573045508720000 LILIK PUJI ASTUTIK P 49 JL. TERUSAN MERGAN RAYA GG 19 087756665820 SINOVAC 15/09/2021 202108123H 14/10/2021 B202106069
180 3573042604930003 RISTYO ARI WIJAYANTO L 28 JL. SUKUN SIDOMULYO N0. O7 083848825085 SINOVAC 14/10/2021 B202106069
181 3573041604730010 HERRY TEGUH ARIFIANTO L JL. TERUSAN MARGAN RAYA GG. 19/45 087754728438 SINOVAC 14/10/2021 B202106069
182 3573040906030005 RENO BAYU PAMUNGKAS L 16 JL. GEMPOL MARGA BAKTI 16 085231314927 SINOVAC 14/10/2021 B202106069
183 3573046709560003 SUMIARSIH P JL. MERGAN SEKOLAHAN 1/18 0895701385319 SINOVAC 14/10/2021 B202106069
184 3523163112030002 AFIFUDDIN ABROR RIZA L 17 PERDIN PT.SG BLOK J-10 082131279493 SINOVAC 08/09/2021 2021081501 14/10/2021 B202106069
185 3573047112780011 SRIYATI P 35 JL. SUKUN GEMPOL 9/9 085920518113 SINOVAC 14/10/2021 B202106069
186 3573045708920005 WAHYU NINGSIH P 29 JL. SUKUN SIDOMULYO 11/07 08213910681 SINOVAC 14/10/2021 B202106069
187 3573044701910002 DIAH EDI FERISTA P 30 JL. IR RAIS IX/181 A 081259816371 SINOVAC 14/10/2021 B202106069
188 3573041609710004 SUROSO L 50 JL. SUKUN SIDOMULYO NO. 6 089656236557 SINOVAC 14/10/2021 B202106069
189 9111026209590001 NUR SASI P 62 JL. BATU BARA 70C 081247702285 SINOVAC 14/10/2021 B202106069
190 3573040912710005 MISKUN L 50 JL. SUKUN SIDOMULYO 30 083848139877 SINOVAC 14/10/2021 B202106069
191 3578060703950012 KANDA POTRIANTO KRISTIAN L 26 JL. SUKUN SIDOMULYO 11/07 081239106861 SINOVAC 14/10/2021 B202106069
192 3507216303950001 NILAM EFRIANA P 26 JL. KASIN JAYA IV/23 081216154590 SINOVAC 13/09/2021 14/10/2021 B202106069
193 3573046109840008 YATINI P 37 JL. TANJUNG PUTRA YUDHA VIB/25 089696652247 SINOVAC 14/10/2021 B202106069
194 3573034912840008 DIAN ANGGUN KUMALA P 37 JL. NUJO 03/13 GAMBIR MANIS 082232510620 SINOVAC 14/10/2021 B202106069
195 3573041603050009 FABIAN RAMA CRISTHOPER L 17 JL. KASIN JAYA 3 NO. 37 082131715739 SINOVAC 14/10/2021 B202106069
196 35730454096500005 ANA LESTARI P 56 JL. KASIN JAYA 4 NO. 23 085784492195 SINOVAC 14/10/2021 B202106069
197 3573044106760002 LILIK HERAWATI P 45 JL. KASIN JAYA 4/16 082244820619 SINOVAC 15/09/2021 24202021 14/10/2021 B202106069
198 35730450008840010 SUSIANI P 37 JL. IR RAIS IX/276 081334507086 SINOVAC 14/10/2021 B202106069
199 3573044703840012 DEWI ANITA P 37 JL. TANJUNG PUTRA 1 07/011 083835789015 SINOVAC 14/10/2021 B202106069
200 3573042403840004 ADI SETIAWAN L 38 JL. IR RAIS IX/257 085655881912 SINOVAC 14/10/2021 B202106069
201 3573045904860009 MIFTACHUL JANNAH P 35 JL. IR RAIS I/49 081230945059 SINOVAC 14/10/2021 B202106069
202 3573056111920005 HEMAS DWI CAHYANING PUTRI P 28 JL. LETJEN S. PARMAN IIIA/23 081232323058 SINOVAC 14/10/2021 B202106069
203 3573040509950006 VIRGIANTO BAYU IRAWAN L 26 JL. SUKUN GEMPOL 49 04/09 087760367946 SINOVAC 14/10/2021 B202106069
204 3573040101710017 SUTRISNO L 50 JL. KASIN JAYA IV/35 085933194794 SINOVAC 14/10/2021 B202106069
205 3573041706090004 SATRIO MANDALA PUTRA L 12 JL. IR RAIS IX/39 083848722566 SINOVAC 14/10/2021 B202106069
206 3573040606810006 DJODI FADILAH KASIONO L 40 JL. SUKUN GEMPOL NO. 8 082331261641 SINOVAC 14/10/2021 B202106069
207 3573052509860005 SARTO L JL. SIDODADI V 21/05 BULULAWANG 089601613848 SINOVAC 14/10/2021 B202106069
208 3573047009630003 MIATI P 58 JL. IR RAIS 9 NO. 379B 085100759686 SINOVAC 14/10/2021 B202106069
Dosis I Dosis 2
Vaksinasi
Vaksinasi
209 3573044904840005 IDA FITRI A P 37 JL. IR RAIS XIV/27 087723303008 SINOVAC 14/10/2021 B202106069
211 3573043112880010 IRAWAN PRASETIYO L 32 JL. SUKUN SIDOMULYO 07/07 0895331276253 SINOVAC 14/10/2021 B202106069
212 357304501190001 SUMAI P 31 JL. KASIN JAYA II/22 087839254635 SINOVAC 14/10/2021 B202106069
213 3573046109550000 SUWARNI P 66 JL. IR RAIS IX NO. 243 SINOVAC 14/10/2021 B202106069
214 3573047112600027 TATIK DJUMATI P 61 JL. SUKUN GEMPOL NO. 31 085101465081 SINOVAC 14/10/2021 B202106069
215 3573040708500005 LALA L 70 JL. SUKUN GEMPOL NO. 31 085101465081 SINOVAC 14/10/2021 B202106069
216 3573040305780005 NURSIDI L 43 JL. TANJUNG PUTRA YUDHA V/5 085856610547 SINOVAC 14/10/2021 B202106069
217 3527135402990001 KURROTUL AINI P 27 JL. TERUSAN TANJUNG PUTRA YUDHA V E/12 085920518244 SINOVAC 14/10/2021 B202106069
218 35730460107000002 SUMARIYAH P 51 JL. NGAGLIK IVB/37 082333871569 SINOVAC 14/10/2021 B202106069
219 3573020401970003 AGUS ALI ALFARIS L 24 JL. SARTONO SH NO. 7 087860828126 SINOVAC 14/10/2021 B202106069
220 357304500668005 KUMA'YAH P JL. TERUSAN TANJUNG PUTRA YUDHA V 01/13 0895621143166 SINOVAC 14/10/2021 B202106069
221 3573046608970003 DURRIYATUS SOLIHAH MASHURI P 24 JL. IR RAIS IX/191 A 082190664400 SINOVAC 14/10/2021 B202106069
222 3528010805930002 ASYARI L 28 JL. SUKUN SIDOMULYO 03/07 081996271718 SINOVAC 14/10/2021 B202106069
223 3573044102490005 RASMINI P 71 JL. MERGAN RAYA III/35 089601169282 SINOVAC 14/10/2021 B202106069
224 3573044907790006 SRIANAH P 42 JL. TANJUNG PUTRA YUDHA VI A/13 089509357354 SINOVAC 14/10/2021 B202106069
225 3573043004540002 HARI WIYOTO L 67 JL. IR RAIS VII/86 089638990806 SINOVAC 14/10/2021 B202106069
226 3507116809040002 MIA KURNIAWAN SANSA BELA P 17 TANJUNGREJO RW 03 081259069270 SINOVAC 14/10/2021 B202106069
227 3573042707050005 AHMAD ROYHAN SABILLA PUTRA L 31 JL. KASIN JAYA IV/28 087863424229 SINOVAC 14/10/2021 B202106069
228 3573044711010003 INDI WULANDARI P 20 JL. KASIN JAYA IV/26 081931518584 SINOVAC 14/10/2021 B202106069
229 3573045711050002 VANIA NASYWA ANINDYA P 17 JL. IR RAIS 14/464 08124825078 SINOVAC 14/10/2021 B202106069
231 3573044101650041 SUKENSIS P 55 JL. SUKUN SIDOMULYO 03/07 081237765856 SINOVAC 14/10/2021 B202106069
232 3517035501970006 DWI RATNA SARI P 24 JL. SUKUN SIDOMULYO NO. 07 RT/RW 07/07 083848825085 SINOVAC 14/10/2021 B202106069
233 3573044607520004 WATINI P 69 JL. TERUSAN TANJUNG PUTRA YUDHA VA/10 SINOVAC 14/10/2021 B202106069
234 3573042704000005 YAYAN ADI PRANATA L 21 JL.MERGAN MUSHOLLAH N0. 33 087881437002 SINOVAC 14/10/2021 B202106069
235 3507021306900001 BUDI PRIONO L 31 JL. CUT NYAK DIEN 02/01 082143455334 SINOVAC 14/10/2021 B202106069
236 3573042309060002 HILAL RAMDAN SAPUTRA L 15 JL. IR RAIS V/116 A 08978999919 SINOVAC 14/10/2021 B202106069
238 3506160512690002 SUKAMTO L JL. SUKUN SIDOMULYO NO. 09 RT/RW 03/07 085855020292 SINOVAC 14/10/2021 B202106069
239 3573042506810004 MOCHAMMAD KHOIRUR ROZIQIN L 40 JL. SATSUITUBUN NO. 35 0895397165826 SINOVAC 14/10/2021 B202106069
240 3573046106550001 NUR FATMA FIRDAUSAH P JL. IR RAIS IX/60 081235321082 SINOVAC 14/10/2021 B202106069
241 3573045309800009 NINA LUTHFIANTHI P 41 JL. IR RAIS IX/60 081283320182 SINOVAC 14/10/2021 B202106069
242 3573042909580002 MUJI RAHARJO L JL. MERGAN LORI 082143455344 SINOVAC 14/10/2021 B202106069
243 3517202312680001 SUPRIANTO P 53 JL. RAHARJO DUSUN KEDUNG TIMONGO 04/17 082234273914 SINOVAC 14/10/2021 B202106069
MEGALUH
244 3508016102000004 KIRANA SURYANI BORNEO P 21 JL. TERUSAN MERGAN RAYA GG 19/23 082336790640 SINOVAC 14/10/2021 B202106069
245 3573042704040001 MOCH FIRDAUS ANDRI PUTRA P 17 JL. NGAGLIK IVB/37 RT/RW 05/09 082333871569 SINOVAC 14/10/2021 B202106069
246 3573040206630002 SAUJAIDI L 58 JL. IR RAIS GG. 7/199 SINOVAC 14/10/2021 B202106069
Dosis I Dosis 2
Vaksinasi
Vaksinasi
247 3573041704740010 FATHUR RODJI L 47 JL. IR RAIS 14/27 08974465526 SINOVAC 14/10/2021 B202106069
248 3573044809070009 SUSIATI P 34 JL. SIMPANG TANJUNG PUTRA YUDHA II 06/13 089679756688 SINOVAC 14/10/2021 B202106069
249 3573040204610001 SARTO L JL. TANJUNG PUTRA YUDHA IVB/15 085850102784 SINOVAC 14/10/2021 B202106069
250 3573045505710020 HARTATIK P 50 JL. SUKUN GEMPOL NO. 8 17/09 SINOVAC 14/10/2021 B202106069
251 3512066406840000 SELVI EFFENDI P 37 LINGKUNGAN 04 RT/RW 03/02 NGUNUT 082140399950 SINOVAC 02/09/2021 24201921 14/10/2021 B202106069
252 3573040904800006 ADI SUCIPTO L 41 JL. PELABUHAN KAMAL 32 RT/RW 02/01 089653750630 SINOVAC 14/10/2021 B202106069
253 3573043108940007 SATRIYO NUGROHO P 27 JL. IR RAIS IX/14 RT/RW 12/04 082139736651 SINOVAC 14/10/2021 B202106069
255 3573040706740003 FRANCISCUS SUTIKNO L 47 JL. DERKUKU BARAT NO. 31 0859180400742 SINOVAC 14/10/2021 B202106069
256 3573046006010007 BELA RISKA MELATI P 20 JL. TANJUNG PUTRA YUDHA III 16/11 089331259012 SINOVAC 14/10/2021 B202106069
257 3573042103090001 HAIKAL MAULANA AKBAR L 12 JL. SIKATAN NO. 23 05/08 083114616498 SINOVAC 14/10/2021 B202106069
258 3573040811630004 HALEON SARAGIH L 58 JL. TANJUNG PUTRA YUDHA IVB 15/11 0895630515944 SINOVAC 14/10/2021 B202106069
259 3507130108560041 WALUYO UTOMO L 65 JL. TERUSAN MERGAN RAYA 814 03/11 082232140303 SINOVAC 14/10/2021 B202106069
260 3573042111640004 DJOKO KUNCORO L 57 081220301957 SINOVAC 14/10/2021 B202106069
261 35730455028800093 DINDA PUTRI DEWI P 33 JL. SUKUN SIDOMULYO 02/07 081318126242 SINOVAC 14/10/2021 B202106069
262 3573042004690002 SUWANDI L 52 JL. PUTER TENGAH 12 08/12 081249388332 SINOVAC 14/10/2021 B202106069
263 35730455085300002 EMI ALARIMI P 68 JL. IR RAIS IX/227 06/04 082333653391 SINOVAC 14/10/2021 B202106069
264 3573046109590001 MUNTAMAH P 62 JL. MERGAN LORI 1/38 082331310948 SINOVAC 14/10/2021 B202106069
265 35730463008000005 RANTI ANGGRAINI PRATIWI P 21 JL. MERGAN RAYA 1/9 RT/RW 07/06 0895366358645 SINOVAC 14/10/2021 B202106069
266 3573041302030002 RIZKY RAHMAD WIBOWO L 18 JL. IR RAIS XIV/29 A 08993516879 SINOVAC 14/10/2021 B202106069
267 3573046603740003 ARI PUDJIASTUTIK P 47 TANJUNGREJO RT/RW 05/05 081334440006 SINOVAC 14/10/2021 B202106069
268 35070430089800001 SUHENDRA ADI ALAMSYAH L SIDOMULYO RT/RW 09/02 TAMBAKASRI 081234362040 SINOVAC 14/10/2021 B202106069
269 3507094112900002 KARTIKA RATRI P 30 JL. CUT NYAK DIEN 02/01 083866595556 SINOVAC 14/10/2021 B202106069
270 SINOVAC 14/10/2021 B202106069
271
272
273
274
275
276
277
278
279
280
FORMAT PENCATATAN PELAKSANAA
TINGKAT PUSKESM

No NIK Nama Penerima Vaksin L/P Umur
3 3573042503490001 SOFI'I L 72
5 35730445065400002 PONITI P 67
9 3573042604560001 BAMBANG SUSANTO L 65
11 357304590960001 LILIK HERAWATI P 61
12 3573040108500000 SYD MUKSIN AGIL AL L 71
16 3573044812430002 MUNAYAH P 78
18 3573042408590003 SISWANDI L 62
20 3573040509530001 SUKIDJA L 68
21 3573047112550056 SAMIRAH P 71
26 3573041010480001 DJAYUSMAN L 73
27 35730451065100001 SITI SUGIHARTI P 70
37 35730421004480001 PUDJIADI L 73
51 3573045007420001 DARMIATI P 79
73 3573044212610001 KATINEM P 60
83 3573045211580002 SUTINI P 63
85 3573040304590003 SLAMET L 62
94 3573045504400003 DJUMA'YA P 81
97 3573042005690003 MISDIONO L 62
102 3573044709570002 JUMANI P 64
106 3573046802540002 JAMI L 67

111 3573045206550008 MARIA MARIATUN P 66
112 3573045403030003 SITI NUR AINI P 118
119 3573046210570002 SUMIATI P 64
120 3573024409500001 SRIANAH P 71
133 3573040103570008 DJUMALI L 63
143 3573040805520001 MISERI L 69
144 3573046709610001 SUNARTI P 60
149 3573041803550001 DAMAT L 66
170 3573045210610003 YULIATI P 60
171 3573046103600002 SAMIHARTI P 61
175 3507264101440023 SUKARTI P 77
186 3573044101420084 SUNINGSIH P 79
207 3573044501590001 SUHARNANING P 64
208 3573042806570004 YUSAK KARYONO L 64
219 3573041508610005 SUWANDI L 60
225 3573046502540003 SUKARTI P 62
258 3573045404590001 MARKINI P 62
260 3573041001600001 DJUMINGAN P 61
281 3573045508500001 KASTIN P 71
300 3573044810580002 INDARWATI P 63
305 3573043112540008 ADIONO L 67
320 3573043112540009 LOHANDI L 67
327 3573041208580002 SUMADJI L 63
331 3573040602550003 RIYONO L 66
334 3573045402580001 DJUMAIYAH P 63
349 3573044910490002 YAMINI P 76
359 3573045608580002 RASMIATI P 63
363 3573014501610004 MUJIATI P 60
364 3573045802600001 LASMI P 61
376 3573046104560004 SUMIATI P 65

390 3508156209550002 SUHERMIN BEKTIAN P 65
392 3508150805470001 SENIDJAN P 74
396 3573044104580001 SUTATIK P 63
406 3573046008590010 NGATENI P 62
407 3573045201550001 RUKAYAH P 66
422 3573045403590004 LILIK FAUZIAH P 62
427 350519410750212 YASRI P 70
431 3573040505570002 KASMURI L 64
441 3573041806560001 DJUMAIN L 65
467 3573044701570001 SUPRIATIN P 64
493 3573046006550001 SULASTRI P 66
496 3573022812570001 SUPRAPTO L 64
510 3573046904430001 TUNI P 78
205 3573044303630004 DJUMAIYAH P 68
213 35730044205550003 SITI ZUBAIDAH P 66
254 3573043105580002 PRASETYO HESTU BAGIO L 63
257 3573040505500008 SUYITNO L 71
323 3573041603610001 SAFUL ZUHRI L 60
324 3505224107510087 KATEMI P 70
340 350713510500001 MARIA MAGDALENA P P 71
342 3573045101420002 ARIS TUSLANIJAH AZAR P 79
362 3507254101600030 JUMAATI P 61

TINGKAT PUSKESMAS
Dosis I
Alamat No. Hp Merek Tanggal
Vaksin Pemberian
Vaksinasi
JL.KEMNATREN II GG JERUK 04 01/03 089662909963 SINOVAC 15/10/2021
JL.KEMANTREN I/1 1/03 0819453900020 SINOVAC 15/10/2021
JL.KEMANTREN II/26 087898706872 SINOVAC 15/10/2021
JL.KEMNATREN II/26 03/03 087709323046 SINOVAC 15/10/2021
JL.KEMNATREN II/45C 04/03 082334662058 SINOVAC 15/10/2021
JL.KEMANTREN I DANURI 23 06/03 085732331394 SINOVAC 15/10/2021
JL.KEMANTREN I-45 11/03 085229110595 SINOVAC
JL.KEMANTREN I/4A 08/03 089516275596 SINOVAC 15/10/2021
JL.KLAYATAN III/16 07/02 085784058991 SINOVAC 15/10/2021
JL.KEMANTREN II/13A 089530533308 SINOVAC 15/10/2021
JL.KEMANTREN II/47 04/03 081229684587 SINOVAC 15/10/2021
JL.KEMANTREN III/32 082132735230 SINOVAC 15/10/2021
JL.KEMANTREN I/35 081249233944'' SINOVAC 15/10/2021
JL.KLAYATAN I/73K 04/12 - SINOVAC 15/10/2021
JL.KEMANTREN I/30 085755992059 SINOVAC 15/10/2021

JL.KEMANTREN I/PATTIMURA 106 082141303125 SINOVAC 15/10/2021
JL.KLAYATAN III/29 10/02 083143013167 SINOVAC 15/10/2021
JL.KEMANTREN I GG SIMP BRAWIJAYA 12/03 083835312075 SINOVAC 15/10/2021
JL.KEMANTREN III/33B 07/13 081330806749 SINOVAC 15/10/2021
JL.KEMANTREN III GH AGUS SALIM 96 085832494599 SINOVAC 15/10/2021
JL.KEMANTREN III /96 H AGUS SALIM 085708970931 SINOVAC 15/10/2021
JL.KEMANTREN I/19 08/03 - SINOVAC 15/10/2021
JL.KEMANTREN III GG AGUS SALIM 112 083134858461 SINOVAC 15/10/2021
JL.BERINGIN JANTI 6/30B 06/09 085732946646 SINOVAC 15/10/2021
JL.KEMANTREN I 12/03 - SINOVAC 15/10/2021
JL.KEMANTREN 11/03 - SINOVAC 15/10/2021
JL.KEMANTREN I/8610/03 083853368425 SINOVAC 15/10/2021
JL.RAYA KEPUH 39 085101706192 SINOVAC 15/10/2021
JL.KEMQANTREN III/13 087701433555 SINOVAC 15/10/2021
JL.KEMANTREN I/27 08/03 - SINOVAC 15/10/2021
JL.KEMANTREN II - SINOVAC 10/15/2021
JL.JANTI BARAT II/35A 081335250441 SINOVAC 10/15/2021
JL.KEMANTREN III/41 0812330818851 SINOVAC 10/15/2021
JL.KLAYATAN I 09/01 0881036054754 SINOVAC 10/15/2021
JL. DANURI 21 KEMANTREN 1 081217942796 SINOVAC 15/10/2021
JL. KEMANTREN I GG NANGKA 02 0895327871101 SINOVAC 15/10/2021
JL. DANURI 2 KEMNATREN/ 40 0895375483344 SINOVAC 15/10/2021
JL. KLAYATAN III GG MELATI 31 1/2 SINOVAC 15/10/2021
JL. KEMANTREN I/PATIMURA NO 55 082257321336 SINOVAC 15/10/2021
JL. KEMANTREN III/30 085803318438 SINOVAC 15/10/2021
JL. KEMANTREN I GG PATIMURA NO 95 085755047818 SINOVAC 15/10/2021
JL. KEMANTREN 2/36 0881027768666 SINOVAC 15/10/2021
JL. KEPUH GG MANDALA A/37 085243036294 SINOVAC 15/10/2021

JL. KEMANTREN 1 0881026053143 SINOVAC 15/10/2021
JL. KEMANTREN 1 0881026053143 SINOVAC 15/10/2021
JL. KEMANTREN I/4 A 089516225596 SINOVAC 15/10/2021
JL. KEMANTREN 3 GG H AGUS SALIM 122 - SINOVAC 15/10/2021
JL. KEMANTREN II/4 082132225699 SINOVAC 15/10/2021
JL. SIMPANG KEPUH D-18 085855509468 SINOVAC 15/10/2021
JL. KEMANTREN 1 GG SIMP BRAWIJAYA B 25 083140430263 SINOVAC 15/10/2021
JL. KLAYATAN II/13 085790809130 SINOVAC 16/09/2021
JL. KEMANTREN II/36 B 081390229698 SINOVAC 15/10/2021
JL. KLAYATAN I/33 - SINOVAC 15/10/2021
JL.SUKUN GEMPOL 2 085100930209 SINOVAC 15/10/2021
JL SUKUN GEMPOL 31 01/09 085770443326 SINOVAC 15/10/2021
JL.PELB BAKAHUNI 34 085604056400 SINOVAC 10/15/2021
JL.KEBONSARI 1A/4D 06/01 085102468624 SINOVAC 10/15/2021
JL. LOWOKWARU III/18 082141883745 SINOVAC 15/10/2021
DSN SUMBERADEN 1/5 MRONJO 082142557683 SINOVAC 15/10/2021
GRIYA CANDRA UTAMA BLOK A 085337165292 SINOVAC 15/10/2021
JL. S. SUPRIADI IV/37 08112500130 SINOVAC 15/10/2021
DSN KRAJAN TIMUR WONOREJO 085103570067 SINOVAC 15/10/2021

Dosis I Dosis 2
Tanggal Keterangan
Vaksinasi
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FIX - VAKSINASI Start SEPT 2021

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FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19

Nama Puskesmas/Jejaring : JANTI

118 ASTRAZENECA K004A

166 ASTRAZENECA K004A

Nama Puskesmas/Jejaring : JANTI

34 3573040803550001 SIYONO L 67 JL.KLAYATAN III/34 12/02 085259058276 ASTRAZENECA 21/09/2021 K004A

2 3271021001960003 ALIP SULISTIO L 81 - 082330598425 ASTRAZENECA 21/09/2021 K004A

29 3507186209800002 CHOIRUL JUBAIDAH P 67 JL.SONOKEMBANG No..5 08179625940 ASTRAZENECA 21/09/2021 K004A

Nama Puskesmas/Jejaring : JANTI

2 3573044307600007 ISMININGSIH P 61 IR RAIS III 6/2 085794776673 ASTRAZENECA 22/09/2021 K004A

3 3573045603610007 MUSRINATUN P 60 IR RAIS IX 12/4 085804504412 ASTRAZENECA 22/09/2021 K004A

4 3573042109780010 HARIYONO L 43 SUKUN SIDOMULYO 4/7 088804922450 ASTRAZENECA 22/09/2021 K004A

8 3573044107440097 SUWARNI P 76 SUKUN SIDOMULYO 6/7 ASTRAZENECA 22/09/2021 K004A

10 3573041708570005 SUTRISNO L 63 MERGAN KERAMAT 3/11 087885386674 ASTRAZENECA 22/09/2021 K004A

12 3573045709600002 SUTIANI P 61 IR. RAIS IX 1/4 089526625050 ASTRAZENECA 22/09/2021 K004A

13 3573044708610006 SUGIATI P 60 TANJUNG PUTRA YUDHA 16/11 ASTRAZENECA 22/09/2021 K004A

14 3573040612580008 BASAR PAIMAN L 63 SIKATAN 5/8 082141310406 ASTRAZENECA 22/09/2021 K004A

16 3573045105020004 ROSALIA NINGSIH P 19 TANJUNG 3/13 0895630918668 ASTRAZENECA 22/09/2021 K004A

20 3573040912720005 JUPRI L 49 MERGAN KELURAHAN 5/11 082140532711 ASTRAZENECA 22/09/2021 K004A

22 3573041307660003 BUANI L 55 RANGKOK SELATAN 3/12 085736838538 ASTRAZENECA 22/09/2021 K004A

23 3573044101800030 WARSIANI P 41 MERGAN RAYA VI 9/6 089644159265 ASTRAZENECA 22/09/2021 K004A

25 3573045703810011 NUR WASITA P 40 GEMPOL 4/9 ASTRAZENECA 22/09/2021 K004A

28 3573040307620004 ABDUL MAJID L 55 GEMPOL 2/10 0895613451847 ASTRAZENECA 22/09/2021 K004A

32 3573044101560053 DAINAH P 64 IR. RAIS 1/2 081235918741 ASTRAZENECA 22/09/2021 K004A

34 3573045206750010 YUNANIK P 46 MERGAN KELURAHAN 12/11 08533525399 ASTRAZENECA 22/09/2021 K004A

37 3573044805880009 SOEKARSIH P 73 TERUSAN MERGAN RAYA 085859323639 ASTRAZENECA 22/09/2021 K004A

42 3573044810610001 SUMARMI P 60 KASIN JAYA 8/1 ASTRAZENECA 22/09/2021 K004A

45 3573041904760006 KOMARUDDIN L 44 TANJUNG PUTRA YUDHA 7/11 ASTRAZENECA 22/09/2021 K004A

46 3573040506580004 KARIYADI L 63 TERUSAN TPY 3/13 083806883779 ASTRAZENECA 22/09/2021 K004A

47 3573046903710003 SARTI P 50 TERUSAN TPY 3/13 083111792656 ASTRAZENECA 22/09/2021 K004A

50 3603312109620001 ROBERLY F. MANDEY L 59 TAMAN ADIYASA 082114251346 ASTRAZENECA 22/09/2021 K004A

52 3573045405530002 SUKARTI P 67 IR. RAIS 1/5 ASTRAZENECA 22/09/2021 K004A

54 3573041308000002 RAHIM P 21 TANJUNGREJO 2/7 088231308245 ASTRAZENECA 22/09/2021 K004A

55 3506126503850010 INDRIANI P 36 IR. RAIS IX/329 082226558987 ASTRAZENECA 22/09/2021 K004A

57 3573044612590003 SUKATMI P 62 IR. RAIS III 6/2 ASTRAZENECA 22/09/2021 K004A

58 3573042502460001 SOEPARNO L 75 MERGAN KELURAHAN 5/11 081945315939 ASTRAZENECA 22/09/2021 K004A

59 3573040903570006 DAMAN L 64 TERUSAN MERGAN RAYA 10/11 ASTRAZENECA 22/09/2021 K004A

60 3573046211840004 NOFI JUWITASARI P 37 JL.BINGKIL CIPTOMULYO 087853848477 ASTRAZENECA 22/09/2021 K004A

64 3573040102420007 SUPARDI L 78 IR. RAIS 1/2 081239680396 ASTRAZENECA 22/09/2021 K004A

65 3573045304530001 ISTRIASIH P 67 IR. RAIS 1/2 081252621340 ASTRAZENECA 22/09/2021 K004A

66 3573040205580002 PAITO L 63 KASIN JAYA IV 12/1 085875387631 ASTRAZENECA 22/09/2021 K004A

68 3573046505820015 SUNARIYANTI P 39 IR. RAIS 14/4 08973263948 ASTRAZENECA 22/09/2021 K004A

74 3573042410620003 ACH. PARIONO L 60 KASIN JAYA I 1/1 ASTRAZENECA 22/09/2021 K004A

75 3573045405600001 RIATIN P 61 IR. RAIS IX 6/4 ASTRAZENECA 22/09/2021 K004A

76 3573044105620010 YATINI P 59 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A

77 3573046101620005 RIANTININGSIH P 59 SUKUN GEMPOL 17/9 ASTRAZENECA 22/09/2021 K004A

79 3573040103610004 MUJIONO L 60 SUKUN SIDOMULYO 4/7 ASTRAZENECA 22/09/2021 K004A

80 3573041212610005 SUHADI L 60 PUTER DALAM UTARA 12/12 ASTRAZENECA 22/09/2021 K004A

81 3573044107450143 SUDILAH P 75 MERGAN MUSHOLLA 10/6 ASTRAZENECA 22/09/2021 K004A

83 3573045208620005 SAMANI P 59 MERGAN LORI IIC 5/6 ASTRAZENECA 22/09/2021 K004A

86 3573044101460020 SOERTINI P 75 KASIN JAYA 12/1 ASTRAZENECA 22/09/2021 K004A

88 3573045409950001 SURTINI P 26 SUKUN GEMPOL 10/9 083848950050 ASTRAZENECA 22/09/2021 K004A

90 3573042007410001 SUWARNO L 70 IR. RAIS IX 3/3 ASTRAZENECA 22/09/2021 K004A

93 3573041705540005 PRASETYO HADI L 62 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A

94 3573040212640003 BUDIONO L 57 MERGAN SEKOLAHAN 6/6 082142196886 ASTRAZENECA 22/09/2021 K004A

98 3573052212820001 ANDRI CAHYONO L 39 TANJUNG 085649422751 ASTRAZENECA 22/09/2021 K004A

99 3573041111590004 KUSBAL 62 MERGAN KERAMAT 3/11 085648497757 ASTRAZENECA 22/09/2021 K004A

101 3573047112550039 SULASTRI P 66 SUKUN SIDOMULYO 2/7 ASTRAZENECA 22/09/2021 K004A

111 3573042505430001 ANWAR L 78 MERGAN LORI II 5/6 ASTRAZENECA 22/09/2021 K004A

113 3573040608460001 WADI L 75 MERGAN LORI II 5/6 ASTRAZENECA 22/09/2021 K004A

120 3573045206600006 SUWARTI P 61 KUNTUL 6/12 ASTRAZENECA 22/09/2021 K004A

129 3573041607540001 PONIRAN L 66 SUKUN SIDOMULYO 11/7 ASTRAZENECA 22/09/2021 K004A

140 3573046001620004 CHOTIMAH P 59 MERGAN LORI II 5/6 ASTRAZENECA 22/09/2021 K004A