Nama Puskesmas/Fasyankes/Pos

Kabupaten/Kota
Provinsi

No No. Tiket

6
7

10

11

12

13

14

15

16

17

18

19

20

21

22

23
24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41
 42

43

44

45

46

47

48

49

50

51

52

53

54

Keterangan
* Pekerjaan dikelompokkan menjadi:
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
 NIK

3601010607650000

3601016712720000

3601012812690000

3601021203640000

3601010207670000

3601024208710000
3601011807620000

3601014509660000

3601011910610000

3601010811690000

3601012802690000

3601011811620000

3601011104770000

3601010509850000

3601016509870000

3601016506800000

3601014501870000

3601011508810000

3601010107870000

36010 14101760001

3601011406800000

3601016611780000

3601026105890000
3601010408810000

3601015105820000

3601014508880000

3601012010600000

3601010809050000

3601016004890000

3601024502880000

3601012208620000

3601014204820000

3601014511860000

3601016412760000

3601016109830000

3601015404900000

3601014604650000

3601021208620000

3601011811620000

3601012003750000

3601011304800000
 3601010704700000

3601010107860020

3601012905880000

3601010107940040

3601014107830090

3601016109770000

3601010107540010

3601015907840000

litas Pelayanan Kesehatan

dapan langsung dengan masyarakat
 Kelompok Umur:
18-30
31-45
46-59
Total
Pekerjaan:
A
B
C
D
E
Total
: Puskesmas Sumur
: Pandeglang
: Banten

Jenis
Nama Penerima Vaksin Pekerjaan*
Kelamin

SAR'AN SS L GURU

EUIS NASYITHAH P GURU

YAYA ZAKARIA L GURU

BUHRO SS L GURU

EDI SUHAEDI L GURU

ATI SUMIATI P GURU

YAYAN SUPARYAN L GURU

MAS"IAH P GURU

SUHANDI L GURU

MAMAT L GURU

H.SUPIANI L GURU

IIN NAPSIRIN L GURU

ASEF SURYANA L GURU

SUPRIANI L GURU

MEGAWATI P GURU

RATMAWATI P GURU

ADE ROSTINI P GURU

ENDANG SUMARNA L GURU

MUSTOFA L GURU

RAMDIAH P GURU

FATHUL MUBIN L GURU

EMUN MUNJIAH P GURU

SITI MASITOH P GURU

SUYAMAN L GURU

YUYUN P GURU

KARTINI P GURU

WAWAN RUKIAWAN L GURU

M NASURIYADI L GURU

WINDA WILANTIKA P GURU

KENAH SUKAENAH P GURU

YANTO SURYANTO L GURU

ERIYAHARSIH P GURU

NURLAELA P GURU

TATI SUSILAWATI P GURU

UCU SULASTRI P GURU

FITRIA P GURU

ELIS SULASTRI P GURU

OTONG SUNATA L KORMIN

IIN NAFSIRIN L GURU

FATHURROHMAN L GURU

HERI YUWONO, S.PD L GURU

DEDI EFENDI L GURU

MOCH NURDIN L GURU

FZ SUTISNA L GURU

ELI HIDAYAT L GURU

ROHAYATI, S.PD P GURU

ARUM RUMSIAH P GURU

SABUR L KORMIN

ARMINAH P GURU

****Merek Vaksin
A = Sinovac
B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes)
elompok Umur: Kepesertaan BPJS
0 BPJS PBI
9 BPJS Non PBI
10 Non Anggota
19 Total
Pekerjaan: Pemberian Dosis
0 Dosis 1
0 Dosis 2
0 Total
0
0
0
 FORMAT PENCATATAN PELAK
TINGKAT PUSKESMAS/FAS

Umur
Kelompok Umur
(18-59 tahun)

55 46-59

48 46-59

51 46-59

57 46-59

53 46-59

43 31-45
59 46-59

55 46-59

60 FALSE

51 46-59

52 46-59

58 46-59

44 31-45

35 31-45

33 31-45

40 31-45

35 31-45

40 31-45

36 31-45

45 31-45

43 31-45

42 31-45

31 31-45
39 31-45

38 31-45

32 31-45

54 46-59

55 46-59

31 31-45

29 18-30

59 46-59

42 31-45

35 31-45

45 31-45

38 31-45

31 31-45

52 46-59

59 46-59

58 46-59

42 31-45

41 31-45
51 46-59

34 31-45

32 31-45

26 18-30

40 31-45

46 46-59

67 FALSE

36 31-45
20
0
5
25

20
17
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI

Alamat

KP CIKAWUNG, 001/001, DS UJUNGJAYA

KP TAMANJAYA, 003/001, DS TAMANJAYA

KP CIKAWUNG, 001/001, DS UJUNGJAYA

KP PADALI, 003/001, DS PADASUKA, KEC CIMANGGU

KP MASJID, 002/004, DS KERTAJAYA

KP CIMANGGU, 002/002, KEC CIMANGGU

KP SAWAH, 001/003, DS CIGORONDONG

KP CIBINUA, 002/002, DS TAMANJAYA

KP KIARA GONDOK, 001/003, DS UJUNGJAYA

KP CIKAWUNG, 001/001, DS UJUNGJAYA

KP TAMANJAYA 002/001 DESA TAMANJAYA

KP HASEUM 002/002 DESA CIGORONDONG

KP SAWAH 001/003 CIGORONDONG

KP NELAYAN 001/003 TAMANJAYA

KP NELAYAN 001/003 TAMANJAYA

KP SAWAH 001/003 CIGORONDONG

KP PANIIS 001/006 TAMANJAYA

KP CIBINUA, 002/002, DS TAMANJAYA

KP SUMUR ADEM 012/006 SUMBERJAYA

KP TAMANJAYA 001/001 DESA TAMANJAYA

KP TAMANJAYA 001/001 DESA TAMANJAYA

KP TAMANJAYA 001/001 DESA TAMANJAYA

KP CITANGKIL LEBAK 003/001 DESA TANGKIL SARI CIMAN

KP TAMANJAYA 001/001 DESA TAMANJAYA

KP NELAYAN 001/003, DS TAMANJAYA

KP LEGON PAKIS, 002/002, DS UJUNGJAYA

KP TAMANJAYA 003/001 DESA TAMANJAYA

KP HASEUM 004/001 DESA CIGORONDONG

KP CIKAWUNG, 002/002, DS UJUNGJAYA

KP CIKAWUNG, 001/001, DS UJUNGJAYA

KP CIKAWUNG, 001/001, DS UJUNGJAYA

KP TANJUNG LAME, 003/002, DS UJUNGJAYA

KP NELAYAN, 002/003, DS TAMANJAYA

KP TAMANJAYA, 003/001, DS TAMANJAYA

KP NELAYAN, 001/003, DS TAMANJAYA

KP NELAYAN, 002/003, DS TAMANJAYA

KP TAMANJAYA, 003/001, DS TAMANJAYA

KP CIBURIAL, KEC CIMANGGU

KP HASEUM, 002/002, DS CIGORONDONG

KP TAMANJAYA 003/001 DS TAMANJAYA

KP DAYEUH MANGSEUH 005/003 DS. KERTAJAYA

KP. POLOS 001/002 DS. WARINGIN KURUNG CIMANGGU

KP. CIBAYONI 003/002 DS.KERTAJAYA

KP. DADAPLANGU 004/005 DS. KERTAJAYA

KP. SUKASARI 002/002 DS. KERTAMUKTI

KP. SUMUR 006/003 DS. SUMBERJAYA

KP.SUMUR 006/003 DS. SUMBERJAYA

KP.SUMUR ADEM 010/005 DS.SUMBERJAYA

KP.BABAKAN 002/003 DS.UJUNGJAYA

 Pekerjaan
A
B
C
D
E
Total
LAKSANAAN VAKSINASI COVID-19
/FASYANKES/POS VAKSINASI

Kepesertaan BPJS (tulis 'Ya' pada kolom yang sesuai)

No. Hp

BPJS PBI BPJS Non PBI

87772407823 YA

85778989118 YA

83841261103 YA

81517707251 YA

8779451976 YA

85216625979 YA
87817311756 YA

85664700774 YA

87775732651 YA

81910836764 YA

85885516169 YA

85773750362 YA

85781650850 YA

85777377789 YA

81617987577 YA

85716013268 YA

85771285841 YA

85891580603 YA

85778276070 YA

85694099161 YA

8558170045 YA

85886832686 YA

85813868038 YA
83890173563 YA

85695151302 YA

87773388008 YA

81517479274 YA

81517031868 YA

83899270250 YA

85714772470 YA

83813230254 YA

81914224205 YA

85780123964 YA

85893329476 YA

8558170036 YA

85778829629 YA

85715246321 YA

81296090686 YA

85773750362 YA

81807006810 YA

85717723859 YA
81383697794 YA

85715750669 YA

87772396629 YA

85890656061 YA

85779838914 YA

85710721838

85710721826 YA

85885848748 YA
aan
0
0
0
0
0
0
a' pada kolom yang sesuai)

Tanggal Screening Nama/Jenis/Merek Vaksin***

Non Anggota

4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac
 4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

YA 4/5/2021 Sinovac

YA 4/5/2021 Sinovac

YA 4/5/2021 Sinovac

YA 4/5/2021 Sinovac

YA 4/5/2021 Sinovac

4/5/2021 Sinovac

4/5/2021 Sinovac

YA 4/5/2021 Sinovac

YA 4/5/2021 Sinovac

4/5/2021 SINOVAC
4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 Sinovac

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/5/2021 SINOVAC

4/6/2021 Sinovac

4/6/2021 Sinovac

4/6/2021 Sinovac
4/6/2021 Sinovac

4/6/2021 Sinovac

4/6/2021 Sinovac

4/6/2021 Sinovac

4/6/2021 Sinovac

4/6/2021 Sinovac

4/6/2021 Sinovac

4/6/2021
 Dosis I

Tanggal Pemberian
No. Batch No. Serial
Vaksinasi

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/5/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

4/6/2021 24001421 16127700086729

 Dosis 2

Tanggal Pemberian
No. Batch No. Serial
Vaksinasi

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

4/20/2021 24001421 16134452159520

 Keterangan
(Ditunda/Tidak Diberikan/Lanjut)

Lanjut

Lanjut

Lanjut

Tidak diberikan

Lanjut

Lanjut
Lanjut

Lanjut

Tidak diberikan

Tidak diberikan

Lanjut

Lanjut

Lanjut

Lanjut

Tidak diberikan demam

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut

Lanjut
Lanjut

Lanjut

Lanjut

Lanjut

lanjur

Lanjut

tidak diberikan

HAMIL