1.

Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

V 2 3 4 5 6
1 8 0 9 0 1 7 0 2 Bulan : 2023
NAMA FASKES/ Pustu Bayas Jaya 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN SUMBER ALOKON

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
STATUS PESERTA KB

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN
ISTRI

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN
PENCABUTAN

PENCABUTAN

KEGAGALAN
PEMBERIAN/

KOMPLIKASI
NAMA SUAMI

OPERATIF/

LAINNYA
TANGGAL

MANDIRI
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

BERAT
LAHIR

(Kode)

TIDAK

APBN

APBD
DAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 01-Jan-2023 SUEMI 1 8 0 9 0 7 5 5 1 0 8 4 0 0 0 1 SURYATI 07-Apr-1988 BAYAS JAYA 1 0 0 0 4 1 0 0 1 0 0 0

2 01-Jan-2023 SATAR 1 8 0 9 0 7 6 4 0 5 8 3 0 0 0 4 DAHLIA 24-May-1983 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

3 01-Jan-2023 BAYHAKI 1 8 0 9 0 7 4 1 0 1 6 3 0 0 0 3 JUNAIDAH 01-Jan-1993 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

4 01-Jan-2023 NURSAMAN 1 8 0 9 0 7 5 5 0 6 8 1 0 0 0 8 YAYAH 15-Jun-1981 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

5 01-Jan-2023 ROHIM 1 8 0 9 0 7 5 0 1 1 7 7 0 0 0 7 MARIAH 10-Nov-1977 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

6 01-Feb-2023 NURSAMAN 1 8 0 9 0 7 5 5 0 6 8 1 0 0 0 8 YAYAH 15-Jun-1981 BAYAS JAYA 2 0 0 0 4 1 0 0 1 0 0 0

7 01-Feb-2023 SATAR 1 8 0 9 0 7 6 4 0 5 8 3 0 0 0 4 DAHLIA 24-May-1983 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

8 01-Feb-2023 SUEMI 1 8 0 9 0 7 5 5 1 0 8 4 0 0 0 1 SURYATI 07-Apr-1988 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

9 01-Feb-2023 BAHRONI 1 8 0 9 0 7 5 3 0 4 8 8 0 0 0 4 HALIMAH 15-Aug-1988 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

10 01-Feb-2023 ROHIM 1 8 0 9 0 7 5 0 1 1 7 7 0 0 0 7 MARIAH 10-Nov-1977 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

11 01-Mar-2023 SARKONI 1 8 7 1 0 9 5 6 0 9 9 2 0 0 0 6 KHOERIYAH 21-Mar-1992 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

12 01-Mar-2023 SYAFEI 1 8 0 9 0 7 4 2 0 9 8 2 0 0 0 3 SANTIAH 02-Sep-1982 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

13 01-Mar-2023 MUHARI 1 8 0 9 0 7 6 1 1 0 8 0 0 0 0 8 SITI AMINAH 11-Oct-1980 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

14 01-Mar-2023 BAHRONI 1 8 0 9 0 7 5 3 0 4 8 8 0 0 0 4 HALIMAH 15-Aug-1988 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

15 01-Mar-2023 SATAR 1 8 0 9 0 7 6 4 0 5 8 3 0 0 0 4 DAHLIA 24-May-1983 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

16 01-Mar-2023 APRIANSYAH 1 8 0 9 0 9 5 7 0 7 9 0 0 0 0 1 SUTIAH 17-Jul-1990 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

17 01-Mar-2023 APRIZAL 1 8 0 9 0 7 5 6 0 3 8 1 0 0 0 2 SAIYAH 16-Mar-1981 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

18 01-Mar-2023 SUMANTRI 1 8 0 9 0 7 6 7 0 9 7 9 0 0 0 6 EPA PRANSISKA 27-Sep-1979 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

19 01-Mar-2023 NURSAMAN 1 8 0 9 0 7 5 5 0 6 8 1 0 0 0 8 YAYAH 15-Jun-1981 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

20 01-Mar-2023 SUEMI 1 8 0 9 0 7 5 5 1 0 8 4 0 0 0 1 SURYATI 07-Apr-1988 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

21 01-Apr-2023 AHYANI 1 8 0 9 0 7 5 5 0 5 9 0 0 0 0 6 SANAH 24-Jul-1988 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

22 01-Apr-2023 SATAR 1 8 0 9 0 7 6 4 0 5 8 3 0 0 0 4 DAHLIA 24-May-1983 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

23 01-Apr-2023 SAUDI 1 8 0 9 0 9 4 1 0 8 8 4 0 0 0 1 IMAS SITI MAYA 01-Aug-1984 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

24 01-Apr-2023 ROHIM 1 8 0 9 0 7 5 0 1 1 7 7 0 0 0 7 MARIAH 10-Nov-1977 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

25 01-Apr-2023 YUNIZAR 1 8 0 9 0 9 6 2 0 2 6 0 0 0 0 1 SITI HALIMAH 21-Apr-1980 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

26 01-Apr-2023 USMAN 1 8 0 9 0 9 4 4 0 4 0 0 0 0 0 1 JUNAINI 04-Apr-2000 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

27 01-Apr-2023 SUEMI 1 8 0 9 0 7 5 5 1 0 8 4 0 0 0 1 SURYATI 07-Apr-1988 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

28 01-Apr-2023 BAHRONI 1 8 0 9 0 7 5 3 0 4 8 8 0 0 0 4 HALIMAH 15-Aug-1988 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

29 01-Apr-2023 SURYADI 1 8 0 9 0 9 4 3 0 3 9 0 0 0 0 1 RANI 03-Mar-1990 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

30 01-Apr-2023 MARHUMI 1 8 0 9 0 7 5 2 1 0 8 6 0 0 0 7 ANISA 12-Oct-1986 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

31 01-Apr-2023 NURSAMAN 1 8 0 9 0 7 5 5 0 6 8 1 0 0 0 8 YAYAH 15-Jun-1981 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

32 01-May-2023 SUKRI 1 8 0 9 0 7 4 7 0 8 9 5 0 0 0 6 SADIAH 07-Aug-1995 BAYAS JAYA 00000000000 3 1 0 0 2 1 0 0 1 0 0 0

33 01-May-2023 ISNEN 1 8 0 4 1 7 5 0 0 7 9 6 0 0 0 1 NUR ASIAH 11-Nov-1998 BAYAS JAYA 00000000000 1 1 1 0 3 1 0 0 1 0 0 0

34 01-May-2023 SUEMI 1 8 0 9 0 7 5 5 1 0 8 4 0 0 0 1 SURYATI 07-Apr-1988 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

35 01-May-2023 NAJAMUDDIN 1 8 0 9 0 7 5 5 0 6 9 5 0 0 0 2 DAHLIYA 15-Jun-1973 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

36 01-May-2023 BUANG 1 8 0 9 0 9 5 4 0 5 7 9 0 0 0 1 BAITI 14-May-1979 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

37 01-May-2023 APIPUDIN 1 8 0 9 0 7 4 2 0 2 7 2 0 0 0 7 AMINAH 02-Feb-1972 BAYAS JAYA 00000000000 3 1 0 0 3 1 0 0 1 0 0 0

38 01-May-2023 ASEP 1 8 0 9 0 7 5 5 0 7 9 4 0 0 0 3 TOHAROH 15-Jul-1994 BAYAS JAYA 00000000000 1 1 1 0 3 1 0 0 1 0 0 0

39 01-May-2023 NURSAMAN 1 8 0 9 0 7 6 0 0 8 7 3 0 0 0 3 SARIAH 15-Jul-1972 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

40 01-May-2023 MAD SARI 1 8 0 9 0 7 5 9 1 0 2 4 0 0 0 1 MARLIYAH 19-Oct-1974 BAYAS JAYA 00000000000 3 1 0 0 3 1 0 0 1 0 0 0

41 01-May-2023 ABDUL ROBI SALI 1 8 0 9 0 7 4 2 0 5 8 5 0 0 0 2 EKA WIDIASTUTI 02-May-1985 BAYAS JAYA 00000000000 3 1 0 0 2 1 0 0 1 0 0 0

42 01-May-2023 SUHANDA 1 8 0 9 0 7 6 5 0 3 7 4 0 0 0 1 NURHAYATI 25-Mar-1974 BAYAS JAYA 00000000000 3 1 0 0 3 1 0 0 1 0 0 0

43 01-May-2023 SADAR 1 8 0 9 0 7 5 9 1 1 8 6 0 0 0 2 SANIFAH 19-Nov-1986 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

44 01-May-2023 OTIB 1 8 0 9 0 9 4 6 0 8 7 8 0 0 0 1 SARMANAH 06-Aug-1978 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

45 01-May-2023 SAIPUL ROZI 1 8 9 9 0 7 4 7 0 8 8 6 0 0 0 7 NUR SAADAH 07-Aug-1986 BAYAS JAYA 00000000000 3 1 0 0 3 1 0 0 1 0 0 0

46 01-May-2023 MADHARI 1 8 0 9 0 7 5 0 0 6 8 3 0 0 0 2 MASNAINI 10-Jun-1983 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

47 01-May-2023 NAIM 1 8 0 9 0 7 5 2 0 7 8 5 0 0 0 4 SITI ALWIYAH 12-Jul-1985 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

48 01-May-2023 HASAN UBAIDILAH 1 8 0 9 0 7 5 5 0 7 8 6 0 0 1 3 ROBIAH 15-Jul-1986 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

49 01-May-2023 ABDULLAH 1 8 0 9 0 7 5 6 0 6 7 1 0 0 1 0 MARDALENA 12-Jun-1974 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

50 01-May-2023 SYAHRONI 1 8 0 9 0 7 4 5 0 2 9 5 0 0 0 1 HASANAH 05-Feb-1995 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

51 01-May-2023 SUKATMA 1 8 0 6 2 7 6 0 0 6 9 2 0 0 0 1 NURBAITI 20-Jun-1992 BAYAS JAYA 00000000000 3 1 0 0 3 1 0 0 1 0 0 0

52 01-May-2023 MUSAWIR 1 8 0 9 0 7 5 8 0 8 7 8 0 0 0 4 UMIYATI 18-Aug-1978 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

53 01-May-2023 SATAR 1 8 0 9 0 7 6 4 0 5 8 3 0 0 0 4 DAHLIA 24-May-1983 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

54 01-May-2023 ROHIM 1 8 0 9 0 7 5 0 1 1 7 7 0 0 0 7 MARIAH 10-Nov-1977 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

55 01-May-2023 KARMIN 1 8 0 9 0 7 5 0 1 1 8 0 0 0 1 3 JUNARIAH 10-Nov-1980 BAYAS JAYA 00000000000 3 1 0 0 3 1 0 0 1 0 0 0

56 01-May-2023 ASTURI 1 8 8 9 0 7 6 7 0 5 8 4 0 0 0 1 ROHAYAH 27-Dec-1984 BAYAS JAYA 00000000000 3 1 0 0 2 1 0 0 1 0 0 0

57 01-May-2023 RAHMAT 1 8 0 6 2 7 5 1 0 4 9 8 0 0 0 4 MERI SUSANTI 20-Aug-1994 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

58 01-Jun-2023 SAPRUDIN 1 8 0 9 0 9 5 3 0 4 7 9 0 0 0 1 SARMINAH 13-Apr-1979 DUSUN 3 LEBAK DAMAR 3 0 0 0 4 1 0 0 1 0 0 0

59 01-Jun-2023 SUPARDI 1 8 0 9 0 9 5 8 0 1 9 5 0 0 0 1 AMNAH 17-Feb-1997 DUSUN 3 LEBAK DAMAR 3 0 0 0 4 1 0 0 1 0 0 0

60 05-Jun-2023 SADAR 1 8 0 9 0 7 4 4 0 9 7 3 0 0 0 3 PATMAH 04-Sep-1973 DUSUN 3 LEBAK DAMAR 3 0 0 0 4 1 0 0 1 0 0 0

61 20-Jun-2023 SAYUTI 1 8 0 9 0 7 5 4 0 3 7 9 0 0 0 4 ROHEMAH 14-Mar-1979 DUSUN 3 LEBAK DAMAR 3 0 0 0 4 1 0 0 1 0 0 0

62 01-Jul-2023 Feri praseta 1 8 0 9 0 7 1 1 0 5 0 1 0 0 0 4 Robunah 11-Nov-1990 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

63 01-Jul-2023 Satar 1 8 0 9 0 7 6 4 0 5 8 3 0 0 0 4 Dahlia 12-Dec-1985 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

64 04-Jul-2023 ROHIM 1 8 0 9 0 7 5 0 1 1 7 7 0 0 0 7 MARIAH 10-Nov-1977 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

65 04-Jul-2023 SARIP 1 8 0 9 0 9 4 4 0 5 7 7 0 0 0 2 ISAH 04-May-1977 DUSUN 4 LEBAK DAMAR 3 0 0 0 2 1 0 0 1 0 0 0

66 04-Jul-2023 NURSAMAN 1 8 0 9 0 7 5 5 0 6 8 1 0 0 0 8 YAYAH 05-Jun-1981 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

67 04-Jul-2023 BAHRONI 1 8 0 9 0 7 5 3 0 4 8 8 0 0 0 4 HALIMAH 15-Aug-1988 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

68 04-Jul-2023 SUEMI 1 8 0 9 0 7 5 5 1 0 8 4 0 0 0 1 SURYATI 07-Apr-1988 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

69 04-Jul-2023 ASMAN 1 8 0 9 0 7 4 4 0 6 8 2 0 0 0 5 RANI 04-Jun-1982 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

70 04-Jul-2023 MUHARI 1 8 0 9 0 7 6 1 1 0 8 0 0 0 0 8 SITI AMINAH 11-Oct-1980 BAYAS JAYA 3 0 0 0 2 1 0 0 1 0 0 0

71 04-Jul-2023 SAPRRUDDIN 1 8 0 9 0 9 4 7 1 1 8 0 0 0 0 1 NURHAMAH 07-Nov-1980 BAYAS JAYA 3 0 0 0 4 1 0 0 1 0 0 0

72 04-Jul-2023 SUANDI 1 8 0 9 0 9 4 1 0 9 9 4 0 0 0 1 SARTI 01-Jul-1994 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

73 04-Jul-2023 DEDE SUHADI 1 8 0 9 0 9 4 4 1 0 9 1 0 0 0 1 SAROH 04-Oct-1991 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

74 04-Jul-2023 SUPRIYANTO 1 8 0 9 0 7 6 4 0 9 8 4 0 0 0 1 ISMINAH 15-Jun-1984 SINAR HARAPAN 3 0 0 0 2 1 0 0 1 0 0 0

75 04-Jul-2023 ADI AFRIYANSAH 1 8 0 9 0 7 6 1 1 2 9 8 0 0 0 2 SITI NURHAYATI 12-Dec-1998 BAYAS JAYA 3 0 0 0 2 1 0 0 1 0 0 0

76 04-Jul-2023 M. ARIFIN 1 8 0 9 0 9 4 1 1 1 8 7 0 0 0 1 ARNAH 01-Nov-1987 DUSUN 3 LEBAK DAMAR 3 0 0 0 2 1 0 0 1 0 0 0

77 04-Jul-2023 SAPRUDIN 1 8 0 9 0 9 5 3 0 9 7 9 0 0 0 1 SARMINAH 13-Apr-1979 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

78 06-Jul-2023 Asmadi 1 8 0 9 0 7 4 1 1 8 1 0 0 0 8 6 Srianah 20-Jul-1992 BAYAS JAYA 3 0 0 0 2 1 0 0 1 0 0 0

79 06-Jul-2023 Rustam 1 8 0 9 0 9 7 4 5 0 6 9 3 0 0 2 Risna 05-May-1993 Bayas jaya 3 0 0 0 2 1 0 0 1 0 0 0

80 01-Aug-2023 Agus 1 8 0 9 2 7 5 2 0 5 8 5 0 0 1 1 Hana usmawati 12-May-1999 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

81 01-Aug-2023 MAWARDI 1 8 0 9 0 7 4 5 0 6 7 7 0 0 0 3 SUMYATI 05-Jun-1977 SINARJAYA 2 0 0 0 3 1 0 0 1 0 0 0

82 03-Aug-2023 WARSA 1 8 0 9 0 9 6 7 0 4 0 5 0 0 0 1 SITI RISKA 27-Apr-2005 DUSUN 4 CIROMPANG 3 0 0 0 3 1 0 0 1 0 0 0

83 07-Aug-2023 DADANG 1 8 0 9 0 7 5 5 0 6 8 0 0 0 0 9 HODIJAH 15-Jun-1980 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

84 07-Aug-2023 Muhammad 1 8 0 9 0 9 5 9 0 8 9 0 0 0 0 3 Juharti 19-Aug-1990 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

85 07-Aug-2023 SUHADI 1 8 0 9 0 9 5 5 0 6 7 9 0 0 0 1 DAMISAH 15-Jun-1979 DUSUN 4 CIROMPANG 3 0 0 0 3 1 0 0 1 0 0 0

86 07-Aug-2023 Idris 1 8 0 9 0 7 4 2 0 9 9 2 0 0 0 4 Lastri 02-Sep-1992 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

87 15-Aug-2023 GUNAWAN 1 8 0 9 0 7 4 5 0 3 8 5 0 0 0 3 UTIAH 18-Mar-1981 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

88 15-Aug-2023 ELI SUPRIADI 1 8 0 9 0 7 4 5 0 3 8 5 0 0 0 2 LENI DAWITA 15-Jun-1985 PEKON TENGAH 3 0 0 0 5 1 0 0 1 0 0 0

89 15-Aug-2023 MEMED 1 8 0 9 0 9 4 5 0 8 7 5 0 0 0 1 SARKI 05-Aug-1974 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

90 15-Aug-2023 IJAL SAPUTRA 1 8 0 9 0 9 4 9 0 4 8 7 0 0 0 1 TUTI HARYATI 09-Apr-1987 KOTA JAWA 3 0 0 0 5 1 0 0 1 0 0 0

91 15-Aug-2023 IDRIS 1 8 0 9 0 7 4 2 0 9 9 2 0 0 0 4 LASTRI 02-Sep-1992 CONGKANAN.BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

92 15-Aug-2023 WARSA 1 8 0 9 0 9 6 7 0 4 0 5 0 0 0 1 SITI RISKA 27-Apr-2005 DUSUN 4 CIROMPANG 3 0 0 0 5 1 0 0 1 0 0 0

93 21-Aug-2023 REFKI 1 8 1 0 0 9 6 0 0 9 9 0 0 0 0 2 INAH 20-Sep-1996 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

94 21-Aug-2023 BAIHAKI 1 8 0 9 0 7 4 1 0 1 9 3 0 0 0 3 JUNAIDA 01-Jan-1993 BAYAS JAYA 3 0 0 0 3 1 0 0 1 0 0 0

95 26-Sep-2023 DAMAN HURI 1 8 0 9 0 7 4 7 0 9 8 0 0 0 0 5 LINDA WATI 07-Sep-1980 SERKUNG SINTUK 3 1 0 0 3 1 0 0 1 0 0 0

96 26-Sep-2023 AHMAD TOJANI 1 8 0 9 0 7 5 0 0 3 9 0 0 0 0 6 LISNA WATI 11-Nov-1986 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

97 26-Sep-2023 NURDIDIH 1 8 0 9 0 7 4 9 0 8 8 0 0 0 0 2 PARIYAH 02-Aug-1980 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

98 26-Sep-2023 LUTPI HAMID 1 8 0 9 0 7 6 4 0 2 8 2 0 0 0 2 RUKMA YANTI 24-Feb-1982 SERKUNG SINTUK 3 1 0 0 3 1 0 0 1 0 0 0

99 26-Sep-2023 SUPRIYADI 1 8 0 9 0 9 4 3 1 0 8 9 0 0 0 2 SANIAH 03-Oct-1989 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

100 26-Sep-2023 AHMAD SUJA 1 8 0 9 0 7 7 0 0 6 9 6 0 0 0 4 SANTI MANDA SARI 30-Jun-1996 SERKUNG SINTUK 3 1 0 0 3 1 0 0 1 0 0 0

101 26-Sep-2023 KOSIM 1 8 0 9 0 9 5 0 0 5 9 5 0 0 0 2 JULIANA 10-May-1995 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

102 26-Sep-2023 APIN 1 8 1 0 0 4 4 9 1 0 9 5 0 0 0 4 ANIMAH 09-Oct-1995 SERKUNG SINTUK 3 1 0 0 3 1 0 0 1 0 0 0

103 26-Sep-2023 ALEK 1 8 0 9 0 9 6 1 0 7 9 5 0 0 0 1 SUHARYAH 28-Jul-1995 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

104 26-Sep-2023 ITO PRAMJGIANTO 1 8 0 9 0 9 4 1 0 7 9 5 0 0 0 2 MUMINAH 01-Jul-1995 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

105 27-Sep-2023 SAIPUR 1 8 0 9 0 9 4 9 1 1 7 6 0 0 0 1 HERAWATI 09-Nov-1976 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

106 27-Sep-2023 AZWAR 1 8 0 6 0 7 4 5 1 2 7 7 0 0 0 3 DAHYANA 05-Dec-1977 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

107 27-Sep-2023 ADI 1 8 0 9 0 1 5 0 0 6 8 7 0 0 0 9 ENDANG SRIMULYANI 10-Jun-1987 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

108 27-Sep-2023 ANTASA 1 8 0 9 0 9 4 2 0 5 8 8 0 0 0 1 NANDA 02-May-1988 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

109 27-Sep-2023 KIWONG 1 8 0 9 0 7 4 6 0 4 0 3 0 0 0 5 ADAH 06-Apr-2003 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

110 27-Sep-2023 JANURI 1 8 0 9 0 9 5 1 1 2 0 0 0 0 0 1 NURAINI 11-Dec-2000 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

111 27-Sep-2023 SYAMSUL BAHRI 1 8 0 9 0 7 5 1 1 2 8 3 0 0 0 5 SITI MASITOH 11-Dec-1983 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

112 27-Sep-2023 HASAN SARIPUDIN 1 8 0 9 0 9 4 5 1 0 8 7 0 0 0 1 JUMRIYAH 05-Oct-1987 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

113 27-Sep-2023 MARKUSEN 1 8 0 9 0 9 4 9 0 8 8 4 0 0 0 1 AMANAH 09-Aug-1984 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

114 27-Sep-2023 HERIYANTO 1 8 0 9 0 9 4 5 1 0 9 4 0 0 0 1 DESTI KOMALASARI 05-Oct-1994 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

115 27-Sep-2023 KUSNADI 1 8 0 9 0 9 4 7 0 0 0 0 0 0 0 1 SULISTIANI 07-Oct-2000 SERKUNG SINTUK 3 1 0 0 3 1 0 0 1 0 0 0

116 27-Sep-2023 MARHALIL 1 8 0 9 0 9 5 6 0 5 7 3 0 0 0 1 ASNAH 16-May-1973 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

117 27-Sep-2023 AHYANI 1 8 0 9 0 9 6 2 0 6 9 7 0 0 0 2 RANI YULIA 22-Aug-1997 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

118 27-Sep-2023 SARIPUDIN 1 8 0 9 0 7 5 4 0 8 9 7 0 0 0 3 ROSITA 14-Aug-1997 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

119 27-Sep-2023 ZAILANI 1 8 0 9 0 9 4 8 0 9 9 5 0 0 0 2 HAMIAH 08-Sep-1995 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

120 27-Sep-2023 ARIF ALFIAN 1 8 0 9 0 7 4 2 0 7 9 9 0 0 0 2 LELI MUNAWAROH 01-May-1999 BAYAS JAYA 3 1 0 0 3 1 0 0 1 0 0 0

121 29-Sep-2023 M.ARIF 1 8 0 9 0 9 5 8 0 5 7 7 0 0 0 1 USNAWIYAH 18-May-1977 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

122 29-Sep-2023 SAIPUR 1 8 0 9 0 9 4 9 1 1 7 6 0 0 0 1 HERAWATI 09-Nov-1976 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

123 29-Sep-2023 SYAHRONI 1 8 0 9 0 7 4 5 0 2 9 5 0 0 0 1 HASANAH 05-Feb-1995 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

124 29-Sep-2023 HUSNI 1 8 0 9 0 9 4 6 0 7 6 5 0 0 0 1 HUDAIPAH 06-Jul-1985 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

125 29-Sep-2023 JUMRI 1 8 0 9 0 9 6 6 1 2 8 6 0 0 0 1 HERLINA 26-Dec-1986 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

126 29-Sep-2023 ZAKARIA 1 8 0 9 0 7 5 2 0 7 7 7 0 0 1 1 YULYANAH 12-Jul-1977 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

127 29-Sep-2023 SARIPUDIN 1 8 0 9 0 7 5 7 0 7 8 3 0 0 0 7 HARTATI 17-Jul-1983 SERKUNG SINTUK 3 0 0 0 5 1 0 0 1 0 0 0

128 29-Sep-2023 JOHALI 1 8 0 9 0 7 4 5 0 5 8 6 0 0 0 6 SANIAH 05-May-1986 CONGKANAN.BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

129 29-Sep-2023 GUNAWAN 1 8 0 6 0 7 5 8 0 3 8 5 0 0 0 3 UTIAH 18-Mar-1985 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

130 29-Sep-2023 ISMAIL 1 8 0 9 0 9 4 9 0 7 8 4 0 0 0 1 YULISTINA 09-Jul-1984 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

131 29-Sep-2023 KAMSIN 1 8 0 9 0 7 5 7 0 8 8 5 0 0 0 8 SUSILAWATI 17-Jul-1986 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

132 29-Sep-2023 SANAJAYA 1 8 0 9 0 7 4 5 0 3 7 6 0 0 0 3 SARNI 05-Mar-1976 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

133 29-Sep-2023 KOSASIH 1 8 0 9 0 7 4 1 0 2 8 1 0 0 0 3 SUPIANA. S. PD. 01-Feb-1981 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

134 29-Sep-2023 WARSA 1 8 0 9 0 9 6 7 0 4 0 5 0 0 0 1 SITI RISKA 27-Apr-2005 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

135 29-Sep-2023 MIRWANTO 1 8 0 6 1 3 4 6 1 1 8 2 0 0 0 4 WIWIN DAHLIA 06-Nov-1982 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

136 29-Sep-2023 AMIRUDIN 1 8 0 9 0 7 4 2 0 2 8 0 0 0 0 6 SUHARNI 02-Feb-1980 SERKUNG 3 0 0 0 5 1 0 0 1 0 0 0

137 29-Sep-2023 MAD YUNUS 1 8 0 9 0 7 5 0 0 8 8 5 0 0 0 6 TITIN.SEPTIANA 10-May-1985 bayas jaya 3 0 0 0 4 1 0 0 1 0 0 0

138 29-Sep-2023 SAHILI 1 8 0 9 0 7 4 4 0 5 9 0 0 0 0 3 YULIANA 04-May-1990 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

139 29-Sep-2023 HASANUDIN 1 8 0 9 0 4 5 7 0 6 9 7 0 0 0 2 JUNIAWAROH 17-Jun-1997 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

140 29-Sep-2023 MEMED 1 8 0 9 0 9 4 5 0 8 7 5 0 0 0 1 SARKI 05-Aug-1974 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

141 29-Sep-2023 SUDARTO 1 8 0 9 0 7 4 5 0 6 9 0 0 0 0 5 SUTIANAH 05-Jun-1990 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

142 29-Sep-2023 ANDRI YANTO 1 8 0 9 0 9 5 1 0 7 7 7 0 0 0 2 IZDALIA 11-Jul-1977 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

143 29-Sep-2023 KUSNADI 1 8 0 9 0 9 4 7 0 0 0 0 0 0 0 1 SULISTIANI 07-Oct-2000 bayas jaya 3 0 0 0 5 1 0 0 1 0 0 0

144 29-Sep-2023 AFRIJAL 1 8 0 9 0 7 4 8 1 2 8 5 0 0 1 1 WARSIH 08-Dec-1985 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

145 29-Sep-2023 ANSORI 1 8 0 9 0 9 6 0 0 2 8 3 0 0 0 1 SUKARNI 20-Feb-1983 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

146 29-Sep-2023 ROHMAN 1 8 0 9 0 7 5 0 0 3 8 5 0 0 0 8 MARIAM 13-Apr-1988 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

147 29-Sep-2023 JAENALABIDIN 1 8 0 9 0 9 4 7 1 2 7 0 0 0 0 1 MAIMUNAH 07-Dec-1970 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

148 29-Sep-2023 SATIB 1 8 0 9 0 7 5 5 1 2 6 4 0 0 0 3 JASINAH 15-Dec-1964 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

149 29-Sep-2023 KHOTIB 1 8 0 9 0 7 5 4 0 1 8 6 0 0 0 2 SALINAH 14-Jan-1986 SERKUNG 3 0 0 0 5 1 0 0 1 0 0 0

150 29-Sep-2023 IDRIS 1 8 0 9 0 7 4 2 0 9 9 2 0 0 0 4 LASTRI 02-Sep-1992 CONGKANAN.BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

151 29-Sep-2023 DADANG 1 8 0 9 0 7 5 1 0 7 8 0 0 0 0 7 RUMNI 11-Jul-1980 CONGKANAN.BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

152 29-Sep-2023 MASRI 1 8 0 9 0 9 6 0 0 3 8 5 0 0 0 1 PATMAWATI 20-Mar-1985 bayas jaya 3 0 0 0 5 1 0 0 1 0 0 0

153 29-Sep-2023 RUSMANI 1 8 0 9 0 7 4 5 0 6 7 5 0 0 1 0 SUARNI 05-Jun-1975 CONGKANAN.BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

154 29-Sep-2023 ROHMAN 1 8 0 9 0 9 6 3 0 1 8 3 0 0 0 3 SUHARTINI 23-Jan-1983 BAYAS JAYA 3 0 0 0 5 1 0 0 1 0 0 0

1) Keterangan Kode

STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi

2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA CENTANG (V)
1. Petugas Entri Lamp.R/I/KB/20
Data LAMPIRAN R/I/KB/20 Lembar 6

1 2 3 4 5 6
1 8 0 9 0 1 7 0 2 Bulan : 2023
NAMA FASKES/ Pustu Bayas Jaya 7 8 V 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

RINGKASAN HASIL PELAYANAN KB

PESERTA KB BARU (PB) PESERTA KB ULANGAN PELAYANAN KASUS

PEMBERIAN
PEMBERIAN INFORMED PB DAN KESERTAAN JKN INFORMED CONSENT
METODE
NO. CONSENT (Untuk Peserta KB
KONTRASEPSI
(Untuk PB) PB PASCA PB PASCA Ulangan) PELAYANAN ULANG KOMPLIKASI BERAT
GANTI CARA PENCABUTAN KEGAGALAN
PERSALINAN KEGUGURAN
PB JKN PB NON JKN TOTAL PB

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 SUNTIKAN 1 1 0 1 1 0 0 0 0 0 0
2 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
3 PIL 0 0 0 0 0 0 0 0 1 0 0
4 PIL 0 0 0 0 0 0 0 0 1 0 0
5 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0
6 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
7 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
8 PIL 0 0 0 0 0 0 0 0 1 0 0
9 PIL 0 0 0 0 0 0 0 0 1 0 0
10 PIL 0 0 0 0 0 0 0 0 1 0 0
11 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0
12 PIL 0 0 0 0 0 0 0 0 1 0 0
13 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0
14 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
15 PIL 0 0 0 0 0 0 0 0 1 0 0
16 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
17 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
18 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0
19 PIL 0 0 0 0 0 0 0 0 1 0 0
20 PIL 0 0 0 0 0 0 0 0 1 0 0
21 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0
22 PIL 0 0 0 0 0 0 0 0 1 0 0

JUMLAH 2 3 0 3 2 0 29 2 149 0 0 0

Pesawaran , 29-September-2023
Pimpinan Faskes KB/Jaringan/Jejaring*

OKTARIDA, A.Md.Keb
( .................................................................................................)
197810172005012007

NIP/NRP
* Coret yang tidak perlu