1.

Petugas Entri Data

REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 2 3 4 5 6
3 6 7 1 2 6 9 Bulan : 2023
NAMA FASKES/ Klinik Efa Medika 7 8 9 10 V 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN

SUMBER ALOKON

STATUS PESERTA KB (Kode)

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
ISTRI

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN

KOMPLIKASI BERAT
PENCABUTAN DAN

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN

PENCABUTAN
NAMA SUAMI

KEGAGALAN
PEMBERIAN/
OPERATIF/
TANGGAL
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

LAINNYA

MANDIRI
LAHIR

TIDAK

APBN

APBD
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-Nov-2023 HENDANG 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 FITRI 06-Nov-2000 SEKNEG 3 1 0 0 2 0 0 1 0 0 1 0

2 02-Nov-2023 ROHMAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 JAYANTI 24-Apr-1978 KB NANAS 3 0 0 0 4 0 0 1 0 0 1 0

3 02-Nov-2023 EKO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ADE 20-Jan-1993 SAWAH DALAM 3 1 0 0 1 0 0 1 0 0 1 0

4 02-Nov-2023 SUHARI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SUWARTI 22-Feb-1980 KEBON NANAS 3 1 0 0 1 0 0 1 0 0 1 0

5 03-Nov-2023 ALI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 IDA 26-Apr-1978 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

6 03-Nov-2023 AGUS 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 WAGINAH 01-Jun-1978 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

7 03-Nov-2023 SRIYONO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SAFITRI 13-Sep-1977 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

8 03-Nov-2023 JONI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MERI 28-Aug-1992 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

9 03-Nov-2023 YADI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 UMAY 09-Jan-1999 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

10 03-Nov-2023 ILHAM 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NENGSIH 08-Jul-1978 KEBON NANAS 3 1 0 0 3 0 0 1 0 0 1 0

11 03-Nov-2023 SAHRUL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 RIA 24-Aug-1995 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

12 04-Nov-2023 SOLEH 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NUR 30-Jan-1992 IRMAS 3 1 0 0 2 0 0 1 0 0 1 0

13 04-Nov-2023 AMIR 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SINTA 26-Dec-1997 SEKNEG 3 1 0 0 2 0 0 1 0 0 1 0

14 04-Nov-2023 FAJRI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 RENI 24-Aug-1995 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

15 05-Nov-2023 SAEFUDIN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 UNI 22-Apr-1995 BLOK MEDE 1 1 0 0 1 0 0 1 0 0 1 0

16 05-Nov-2023 WAHYU 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI 19-Jun-1995 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

17 05-Nov-2023 SARYANTO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SUMARNI 07-Apr-1985 KB NANAS 3 0 0 0 4 0 0 1 0 0 1 0

18 05-Nov-2023 SONI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ANDELA 30-Apr-1996 GG. KEAMILAN 1 0 0 0 4 0 0 1 0 0 1 0

19 05-Nov-2023 GIRI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ELSA 27-May-1997 GG. KEAMILAN 3 1 0 0 1 0 0 1 0 0 1 0

20 05-Nov-2023 BUDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 WIWIN 30-Sep-1992 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

21 05-Nov-2023 HAGI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NITA 24-Jan-1997 GG. KEAMILAN 3 1 0 0 2 0 0 1 0 0 1 0

22 05-Nov-2023 SUHENDRA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DESI 05-Dec-1984 BONA 3 1 0 0 1 0 0 1 0 0 1 0

23 05-Nov-2023 RUSDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 IYAH 11-Jul-1984 SAWAH DALAM 3 1 0 0 2 0 0 1 0 0 1 0

24 06-Nov-2023 MULYANA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 PAZRIAH 20-Jul-1981 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

25 06-Nov-2023 ADRI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 EVA 22-Jul-1987 GG KEAMILAN 3 1 0 0 1 0 0 1 0 0 1 0

26 06-Nov-2023 SLAMET 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MASRIATI 25-Mar-1988 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

27 06-Nov-2023 DANI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI M 07-Aug-1987 SEKNEG 3 1 0 0 1 0 0 1 0 0 1 0

28 06-Nov-2023 SAMSUL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 EVI 19-Apr-1983 SAQWAH DALAM 3 1 0 0 1 0 0 1 0 0 1 0

29 06-Nov-2023 ANAH 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI K 27-Jul-1992 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

30 07-Nov-2023 SUHENDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NANET 14-Apr-1976 BONA SARANA INDAH 3 1 0 0 1 0 0 1 0 0 1 0

31 07-Nov-2023 IMAM 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 TRI 23-Apr-1983 GG DAMAI 3 1 0 0 1 0 0 1 0 0 1 0

32 07-Nov-2023 MUJIB 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ERNA 26-Mar-1995 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

33 07-Nov-2023 TAUFIK 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 OKTAVIANI 06-Oct-1994 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

34 08-Nov-2023 DWI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 WASTINAH 19-Aug-1981 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

35 08-Nov-2023 DIDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NUR ISNAENI 03-Apr-1989 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

36 08-Nov-2023 TOMI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 VIA 25-Mar-1994 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

37 08-Nov-2023 AKBAR 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 BINTANG 21-Mar-2001 GG WAKAF 3 1 0 0 1 0 0 1 0 0 1 0

38 08-Nov-2023 HARIS 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 LUSI 17-Nov-1984 BONA 3 1 0 0 1 0 0 1 0 0 1 0

39 08-Nov-2023 DENI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SINTA 07-Jan-1995 GG WAKAF 3 1 0 0 1 0 0 1 0 0 1 0

40 08-Nov-2023 NAFI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DESI 13-Jul-1985 SEKNEG 3 1 0 0 2 0 0 1 0 0 1 0

41 08-Nov-2023 ARDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 INTAN 04-Feb-2000 GG WAKAF 3 1 0 0 1 0 0 1 0 0 1 0

42 08-Nov-2023 JUARNO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NUR HAGI 03-Nov-1982 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

43 08-Nov-2023 WIDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ERLIS 14-Sep-1985 SAWAH DALAM 3 1 0 0 1 0 0 1 0 0 1 0

44 08-Nov-2023 UJAY 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 WATI 26-May-1983 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

45 09-Nov-2023 YADI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SELA 25-Jul-1988 BETUNG 3 1 0 0 1 0 0 1 0 0 1 0

46 09-Nov-2023 FAHRUL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI 10-Oct-1996 KB NANAS 3 0 0 0 4 0 0 1 0 0 1 0

47 09-Nov-2023 MUAZ 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MULYATI 15-Sep-1984 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

48 10-Nov-2023 SOLEH 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DEWI 01-Feb-1986 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

49 10-Nov-2023 RULI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 EDAH 10-May-1991 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

50 10-Nov-2023 FAUZAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 EKA 18-Mar-2000 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

51 10-Nov-2023 ALVIAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 FITRI 11-Mar-1995 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

52 10-Nov-2023 FADIL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MASNI 15-Apr-2000 KB NANAS 3 0 0 0 4 0 0 1 0 0 1 0

53 10-Nov-2023 ANDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SRI UTAMI 10-Aug-1978 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

54 11-Nov-2023 FEBI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 YUNI 03-Nov-1993 SAWAH DALAM 3 1 0 0 2 0 0 1 0 0 1 0

55 11-Nov-2023 ARIFIN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI JAHRONAH 27-Jul-1989 GG KEAMILAN 3 1 0 0 1 0 0 1 0 0 1 0

56 11-Nov-2023 ACONG 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 UMI 13-Mar-1980 BLOK MEDE 3 1 0 0 2 0 0 1 0 0 1 0

57 11-Nov-2023 SURATIN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ARIS 30-Apr-2000 BETUNG 3 1 0 0 1 0 0 1 0 0 1 0

58 11-Nov-2023 INDRA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 EVA 28-Sep-1991 GG MADRASAH 3 1 0 0 1 0 0 1 0 0 1 0

59 11-Nov-2023 SAMSURI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI SUHERNI 12-Jun-2000 SAWAH DALAM 3 1 0 0 2 0 0 1 0 0 1 0

60 11-Nov-2023 MASNO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ELISA 18-Jul-1999 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

61 12-Nov-2023 IWAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NENENG 15-Oct-1990 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

62 12-Nov-2023 M. FADIL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MASNI 15-Apr-1976 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

63 12-Nov-2023 JOHADI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 EMI 21-Jun-1991 SAWAH DALAM 3 1 0 0 1 0 0 1 0 0 1 0

64 12-Nov-2023 FERI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 LINDA 05-Jun-1982 KP KELAPA 3 1 0 0 2 0 0 1 0 0 1 0

65 12-Nov-2023 SUKARTA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 KHADIJAH 28-May-1992 SAWAH DALAM 3 1 0 0 1 0 0 1 0 0 1 0

66 13-Nov-2023 ROMEN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ROGAYAH 22-Feb-1997 KB. NANAS 3 1 0 0 2 0 0 1 0 0 1 0

67 13-Nov-2023 SUNANDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 RESA 04-Apr-1998 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

68 13-Nov-2023 WANDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NURPUTRI 10-Oct-1986 KB. NANAS 3 1 0 0 3 0 0 1 0 0 1 0

69 13-Nov-2023 SUPARNO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SRI WAHYUNI 18-Jun-1978 KB. NANAS 3 0 0 0 4 0 0 1 0 0 1 0

70 13-Nov-2023 RAHMAT 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SUHERNI 10-Oct-1987 IRMAS 3 1 0 0 2 0 0 1 0 0 1 0

71 13-Nov-2023 JUMENO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ITA 30-Nov-1987 KB. NANAS 3 1 0 0 2 0 0 1 0 0 1 0

72 14-Nov-2023 BAMBANG 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SEFI 13-Sep-1995 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

73 14-Nov-2023 NOVA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NIA 19-Dec-1995 KB. NANAS 3 1 0 0 2 0 0 1 0 0 1 0

74 14-Nov-2023 SLAMET 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 AYU ROSIDA 06-Oct-1989 IRMAS 3 1 0 0 2 0 0 1 0 0 1 0

75 14-Nov-2023 UDING 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MUASIH 14-Aug-1982 KB. NANAS 3 1 0 0 2 0 0 1 0 0 1 0

76 14-Nov-2023 DAMRI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ADEL 13-Sep-1995 KB. NANAS 3 1 0 0 1 0 0 1 0 0 1 0

77 14-Nov-2023 BUDIARTO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ENEN 12-Jul-1982 SAWAH DALAM 3 1 0 0 1 0 0 1 0 0 1 0

78 14-Nov-2023 FAUZAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DESI 10-Dec-1996 BONA 3 1 0 0 2 0 0 1 0 0 1 0

79 15-Nov-2023 AHMAD 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 RIA 30-Jun-1988 KB. NANAS 3 1 0 0 1 0 0 1 0 0 1 0

80 15-Nov-2023 SUKARNO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 HANI 10-Mar-1979 KB. NANAS 3 1 0 0 1 0 0 1 0 0 1 0

81 15-Nov-2023 SAMSUL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 INDAH 31-Aug-1980 KB. NANAS 3 1 0 0 2 0 0 1 0 0 1 0

82 15-Nov-2023 TRI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 LANTIKA 08-Oct-1988 KB.NANAS 3 1 0 0 1 0 0 1 0 0 1 0

83 16-Nov-2023 SALIM 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MUMUN 31-Dec-1980 KB. NANAS 3 1 0 0 1 0 0 1 0 0 1 0

84 16-Nov-2023 KHASIM 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 IMROATUL 12-Oct-1998 KB.NANAS 3 1 0 0 1 0 0 1 0 0 1 0

85 16-Nov-2023 SURYA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 HERTIANTI 15-Oct-1982 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

86 16-Nov-2023 LUKMAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 KRISNAWATI 31-Oct-1991 SEKNEG 3 1 0 0 1 0 0 1 0 0 1 0

87 16-Nov-2023 TUMIAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MIMIN 10-Jun-1990 KB. NANAS 3 1 0 0 1 0 0 1 0 0 1 0

88 17-Nov-2023 AZMI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 WIWIT 23-Jan-1972 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

89 17-Nov-2023 IQBAL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DEWI 30-Dec-1990 SEKNEG 3 1 0 0 1 0 0 1 0 0 1 0

90 17-Nov-2023 SURSAID 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NURYANI 07-Jul-1983 IRMAS 3 1 0 0 2 0 0 1 0 0 1 0

91 17-Nov-2023 ILBAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 YANAH 04-May-1983 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

92 17-Nov-2023 HERDIANSYAH 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DWI 10-Sep-1986 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

93 17-Nov-2023 AMER 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NURMI 10-Dec-1999 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

94 17-Nov-2023 MARYADI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DEWI 20-May-1996 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

95 18-Nov-2023 RISKA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI 07-Dec-1992 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

96 18-Nov-2023 SAEFUL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI 22-Jul-1980 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

97 18-Nov-2023 TASEN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DEWI 09-Jul-1990 IRMAS 3 1 0 0 2 0 0 1 0 0 1 0

98 18-Nov-2023 MAHMUD 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DWI 18-Sep-1995 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

99 18-Nov-2023 WIDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ANGELINA 26-Sep-1992 IRMAS 3 1 0 0 1 0 0 1 0 0 1 0

100 18-Nov-2023 RUDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 JUMIATUL 12-Feb-1989 KB NANAS 3 1 0 0 3 0 0 1 0 0 1 0

101 18-Nov-2023 WIWI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 FITRI 09-Jan-1986 BETUNG 3 1 0 0 2 0 0 1 0 0 1 0

102 18-Nov-2023 HIDAYAT 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SRI 14-May-1996 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

103 18-Nov-2023 ANDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MINAH 01-Oct-1997 IRMAS 3 1 0 0 2 0 0 1 0 0 1 0

 104 19-Nov-2023 SAEFUL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 RINDI 18-Jun-1997 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

105 19-Nov-2023 PURWANTO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MUJIANAH 07-Mar-1983 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

106 19-Nov-2023 MAHFUDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 PUTRI 27-Jun-1994 BUARAN 3 1 0 0 1 0 0 1 0 0 1 0

107 19-Nov-2023 AWAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 RIRIN 21-Jul-1994 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

108 20-Nov-2023 AJID 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 INA 28-Apr-1992 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

109 20-Nov-2023 SUDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 AISYAH 08-Jul-1992 BETUNG 3 1 0 0 2 0 0 1 0 0 1 0

110 20-Nov-2023 YAHYA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 YULIAN 21-Jul-1994 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

111 21-Nov-2023 SURYADI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 IDA 21-Dec-1989 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

112 21-Nov-2023 JAMAL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DIANA 12-Mar-1990 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

113 21-Nov-2023 DADAN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DINA 25-Sep-1984 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

114 21-Nov-2023 NOPA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 WIWI 04-Feb-1999 BETUNG 3 1 0 0 1 0 0 1 0 0 1 0

115 21-Nov-2023 ADE 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MUATIKO 27-Dec-1997 CIKOKOL 3 1 0 0 2 0 0 1 0 0 1 0

116 22-Nov-2023 DISKI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 EKA 09-Sep-1986 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

117 22-Nov-2023 SANAD 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 WULAN 18-Feb-1982 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

118 22-Nov-2023 DEDE 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ISMIATI 11-May-1995 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

119 22-Nov-2023 WAHYU 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SITI 21-Apr-1992 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

120 22-Nov-2023 ARIF 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 ANDINI 10-May-2001 SEMBUNG 3 1 0 0 2 0 0 1 0 0 1 0

121 22-Nov-2023 AHMAD DONI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 HERNAWATI 03-Aug-1987 BETUNG 3 1 0 0 2 0 0 1 0 0 1 0

122 22-Nov-2023 ZAFA'AT 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 RUSMIATUN 28-Dec-1988 BUARAN 3 1 0 0 2 0 0 1 0 0 1 0

123 23-Nov-2023 JESDIAL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SUSILOWATI 10-Jan-1997 SAWAH DALAM 3 1 0 0 2 1 0 0 0 1 0 0

124 23-Nov-2023 LEO 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 YENI 01-Dec-1996 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

125 23-Nov-2023 RAHMAT 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 GITA 30-Nov-1995 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

126 23-Nov-2023 ALI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 IRA 15-May-1988 IRMAS 3 1 0 0 2 0 0 1 0 0 1 0

127 23-Nov-2023 FADIL 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 LISTANTI 08-Sep-1991 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

128 23-Nov-2023 SINGGIH 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SELVI 09-Mar-1999 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

129 24-Nov-2023 YAYA 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 NURMA 07-Nov-1995 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

130 24-Nov-2023 BINTANG 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 FITRIYAH 25-Mar-1993 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

131 24-Nov-2023 AMRULLAH 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DESITA 19-Dec-1996 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

132 24-Nov-2023 DIDI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 SUHENI 09-Feb-1974 KB NANAS 3 1 0 0 1 0 0 1 0 0 1 0

133 24-Nov-2023 SANAD 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 MARSINAH 21-Dec-1976 KB NANAS 3 1 0 0 2 0 0 1 0 0 1 0

134 24-Nov-2023 DAYAT 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DAHLIA 07-Sep-1983 BLOK MEDE 3 0 0 0 4 0 0 1 0 0 1 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 Data Lamp.R/I/KB/20
LAMPIRAN R/I/KB/20 Lembar 5

1 2 3 4 5 6
3 6 7 1 2 6 9 Bulan : 2023
NAMA FASKES/ Klinik Efa Medika 7 8 9 10 V 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
NO. METODE KONTRASEPSI CONSENT
(Untuk Peserta KB
(Untuk PB) PB PASCA PB PASCA Ulangan) GANTI CARA PELAYANAN ULANG PENCABUTAN KOMPLIKASI BERAT 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 0 0 0 0 0 0 1 0 1 0 0
2 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
3 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
4 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
5 SUNTIKAN 0 0 0 0 0 0 1 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 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
9 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
10 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
11 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
12 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
13 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
14 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
15 SUNTIKAN 0 0 0 0 0 0 1 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 1 0 1 0 0
19 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
20 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
21 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
22 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0

JUMLAH 1 0 0 0 0 0 126 0 132 0 0 0

71 - KOTA , 06-December-2023
Pimpinan Faskes KB/Jaringan/Jejaring*

00
NIP/NRP
* Coret yang tidak perlu