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KABUPATE KECAMATA KELURAHA URUT

PROV. KODE PKM RW RT URUT KLG NAMA


N N N RUMAH

1 2 3 4 5 6 7 8 9 10

34 1 sugito
35 2 mulyono
36 imam
3 musanep
37 4 maliki
38 5ahmad alpin
39 hariyatiningsih
6
40 7 suprapto
41 budi
8 bayu prasetyo
42 9 Hadiri
43 10
mory ariyanto
44 11 khotijah
45 12 sugiharto
KESIMP .
KESIMP . KESIMP . KESIMP . KESIMP .
SKIZO/G3 KESIMP . KESIMP . KESIMP . KESIMP . KESIMP .
PENGGUNA PERILAKU PERILAKU ASI
JIWA PUNYA JKN TB PARU HT / TD KB LINAKES
AN SAB BAB MEROKOK EXLUSIF
BERAT

1 1 N 0 1 N 0 N N N
1 1 N 0 1 N N 1 N N
1 1 N 0 0 N 0 1 N N
1 1 N 0 1 N N N N N
1 1 N 0 0 N 0 N N N
1 1 N 0 0 N N N N N
1 1 N 0 0 N 0 N N N
1 1 N 0 0 N 0 N N N
1 1 N 0 0 N 0 N N N
1 1 N 0 0 N N N N N
1 1 N 0 0 N N N N N
1 1 N 0 0 N 0 N N N
JUMLAH 12 Ʃ 12 INDIKATOR
KATEGORI
KESIMP . KESIMP . INDIKATOR JUMLAH "N") BERNILAI 1/(12-
IMUNISASI TUMBANG KELUARGA
BERNILAI 1 N)

34 35 36 37
N N 3 7 0.600 0
N N 4 7 0.800 2
N N 3 6 0.500 2
N N 3 8 0.750 2
N N 2 7 0.400 0
N N 2 8 0.500 2
N N 2 7 0.400 0
N N 2 7 0.400 0
N N 2 7 0.400 0
N N 2 8 0.500 2
N N 2 8 0.500 2
N N 2 7 0.400 0
KABUPATE KECAMATA KELURAHA URUT
PROV. KODE PKM RW RT URUT KLG NAMA
N N N RUMAH

1 2 3 4 5 6 7 8 9 10

34 1 sugito
35 2 mulyono
36 imam
3 musanep
37 4 maliki
38 5ahmad alpin
39 hariyatiningsih
6
40 7 suprapto
41 budi
8 bayu prasetyo
42 9 Hadiri
43 10
mory ariyanto
44 11 khotijah
45 12 sugiharto
SEDANGA
NO.URUT STATUS HAMIL
JENIS
HUB KELG ANGGOTA NIK TANGGAL LAHIR USIA PERKAWIN (KHUSUS AGAMA
KELAMIN
KLG AN WANITA 10-
54 TH

11 12 14 6 7 8 9
1 1 3510131111690006 30/12/1964 53 1 3 1
1 1 3510131610670001 4/8/1965 45 1 4 1
1 1 3510131111690006 23//12/1956 64 1 6 1
1 1 351022211610003 6/26/1964 48 1 5 1
1 1 3510221102720003 23//12/1956 63 1 5 1
1 1 3510216511650002 7/23/1970 44 2 5 1
1 1 3510211204700005 7/12/1964 54 1 7 1
1 1 3510211303760002 9/29/1991 27 1 7 1
1 1 3510210909770010 8/27/1970 46 1 4 1
1 1 3510211212350002 11/5/1984 34 1 4 1
1 1 3510211204610005 12/15/1946 72 1 4 1
1 1 3510216703730002 9/6/1970 46 1 5 1
ANGGOTA
ANGGOTA
KELUARGA KESIMP .
KELUARGA KESIMP . KESIMP . KESIMP .
USIA > 10 SKIZO/G3 KESIMP . KESIMP . KESIMP . KESIMP .
> 5 TH PENGGUNA PERILAKU PERILAKU
TH JIWA PUNYA JKN TB PARU HT / TD KB
PENDIDIKA AN SAB BAB MEROKOK
PEKERJAA BERAT
N
N

10 11
3 5 1 1 N 0 1 N 0 N
4 5 1 1 N 0 1 N N 1
6 5 1 1 N 0 0 N 0 1
5 3 1 1 N 0 1 N N N
5 5 1 1 N 0 0 N 0 N
5 4 1 1 N 0 0 N N N
7 4 1 1 N 0 0 N 0 N
7 4 1 1 N 0 0 N 0 N
4 4 1 1 N 0 0 N 0 N
4 4 1 1 N 0 0 N N N
4 6 1 1 N 0 0 N N N
5 4 1 1 N 0 0 N 0 N
JUMLAH 12 Ʃ 12 INDIKATOR
KESIMP .
KESIMP . KESIMP . KESIMP . INDIKATOR JUMLAH "N") BERNILAI 1/(12- KATEGORI KELUARGA
ASI
LINAKES IMUNISASI TUMBANG
EXLUSIF BERNILAI 1 N)

34 35 36 37
N N N N 2 7 0.400 Tidak Sehat
N N N N 4 7 0.800 PraSehat
N N N N 3 6 0.500 PraSehat
N N N N 3 8 0.750 PraSehat
N N N N 2 7 0.400 Tidak Sehat
N N N N 2 8 0.500 PraSehat
N N N N 2 7 0.400 Tidak Sehat
N N N N 2 7 0.400 Tidak Sehat
N N N N 2 7 0.400 Tidak Sehat
N N N N 2 8 0.500 PraSehat
N N N N 2 8 0.500 PraSehat
N N N N 2 7 0.400 Tidak Sehat
KABUPATE KECAMATA KELURAHA URUT
PROV. KODE PKM RW RT URUT KLG NAMA
N N N RUMAH

1 2 3 4 5 6 7 8 9 10

34 1 sugito
34 1 misnah
34 1 nur kholis
34 sandy
1 prasetyo
35 2 mulyono
35 2 sri astuti
35 yogie
2 aprisnanda
35 zelika
2 kharisma
35 ngestu2 rama alamsyah
36 imam
3 musanep
36 3qomariyah
36 anas
3 saiful ulum
36 risza3 fitri nur umami
37 4 maliki
37 4ida indrawati
37 aldy
4 yanuar rizky
37 4rizka nirmala
38 5ahmad alpin
38 5 suhairi
38 yuliana
5 fransiska
39 hariyatiningsih
6
40 7 suprapto
40 7 suryani
40 tony 7 oktareza putra
41 budi8 bayu prasetyo
41 8 deni fitria
41 rayhan 8 firdaus al fatrus
muhammad
41 sulton
8 al baraqqie putra prasetyo
42 9 Hadiri
42 9 sumilati
42 siti
9 mariyam ulfa
42 Amanda
9 hardiyanti
43 10
mory ariyanto
43 10
hermelina putri
44 11 khotijah
44 11siti jubaidah
45 12 sugiharto
45 12ririn sumarsih
45 12
yeni nurita sari
45 andrean
12 arta nugraha
SEDANGA
NO.URUT STATUS HAMIL
JENIS
HUB KELG ANGGOTA NIK TANGGAL LAHIR USIA PERKAWIN (KHUSUS AGAMA
KELAMIN
KLG AN WANITA 10-
54 TH

11 12 14 6 7 8 9
1 1 3510131111690006 30/12/1964 53 1 3 1
2 2 3510185304770006 30/12/1965 45 1 3 2 1
3 3 3510185910970001 5/8/1988 27 1 5 1
3 4 3510185001100002 7/15/2008 14 1 4 1
1 1 3510131610670001 4/8/1965 45 1 4 1
2 2 3510125207790011 12/4/1960 41 1 4 2 1
1 3 3510131011930003 4/12/1996 24 1 6 1
2 4 3510135610970002 11/29/2002 16 1 4 1
3 5 3510124012000003 5/27/2009 9 1 3 1
1 1 3510131111690006 23//12/1956 64 1 6 1
2 2 3510136812810005 4/30/1971 42 1 5 2 1
3 3 3510137009010004 11/25/1996 24 1 4 1
3 4 3510131402050004 2/12/2002 16 1 5 1
1 1 351022211610003 6/26/1964 48 1 5 1
2 2 351022331640004 9/24/1965 49 1 5 2 1
3 3 3510220403910003 5/19/1996 22 1 5 1
3 4 3510121206650001 9/19/2000 18 1 4 1
1 1 3510221102720003 23//12/1956 63 1 5 1
2 2 3510224701700004 4/30/1971 44 1 4 2 1
3 3 3510220412980003 11/25/1996 21 1 6 1
1 1 3510216511650002 7/23/1970 44 1 5 1
1 1 3510211204700005 7/12/1964 54 1 7 1
2 2 3510215408750008 4/23/1970 48 1 4 2 1
3 3 3510212005060002 7/26/1997 21 1 5 1
1 1 3510211303760002 9/29/1991 27 1 7 1
2 2 3510216607850005 12/2/1987 31 1 5 2 1
3 3 3510212112010003 8/12/2010 8 1 2 1
3 4 3510210707430001 9/3/2016 2 1 1 1
1 1 3510210909770010 8/27/1970 46 1 4 1
2 2 3510215506850008 7/4/1970 46 1 3 2 1
3 3 3510212103050004 9/12/1996 24 1 5 1
3 4 3510215711100001 7/23/2005 14 1 3 1
1 1 3510211212350002 11/5/1984 34 1 4 1
2 2 3510215101580001 8/7/1985 35 1 3 2 1
1 1 3510211204610005 12/15/1946 72 1 4 1
2 2 3510216511650002 1/7/1996 24 1 4 2 1
1 1 3510216703730002 9/6/1970 46 1 5 1
2 2 3510216508930001 6/1/1973 43 1 5 2 1
3 3 3510216410010003 6/30/1997 21 1 6 1
3 4 3510210808070001 12/12/2006 12 1 4 1
ANGGOTA
ANGGOTA
KELUARGA
KELUARGA KESIMP . PERILAKU KESIMP .
USIA > 10 PENGGUNAA
> 5 TH
TH
SAB Sbr.SAB N AIR BERSIH PENGGUNA JAMB. Jns.JAMB BAB DI PERILAKU
PENDIDIKA AN SAB JAMBAN BAB
PEKERJAA
N
N

10 11
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 2
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
KESIMP .
KESIMP .
SKIZO/G3 KEPEMILIK KESIMP .
SKIZO OBT.SKIZO PASUNG JIWA AN JKN PUNYA JKN
MEROKOK PERILAKU DX. TB TX. TB
MEROKOK
BERAT

15 16 19 20

2 2 2 N 2 0 1 0 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 N 2 0 1 0 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 N 2 0 2 1 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 N 2 0 1 0 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 N 2 0 2 1 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 N 2 0 2 1 2 2
2 2 2 N 2 0 2 1 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 N 2 0 2 1 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 N 2 0 2 1 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 1 2 N 2 0 2 1 2 2
2 2 2 2 2 2 2
2 2 2 N 2 0 2 1 2 2
2 2 2 2 2 2 2
2 1 2 2 0 2 1 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
BATUK > 2 KESIMP . KESIMP . KESIMP .
DX HT / TD TX. HT / TD UKU TD SIST. DIAST. KONTRS.
mgg. TB PARU HT / TD KB

21 22 23 24 25 26 27
2 N 2 2 1 130 90 0 2 N
2 2 2 1 120 90 2
2 2 2 1 100 90 0
2 2 2 1 120 90 0
2 N 2 2 2 2 2 N 2 1
2 2 2 2 2 2 1
2 2 2 2 2 2 0
2 2 2 2 2 2 0
2 2 2 2 2 2 0
2 N 2 2 1 120 80 0 2 1
2 2 2 1 110 90 1
2 2 2 1 120 80 2
2 2 2 2 2 2 2
2 N 2 2 2 2 2 N 2 N
2 2 2 2 2 2 2
2 2 2 2 2 2 0
2 2 2 2 2 2 0
2 N 2 2 1 100 80 0 2 N
2 2 2 1 120 80 2
2 2 2 1 120 90 0
2 N 2 2 2 2 2 N 2 N
2 N 2 2 1 120 90 0 2 N
2 2 2 2 2 2 2
2 2 2 2 2 2 0
2 N 2 2 1 130 90 0 2 N
2 2 2 1 120 90 2
2 2 2 1 2 2 0
2 2 2 2 2 2 0
2 N 2 2 1 100 90 0 2 N
2 2 2 1 130 80 2
2 2 2 1 120 70 0
2 2 2 1 100 70 0
2 N 2 2 2 2 2 N 2 N
2 2 2 2 2 2 2
2 N 2 2 2 2 2 N 2 N
2 2 2 2 2 2 2
2 N 2 2 1 100 90 0 2 N
2 2 2 1 130 80 2
2 2 2 1 120 70 0
2 2 2 1 100 70 0
KESIMP .
KESIMP . KESIMP . KESIMP .
LINAKES ASI EKLS. ASI IMUN TUMBANG
LINAKES IMUNISASI TUMBANG
EXLUSIF

28 29 30 31
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 N 0 N 0 N 0 N
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 N 0 N 0 N 0 N
0 0 0 0
0 0 0 0
0 0 0 0
KABUPATE KECAMATA KELURAHA URUT
PROV. KODE PKM RW RT URUT KLG NAMA
N N N RUMAH

1 2 3 4 5 6 7 8 9 10

34 1 sugito
35 2 mulyono
36 imam
3 musanep
37 4 maliki
38 5ahmad alpin
39 hariyatiningsih
6
40 7 suprapto
41 budi
8 bayu prasetyo
42 9 Hadiri
43 10
mory ariyanto
44 11 khotijah
45 12 sugiharto

45 12
yeni nurita sari
45 andrean
12 arta nugraha
8 9 kauli
11 13 misdi
13 14 saniyati
SEDANGA
NO.URUT STATUS HAMIL
JENIS
HUB KELG ANGGOTA NIK TANGGAL LAHIR USIA PERKAWIN (KHUSUS AGAMA
KELAMIN
KLG AN WANITA 10-
54 TH

11 12 14 6 7 8 9
1 53 3510131111690006 30/12/1964 53 1 1 1
1 1 3510131610670001 4/8/1965 45 1 1 1
1 1 3510131111690006 23//12/1956 64 1 1 1
1 1 351022211610003 6/26/1964 48 1 1 1
1 1 3510221102720003 23//12/1956 63 1 1 1
1 1 3510216511650002 7/23/1970 44 2 4 1
1 1 3510211204700005 7/12/1964 54 1 1 1
1 1 3510211303760002 9/29/1991 27 1 1 1
1 1 3510210909770010 8/27/1970 46 1 1 1
1 1 3510211212350002 11/5/1984 34 1 1 1
1 1 3510211204610005 12/15/1946 72 1 3 1
1 1 3510216703730002 9/6/1970 46 1 1 1

3 21 2 2 1 6 2 1
3 12 1 2 1 4 2 1
1 1 3510210710750003 7/10/1975 43 1 1 2 1
1 1 3510211708790007 11/7/1980 38 1 1 2 1
1 1 3510215410740004 14/10/1979 39 2 2 1
ANGGOTA
ANGGOTA
KELUARGA KESIMP .
KELUARGA KESIMP . KESIMP . KESIMP .
USIA > 10 SKIZO/G3 KESIMP . KESIMP . KESIMP . KESIMP .
> 5 TH PENGGUNA PERILAKU PERILAKU
TH JIWA PUNYA JKN TB PARU HT / TD KB
PENDIDIKA AN SAB BAB MEROKOK
PEKERJAA BERAT
N
N

10 11
3 5 1 1 N 0 1 N N 1
4 5 1 1 N 0 1 N N 1
6 5 1 1 N 0 0 N N 1
5 3 1 1 N 0 1 N N 1
5 5 1 1 N 0 0 N N 1
5 4 1 1 N 0 0 N N 1
7 4 1 1 N 0 0 N N 1
7 4 1 1 N 0 0 N N N
4 4 1 1 N 0 0 N N 1
4 4 1 1 N 0 0 N N 1
4 6 1 1 N 0 0 N N 1
5 4 1 1 N 0 0 N N N

1 1
1 1
3 6
4 4
3 6
KESIMP .
KESIMP . KESIMP . KESIMP .
ASI
LINAKES IMUNISASI TUMBANG
EXLUSIF

N N N N
N N N N
N N N N
N N N N
N N N N
N N N N
N N N N
N N N N
N N N N
N N N N
N N N N
N N N N
KABUPATE KECAMATA KELURAHA URUT
PROV. KODE PKM RW RT URUT KLG NAMA
N N N RUMAH

1 2 3 4 5 6 7 8 9 10

34 1 sugito
34 1 misnah
34 1 nur kholis
34 sandy
1 prasetyo
35 2 mulyono
35 2 sri astuti
35 yogie
2 aprisnanda
35 zelika
2 kharisma
35 ngestu2 rama alamsyah
36 imam
3 musanep
36 3qomariyah
36 anas
3 saiful ulum
36 risza3 fitri nur umami
37 4 maliki
37 4ida indrawati
37 aldy
4 yanuar rizky
37 4rizka nirmala
38 5ahmad alpin
38 5 suhairi
38 yuliana
5 fransiska
39 hariyatiningsih
6
40 7 suprapto
40 7 suryani
40 tony 7 oktareza putra
41 budi8 bayu prasetyo
41 8 deni fitria
41 rayhan 8 firdaus al fatrus
muhammad
41 sulton
8 al baraqqie putra prasetyo
42 9 Hadiri
42 9 sumilati
42 siti
9 mariyam ulfa
42 Amanda
9 hardiyanti
43 10
mory ariyanto
43 10
hermelina putri
44 11 khotijah
44 11siti jubaidah
45 12 sugiharto
45 12ririn sumarsih
45 12
yeni nurita sari
45 andrean
12 arta nugraha
ANGGOTA
SEDANGA ANGGOTA
KELUARGA
STATUS HAMIL KELUARGA
JENIS USIA > 10
HUB KELG USIA
KELAMIN
PERKAWIN (KHUSUS AGAMA > 5 TH
TH
SAB Sbr.SAB
AN WANITA 10- PENDIDIKA
PEKERJAA
54 TH N
N

11 12 13 14 15 16 17 18 19 20
1 53 1 1 1 3 5 1 1
2 45 2 1 2 1 3 1 1 1
3 27 1 2 1 5 5 1 1
3 14 2 2 1 4 2 1 1
1 45 1 1 1 4 5 1 1
2 41 2 1 2 1 4 1 1 1
1 24 1 1 1 6 2 1 1
2 16 2 1 1 4 2 1 1
3 9 1 1 1 3 2 1 1
1 64 1 1 1 6 3 1 1
2 42 2 1 2 1 5 4 1 1
3 24 1 1 1 4 2 1 1
3 16 2 2 1 5 2 1 1
1 48 1 1 1 5 3 1 1
2 49 2 1 2 1 5 1 1 1
3 22 1 2 1 5 1 1 1
3 18 2 2 1 4 2 1 1
1 63 1 1 1 5 5 1 1
2 44 2 1 2 1 4 1 1 1
3 21 2 2 1 6 2 1 1
1 64 2 4 1 5 4 1 1
1 54 1 1 1 7 4 1 1
2 48 2 1 2 1 4 5 1 1
3 21 1 2 1 5 2 1 1
1 27 1 1 1 7 4 1 1
2 31 2 2 2 1 5 1 1 1
3 8 1 2 1 2 0 1 1
3 1 1 1 0 1 1
1 46 1 1 1 4 4 1 1
2 46 2 1 2 1 3 4 1 1
3 24 2 2 1 5 2 1 1
3 14 2 2 1 3 2 1 1
1 34 1 1 1 4 4 1 1
2 35 2 1 2 1 3 4 1 1
1 72 2 4 2 1 4 6 1 1
2 24 2 2 1 4 5 1 1
1 46 1 1 1 5 4 1 1
2 43 2 1 2 1 5 5 1 1
3 21 2 2 1 6 2 1 1
3 12 1 2 1 4 2 1 1
PERILAKU
PENGGUNAA KEPEMILIK
N AIR BERSIH JAMB. Jns.JAMB BAB DI SKIZO OBT.SKIZO PASUNG AN JKN
MEROKOK DX. TB
JAMBAN

21 22 23 24 25 26 27 28 29 30
1 1 1 1 2 2 2 2 1 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 1 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 1 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 2 2 2 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
1 1 1 1 2 2 2 2 2 2
BATUK > 2
TX. TB DX HT / TD TX. HT / TD UKU TD SIST. DIAST. KONTRS. LINAKES ASI EKLS.
mgg.

31 32 33 34 35 36 37 38 39 40
2 2 2 2 1 130 90 2 0 0
2 2 2 2 1 120 90 2 0 0
2 2 2 2 1 100 90 0 0 0
2 2 2 2 1 120 90 0 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 0 0 0
2 2 2 2 2 2 2 0 0 0
2 2 2 2 2 2 2 0 0 0
2 2 2 2 1 120 80 2 0 0
2 2 2 2 1 110 90 1 0 0
2 2 2 2 1 120 80 2 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 0 0 0
2 2 2 2 2 2 2 0 0 0
2 2 2 2 1 100 80 2 0 0
2 2 2 2 1 120 80 2 0 0
2 2 2 2 1 120 90 0 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 1 120 90 2 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 0 0 0
2 2 2 2 1 130 90 2 0 0
2 2 2 2 1 120 90 2 0 0
2 2 2 2 1 2 2 0 0 0
2 2 2 2 2 2 2 0 1 0
2 2 2 2 1 100 90 2 0 0
2 2 2 2 1 130 80 2 0 0
2 2 2 2 1 120 70 0 0 0
2 2 2 2 1 100 70 0 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 2 2 2 2 0 0
2 2 2 2 1 100 90 2 0 0
2 2 2 2 1 130 80 2 0 0
2 2 2 2 1 120 70 0 0 0
2 2 2 2 1 100 70 0 0 0
IMUN TUMBANG

41 42
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
KABUPATE KECAMATA KELURAHA URUT
PROV. KODE PKM RW RT URUT KLG NAMA
N N N RUMAH

1 2 3 4 5 6 7 8 9 10

34 1 sugito
34 1 misnah
34 1 nur kholis
34 sandy
1 prasetyo
35 2 mulyono
35 2 sri astuti
35 yogie
2 aprisnanda
35 zelika
2 kharisma
35 ngestu2 rama alamsyah
36 imam
3 musanep
36 3qomariyah
36 anas
3 saiful ulum
36 risza3 fitri nur umami
37 4 maliki
37 4ida indrawati
37 aldy
4 yanuar rizky
37 4rizka nirmala
38 5ahmad alpin
38 5 suhairi
38 yuliana
5 fransiska
39 hariyatiningsih
6
40 7 suprapto
40 7 suryani
40 tony 7 oktareza putra
41 budi8 bayu prasetyo
41 8 deni fitria
41 rayhan 8 firdaus al fatrus
muhammad
41 sulton
8 al baraqqie putra prasetyo
42 9 Hadiri
42 9 sumilati
42 siti
9 mariyam ulfa
42 Amanda
9 hardiyanti
43 10
mory ariyanto
43 10
hermelina putri
44 11 khotijah
44 11siti jubaidah
45 12 sugiharto
45 12ririn sumarsih
45 12
yeni nurita sari
45 andrean
12 arta nugraha
SEDANGA
NO.URUT STATUS HAMIL
JENIS
HUB KELG ANGGOTA NIK TANGGAL LAHIR USIA PERKAWIN (KHUSUS AGAMA
KELAMIN
KLG AN WANITA 10-
54 TH

11 12 13 14 15 16 17 18 19
1 1 3510131111690006 30/12/1964 53 1 3 1
2 2 3510185304770006 30/12/1965 45 1 3 2 1
3 3 3510185910970001 5/8/1988 27 1 5 1
3 4 3510185001100002 7/15/2008 14 1 4 1
1 1 3510131610670001 4/8/1965 45 1 4 1
2 2 3510125207790011 12/4/1960 41 1 4 2 1
1 3 3510131011930003 4/12/1996 24 1 6 1
2 4 3510135610970002 11/29/2002 16 1 4 1
3 5 3510124012000003 5/27/2009 9 1 3 1
1 1 3510131111690006 23//12/1956 64 1 6 1
2 2 3510136812810005 4/30/1971 42 1 5 2 1
3 3 3510137009010004 11/25/1996 24 1 4 1
3 4 3510131402050004 2/12/2002 16 1 5 1
1 1 351022211610003 6/26/1964 48 1 5 1
2 2 351022331640004 9/24/1965 49 1 5 2 1
3 3 3510220403910003 5/19/1996 22 1 5 1
3 4 3510121206650001 9/19/2000 18 1 4 1
1 1 3510221102720003 23//12/1956 63 1 5 1
2 2 3510224701700004 4/30/1971 44 1 4 2 1
3 3 3510220412980003 11/25/1996 21 1 6 1
1 1 3510216511650002 7/23/1970 44 1 5 1
1 1 3510211204700005 7/12/1964 54 1 7 1
2 2 3510215408750008 4/23/1970 48 1 4 2 1
3 3 3510212005060002 7/26/1997 21 1 5 1
1 1 3510211303760002 9/29/1991 27 1 7 1
2 2 3510216607850005 12/2/1987 31 1 5 2 1
3 3 3510212112010003 8/12/2010 8 1 2 1
3 4 3510210707430001 9/3/2016 2 1 1 1
1 1 3510210909770010 8/27/1970 46 1 4 1
2 2 3510215506850008 7/4/1970 46 1 3 2 1
3 3 3510212103050004 9/12/1996 24 1 5 1
3 4 3510215711100001 7/23/2005 14 1 3 1
1 1 3510211212350002 11/5/1984 34 1 4 1
2 2 3510215101580001 8/7/1985 35 1 3 2 1
1 1 3510211204610005 12/15/1946 72 1 4 1
2 2 3510216511650002 1/7/1996 24 1 4 2 1
1 1 3510216703730002 9/6/1970 46 1 5 1
2 2 3510216508930001 6/1/1973 43 1 5 2 1
3 3 3510216410010003 6/30/1997 21 1 6 1
3 4 3510210808070001 12/12/2006 12 1 4 1
ANGGOTA
ANGGOTA
KELUARGA
KELUARGA PERILAKU
USIA > 10 PENGGUNAA
> 5 TH
TH
SAB Sbr.SAB N AIR BERSIH JAMB. Jns.JAMB BAB DI SKIZO OBT.SKIZO
PENDIDIKA JAMBAN
PEKERJAA
N
N

20 21 22 23 24 25 26 27 28 29
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 2 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 1
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 1
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
1 1 1 1 1 1 1 1 2 2
JKN
BATUK > 2
PASUNG PUNYA MEROKOK DX. TB TX. TB
mgg.
DX HT / TD TX. HT / TD UKU TD SIST.
TULIS NO

30 31 32 33 34 35 36 37 38 39

2 2 1 2 2 2 2 2 1 130
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 1 100
2 2 2 2 2 2 2 2 1 120
2 2 1 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 1 110
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 2 2
2 2 1 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 1 100
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 1 130
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 1 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 1 100
2 2 2 2 2 2 2 2 1 130
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 1 100
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2 2 2 1 100
2 2 2 2 2 2 2 2 1 130
2 2 2 2 2 2 2 2 1 120
2 2 2 2 2 2 2 2 1 100
KONTRS. /
DIAST. LINAKES ASI EKLS. IMUN TUMBANG
KB

40 41 42 43 44 45
90 2 0 0 0 0
90 2 0 0 0 0
90 0 0 0 0 0
90 0 0 0 0 0
2 2 0 0 0 0
2 1 0 0 0 0
2 0 0 0 0 0
2 0 0 0 0 0
2 0 0 0 0 0
80 2 0 0 0 0
90 1 0 0 0 0
80 2 0 0 0 0
2 2 0 0 0 0
2 2 0 0 0 0
2 2 0 0 0 0
2 0 0 0 0 0
2 0 0 0 0 0
80 2 0 0 0 0
80 2 0 0 0 0
90 0 0 0 0 0
2 2 0 0 0 0
90 2 0 0 0 0
2 2 0 0 0 0
2 0 0 0 0 0
90 2 0 0 0 0
90 2 0 0 0 0
2 0 0 0 0 0
2 0 0 0 0 0
90 2 0 0 0 0
80 2 0 0 0 0
70 0 0 0 0 0
70 0 0 0 0 0
2 2 0 0 0 0
2 2 0 0 0 0
2 2 0 0 0 0
2 2 0 0 0 0
90 2 0 0 0 0
80 2 0 0 0 0
70 0 0 0 0 0
70 0 0 0 0 0
NO.RES. ORDINAT KEL. LING. RT RW NO.RMH NO.KLG Alamat
1 2 3 4 5 6 7 8 9
1 1 34 37 telemungsari
1 1 35 38 telemungsari
1 1 36 39 telemungsari
1 1 37 40 telemungsari
1 1 38 41 telemungsari
JAMBAN

N. KK Ʃ KLG ƩWNC >15 10 - 54 th 12 - 59 bl 0 - 11 bl SAB JIWA


10 11 12 13 14 15 16
lasmono 4 4 4 4 0 0 1 1 N
buang 2 2 2 2 0 0 1 1 N
djamhari 3 3 3 3 0 0 1 1 N
slamet 3 3 2 2 0 0 1 1 N
sukisno 3 3 3 3 0 0 1 1 N
Santoso 4 4 4 4 0 0 1 1 N
5 5 0
JUMLAH 12
HIPERTE ASI TUMBAN
JKN ROKOK TBC KB LINAKES IMUN INDIKATOR
NSI EKLS. G BERNILAI 1

34

0 0 N N 1 N N N N 3
0 0 N N N N N N N 2
0 0 N N N N N N N 2
0 0 N N 1 N N N N 3
0 0 N 0 1 N N N N 3
1 1 N N N N N 1 N 5
0 0 0 3 0 0 0 0
Ʃ 12 INDIKATOR
JUMLAH "N") BERNILAI 1/(12- KATEGORI KELUARGA
N)

35 36 37

7 0.600 PraSehat
8 0.500 PraSehat
8 0.500 PraSehat
7 0.600 PraSehat
6 0.500 PraSehat
7 1.000 Keluarga Sehat
5
0

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