1.

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

1 2 3 4 5 6
5 2 0 6 0 1 9 0 2 Bulan : 2023
NAMA FASKES/ KKB KARAMPI V 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 06-Jul-2023 IKRAMAN 5 2 0 6 1 1 4 3 0 5 9 6 0 0 0 2 NURZAITUN 03-Jun-1996 DUSUN SOROBALI 2 1 0 0 8 1 0 0 1 0 0 1

2 06-Jul-2023 M JAFAR 5 2 0 6 1 1 4 8 0 5 0 1 0 0 0 2 FINARTI 06-May-2001 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

3 06-Jul-2023 M YANI 5 2 0 6 1 1 4 1 0 4 9 8 0 0 0 2 JULAIHA 01-Apr-1998 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

4 06-Jul-2023 JUNAIDIN 5 2 0 6 1 1 4 3 0 7 9 5 0 0 0 1 LENI HERLINA 03-Jul-1995 DUSUN SIDO DESA SARAE RUMA 1 1 1 0 8 1 0 0 1 0 0 1

5 06-Jul-2023 IWARDIN 5 2 0 6 1 1 6 1 0 8 9 7 0 0 0 2 ISATRRADIAH 21-Aug-1997 DUSUN MAMBANAE DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

6 06-Jul-2023 AYUB 5 2 0 6 1 1 1 1 0 5 9 3 1 0 0 2 HALIFAH 11-May-1993 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

7 06-Jul-2023 SUPRIADIN 5 2 0 6 1 1 5 2 0 2 8 3 0 0 0 1 RUSIAH 12-Feb-1983 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

8 06-Jul-2023 M.SAID 5 2 7 2 0 2 4 3 0 5 8 9 0 0 9 1 SRI ANITA 03-May-1989 DUSUN SORO BALI DESA KARAMPI 1 1 0 0 8 1 0 0 1 0 0 1

9 06-Jul-2023 MUJDUN 5 2 0 6 1 1 4 5 0 1 8 1 0 0 0 2 ASURAH 05-Jan-1981 DESA KARAMPI Kec.LANGGUDU 2 1 0 0 8 1 0 0 1 0 0 1

10 06-Jul-2023 RUSLIN 5 2 0 6 1 1 4 5 0 6 9 2 0 0 0 2 MARLINAH 09-Mar-1993 DUSUN SOROBALI DESA KARAMPI 1 1 0 0 8 1 0 0 1 0 0 1

11 06-Jul-2023 UNHAR 5 2 0 6 1 1 4 3 0 6 9 1 0 0 0 1 RAHMAWATI 03-Jun-1991 KARAMPI 2 1 0 0 8 0 0 1 1 0 0 1

12 06-Jul-2023 HAIRAN 5 2 0 6 1 1 4 7 0 9 8 6 1 0 0 3 NURMUFIDAH 07-Sep-1986 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

13 06-Jul-2023 MAHDIN 5 2 0 6 1 1 4 1 0 7 8 3 1 1 4 2 RAHMANI 01-Jul-1983 DUSUN MAMBANAE DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

14 06-Jul-2023 BAMBANG 5 2 0 6 1 1 4 2 0 3 8 1 0 0 0 1 IMRI 03-May-1981 KARAMPI 1 1 0 0 8 0 0 1 1 0 0 1

15 06-Jul-2023 ASIKIN 5 2 0 6 1 1 4 8 0 7 9 9 1 0 0 2 JAMIAH 08-Jul-1999 KARAMPI 1 1 0 0 8 1 0 0 1 0 0 1

16 06-Jul-2023 MUNAWIR 5 2 0 6 1 1 4 7 0 5 9 4 1 0 0 7 NURHASANAH 07-May-1994 DUSUN MAMBANAE K 2 1 0 0 8 1 0 0 1 0 0 1

17 06-Jul-2023 JAIDIN 5 2 0 6 1 1 0 5 0 8 8 4 0 0 0 2 SRI NANDI 05-Aug-1984 RT11/RW03 2 1 0 0 8 0 0 1 1 0 0 1

18 06-Jul-2023 RUSLAN 5 2 0 6 1 1 4 5 0 7 9 1 0 0 0 2 MARIAMAH 05-Jul-1991 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

KARAMPI
19 06-Jul-2023 FATAHULLAH 5 2 0 6 1 1 4 8 0 2 8 3 0 0 0 2 AFRIYANI 08-Feb-1983 2 1 0 0 8 1 0 0 1 0 0 1

20 06-Jul-2023 BUSYAINAWAN 5 2 0 6 1 1 6 7 0 9 9 4 1 0 0 5 ST HABIBAH 27-Sep-1994 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

21 06-Jul-2023 SUHAIDIN 5 2 0 6 1 1 4 7 0 9 9 9 0 0 0 3 ST MAISARAH 07-Sep-1999 DUSUN SOROBALI 1 1 0 0 8 0 0 1 1 0 0 1

22 06-Jul-2023 MUHAJIR 5 2 0 6 1 1 4 5 0 6 8 0 0 0 0 4 HASIAH 05-Jun-1980 DUSUN MAMBANAE DESA KARAMPI 2 1 0 0 8 0 0 1 1 0 0 1

23 06-Jul-2023 JULKIFLIN 5 2 0 6 1 1 4 6 0 6 9 4 0 0 0 1 NURFATHI 06-Jul-1994 KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

24 06-Jul-2023 AKHI 5 2 0 6 1 1 5 5 1 0 8 2 0 0 0 1 SARMAEH 15-Oct-1982 DESA KARAPI 2 1 0 0 8 1 0 0 1 0 0 1

25 06-Jul-2023 A MANAN 5 2 0 6 1 1 4 1 1 1 8 4 0 0 0 1 RUFI,AH 01-Nov-1984 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

26 06-Jul-2023 LAHFIN 5 2 0 6 1 1 4 1 0 3 9 8 0 0 0 4 NUR AFINI 01-Mar-1998 DUSUN OI TEMBA DESA KARAMPI 1 1 0 0 8 1 0 0 1 0 0 1

27 06-Jul-2023 BAHARUDIN 5 2 0 6 1 1 4 1 0 7 7 9 1 2 1 6 NURHAIDAH 01-Jul-1979 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

28 06-Jul-2023 RAHMADIN 5 2 0 6 1 1 4 3 0 3 8 2 0 0 0 3 MISKUL 03-Apr-1982 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

29 06-Jul-2023 SAHRUDIN 5 2 0 6 1 1 4 1 0 6 8 4 0 0 0 1 BURAIDAH 01-Jun-1984 DUSUN SOROBALI DESA KARAMPI 1 1 0 0 8 1 0 0 1 0 0 1

30 06-Jul-2023 ZAINUDIN 5 2 0 6 1 1 6 4 0 1 9 7 0 0 0 1 MASWAH 24-Jan-1997 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

31 06-Jul-2023 ABD RAJAK 5 2 0 6 1 1 4 5 0 7 8 0 1 0 0 3 NURSAH 05-May-1980 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

32 06-Jul-2023 ISMAIL 5 2 0 6 1 1 4 4 0 5 9 9 1 0 0 3 NUR'INAYAH 04-May-1999 DUSUN OI TEMBA DESA KARAMPI 1 1 0 0 8 0 0 1 1 0 0 1

33 06-Jul-2023 RIDWAN 5 2 0 6 1 1 5 0 1 0 8 3 1 0 0 5 SITI FARIDAH 10-Oct-1983 DESA KARAMPI Kec.LANGGUD 2 1 0 0 8 0 0 1 1 0 0 1

34 06-Jul-2023 ARDIN 5 2 0 6 1 1 5 4 0 2 9 4 1 0 0 7 JUSTIKA 14-Feb-1999 DUSUN OI TEMBA DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

35 06-Jul-2023 YUSAN 5 2 0 6 1 1 4 2 0 7 7 8 0 0 0 3 MARIANI 02-Jul-1978 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

36 06-Jul-2023 IHSAN 5 2 0 6 1 1 6 8 0 6 9 9 1 0 0 3 FITRATI 28-Jun-1999 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

37 06-Jul-2023 AULIA 5 2 0 6 1 1 6 4 0 6 0 1 0 0 0 3 ETI MUSTIKA 24-Jun-2001 DUSUN SOROBALI DESA KARAMPI 1 1 0 0 8 1 0 0 1 0 0 1

38 06-Jul-2023 ABDULLAH 5 2 0 6 1 1 6 9 1 1 7 8 1 0 0 2 MISLAH 29-Nov-1978 SORO BALI 2 1 0 0 8 1 0 0 1 0 0 1

39 06-Jul-2023 M.ALI 5 2 0 6 1 1 5 9 0 5 9 2 1 0 0 6 ROSIDAH 18-May-1992 DESA KARAMPI Kec.LANGGUDU 1 1 0 0 8 0 0 1 1 0 0 1

DUSUN SARAE RUMA DESA SARAE

40 08-Jul-2023 MUSTAKIM 5 2 0 6 1 1 5 0 0 7 8 4 0 0 0 2 MUKJIJAH 10-Jul-1984 1 1 0 0 8 1 0 0 1 0 0 1
RUMA Kec. LANGGUDU

41 08-Jul-2023 UNHAR 5 2 0 6 1 1 4 7 1 2 8 6 0 0 0 3 IMAH 07-Dec-1986 DESA KARAMPI 2 1 0 0 8 1 0 0 1 0 0 1

42 08-Jul-2023 ADHAR 5 2 0 6 1 1 0 6 0 6 7 8 0 0 0 1 HARNANI 06-Jun-1978 RT002/RW001SARAERUMA 2 1 0 0 8 1 0 0 1 0 0 1

43 08-Jul-2023 RAJULAN 5 2 0 6 1 1 4 7 0 6 0 2 1 0 1 1 NAZIRAH 07-Aug-2002 DUSUN SIDO DESA SARAE RUMA 1 1 1 0 8 0 0 1 1 0 0 1

44 08-Jul-2023 AKHALIK 5 2 0 6 1 1 6 0 0 6 7 6 0 0 0 5 NUR HAIDAH 20-Jun-1976 DUSUN SIDO DESA SARAE RUMA 2 1 0 0 8 1 0 0 1 0 0 1

45 08-Jul-2023 ZULKIFLI 5 2 0 6 1 1 4 1 0 7 7 6 0 1 1 2 ST ROHANA 01-Jul-1976 DESA SARAERUMA 2 1 0 0 8 1 0 0 1 0 0 1

46 08-Jul-2023 ISMAIL 5 2 0 6 1 1 5 0 0 3 8 4 1 0 1 0 SITI ULFAH 10-Mar-1984 KARAMPI 1 1 0 0 8 1 0 0 1 0 0 1

47 12-Jul-2023 HANAFI 5 2 0 6 0 1 4 4 0 5 9 1 1 0 0 3 ST NURRAMAWATI 04-May-1991 DESA SARAERUMA 1 0 1 0 3 0 0 1 1 0 0 0

48 12-Jul-2023 SAAMIN 5 2 0 6 1 1 1 6 0 3 9 6 0 0 0 2 ST ARIJAH 16-Mar-1996 RT001/RW001DESASARAERUMA 1 0 1 0 3 1 0 0 1 0 0 0

49 12-Jul-2023 MUHAJIRIN 5 2 0 6 1 1 6 8 0 9 9 8 0 0 0 2 MISNA 15-Jul-1998 DUSU TANGGANI 1 0 1 0 3 1 0 0 1 0 0 0

50 12-Jul-2023 ZAINUDIN 5 2 0 6 1 1 2 1 0 5 8 4 0 0 0 3 NAFIDAH 21-May-1984 RT001/RW001DESASARAERUMA 1 0 1 0 3 1 0 0 1 0 0 0

51 12-Jul-2023 DULAJIS 5 2 0 6 1 1 5 9 0 3 9 2 0 0 0 5 MISKUL HITAM 19-Mar-1992 DUSUN SIDO 1 0 0 0 3 0 0 1 1 0 0 0

52 12-Jul-2023 ABD.RASYAD 5 2 0 6 1 1 5 2 1 1 9 1 1 0 0 4 NURHAIDAH 12-Nov-1991 DUSUN SIDO 1 0 1 0 3 0 0 1 1 0 0 0

53 12-Jul-2023 FIRMAN 5 2 0 6 1 1 5 1 1 0 8 8 1 0 0 4 ASTUTI 11-Aug-1988 SARAERUMA 1 0 1 0 3 1 0 0 1 0 0 0

54 12-Jul-2023 RUSLAN 5 2 0 6 1 1 5 2 0 0 3 9 5 0 0 4 ARINI 23-Mar-1995 DESA SARAERUMA 1 0 1 0 3 0 0 1 1 0 0 0

55 12-Jul-2023 SAMSUDIN 5 2 0 6 1 1 4 1 0 7 8 0 1 2 3 4 BURAIDAH 01-Jul-1980 RT002/RW001SARAERUMA 1 0 1 0 3 1 0 0 1 0 0 0

56 12-Jul-2023 M YUSUF 5 2 0 6 1 1 6 7 0 7 8 6 0 0 0 3 MUKMINAH 27-Jul-1986 DESA SARAERUMA 1 0 0 1 3 1 0 0 1 0 0 0

DUSUN MAMBA NAE DESA

57 26-Jul-2023 KASLIN 5 2 0 6 1 1 4 5 0 8 8 3 1 0 0 9 ASTUTI 05-Aug-1983 1 0 1 0 3 0 0 1 1 0 0 0
KARAMPI

58 26-Jul-2023 SAIFIN 5 2 0 6 1 1 4 4 0 5 9 8 0 0 0 1 RAHMAWATI 03-Dec-1997 DESA KARAMPI 1 0 1 0 3 0 0 1 1 0 0 0

59 26-Jul-2023 M YASIN 5 2 0 6 1 1 4 1 0 7 7 6 0 1 1 0 HALIJAH 11-Mar-1976 KARAMPI 2 0 0 0 3 1 0 0 1 0 0 0

60 26-Jul-2023 NASARULLAH 5 2 0 6 1 2 5 0 0 5 9 5 0 0 0 2 HESTI KURNIATI 10-May-1995 DUSUN OI TEMBA DESA KARAMPI 1 0 0 0 3 0 0 1 1 0 0 0

61 26-Jul-2023 AJRUN 5 2 0 6 1 1 5 5 1 1 8 4 0 0 0 1 JUNARI 15-Nov-1984 DESA KARAMPI 1 0 0 1 3 1 0 0 1 0 0 0

62 26-Jul-2023 AHMAD 5 2 0 6 1 1 6 3 0 8 8 4 0 0 0 1 NUR,AH 23-Aug-1984 DESA KARAMPI 3 0 0 0 3 1 0 0 1 0 0 0

63 26-Jul-2023 AMRAN 5 2 0 6 1 1 2 8 1 1 9 7 0 0 0 2 FIJRIATUN 12-Nov-1997 DESA KARAMPI 1 0 0 0 3 1 0 0 1 0 0 0

64 26-Jul-2023 IBRAHIM 5 2 0 6 1 1 4 1 0 7 8 0 1 1 9 6 NURLAILAH 01-Jul-1980 RT11/RW03 2 0 0 0 3 1 0 0 1 0 0 0

DESA KARAMPI
65 26-Jul-2023 ABD HAER 5 2 0 6 1 1 5 8 0 7 8 6 0 0 0 4 RUSIAH 18-Jul-1986 3 0 0 0 3 1 0 0 1 0 0 0
 66 26-Jul-2023 ANHAR 5 2 0 6 1 1 5 5 0 9 9 7 0 0 0 1 NUR,INAYAH 15-Sep-1997 DUSUN SORO BALI 1 0 1 0 3 1 0 0 1 0 0 0

DUSUN MAMBA NAE DESA

67 26-Jul-2023 NASRUL MULUK 5 2 0 6 1 1 4 1 0 7 8 9 0 0 9 9 USWATUN HASANAH 21-Apr-1988 3 0 0 0 3 1 0 0 1 0 0 0
KARAMPI
DUSUN MAMBA NAE DESA
68 26-Jul-2023 LAJIMAN 5 2 0 6 1 1 5 1 1 2 9 4 1 0 0 4 NUR AHSANI 11-Dec-1994 1 0 1 0 3 0 0 1 1 0 0 0
KARAMPI

69 26-Jul-2023 ABDL.THALIB 5 2 0 6 1 1 5 2 1 0 8 7 0 0 0 4 SURYATI 12-Oct-1987 DESA KARAMPI 2 0 0 0 3 1 0 0 1 0 0 0

70 26-Jul-2023 NUJRAN 5 2 0 6 1 1 4 5 0 8 8 0 1 0 0 6 NURHASANAH 05-Aug-1980 RT11/RW03 1 0 0 1 3 1 0 0 1 0 0 0

DUSUN MAMBA NAE DESA

71 26-Jul-2023 RUSLIN 5 2 0 6 1 1 5 7 0 3 9 0 0 0 0 2 MARIATI 17-Mar-1990 3 0 0 0 3 1 0 0 1 0 0 0
KARAMPI

72 26-Jul-2023 MAFRUDAN 5 2 0 6 0 2 7 1 1 2 9 6 1 0 1 2 ENDANG 31-Dec-1996 DUSUN OI TEMBA DESA KARAMPI 1 0 1 0 3 1 0 0 1 0 0 0

73 26-Jul-2023 SIRAJUDIN 5 2 0 6 1 1 4 5 1 0 8 2 0 0 0 1 NURHIDAYAH 05-Oct-1988 DESA KARAMPI 3 0 0 0 3 1 0 0 1 0 0 0

74 26-Jul-2023 ACCO 5 2 0 6 1 1 4 1 0 7 7 9 1 1 8 1 HADIJAH 01-Jul-1979 RT11/RW3 3 0 0 0 3 1 0 0 1 0 0 0

75 26-Jul-2023 FAHMAN 5 2 0 6 1 1 6 3 0 4 9 1 0 0 0 1 RISMAWATI 23-Apr-1991 DUSUN MAMBA DESA KARAMPI 1 0 1 0 3 1 0 0 1 0 0 0

76 26-Jul-2023 MUHAMAD 5 2 0 6 1 1 4 6 1 1 8 6 0 0 0 1 NURHAYATI 06-Nov-1986 DESA KARAMPI 1 0 1 0 3 1 0 0 1 0 0 1

DUSUN MAMBA NAE DESA

77 26-Jul-2023 MUKHALAS 5 2 0 6 1 1 6 6 0 5 9 8 0 0 0 1 NURNAS MULIAWATI 26-May-1998 1 0 1 0 3 1 0 0 1 0 0 0
KARAMPI

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 4

1 2 3 4 5 6
5 2 0 6 0 1 9 0 2 Bulan : 2023
NAMA FASKES/ KKB KARAMPI V 8 9 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 0 0 0 0 1 0 0 0 0 0 0
2 SUNTIKAN 0 1 0 1 1 0 0 0 0 0 0
3 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
4 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
5 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
6 SUNTIKAN 0 1 0 1 1 0 0 0 0 0 0
7 SUNTIKAN 0 1 0 1 1 0 0 0 0 0 0
8 SUNTIKAN 0 1 0 1 0 0 0 0 0 0 0
9 IMPLAN 1 1 0 1 0 0 0 0 0 0 0
10 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
11 IMPLAN 1 1 0 1 0 0 0 0 0 0 0
12 SUNTIKAN 0 0 0 0 0 0 0 1 0 0 0
13 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
14 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0
15 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
16 SUNTIKAN 0 0 0 0 0 0 0 1 0 0 0
17 SUNTIKAN 0 1 0 1 1 0 0 0 0 0 0
18 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
19 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0
20 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
21 IMPLAN 1 0 0 0 0 0 0 0 0 0 0
22 IMPLAN 0 0 0 0 0 0 1 1 0 0 0

JUMLAH 14 23 0 23 18 0 32 35 6 0 0 0

Bima , 14-August-2023
Pimpinan Faskes KB/Jaringan/Jejaring*

Nurimaniah, Amd. Keb

( .................................................................................................)

NIP/NRP
* Coret yang tidak perlu