SIMULASI
PELAKSANAAN
IMUNISASI
RSUD dr. Rubini Mempawah Kabupaten Mempawah Provinsi Kalimantan Barat
LAPORAN
01 PROFIL RS
02 SASARAN IMUNISASI
03 MIKROPLANNING
04 SIMULASI PELAKSANAAN
MISI
MOTTO
Jl. Raden Kusno No. 1 Mempawah (78912) Telp/Fax.(0561)691981, E-mail :
rs_rubini@yahoo.com
Website: www.rsudrubini.com
SASARAN IMUNISASI
JUMLAH TENAGA KESEHATAN = 445
19 10 2 180 34
DOKTER DOKTER DOKTER
PERAWAT BIDAN
SPESIALIS UMUM GIGI
32 1 4 162
PENUNJANG
FARMASI KESMAS KESLING
LAIN
MIKROPLANNING
PENDATAAN FASYANKES
YANG AKAN MEMBERIKAN LAYANAN VAKSINASI COVID-19
Kondisi Lemari Es
Jam Pelayanan
Hari Pelayanan
No.
yang terlibat
Vaksinator
Tidak berfungsi
dalam tim
Berfungsi
pelayanan
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
KOMPILASI PENDATAAN FASYANKES
YANG AKAN MEMBERIKAN LAYANAN VAKSINASI COVID-19
:
Kabupaten/Kota Mempawah
:
Kalimantan
Provinsi Barat
Jumlah Tenaga Kesehatan
yang berperan dalam
Jadwal Pelayanan Jumlah dan Kondisi Cold Chain yang Tersedia
pelaksanaan vaksinasi
COVID-19
Kondisi
Jam Pelayanan
Hari Pelayanan
Fasyankes
Vaksinasi Vaksinasi lain yang
Vaksinator
Tidak berfungsi
COVID-19 terlibat
dalam tim
Berfungsi
pelayanan
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
ruma
h
RSUD dr. Rubini bd. Asih 08.00- tangg
PERHITUNGAN KEBUTUHAN LOGISTIK DAN PEMBIAYAAN
Kabupaten/Kota : Mempawah
Hand Sanitizer
Kit Anafilaktik
Masker Medis
Desinfektan
Face Shield
Form KIPI
Apron
Jumlah
Sumber Dana
kebutuhan
1 2 3 4 5 6 7 8 9 10 11 12
Rencana Kegiatan Advokasi, Koordinasi dan Sosialisasi serta Pelatihan Vaksinasi COVID-19
Provinsi KALBAR
Tanggal
No Jenis Kegiatan Frekuensi Sasaran Pelaksana Jumlah Dana yang dibutuhkan Sumber Pendanaan
Pelaksanaan
tim yg sudah
sosialisasi kepada tim vaksinator
1 22/2/2021 tim vaksinator RS mengikuti pelatihan sesuai kebutuhan
RS
vaksinator
BLUD
SIMULASI
PELAKSANAAN
PENCATATAN DAN
PELAPORAN
FORMAT PENCATATAN PELAKSANAAN VAKSINASI COVID-19
TINGKAT PUSKESMAS/FASYANKES/POS VAKSINASI
Nama : RSUD dr.
Puskesmas/Fasy RUBINI
ankes/Pos MEMPAWAH
Kabupaten/Kota : MEMPAWAH
Provi : KALIMANTAN
nsi BARAT Kepesertaan BPJS (tulis
'Ya' pada kolom yang Dosis I Dosis 2
sesuai)
Nama/ Keterangan
Jenis Umur Tanggal
Nama Penerima Pekerj Kelomp Jenis/Merek (Ditunda/Tidak
No No. Tiket NIK Kela (18-59 Alamat No. Hp Screening Tanggal Tanggal
Vaksin aan* ok Umur BPJS Non Vaksin*** Diberikan/Lanjut)
min tahun) BPJS Pemberia No. Pemberia
Non Anggot No. Batch No. Batch No. Serial
PBI n Serial n
PBI a
Vaksinasi Vaksinasi
Nama
Puskesmas : RSUD dr. RUBINI MEMPAWAH
Kabupaten/Kota : MEMPAWAH
Provi
nsi : KALIMANTAN BARAT
Kepesertaan BPJS Dosis 1 Dosis 2
Um KEERANGAN
Jenis Kelom Tgl
No Nama Penerima ur BPJS Non Merk Scree (ditunda/tidak
No. NIK Kela Pekerj pok Alamat No HP BPJS Tgl Tgl
Registrasi Vaksin 18- Non Angg Vaksin ning No diberikan/lanjut
min aan* Umur PBI Pemberian No Batch Pemberian
59 PBI ota Batch )
Vaksin Vaksin
Jl. Kampung
W- Arly Nanda 85255203 22-1- Coron 20200900
1 18-30 Pasir Ya
0C257C20: 7.47105E Iskandar, S. 885 2021 avac 22-1-2021 9
5/2/2021 Lanjut
Mempawah
L238C7 +15 Farm, Apt L PNS 29
W- BTN 20200900
2 6.10202E Rosidah, SKM, 81257544 26-1- coron 26-1-2021 9
9/1/2021 lanjut
8CEFD0C P PNS 50 46-59 bhayangkara Ya
+15 MPH 71 2021 avac
6 Asri
20200900
21-01-2021 4/1/2021 lanjut
3 W- 6.10202E Nengsih Juniarti, BTN Bali 82350157 21-01- coron 9
P PNS 41 31-45 Ya
915B29AA +15 STR. Kep Permai 777 2021 avac
20200900
4 W- 6.10202E jl. Era Baru 81257196 22-01- Coron 22-01-2021 9
5/2/2021 lanjut
Rahmawati P PNS 40 31-45 Ya
B1C9E5F6 +15 Mempawah 80 2021 avac
Nama
: RSUD dr. RUBINI MEMPAWAH
Puskesmas/Fasyankes/Pos
Kabupaten/Kota : MEMPAWAH
Provinsi
: KALIMANTAN BARAT
VAKSIN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
http://keamananvaksin.kemkes.go.id/
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