FORMAT PENCATATAN HASIL PELAYANAN

Posyandu/Pos ayanan BIAN lainnya : SD INPRES KOTARAJA

Desa/kelurahan : VIM
Tanggal : 19/07/2022

Jenis Kelamin
No. Nama Anak Tgl lahir Umur Nama orang tua Alamat
(L/P)

a b c d e f g
1 ANDREAS IYAI 24/12/2015 #VALUE! L
2 ANTONIA SONAP 10/11/2016 5 P
3 ANTONIO RENRUSUN 5/7/2015 7 L
4 FELISIA NUSSY 13/06/2015 #VALUE! P
5 IZJAL PRAMESU 18/03/2016 #VALUE! L
6 JULIO DEDA 29/07/2015 #VALUE! L
7 KRISIA SROYER 8/7/2015 7 P
8 OKTAVIA AULIA 15/10/2015 #VALUE! P
9 REYNARD LOI 15/12/2015 #VALUE! L
10 SYAHBANI NGABALIN 11/6/2015 6 P
11 VISCO MANUA 10/2/2016 5 L
12 ZAHRATUL AINI 20/03/2016 #VALUE! P
13 ALEXANDRO LEWAR 23/12/2014 #VALUE! L
14 ALVIN DWI CAHY0 1/5/2015 7 L
15 CEZKA KORUA 6/10/2015 7 P
16 DAVE JEUJANAN 14/02/2016 #VALUE! L
17 HAFIFAH RAFANDA 7/10/2015 7 P
18 HETZON WARWETAN 31/01/2016 #VALUE! L
19 GLORIA WONDOU 16/12/2015 #VALUE! P
20 MUH.ALFARIZI 13/06/2015 #VALUE! L
21 MUH.RIDHO DATAU 17/05/2016 #VALUE! L
22 REINALDY DAUD 20/06/2015 #VALUE! L
23 SERGIO NGELIARATAN 30/07/2015 #VALUE! L
24 EIFEL ANDREA AUPARAY 122 P
25 ALEXANDRO ROSSIL 28/11/2014 #VALUE! L
26 ALVIANUS GOGANI 26/11/2015 #VALUE! L
27 AYLANI AMILASYAH 22/04/2016 #VALUE! P
28 ELYON WALLY 8/12/2014 8 L
29 FARLAN WENDEY 29/10/2015 #VALUE! L
30 GELOOF YOUWE 10/2/2016 5 L
31 GERSOM WONDOW 16/12/2015 #VALUE! L
32 GODHELP ROSUMBRE 26/06/2015 #VALUE! L
33 HANIEL RENATA KETAREN 2/10/2015 7 P
34 KEISHA NUGROHO 2/11/2015 7 P
35 NIMAS AYU ZALSABILAH 26/11/2015 #VALUE! P
36 MUH.HILAL 14/01/2016 #VALUE! L
37 RACHEL PAPADAK 4/2/2016 6 P
38 REY GAVRIEL ARION 25/02/2016 #VALUE! L
39 FREDERIKUS ARI KBAREK 122 L
40 ACHEYRA ODE 12/2/2015 6 P
41 AGUSTO ELEWYAAN 20/08/2015 #VALUE! L
42 ALDRICH JORDAIN 25/02/2016 #VALUE! L
43 DREAN BAYU MALIK 20/08/2015 #VALUE! L
44 FORLAN WENDEY 29/10/2015 #VALUE! L
45 HELEN ASMURUF 30/10/2015 #VALUE! P
46 GIAN SAPUTRA 31/07/2015 #VALUE! L
47 JUBAIR TSAQIB 16/04/2016 #VALUE! L
48 KANYAKA HANDOKO 2/2/2016 6 P
49 MARICE UDAM 19/10/2014 #VALUE! P
50 NATHANIELA FELICIA 17/07/2016 #VALUE! P
51 PANGERAN SALULINO 10/10/2015 6 L
52 REVALINA PARUBAK 22/03/2016 #VALUE! P
53 SEAN MERAUDJE 20/10/2015 #VALUE! P
54 ZAIN MALIK AKBAR YAMBI 17/03/2016 #VALUE! L
55 MAX GEIS KORWA 122 L
56 NUR ALIYAH 122 P
57 ARJAQCCLIEN DATURATTE 31/07/2015 #VALUE! P
58 ALFIN HILMI 27/11/2014 #VALUE! L
59 ARJUNA WICAKSONO 22/06/2014 #VALUE! L
60 FEBRIYANTI LIRONG 11/2/2015 6 P
61 FERDI SAMBARA 29/12/2014 #VALUE! L
62 FREDERICK SAMBARA 23/01/2015 #VALUE! L
63 JERRY NOEL TUTUPARY 1/12/2014 8 L
64 JHERYCHO PIRRI 17/01/2015 #VALUE! L
65 LOIS MANURUNG 12/3/2015 6 P
66 MUH.AUFAR 18/10/2014 #VALUE! L
67 NATALIA ELOPERE 30/12/2014 #VALUE! P
68 PETER SHANE JEUJANA 1/10/2014 8 L
69 RAMON NORANA 8/1/2015 7 L
70 SHEAN LYN MASERO 30/03/2015 #VALUE! P
71 SITI AISYAH HAWA 5/5/2014 8 P
72 SITI NUR FADILAH 14/02/2015 #VALUE! P
73 ZEFANYA WAKUM 19/08/2014 #VALUE! P
74 ALGHIFARY PUTRA 15/05/2014 #VALUE! L
75 ANDRIANI SOLOSA 2/2/2015 7 P
76 AXELO PAPARE 12/12/2013 8 L
77 FREDERICO BREIDAM 23/01/2015 #VALUE! L
78 FRISKI JOVAN LIKU 4/5/2015 7 L
79 HAFIZUDIN AQIL AZAM 3/1/2015 7 L
80 JOY PRATAMA TU'BARAN 27/11/2014 #VALUE! L
81 LOUIS MAGANTA TEHUAJO 20/08/2015 #VALUE! P
82 MARCELLO SONDAKH 12/12/2014 7 L
83 MUH.ALKHALIFI 18/05/2015 #VALUE! L
84 NUR RAHMA SUKARDI 30/03/2015 #VALUE! L
85 RAHEL TABE BORLYN 22/03/2014 #VALUE! P
86 RANIAH ATTAYAH PUTRI 18/08/2014 #VALUE! P
87 REVA APRILIA 24/04/2015 #VALUE! P
88 THERESIA PIPA 3/5/2015 7 P
89 TOMOTY THIU 5/6/2014 8 L
90 WA ODE NAURA ANNIDA 23/01/2015 #VALUE! P
91 YOHANES TANDORA 25/08/2014 #VALUE! L
92 ALDRICH NEVAN NANLOHY 19/04/2015 #VALUE! L
93 AMSTRONG HEUMASSE 29/03/2015 #VALUE! L
94 CHELSIA SANUEL 10/3/2015 6 P
95 DIRGA IMANUEL RIWA 8/10/2014 8 L
96 ELIAS SEFNAT AP 3/6/2014 8 L
97 GEORGE KOWET 24/11/2014 #VALUE! P
98 JOANISSA ROSUMBRE 14/09/2013 #VALUE! P
99 MARCELLO BUSUB 6/5/2015 7 L
100 MARIA SEMBOR 7/10/2014 8 P
101 PRISKA SESA 25/05/2015 #VALUE! P
102 RASYA ADITYA CHANDRA 5/1/2015 7 P
103 SIMON RENYAAN 19/04/2014 #VALUE! L
104 ZAHRA AULIA WULANDARI 15/08/2014 #VALUE! P
105 ALVARO GAVRIEL 12/3/2015 6 L
106 AQILA WARA 24/10/2014 #VALUE! P
107 ASSYIFATUN MUSLIMIN 10/1/2015 6 P
108 AURORA WAMBRAUW 24/08/2014 #VALUE! P
109 AZ ZAHRA PUTRI 15/04/2014 #VALUE! P
110 BERRYFOX KAFIAR 27/12/2014 #VALUE! L
111 DANIEL DAUD 15/03/2015 #VALUE! L
112 GREGORIUS WIDYASTO 1/6/2014 8 L
113 KEZIA SAMOSIR 31/05/2015 #VALUE! P
114 LICIA TRIVANA PAULANG 5/12/2014 8 P
115 OSVALDO GRACIO AUPARAY 26/02/2015 #VALUE! L
116 SALSABILA RHAMADANI 11/7/2014 7 P
117 WULANDARI PRAWAR 18/10/2013 #VALUE! P
118 CHRISTHOPERUS BHAKTI 28/07/2014 #VALUE! L
119 FARHAN SAPUTRA 2/9/2013 9 L
120 FRANSISKUS DIEGO 2/9/2013 9 L
121 GABRIEL ROMBE TARUK 17/07/2013 #VALUE! L
122 KHAIRUL ANAM 30/01/2014 #VALUE! L
123 MESAK LUKAS KORIDAMA 27/07/2013 #VALUE! L
124 MUH.FAHRIZQI AULIA 12/3/2014 7 L
125 NOVRIANTO ALA 30/11/2013 #VALUE! L
126 NURINTAN CHANDRA 23/02/2014 #VALUE! P
127 QUEENZAHRA ARUNI 28/11/2013 #VALUE! P
128 REYNALDI PATTIEUWEAN 13/03/2014 #VALUE! L
129 RIVANO PUTRA 11/3/2013 8 L
130 SEPTIANI ROSARIO 3/9/2013 9 P
131 ADINDA PUTRI MAHARANI 24/09/2013 #VALUE! P
132 ALQIANDO BHATARA 4/9/2013 9 L
133 ARKA AGUNG PRATAMA 7/12/2013 9 L
134 BILQIS NAFISAH 2/9/2014 8 P
135 BRANDSMA UTAN 27/07/2013 #VALUE! L
136 FIDELIO TODUHO 19/04/2014 #VALUE! L
137 FRANCO RUMANASEN 8/2/2014 8 L
138 GERRIT LEIWAKABESSY 9/12/2013 8 P
139 JOERDAN LAY 28/05/2014 #VALUE! L
140 MARCYA SILAHOOY 10/9/2013 8 P
141 RONALD BUSUB 14/08/2013 #VALUE! L
142 SENANDUNG NAHAK 4/9/2013 9 P
143 VELDERICK GINTING 28/07/2013 #VALUE! L
144 JESUS SUREZ MATUI 122 L
145 ALQIANO BHATARA 4/9/2013 9 L
146 ALVINAN HILMA 22/08/2013 #VALUE! L
147 AULIA DWIA PUTRI 27/04/2014 #VALUE! P
148 AZKA ZAIM WIJAYA 21/04/2014 #VALUE! L
149 BAGAS SETYO 7/10/2013 9 L
150 FEBIYUDITA DAUD MINGGU 10/8/2013 8 P
151 JUANITA SEKEWAEL 18/06/2014 #VALUE! P
152 KIREI PASAMAN 13/01/2014 #VALUE! P
153 LOUIS SANTO KOWET 27/10/2013 #VALUE! P
154 MARGARET TAPLO 30/07/2013 #VALUE! P
155 PASYA JONAS BOINSERA 11/11/2013 8 L
156 SYALOM PAEMBONAN 4/2/2014 8 P
157 YOEL RAMBA 24/06/2014 #VALUE! L
158 AORORA PAIGINAN 13/07/2014 #VALUE! P
159 AZWA SITEPU 31/10/2014 #VALUE! L
160 EUGHINEA BEVERLLY 8/1/2014 8 P
161 EVELYN MANURUNG 25/01/2014 #VALUE! P
162 FARDI SAPUTRA 2/9/2013 9 L
163 GILBERT OMPUNGSUGGU 26/04/2014 #VALUE! L
164 GRACIA SIRANDAN 8/11/2013 9 P
165 JOHANA TEHUAJO 18/12/2013 #VALUE! P
166 KAYLA CHANDRA 21/10/2013 #VALUE! P
167 MARIA SALOSSA 30/08/2013 #VALUE! P
168 MARIJEANE APASERAY 8/1/2014 8 P
169 QIANDRA DIVANA 13/04/2014 #VALUE! P
170 VALLERY ROMPIS 6/11/2012 10 L
171 ATIRA SALEPPANG 7/4/2013 9 P
172 FARHAN ADITYA 30/01/2013 #VALUE! L
173 GABRIEL TANDINGAN 24/06/2012 #VALUE! L
174 GHITA SAKETA 17/08/2012 #VALUE! P
175 LAUREL RUMAROPEN 12/1/2013 8 P
176 LIAN HASANA 7/4/2012 10 L
177 NOEL MANGONTAN 11/12/2012 9 L
178 VANIA PAYUNG 22/07/2013 #VALUE! P
179 ADELINE LUMBAN GAOL 26/11/2012 #VALUE! P
180 AERYLIN KIRANA 12/1/2013 8 L
181 ALEXANDRA DEWANTI 25/11/2012 #VALUE! P
182 ALFONSIUS ATAKELANG 10/2/2013 8 P
183 ARGYO DATURATTE 18/06/2012 #VALUE! L
184 GABRIEL WAKUM 2/5/2012 10 L
185 GARLAND BANGNGA 7/2/2013 9 L
186 IMANUEL ARITONANG 27/05/2013 #VALUE! L
187 JEIN NARA BELA 5/1/2013 9 P
188 JOSIAS NAHUMURY 23/03/2013 #VALUE! P
189 KASIH MANDILA 23/06/2012 #VALUE! P
190 MEYLANI AZISAH 17/05/2013 #VALUE! P
191 SALFA SASABILLAH 30/05/2012 #VALUE! L
192 ALBERTH LAYUK 24/07/2013 #VALUE! L
193 ALBERTHZON REYNALDY 10/4/2013 8 P
194 ALISYA RENMAUR 2/4/2013 9 P
195 ALYKKA MEIDNATA 26/05/2012 #VALUE! P
196 ANASTASIA PATALE 10/11/2012 9 P
197 GILANG SAKETA 17/08/2012 #VALUE! L
198 LIONEL PASAMMAN 5/2/2013 9 L
199 MAHIR ALHADY 29/10/2012 #VALUE! L
200 RAISYAH NEFA 8/11/2012 10 P
201 RAYLEE SAMPEBUA 17/05/2012 #VALUE! L
202 RHENATABCHRISTALOVA 25/12/2012 #VALUE! P
203 SAMUEL SARONGALLO 31/03/2013 #VALUE! L
204 ARJUNA YUSUF 18/04/2013 #VALUE! L
205 AYLA PUTRI 20/04/2013 #VALUE! P
206 FALERIA BA'A 29/04/2012 #VALUE! P
207 GEORGE SAPAN 3/11/2013 9 L
208 JESSICCA LOKDEN 7/4/2012 10 P
209 LAURENSIA WEA 8/10/2012 10 P
210 QUEENI PERMATA SARI 6/11/2012 10 P
211 RACHEL TUNYAN 22/10/2012 #VALUE! P
212 REZKY SAPUTRA 26/09/2012 #VALUE! L
213 SAKINAH NS 1/5/2013 9 P
214 YEHEZKIEL SIAGIAN 7/12/2013 9 L
215 ASTID SUPUSEPA 14/07/2011 #VALUE! P
216 AURELIA SURYA 27/05/2011 #VALUE! P
217 CHESARIO RUMBE 14/05/2011 #VALUE! L
218 CHRISTIAN APALEM 25/12/2009 #VALUE! L
219 CHRISTIANI SARAWA 10/1/2011 10 P
220 ELSHADDAI SIRANDAN 10/10/2010 11 P
221 EVANDER RORIMPANDEY 21/02/2011 #VALUE! L
222 GINA SOMALINGGI 15/11/2010 #VALUE! P
223 GLADY SIRAIT 21/02/2011 #VALUE! P
224 MUH.AMAR 29/06/2012 #VALUE! L
225 KEISYA SINABUNG 17/12/2010 #VALUE! P
226 MARCEL ALEXANDER 14/03/2011 #VALUE! L
227 MARIA MAMBRASAR 23/12/2010 #VALUE! P
228 MARTHINA KAIWAY 19/06/2011 #VALUE! P
229 MIFTAHUL JANNAH 30/09/2011 #VALUE! P
230 NATHANIA ZIVZNIA 18/01/2011 #VALUE! L
231 REZA BANGKI 26/10/2010 #VALUE! L
232 RUKNUDIN RIFAT 24/08/2011 #VALUE! L
233 ALVIAN RIAWAN 27/04/2011 #VALUE! L
234 AVISHA DAUD 11/8/2011 10 P
235 AZRA NABILLA 13/06/2011 #VALUE! P
236 BIMO PRATAMA 2/2/2011 11 L
237 GIONANNO 10/6/2011 10 L
238 GLORIA LA'BI 3/2/2011 11 P
239 JOHANA SUITELLA 21/01/2011 #VALUE! P
240 JULIUS JABARMASE 17/6/2011 #VALUE! L
241 JULIUS GARPENASSY 13/06/2011 #VALUE! L
242 KEVIN CRISTO 10/11/2010 11 L
243 MICHELLE RUMABAR 24/05/2011 #VALUE! L
244 MUH.AZZAM 5/3/2011 11 L
245 MUH.ANDIKA 3/1/2011 11 L
246 NOVELITHA PADANG 2/11/2010 12 P
247 SINTIA INDEY 3/4/2011 11 P
248 SITI ZAHRA 30/01/2011 #VALUE! P
249 QVINZA NADYA 122 P
250 ANNA YAMBISE 19/01/2011 #VALUE! P
251 AZIZAH AYU 24/07/2011 #VALUE! P
252 BEATRIX TOSULI 21/12/2010 #VALUE! P
253 FADIL 20/07/2010 #VALUE! L
254 FEBE TULING 12/2/2011 10 L
255 GRADY LUMAINDONG 13/05/2010 #VALUE! L
256 HIZKIA YUDIANTO 10/3/2011 10 P
257 KAYANA SUWANDI 30/06/2011 #VALUE! P
258 MUH.FAJAR 31/08/2010 #VALUE! L
259 RANGGA ABIMANYU 29/12/2010 #VALUE! L
260 SANDY PRATAMA 12/2/2011 10 L
261 ADE FITA 5/6/2011 11 P
262 AMIRA MANILET 16/07/2010 #VALUE! P
263 AUREYLIA PARUBAK 28/09/2010 #VALUE! P
264 FEDELYA PUTRI 9/2/2011 11 P
265 MILA SAUDI 23/06/2009 #VALUE! P
266 MILION LIKU 9/1/2011 11 L
267 MUH.AULIA 26/09/2010 #VALUE! L
268 PUTRI KINARSIH 27/03/2011 #VALUE! P
269 REINHARD PASOLANG 16/07/2010 #VALUE! L
270 RIAGNESYA DENDA 2/7/2010 12 P
271 ROSALIA IREEUW 5/8/2010 12 P
272 SETIO JUNIOR 24/11/2010 #VALUE! L
273 STEFANIA RAWAR 8/3/2011 11 P
274 ZALVA TIKUPADANG 5/7/2011 11 P
275 FUIGENTIO 122 L
276 CAESARIA SHAFIRA 26/03/2015 #VALUE! P
277 HATIM SAMPULAWA 29/08/2014 #VALUE! L
278 MARSYA RAMELAN 7/12/2014 8 P
279 YOEL L
280 HANAFI EXEL L
281 KINESHA TUMBEL P
282 AFRISA SINDY 13/04/2012 #VALUE! L
283 ASHYFA KATERINA 28/04/2012 #VALUE! L
284 ELIA ROSUMBRE 3/7/2011 11 L
285 EUGENERYO MAUR 9/1/2012 10 L
286 MESSY NADE 11/6/2012 9 L
287 MUH.ILHAM RUSDI 17/09/2011 #VALUE! L
288 REYNDRA 22/08/2011 #VALUE! L
289 SHELA 9/10/2011 10 P
290 SHIREEN RANNU 8/9/2011 11 P
291 RAISA YAMBI 22/11/2011 #VALUE! P
292 ANDREA SOLOSSA 18/11/2011 #VALUE! L
293 APRILIA ELEWYAAN 26/04/2012 #VALUE! P
294 CARISSA BHATARA 8/4/2011 11 P
295 CHINDYANA RUMAHORBO 13/05/2012 #VALUE! P
296 DEVIKA PUNDARIKA 19/07/2012 #VALUE! P
297 JEDY GABRIEL 16/07/2012 #VALUE! L
298 MUH.AUFA GHAZALI 28/11/2011 #VALUE! L
299 RAMADAN MURSALIM 15/08/2011 #VALUE! L
300 REALINO ATAKELANG 27/09/2011 #VALUE! L
301 SEANE PURBA 6/9/2012 10 P
302 VELISCITA PAYUNG 20/04/2012 #VALUE! P
303 YOEL HEHAMAHWA 14/02/2012 #VALUE! L
304 YUNITA RUM 19/06/2012 #VALUE! P
305 RAFLY LANDE 24/06/2012 #VALUE! P
306 AJI SETIA RAMADANI 16/10/2011 #VALUE! L
307 ANGELLYNN BONAY 20/04/2012 #VALUE! P
308 AURELIA PASALI 9/9/2011 10 P
309 BELLVANIA BUNGA 24/04/2012 #VALUE! P
310 DONA BEAY 22/04/2012 #VALUE! P
311 EDWIN RAFAEL 1/7/2012 10 L
312 ELYAN KALEM 4/10/2011 11 L
313 GAVRIEL MANGONTAN 9/6/2012 10 L
314 JANITHA RUMBIAK 12/1/2012 9 P
315 RHAVA FIDYANZA 22/10/2011 #VALUE! L
316 RIO RIVANO WARA 17/12/2011 #VALUE! L
 317 BRYVEN TANAMAL 4/1/2012 10 L
318 CHIKA PARUBAK 11/2/2011 10 P
319 DYAN ULIM 22/09/2011 #VALUE! L
320 ISMAN HASANI 16/09/2011 #VALUE! L
321 JUSUF AYOMI 20/07/2012 #VALUE! L
322 LOVIANA SERO 17/11/2011 #VALUE! P
Jumlah vaksin (vial) dan logistik yang digunakan
Pelarut Campak
Jenis logistik OPV IPV DPT-HB-HIB CAMPAK RUBELA
Rubela
Jumlah 32 32
Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
NCATATAN HASIL PELAYANAN
Nama petugas ALFARIDA,YUDITH,MASNIARI
Puskesmas KOTARAJA
Kabupaten JAYAPURA

Imunisasi Kejar
(Ya = 1, Tidak=0)
Ket** (bila anak mendapatkan
Campak
dosis kedua/keetiga/keempat
Rubela
No.Hp NIK OPV/Penta saat BIAN, maka tetap
(Ya=1,
dicatat namun tidak dimasukkan
Tidak=0)
OPV IPV DPT-HB-Hib sebagai cakupan BIAN)

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(vial) dan logistik yang digunakan

Dropper ADS 0,5 ML ADS 5 ML Safety Box Pen Marker

322 32 2 4
 FORMAT PENCATATAN HASIL PELAYANAN
Posyandu/Pos ayanan BIAN lainnya : SD VIM II KOTARAJA
Desa/kelurahan : WAHNO
Tanggal : 7/21/2022

Jenis
No. Nama Anak Tgl lahir Umur (thn) Kelamin Nama orang tua Alamat
(L/P)

a b c d e f g
1 AURORA G. MANGGAPROUW 7 P
2 APRILIA OLGA INDEY 7 P
3 BATYA KAKINAAN SIAGIAN 7 L
4 BEN AZIRIA KREY 7 L
5 DAVID B. O PAUGA DOUW 7 L
6 FELICIA NATANIA C. ROLLO 7 P
7 GRACE HERLINA RAMANDEY 7 P
8 GERALDI F. IMBIRI 7 L
9 HENDRIKA G. DEMOTOKAY DARINYA 7 P
10 JENIFER ANGGELINE OKOSERAY 7 P
11 KIMBERLY N. A. SUPIT 7 P
12 LEBERINA INSEREN N. ORBOY 7 P
13 MUHAMMAD SADDAM 7 L
14 MERCSHELI MANDEROS 7 P
15 NATASYA F. PRATAMA 7 P
16 ROSALINA Y. AFFAR 7 P
17 SOFIYOLA S. D. KAFIAR 7 P
18 VERREL RAMADAN LOLOWANG 7 L
19 YOHANES HAAY 7 L
20 ZENDING C. W. BEROTABUI 7 L
21 AMORA A. S. KALUA 7 P
22 ASHIELA A. AZZURA 7 P
23 AZRIEL A. TUHUSULA 7 L
24 CAHRLES TABUNI 7 L
25 CHELSYA SESERAY 7 P
26 CHRISIENA B . YULIN MANGGAPROUW 7 P
27 CHRITINA SARAH YIKWA 7 P
28 ELIAS FAIT MANGGAPROUW 7 L
29 GABRIEL F. OHEE 7 L
30 GERALDO F. IMBIRI 7 L
31 MARIBELLA M. KABIAY 7 P
32 MARCSHELA MANDEROS 7 P
33 NIKODEMUS OZIL ROHUA 7 L
34 NOFA AFAAR 7 P
35 ORIDEK MARTEN L. BAAY 7 L
36 PUTRI HAAY 7 P
37 REFLY GLENSKY PANGI 7 L
38 RODE AGUSTHA R. IWO 7 L
39 SARAH K. S. MOFU 7 P
40 SHANEY E. RONI 7 P
41 VELENSIUS J. BOLOGI 7 L
42 AI KUMUD WAYOI 8 L
43 AIDYYANSA TILAAR 8 L
44 ALVIN MAX CHRISTOFELURUS 8 L
45 ELISABEDT RUDE GOMBO 8 P
46 EMMANUEL P. C. IWANGGIN 8 L
47 FRED F. IMBIRI 8 L
48 GABREL MENIS KOGOYA 8 L
49 GIOVANY SIMOPIAREF 8 P
50 ISMAIL TAKDIR KOGOYA 8 L
51 JOHAN W. SEM WAIRARA 8 L
52 JUAN ALFREDO AMBORAM 8 L
53 MARIA JIHAN KLAU 8 P
54 MARICE MONALISA JARANGGA 8 P
55 MIKELDA KAYAME 8 P
56 PULPA IVON MANO 8 P
57 RIHANNA O. W. KREY 8 P
58 TRIVENA HERODIA RUATAKUREI 8 P
59 YOHANIS PESTI MASOKA 8 L
60 ENJELI M. ABIGAEL YIKWA 8 P
61 MARINA A. HAAY 8 P
62 ALBERTHZON RIVANI YIGIBALON 8 L
63 ALFRI PUTRA R. LOLOWANG 8 L
64 ANNA IVONE A. AFFAR 8 P
65 CHERISH IVANA WAYEGA 8 P
66 EILEEN NANETTA SALLAO 8 P
67 ERLYTA YIGIBALON 8 P
68 FEBRIAN FRANS AMOS DANSIDAN 8 L
69 FILEP BOROWAI 8 L
70 GEVARIEL R. TOROBY 8 L
71 MAJESTY P. KABIAY 8 P
72 NONA SABATANIA HAYON 8 L
73 RAFFA FAUZAN KAMIL 8 L
74 SUQILAR ZEROUN AL'ABBYU 8 L
75 ISWAR MANAN 8 L
76 RASYA ALDY 8 L
77 AYUB IZRAIL AIMBEBROK 5/16/2014 8 L
78 CHATALEYA MOFU 6/8/2013 9 P
79 CHESHYA UYO 4/11/2014 8 P
80 CLARA RENMAUR 12/31/2013 8 P
81 DOMINIKA WAKERWA 2/4/2012 10 P
82 ETNA MODOUW 8/22/2013 9 P
83 GOLDA BEROTABUI 7/24/2013 9 P
84 JHOSE K. JAFLEAN 5/21/2013 9 L
85 KEVIN KAMBU 4/29/2013 9 L
86 LEAURENSIUS NARAHAWARIN 1/22/2014 8 L
87 LEA HARA 6/15/2014 8 P
88 MARICE MASOKA 3/3/2012 10 P
89 MARKUS D.D KBAREK 7/10/2013 9 L
90 MARLINA KAFIAR 3/28/2014 8 P
91 OSKAR PULANDA 8/7/2013 9 L
92 QUINZE HASSOR 1/12/2014 8 P
93 TRESIA SAWA 2/22/2013 9 P
94 WHILMA MAWUNTU 10/25/2013 8 P
95 YESAYA YANENGGA 11/1/2013 8 L
96 BERURIAH DOUW 4/1/2014 8 P
97 DEALOVA SESERAY 12/13/2013 8 P
98 HERMELINA PANDORI 7/15/2013 9 P
99 IMANUEL KBAREK 11/22/2013 8 L
100 JENNY FERLIN HAMADI 6/20/2013 9 P
101 MUHAMMAD SAHRIL 5/4/2013 9 L
102 NINGRUM CHUSAENI 10/9/2013 8 P
103 ALFARO GANZO NDAHIU 2/27/2013 9 L
104 ANCELO FERNANDO WENDA 8/26/2013 9 L
105 APRILYA ALWINA MAK 4/1/2013 9 P
106 BEATRIK A. DWEMANSER 3/20/2013 9 P
107 BRIANO KAFIAR 1/29/2012 10 L
108 FERLLY TAHAPARY 11/3/2012 9 L
109 FRENGKI Y. KIA BOLI LUON 2/21/2012 10 L
110 HERMANUS RUATAKUREI 5/22/2013 9 L
111 ISMAEL Y. DUKA 7/1/2013 9 L
112 JUBELINO KARUBABA 4/23/2013 9 L
113 JUSTICIA PEKEI 4/16/2012 10 P
114 MARIA BADII 10/7/2012 9 P
115 MARIA REMBA 1/24/2012 10 P
116 MECHAEL TUNGKELE TAWAS 11/17/2012 9 L
117 MELKYZEDEKH IWO 1/7/2013 9 L
118 MONICA AFFAR 3/23/2012 10 P
119 NATASYA PANGKEY 4/15/2013 9 P
120 NI KOMANG STEFANY 6/16/2012 10 P
121 PIET SADA 6/12/2012 10 L
122 VHENSES WAIRARA 1/30/2013 9 P
123 WESLEY PARMINO 7/20/2012 10 L
124 YOEL NARI 4/18/2012 10 L
125 ALFALHEYA SESA 10/15/2012 9 P
126 AUGSHELYA TOISUTA 4/14/2012 10 P
127 DANIEL KOGOYA 11/19/2012 9 L
128 DESI MANGGAPROUW 12/21/2012 9 P
129 IVAN T. SAPUTRA 11/2/2012 9 L
130 MARCHELLINO KAMBU 3/17/2012 10 L
131 MARSHA G. BUINEY 3/22/2013 9 P
132 PRISTELA WENDA 9/20/2012 9 P
133 RAPHEL SAWAKI 4/29/2013 9 L
134 STEVANY SANDA 9/29/2012 9 P
135 TITUS MEHO 1/23/2013 9 L
136 WELMINCE MORA 6/21/2013 9 P
137 ZIRAH PEKEI 4/16/2012 10 L
138 ANGEL ANTAMENG 10/8/2012 9 P
139 VERDIANO TUMBEL 10/1/2012 9 L
140 ABIGAIL AMBORAM 8/27/2011 11 P
141 CHELSE MULINCE ORBOY 6/30/2011 11 P
142 GALANG FAHRIZI 7/24/2011 11 L
143 INDRA WERO WENDA 3/21/2011 11 L
144 JULITA RAMPALA 7/25/2012 10 P
145 JUNIOR RUMBIAK 6/24/2012 10 L
146 KAROLINA WENDA 5/15/2012 10 P
147 LODEWCK HAMADI 2/16/2012 10 L
148 ROBINSON ONDOWAPO 7/29/2010 12 L
149 WHITNEY MAWUNTU 2/18/2012 10 P
150 YASON AIBINI 5/14/2012 10 L
151 YEFTA FINA 1/26/2012 10 L
152 YUSUF DOUW 6/4/2012 10 L
153 DAVID DAMIMETOUW 1/7/2012 10 L
154 DESTRIA KAMBU 10/10/2010 11 P
155 GABRIELA MANGGO 11/4/2010 11 P
156 JIREH LAMIA 8/17/2011 11 L
157 KINCE KOGOYA 6/26/2010 12 P
158 MARSELINO HAAY 3/30/2011 11 L
159 NENCY RUMABAR 11/22/2011 10 P
160 PAUL MANO 6/20/2012 10 L
161 WELHELMUS KAMIROKI 6/10/2011 11 L
162 ADOLF AMBORAM 11 L
163 ALFINO MANGGO 11 L
164 ASHLEY LIEY 11 L
165 CLARITA WAKERKWA 11 P
166 DAONE AFFAR 11 L
 167 FERDINAN RUATAKUREI 11 L
168 GABRIEL ANTAMENG 11 L
169 GRACE SIMAMORA 11 P
170 IRINCE KOGOYA 11 P
171 KESATRIANWAN TAIME 11 L
172 MEISCHE PULANDA 11 L
173 MICHAEL HUTAHAEAN 11 L
174 MIGUEL LOUHENAPESSY 11 P
175 REVANNO IMBIRI 11 L
176 RITA MAY 11 P
177 ROSAH AFAAR 11 P
178 ANDRE RUMAIKEUW 7/17/2010 12 L
179 DANIELO KAMBU 11/5/2010 11 L
180 DESI AREBO 12/14/2009 12 P
181 ELZAH PAGAWAK 10/20/2011 10 P
182 FARLINE MAMBRASAR 2/3/2011 11 P
183 GRACELLA YERISETOU 5/20/2011 11 P
184 KARTINI AFAAR 4/21/2011 11 P
185 KEIZA ANURAGA 5/16/2011 11 L
186 KRISTIAN KOGOYA 5/20/2010 12 L
187 LAILA SYAFIYAH 12/26/2011 10 P
188 MARVEL OHOIWIRIN 3/20/2011 11 L
189 MICHEL KABIAY 8/23/2011 11 P
190 MICHIEL MANO 7/10/2011 11 P
191 MUHAMMAD ILHAM 4/13/2009 13 L
192 REINARD NAHUMURY 6/20/2011 11 L
193 WAYNE ROONEY 12/18/2010 11 L
194 IMANUEL SIMBIRING 5/10/2017 5 L
195 METANI SONDAK 5/5/2015 7 P
196 SAUL RAWAI 6/21/2013 9 L
197 MEFELINKOGOYA 7/26/2011 11 P
Jumlah vaksin (vial) dan logistik yang digunakan
CAMPAK Pelarut
Jenis logistik OPV IPV DPT-HB-HIB RUBELA Campak
Rubela
Jumlah 20 20
Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom kete
HASIL PELAYANAN
Nama petugas YUDITH, RIRIN
Puskesmas KOTARAJA
Kabupaten JAYAPURA Ket** (bila
anak
mendapatk
Imunisasi Kejar an dosis
(Ya = 1, Tidak=0) kedua/keeti
ga/keempat
Campak OPV/Penta
Rubela saat BIAN,
No.Hp NIK
(Ya=1, maka tetap
Tidak=0) dicatat
OPV IPV DPT-HB-Hib namun
tidak
dimasukkan
sebagai
cakupan
h i j k l m n
BIAN)
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gistik yang digunakan

Dropper ADS 0,5 ML ADS 5 ML Safety Box Pen Marker

197 20 2 6

si susulan pada kolom keterangan

 FORMAT PENCATATAN HASIL PELAYANAN
Posyandu/Pos ayanan BIAN lainnya : MI AL HIDAYAH
Desa/kelurahan : WAIMHOROCK
Tanggal : 7/26/2022

Jenis
No. Nama Anak Tgl lahir Umur Kelamin Nama orang tua Alamat
(L/P)

a b c d e f g
1 ABDILAH AGAM 7 L
2 ADHYASTHA A. ARDHANI 7 P
3 AISYAH NIVALDA 7 P
4 ALVARES LESTOIN 7 P
5 ALYCIA CLARITA WAMBRAUW 7 P
6 AQIFA DWI MARWAM 7 L
7 AQILA PUTRI 7 P
8 BAMS RERUNGAN 7 L
9 CHRISTIAN DAVE MARANI 7 L
10 DWI ADITYA NAUFAL 7 L
11 EL BARACK MAHESWARA 7 L
12 ELSHADAI SALIPANG 7 L
13 GETRUDA P. AWURAN 7 L
14 WINRAY SAAY 7 L
15 JOEY E. THIAN 7 P
16 MUHAMMAD AFDAL RAMADHAN 7 L
17 MUHAMMAD AZHAR KAHFI 7 L
18 NAFISA ZAHRA IRANIAN 7 P
19 NOAH ABRIAWAN SIBARANI 7 L
20 OKTOVIANUS GABRIEL TOTOUW 7 L
21 RAFAEL LONDONG 7 L
22 SATRIO WIBAWA MUNA 7 L
23 SUMARYANI K. PUTRI AGUSTINE 7 P
24 YULCE HANA WAIMURI 7 P
25 ZAIN AQILA RAJENDRA 7 L
26 ZERINA K. HERMAWAN 7 P
27 ASYFA BELLVANIA 7 P
28 MUHAMMAD AEZACHEL ZULIAN 7 L
29 AHMAD WALID WAIFULLAH 7 L
30 AISYAH FARAH 7 P
31 ALESANDRA 7 P
32 APRILILIA HILDA SIDABUTAR 7 P
33 BRIAN IBADIR RAHMAN 7 L
34 DANIEL F. MANIAGASI 7 L
35 DIMAS GILANG 7 L
36 GABRIEL MARKUS 7 L
37 KEYSHA AZZAHRA PUTRI 7 P
38 LUTFIA DZAHRA ZAIDAH 7 P
39 LYDIA TANTRIANA ANAPAH 7 P
40 MAHESWARA ARYA ABIMAYU 7 L
41 MUH. RAYYAN D. IKSAN 7 L
42 NUR ALIYA PUTRI YUSUF 7 P
43 RAFA AZKA DWI PUTRA HERIANSA 7 L
44 SHARBELA SINDI BALAN ELU 7 P
45 SILVIANO HENDRI TANGGUR 7 L
46 SITTI NUR AIFA ADI 7 P
47 YEHEZKIEL MANGAPANG 7 L
48 RISWAN 7 L
49 AISYAH AZ ZAHRA AKBAR 8 P
50 ALIFKA JUMARDIN 8 P
51 AMARISA RUMBINO 8 P
52 CHRISTIANO V. MONAS 8 L
53 CRISTIANO S. OETASI 8 L
54 ENJELITA YUNUS 8 P
55 ESTERLINA RUMBIAK 8 P
56 JILL APRILIAN K. 8 L
57 MALISA SETIAWATI 8 P
58 MUHAMMAD BILLAL 8 L
59 MUHAMMAD KARAN 8 L
60 MUHAMMAD RIFQI 8 L
61 MUSDALIPA MUNIR 8 P
62 REINAL A. NATAN 8 L
63 RINELS IMBIRI 8 L
64 ABIAS MAHKOTA PUTRA 8 L
65 AINUN MAHYA 8 P
66 AISYAH AGUSTIN 8 P
67 ALEXA A. DUWIRI 8 P
68 DINDA ZAHYRA 8 P
69 HEIDI Z. WAREMAN 8 L
70 M. RIZAL BIRRIZKY 8 L
71 MHD. IZSAHARA 8 L
72 MUHAMMAD ALAMSYAH 8 L
73 NAJWA RAMLY 8 P
74 NUR AZIZAH 8 P
75 SATRIA MUNA 8 L
76 JELSI PABISA 8 P
77 VELOVE 8 P
78 ARIQA NUR F 9 P
79 ARNOL HUBY 9 L
80 BENEDIKTO MANUK 9 L
81 CONNI A. DAISIU 9 P
82 ELISABETH MAINTINDOM 9 P
83 GRISELA SOSELISA 9 P
84 JENIFER AMBAT 9 P
85 KAISAR SIBARANI 9 L
86 KELVIN LUKAS 9 L
87 LATIZIA RAIHANA 9 P
88 M. RAFAUL HAMMI 9 L
89 MAGDALENA KARUBABA 9 P
90 MUHAMMAD FAHRUN 9 L
91 MUHAMMAD REINALDY 9 L
92 NUR HALIZA RAHMAWATI 9 P
93 PATRICK PAKAGE 9 L
94 PAUL BILI TATAGO 9 L
95 PUPUT CEYARANI 9 P
96 RADEN IRHAM KEAGOP 9 L
97 RADITHYA IBRAHIM 9 L
98 SHAFWAN SHAUFI 9 P
99 TSANIA MARWAH B. 9 P
100 AFIQAH EKA HERIANSA 10 P
101 AQILA NURCAHAYA MAHU 10 P
102 AZARYA SALIPADANG 10 P
103 AZ-ZAHRA NAILA 10 P
104 FITRAH YURI 10 L
105 FRILLISYE MOLLE 10 P
106 JHONATAN ALEX MANIAGASI 10 L
107 MELODY S. OPADA 10 P
108 MICHELLE MOTE 10 P
109 MIRAKHEL RANTE MIA 10 P
110 MUHAMMAD AKBAR 10 L
111 MUHAMMAD IQBAL 10 L
112 MUHAMMAD IZSAHARA 10 L
113 RAISANDRIA YUNUS 10 P
114 ARISTA SIRAIT 10 P
115 CAROLINE SANGGENAFA 10 P
116 DANISH MASYKUR 10 L
117 EDWARLD MANUPAPANI 10 L
118 GENTA WIRANATA 10 P
119 GEORGE RERUNG 10 L
120 JEMITA MIA 10 P
121 SELFESTER LAIYAN 10 L
122 SIMON TATOGO 10 L
123 ZENON JACKSONO 10 L
124 AHMAD SUGIARTO 11 L
125 ALIYA MELLO 11 P
126 ANDI MERLINDA 11 L
127 ANTONIO ELOSACK 11 L
128 DAVID FAHRESI 11 L
129 EARLY HASIHOLAN 11 P
130 ELISABET RUMBIAK 11 P
131 EPIPANI ELOPERE 11 P
132 ESAU JIKWA 11 L
133 GIOVANI GIBRAN 11 L
134 MUH. RAIHAN ANAM 11 L
135 MUH. ULINNUHA SAPUTRA 11 L
136 QONITHA SINAGA 11 P
137 SANTRI SATUR 11 P
138 VEYRON SAWAKI 11 L
139 ZETH WAMBRAUW 11 L
140 AVRILIA MANUK 11 P
141 BHAGAS TASIK 11 L
142 CARISSA AURELIA 11 P
143 CLAIRINE MATULESSY 11 P
144 CLARISSA MATULESSY 11 P
145 FAEYZA ARJUNA JUARNA 11 L
146 KHAIR MAHMUD SAJID 11 L
147 KHOSYI PRATAYA 11 L
148 MUHAMMAD RIZKY 11 L
149 PRISKA HATU 11 P
150 SYAFIQA WIJAYA 11 P
151 AHMAD RAFFI 11 L
152 BEN WAMBRAW 12 L
153 DEO HUBY 12 L
154 FATHIAN TANEL 12 P
155 GROWEN MANUHUTU 12 L
156 M. FAHRI AZAHRI 12 L
157 NADIA HUMARIAH 12 P
158 NATHALINE SAFLEMBOLO 12 P
159 RAIMON FONATABA 12 L
160 RATU CLEOPATRA MATULESSY 12 P
161 SIMON KAROBA 12 L
162 SYAFA KURNIA PUTRI 12 P
163 SYIFARRAH WIBHAWA 12 P
164 AKMALIA MANGADIL 12 P
165 ANDI HUSNA 12 P
166 ANDRA MAHAYADI 12 L
 167 ARDIAWAN TUKUWAIN 12 L
168 BAGAS SIKOWAY 12 L
169 FAIRUNISA ISMAN 12 P
170 HIMMATU NAILIZZULFA 12 P
171 NADIFA ZULIAN 12 P
172 NATANAEL NGETA 12 L
173 PUTRI SATO 12 P
174 NUR AFIQA 11 P
175 SAFIRA CHAIRUNISA 12 P
Jumlah vaksin (vial) dan logistik yang digunakan
Pelarut
CAMPAK
Jenis logistik OPV IPV DPT-HB-HIB RUBELA Campak
Rubela
Jumlah 18 18
Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom kete
HASIL PELAYANAN
Nama petugas YUDITH, RIRIN
Puskesmas KOTARAJA
Kabupaten JAYAPURA Ket** (bila
anak
mendapatk
Imunisasi Kejar an dosis
(Ya = 1, Tidak=0) kedua/keeti
ga/keempat
Campak OPV/Penta
Rubela saat BIAN,
No.Hp NIK
(Ya=1, maka tetap
Tidak=0) dicatat
OPV IPV DPT-HB-Hib namun
tidak
dimasukkan
sebagai
cakupan
h i j k l m n
BIAN)
1
1
1
1
1
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ogistik yang digunakan

Dropper ADS 0,5 ML ADS 5 ML Safety Box Pen Marker

175 18 2 4

sasi susulan pada kolom keterangan