FORMAT PENCATATAN HASIL PELAYANAN PIN POLIO nOPV2

Nama Posyandu/Sekolah/Pos layanan Nama petugas

Nama Desa/kelurahan : Puskesmas
Tanggal : Kabupaten

* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan

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

a b c d e f g h i j

1 9/13/2021 34 P 3504115309210000 Rubia Intan Yuana 3504116309950004 TUE

Mafasa Nafiza K RD
2 M. AR Rayyan Rifaat 1/3/2024 7L 6202120900220001 Rubia Intan Yuana 3504116309950000 TUE

3 Yohanes Sergio N 9/1/2020 46 L 6207010109200002 Maria L 5309065710930002 TUE

4 Kamila Nafidan 11/9/2021 32 P 3307020411210001 Lina Lisnawati 3308166002920001 TUE

5 M. Aldevaro R 7/4/2021 36 L 3307110407210000 Koinah 360206540430002 TUE

6 Fattan Ramadhani B 4/20/2022 27 L 352104200422002 Supiati 3521044903850003 TUE

7 Desi Ratna Putri 5/26/2022 26 P 5204066605220001 Yuni Kulsum 520466201130001 TUE

8 Denia Kanza Azzahra Akhir Wahyuni 3310064101890003 TUE

9 Muhammad Nabil 2/3/2021 41 L 6206100302210001 Nursiah 6206104605880001 TUE

10 Ahmad Luthfi Al F 6/11/2021 37 L 6207071106210001 Marijatul K 3514194110940003 TUE

11 Dwi Aulia I 8/20/2020 47 P 3307046008200002 Sustianah 3307045110950004 TUE

12 Kamilah Billah M 3/30/2022 27 P 6207077003220001 Supiyah 6207077112891001 TUE

13 Adifa Cahaya Kanza 7/7/2021 36 P 3323174707210003 Tri Utami 3323015001900003 TUE

14 Fionisia Yafa K 11/29/2021 32 L 5319016911210002 Yuliva K 5319016707000007 TUE

15 Alisiya Saffa F 6/21/2022 23 P 3307106106220003 Nur Fadilah 3307104306030002 TUE

16 Muhamad Iqbal D 4/2/2020 50 L 3671130204200003 Siti Widayanti 3671135203900007 TUE

17 Danendra F 7/19/2020 48 L 3307111907200001 Leili Afni 3307111907200001 TUE

18 Syuwitri Aeira 2/52022 26 P Rapika 62021226309040001 TUE

19 Al Fahri M 7/22/2021 36 L 3316112207210001 Sami 3316115505880001 TUE

20 Fattan Ramadhani Basma 4/20/2022 26 L 3521042004220002 Supiati 3521044903850003 TUE

21 M. Febian D 2/7/2022 29 P 6202060702220001 Mei Ardian 3304165705020001 TUe

22 Kayla Nova 11/26/2020 44 P 6207076611200002 Bernadet Rampo 7318116405860001 TUE

23 Kaysya Cantika D 7/27/2020 48 P 6206106707200003 Mariah 6206105003870002 WED

24 Adnan N 5/16/2022 26 L 6207071605220001 Sumiyati 3304114412840000 TUE

25 Nuta Prana A 10/19/2023 9L 3307071910230002 Sunarsih 6207075702911001 TUE

26 Andra Faris Maulana 4/24/2023 15 L 3307072504230000 Nurhatimah 6207036801000002 TUE

27 Restu Febriyansyah 5/2/222 29 L 3307070502220002 Marhamah 6207075501901001 TUE

28 Al Gustiawan 8/14/2022 23 L 6202061408220003 Tiara Amelia 6202064104050003 TUE

29 Almahyra P 6/30/2023 13 P 6207077006230001 Jarwi 6207074107851001 TUE

30 Rayyan Hafiz 7/14/2022 24 L 3301091407220003 Lilis H 3301094307940002 TUE

31 Zahwa Anggita Putri 4/7/2023 15 P 6202164704230001 Lusy S 6202165011030003 TUE

32 Yumna Nurb A R 4/10/2023 15 P 3316115004230002 Isnin Rahayu 3316114906980002 TUE

33 Muhammad Rafassya 8/9/2022 23 L 6202120908220001 Putri Herlina R 6202125912990001 TUE

34 Alfarel M 3/19/2023 16 L Amelia 6202064503010005 TUE

35 Izza Izzera 11/25/2023 8P Ita Adiputriana 5203011810150003 TUE

36 Ahmad abi K 2/25/2024 5L Ani Dwi Astuti 3316115108930001 TUE

37 M Aksal Narendra 3/13/2024 4L Erlina 3316115108930001 TUE

38 Clarissa Tarihoran 9/20/2023 10 P 1208186009230001 Rina P 1218176105920001 TUE

39 Clarista Tarihoran 9/20/2023 10 P 1208186009230002 Rina P 1218176105920000 TUR

40 Gabriel Azidzn 8/19/2022 23 L Lelionara 5315024307970004 TUE

41 Adelia Jasmin 6/27/2023 13 P Nurul Ulfa TUE

42 Fathan Ramadani Basma 4/21/2022 27 L 3521042004220000 Supiati 3521044903850003 TUE

43 Danis S F 10/12/2023 9L Nevy 6207016111980002 TUE

44 Janu Idam Sanjaya 1/26/2024 6L Suryati TUE

45 Ghaidan Cipta j 11/4/2023 7L Eka Ardiyana TUE

46 Adzkiya naila K 12/2/2023 7P Muhatimah 3323171706920003 TUE

47 Alesha Zahra Budi 7/18/2022 12 P 3508125807220001 Indah 3508122102220004 TUE

48 Sakif Rafidan 4/28/2024 3L Rosidah 3330000520544981 TUE

49 Kayca Asifa N 4/17/2024 3P Siti Nur Yanti 6202064102810004 TUE

50 Serhan Artafariq P 4/27/2024 3L Murfina 33061665005880003 TUE

51 TUE

52 TUE

53 TUE

54 TUE

55 TUE
56 TUE

57 TUE

58 TUE

59 TUE

60 TUE

61 SAT

62 SUN

63 MON

64 TUE

65 WED

66 THU

67 FRI

68 SAT

69 SUN

70 MON

71 TUE

72 WED

73 THU

74 FRI

75 SAT

76 SUN
77 MON

78 TUE

79 WED

80 THU

81 FRI

82 SAT

83 SUN

84 MON

85 TUE

86 WED

87 THU

88 FRI

89 SAT

90 SUN

91 MON

92 TUE

93 WED

94 THU

95 FRI

96 SAT

97 SUN
98 MON

99 TUE

100 WED

TOTAL

Jumlah vial Jumlah vial Jumlah vial

Jumlah Vial Sisa
dibawa dipakai rusak
Jumlah Vial nOPV2
0

Keterangan : Diisi oleh Petugas kesehatan

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Dosis 1 Dosis 2
Keterangan
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
k l m n o
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