FORMAT PENCATATAN HASIL IMUNISASI LANJUTAN PADA ANAK USIA S

KABUPATEN/KOTA : SERANG
PUSKESMAS : PEMATANG
SEKOLAH : SDN DUKUH 1
TAHUN : 2024

No. Nama NIK Anak Tanggal Lahir

1 ABDUL MALIK 3604110411170002 11/4/2017

2 AINUN 3604114707180001 6/7/2018
3 ALISKA NUR WIJAYA 3604115404180003 4/14/2018
4 ALMIRA RAMADITA 3604114610170001 10/16/2017
5 AZKIA MEIRANI 3604115205180001 5/12/2018
6 BAGAS LUNGGUH PERMANA 3604111703180002 3/17/2018
7 FARHANA ALIKA PUTRI 3604116804180002 4/28/2018
8 GIBRAN ALKHALIFI 3604110502180002 2/5/2018
9 HAFIZAH NOVALIA HERMANSYAH 3604114302180003 2/3/2018
10 LUDIYAH TULJANAH 3604114908170003 8/9/2017
11 MAULANA SYAHWALUDIN 3604111307170001 7/13/2017
12 MU'AZ ZAIN AL-HAFIDZ 3604111507170003 7/15/2017
13 MUFTIH MUHAJIR 3604113008170001 8/30/2017
14 MUHAMAD AL-AKHDORI 3604112109170002 9/21/2017
15 MUHAMAD DAFA AFRIANSYAH 3604170404180001 4/8/2018
16 MUHAMAD LUTFI HALI 3604111301180001 1/13/2018
17 MUHAMAD RAFFASYA 3604112901180003 1/29/2018
18 MUHAMAD REZA 3604110512170004 12/5/2017
19 MUHAMAD RONAL 3604111002180002 2/10/2018
20 MUHAMMAD NAUFAL AL-BASIR 3604112603180002 3/26/2018
21 MUHAMMAD RIFFALDI AKBAR 3604110403180001 3/4/2018
22 MUHAMMAD SAFARUDIN 3604111411170005 11/14/2017
23 MUHAMMAD SAHDY ARMANSYAH 3604112804170003 4/28/2017
24 MUHAMMAD SYABIL ARRAFKA 3604110503180001 4/5/2018
25 NADIYA KAYSA SYIFA 3604115404180004 4/14/2018
26 NIA SUCI RAHMADANI 3604116805180004 5/28/2018
27 NURJANAH 3604116706180001 6/27/2018
28 REVALDO 3604111807180001 6/18/2018
29 SAPUTRA 3604111111170003 11/11/2017
30 SASKIYA PUTRI 3604116206180007 6/22/2018
31 SITI LISNAWATI 3604115702180001 2/17/2018
32 SUMIYATUL HOIRIYAH 3604114109170002 9/1/2017
33 SYEHFUDIN 3604111506180001 6/15/2018
34 TEGUH 3604110112160002 12/1/2016
N HASIL IMUNISASI LANJUTAN PADA ANAK USIA SEKOLAH DI UNIT PELAYANAN

Tanggal Imunisasi

Nama Orang Tua NIK Orang Tua KELAS Campak

DT (kelas Td (Kelas Td
Rubella
1) 2) (kelas 5)
(kelas 1)
JAKIM 3604112002830003 1
SUKARDINATA 3604230404910001 1
ANTON WIJAYA RISMAWAN 3604111703940003 1
SAMLAWI 6304111012890003 1
SRI HARTATI 3604114101890007 1
ROYADI 3604231205940001 1
MUHAJA 3604111206750004 1
TAUFIK HIDAYAT 3604111502840001 1
HERMANSYAH 3604251504920003 1
IMAN SETIAWAN 3604111712730002 1
SANHADI 3604110503890001 1
DARIA 3603060106910003 1
SAPARUDIN 3604110901820002 1
M LUKMAN SADELI 3604110505740002 1
ASMUNI 3604160712830002 1
HALILI 3604110507710003 1
MANSUR 3604110101900010 1
RUDI 36040915-7910005 1
ROBANI 3604230107830003 1
JUNEDI 3604111506900006 1
SAPEI 3604111007890002 1
SOHIM 3604112406880002 1
SARWANI 3604111005800009 1
LOLI ASROLI 3604110511920003 1
ROJAK 3604111506910009 1
SUMARDIN 3604110808800004 1
LAMIN 3604110904710006 1
TARYONO 3604111804700002 1
ABDULLOH 3329022607890003 1
SARMUDI 3604111102840005 1
LANI 6304112005870006 1
MAHDI SINGGIH 3604111304910001 1
KURNIAWAN 3604111504800003 1
EDI SUTARDI 3604110403770002 1
sasi

HPV (Kelas
5)
 FORMAT PENCATATAN HASIL IMUNISASI LANJUTAN PADA ANAK USIA SEKO

KABUPATEN/KOTA : SERANG
PUSKESMAS : PEMATANG
SEKOLAH : SDN DUKUH 1
TAHUN : 2024

No. Nama NIK Anak Tanggal Lahir Nama Orang Tua

1 AL ADIYAT 3604111404170001 4/14/2017 Abudin

2 ALEANA GITA 3604116302170002 2/23/2017 Abdul Hadi
3 ALIF MAULANA PUTRA 3604112305170001 5/23/2017 Medi Setiadi
4 ALISA OKTAVIANI 3604116810160004 10/28/2016 Agung Hermansyah
5 AMELIA PUTRI 3604114311160001 3/11/2016 Sohim
6 ARSYA ADZIKRI 3604110311160004 11/3/2016 Nurmansyah
7 ARUMI NASHA RAZITA 3604117003170001 3/30/2017 Muhamad Taufik
8 FADELIA RAMADANI 3604115806170002 6/18/2017 Padi
9 FATIH MUAI RIZKE 3604116802170002 2/28/2017 Iswadi
10 ISMA MAULIDIA 3604114212160003 12/2/2016 Tisna
11 JAMILATUS SALBIAH 3604114511160001 11/5/2016 Dullah
12 JENITA RAHMA AUGISTA 8/2/2016 Jamaludin
13 JIAD MUSA AL-RAPIANSYAH 3604111006170001 6/10/2017 Rapiudin
14 KHAERUL RIJAL 3604111312160001 12/13/2016 Madharona
15 KHANAYA PUTRI AZZAHRA 3673056002170001 2/20/2017 Lia Lestiova
16 KINARA FARA DIVA 3604114302170002 2/3/2017 Kunut
17 KURNIAWAN 3604111503170001 3/15/2017 Sahroni
18 LATIF HIDAYAT 3604112106170001 6/21/2017 Yayan Supiyadi
19 LUTFI 3604112303170004 3/23/2017 Habudin
20 MAHWA 3604114508160001 5/8/2016 Masuri
21 MANDA AULIA PUTRI 3604116302170003 2/23/2017 Manan
22 MARTIN 3604112102170004 2/21/2017 Rusmani
23 MARWAN MAULANA 3604110412160004 12/4/2016 Nurdi
24 MUHAMAD FAHMI AL-FAUJI 3604113008160002 8/30/2016 Ujang
25 MUHAMAD GALIH SAPUTRA 3604112708160001 8/27/2016 Sukeni
26 MUHAMAD RAIHAN 3604111401170001 1/14/2017 Daman Huri
27 MUHAMAD RIDWAN 3604111704170001 4/17/2017 Wawan Purwana
28 MUHAMAD SYIHABUDIN 3604110601160002 1/6/2016 Komarudin
29 MUHMAD SOPIAN 3604111411160002 11/14/2016 Solihin
30 MURTAJI 3604115810160001 10/18/2016 Badru Zaman
31 MUTIARA RAHMADANI 3604114506170003 6/5/2017 Ahmad Sodri Wardani
32 NABILA FEBRIYANATI 3604114902170002 2/9/2017 Sarnata
33 NISAUL FAADHILAH BILQIS 3604296003170001 3/20/2017 Muamar Kadafi
34 REVA TIARA PUTRI 3604115501170002 1/15/2017 Sakim
35 RIZAL SAPUTRA 3604111612160003 12/16/2016 Sukem Bt Kamar
36 ROHMANI 3604111805160002 5/18/2016 Sarnen
37 RUSLLY LUBAWI 3604112602170003 2/26/2017 Sam'un b Marja
38 SELI LIS PUTRI 3604115009160002 9/10/2016 Sanwani
39 SITI MUNAWAROH 3604114104170001 4/1/2017 Dulmanap
40 SRI WULANDARI 3604115110160001 10/11/2016 Dasim
41 TRI ANGGRAENI 3604115008160001 8/10/2016 Tinggal
AN PADA ANAK USIA SEKOLAH DI UNIT PELAYANAN

Tanggal Imunisasi

NIK Orang Tua KELAS Campak

DT (kelas Td (Kelas Td HPV (Kelas
Rubella
1) 2) (kelas 5) 5)
(kelas 1)
3604110504790009 2
3604111204900004 2
3604111009910001 2
3604110202860004 2
3604112406880002 2
3603032608860001 2
3604152104880001 2
3604230607960002 2
3604231510830002 2
3604110304790006 2
3604115206770005 2
3604111706950004 2
3604111509810004 2
3604112112900002 2
3604115505940002 2
3604110802880001 2
3604110106700001 2
3604110607880007 2
3604112706840001 2
3604110304810004 2
3601290502910001 2
3604110805760004 2
3604110506760004 2
3604111102930002 2
3604111507780011 2
3604110706820007 2
3604112303860007 2
3604110102680002 2
3604111506880010 2
3604111303770001 2
3604115708830005 2
3604110206680004 2
3604292604860003 2
3604111805710001 2
3604111710640001 2
3604110101700029 2
3604111002810007 2
3604110607840006 2
3604111303900002 2
3604112707820002 2
3604160607800003 2
 FORMAT PENCATATAN HASIL IMUNISASI LANJUTAN PADA ANAK USIA SEKOL

KABUPATEN/KOTA : SERANG
PUSKESMAS : PEMATANG
SEKOLAH : SDN DUKUH 1
TAHUN : 2024

No. Nama Tanggal lahir NIK Anak Nama Orang Tua

1 ABILAH FEBIOLA 2014-02-07 3604114702140002 Hamid

2 AYU OKTAFIA 2013-10-07 3604114710130003 Masrudin
3 GHANIA QURROTA AINI 2014-07-07 3604114708140001 Muryantono
4 HUTRIYANI 2013-08-17 3604115708130001 Samhudi
5 MILA FEBRIYANA AZ-ZAHRA 2014-02-12 3604115202140002 Minan
6 MUFLIHAH 2013-05-30 3604117005130001 Masrip
7 MUTYANA DEWI 2014-02-12 3604235202140003 Muktar
8 NAZWA KISWAH DAMAI SAPUTRI 2013-10-09 3604114910130001 Haer Suherman
9 PRITA EKA PUTRI HANDAYANI 2014-02-24 3604116402140002 Karyani
10 SAKIRATUNNISA 2014-04-18 3604115804140004 Sutihat
11 SAROH 2014-07-06 3604114607140001 Samin
12 SITI ZAHROTUL ZANNAH 2014-04-08 3604114804140001 Ahmad Royani
13 ZUB NURUL SHOFIYYAH 2013-10-23 3604116310130001 Achmad Bisri
UTAN PADA ANAK USIA SEKOLAH DI UNIT PELAYANAN

Tanggal Imunisasi

NIK Orang Tua KELAS Campak

DT (kelas Td (Kelas Td HPV (Kelas
Rubella
1) 2) (kelas 5) 5)
(kelas 1)
3604110508730006 5
3604110506760003 5
3604110706760004 5
3604111912800002 5
3604110405760002 5
3604112205830001 5
3604232504640002 5
3604115701910001 5
3604112606860004 5
3604115707880004 5
3604231107870001 5
3604112308800002 5
3603291206780002 5
 FORMAT PENCATATAN HASIL IMUNISASI LANJUTAN PADA ANAK USIA SEKOLAH DI

KABUPATEN/KOTA : SERANG
PUSKESMAS : PEMATANG
SEKOLAH : SDN DUKUH 1
TAHUN : 2024

No. Nama Tanggal Lahir NIK anak Nama Orang Tua

1 ABILAH FEBIOLA 2014-02-07 3604114702140002 Hamid

2 ALIM ALAYUBI PIRDAUS 2013-01-11 3604111101130003 Iman Setiawan
3 AYU OKTAFIA 2013-10-07 3604114710130003 Masrudin
4 FADLAN 2014-03-16 3604111603140002 Masuri
5 GANESHA AKBAR 2013-03-18 3305121308130001 Romli
6 GHANIA QURROTA AINI 2014-07-07 3604114708140001 Muryantono
7 HUTRIYANI 2013-08-17 3604115708130001 Samhudi
8 MILA FEBRIYANA AZ-ZAHRA 2014-02-12 3604115202140002 Minan
9 MUFLIHAH 2013-05-30 3604117005130001 Masrip
10 MUHAMAD IBNI ABDILAH
11 MUHAMAD IQBAL REZA 2013-07-09 3604110907130002 Asmudi
12 MUHAMAD PARHAN 2014-06-03 3604110308140002 Sainta
13 MUHAMAD SANJAYA 2013-09-30 3604163009130002 Samani
14 MUTYANA DEWI 2014-02-12 3604235202140003 Muktar
15 NANDA SAPUTRA 2013-12-18 3604231812130001 Faizudin
16 NAZWA KISWAH DAMAI SAPUTRI 2013-10-09 3604114910130001 Haer Suherman
17 PRITA EKA PUTRI HANDAYANI 2014-02-24 3604116402140002 Karyani
18 RESKY RIDFADSYAH 2013-01-04 3604110401130003 Irwan Karnawan
19 RIZQI PUTERA PRATAMA 2014-05-17 3604081706140002 Agus Bahruji
20 ROMADONI 2014-06-30 3604113006140001 Sarnen
21 SAKIRATUNNISA 2014-04-18 3604115804140004 Sutihat
22 SAROH 2014-07-06 3604114607140001 Samin
23 SATRIA 2013-09-16 3604111609130003 Jumri
24 SITI ZAHROTUL ZANNAH 2014-04-08 3604114804140001 Ahmad Royani
25 ZUB NURUL SHOFIYYAH 2013-10-23 3604116310130001 Achmad Bisri
JUTAN PADA ANAK USIA SEKOLAH DI UNIT PELAYANAN

Tanggal Imunisasi

NIK Orang Tua KELAS Campak

DT (kelas Td (Kelas Td HPV
Rubella
1) 2) (kelas 5) (Kelas 5)
(kelas 1)
3604110508730006 5
3604111712730002 5
3604110506760003 5
3604110304810004 5
3305121004840009 5
3604110706760004 5
3604111912800002 5
3604110405760002 5
3604112205830001 5
5
3604110802820010 5
3604111401740003 5
3604112506880001 5
3604232504640002 5
3604112312910002 5
3604115701910001 5
3604112606860004 5
3210200906880001 5
3604080607890001 5
3604115207750001 5
3604115707880004 5
3604231107870001 5
3604111204710003 5
3604112308800002 5
3603291206780002 5