FORMAT PENCATATAN HASIL PELAYANAN PIN POLIO nOPV2

Nama Posyandu/Sekolah/Pos layanan

Nama Desa/kelurahan :
Tanggal :

* 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
(L/P)

a b c d e f g

1 8/11/2022 1,9 BLN P "6302014811220001 SULDIANA/ERWIN

NUR SAVNA ATAILLAH
2 GERHANA ALFARIZQY 8/11/2022 1,9 BLN L "63020108110001 RAHMAWATI/MUHAMMAD BASRI

3 MUHAMMAD ZAM ZANI 15/02/2023 1,6 BLN L "630201150223002 SUNAENI/MINHAT

4 MUHAMMAD IJBAR HAFIZH 5/10/2023 10 BLN L "6302010510230001 JUMURIANI/ISRA

5 MUHAMMAD RAFFASYA RAFIANDRA 6/9/2023 11 BLN L "6302010609230001 AGUS KRISNAWATI/IUK SUGARA

6 NURUL AISYAH 29/08/2020 4 THUN P "6302015012190001 SUBAEDA/ASRA

7 SULASTRI SAAIDA 7/3/2023 1,5 BULAN P "6302014703230001 SUSANTI/DAHLAN

8 ASYILAH KHAIRUNNISWAH 11/4/2021 3,4 BULAN P "6302015104210001 SUARNI/ABDUL AHMAD

9 FATIMAH MARSANDA 9/12/2020 3,8 BLN P "6302014912200001 NUR INDAH SARI/UMAR

10 MUHAMMAD FARHAN 2/5/2018 6,3BULN L "6302010205180001 FATMAWATI/MUHTAR YADI

11 NUR AZIZAH 13/07/2016 7,1 BLN P "6302015307160001 NURMIA/ALIMUDDIN

12 SALMAN ALFARIZI 25/01/2017 7,7 BLN L "6302012501170001 ENDANG/ARIPUDDIN

13 SAPRIANA 8/11/2017 7,9 BLN P "6302014811170001 SUDANA/SAMIRUDDIN

14 AHMAD SEPTIAN 1/9/2016 7,11 BLN L "6302010109160001 MASIDAH/KASMAN

15 NURBIA 29/12/2017 6,8 BLN P "6302016912170001 AGUSTINA/BAHARUDDIN LOPA

16 NUR JANNAH 12/8/2017 7THN P "6302015208170001 DIANA/JANATIN

17 AZLAN ZAIDAN HIDAYAT 21/12/2018 6 THN L "6302012112180001 SURIANA/SAIFUL

18 DILAN SAPUTRA 3/12/2018 6 THN L "6302010312180001 MARJAHANI/ADIL SAPUTRA

19 NUR AISYAH RAMADANI 25/05/2018 6 THN P "6302016505180001 NUR IJAH/SAMSUDIN

20 AWLIYA IZZATUNNISA 8/10/2019 5 THN P "6302014810190001 IDA WATI/AHMAD

21 AZLAN ARIFKAN 16/09/2019 5 THN L "6302171609190001 NOVI AMBARWATI/ALAN PRADWI

22 PUTRI KHANZA HUMAIRA 25/08/2020 4 THN P "3529256508200001 HAYATUL INAYAH/ADRIANSYAH

23

24

25

26

27

28

29

30

31

32

33

34
35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55
56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76
77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97
98

99

100

TOTAL

Jumlah vial Jumlah vial Jumlah vial

Jumlah Vial Sisa
dibawa dipakai rusak
Jumlah Vial nOPV2
0
YANAN PIN POLIO nOPV2

Nama petugas :
Puskesmas :
Kabupaten :

Dosis 1 Dosis 2
NIK Orang Tua Alamat No.Hp
Tanggal Diimunisasi nOPV2 No Batch Vaksin Tanggal Diimunisasi nOPV2 No Batch Vaksin
h i j k l m n

6302015106030001/6302012104990001 001/001 6/8/2024

6310046711960003/6302010702970001 003/002 6/8/2024

6302014306900002/6302011809870001 001/001 6/8/2024

6302016704980002/6302011202910001 001/001 6/8/2024

6302015708940001/6302010101930004 001/001 6/8/2024

6302014306900003/7310024308820001 002/001 6/8/2024

6302015210950001/6302010701900001 004/002 6/8/2024

6302015307020002/6302010903970001 002/001 6/8/2024

6302015707920001/6302011101850001 002/001 6/8/2024

6302014107810082/6302011006820001 002/001 6/8/2024

6302015101790001/6302011001760001 001/001 6/8/2024

6302014201820001/6302010103770001 001/001 6/8/2024

6302014101900003/6302010104790001 002/001 6/8/2024

6302014206860001/6302010108830003 002/001 6/8/2024

6302014201840001/6302010101830002 001/001 6/8/2024

6302016007840001/6302012305820001 002/001 6/8/2024

6302015001820003/6302011104750001 001/001 6/8/2024

6302016103960001/6302010808860001 001/001 6/8/2024

6302015909830001/6302011405730001 008/004 6/8/2024

6302014201830001/6302010101780002 001/001 6/8/2024

6302016801030002/3529250107050048 001/001 6/8/2024

3529256712960002/6302012205950001 001/001 6/8/2024

999922
Keterangan