Posyandu/Pos Layanan BIAN lainnya :SD PANERAYA

Desa/kelurahan : PANE RAYA

Tanggal : 10 JUNI 2022

Jenis Kelamin
No. NAMA ANAK Tgl lahir Umur
(L/P)

a b c d e
KELAS 1
1 KATUA JAKSANA SIPAYUNG 03/06/2015 7L
2 RIFAI 14/02/2015 7L
3 JHON PRIANDO SINAGA 14/04/2015 7L
4 JOI NRASYA HAKIKI SARAGIH 30/12/2014 8L
5 BALVIN CHRISTON PURBA 14/06/2015 7L
6 MACIA CLARA C SINAGA 05/07/2015 7P
7 ERINA SAKYA PUTRI 24/11/2014 8P
8 SELAMAT SARAGIH 22/12/2014 8L
9 NOVI CRISTIN DAMANIK 06/05/2014 8P
10 KHANSA FAYYOLA PURBA 19/07/2015 7P
11 YERVANT ARELIAN ARDANI 24/11/2014 8L
12 KEYSHA SYAKIRA 06/05/2015 7P
13 JUANDA OLOAN DAMANIK 07/05/2015 7L
14 MARVEL CRISTIAN DAMANIK 21/11/2014 8L
16 APRILIO EINSTEIN PURBA 15/04/2015 7L
17 SABILA HAFIZAH SINAGA 16/11/2014 8P
18 KAYLA REPINA HASIOLAN SINAGA 08/01/2015 7P
19 NATANAEL SINAGA 01/04/2015 7L
20 PARULIAN DAMANIK 24/10/2014 8L
 21 ADELIA EVARINA SIPAYUNG 25/02/2015 7P
22 AZIS MAULANA 13/09/2014 8L
23 SYAHPUTRI RAMADHANI 30/06/2015 7P
24 ARNISA NUR AQILA SARAGIH 02/04/2015 7P
25 ANGELINA PURBA 02/01/2015 7P
26

KELAS 2
1 SEPRI YERIKO SARAGIH 25/09/2013 9L
2 SUFIA ARIANTA TANJUNG 07/05/2014 8P
3 RIZKI MAULANA SARAGIH 31/01/2014 8L
4 ANGGUN PURBA 06/04/2014 8P
5 NURCAHYATI DAMANIK 27/06/2014 8P
6 FATHIR RAYANSYAHBAN SINAGA 26/06/2014 8L
7 RAJA PANDAPOTAN SARAGIH 06/10/2013 9L
8 JOVAN SARAGIH 30/01/2014 8L
9 ARDHA RIZKI PUTRA 10/05/2014 8L
10 ARIFIN PURBA 13/12/2013 9L
11 CELSI OKTAVIA PURBA 27/06/2014 8P
12 ALVRIYANDI 06/04/2014 8L
13 IHSANUL HUDA 02/05/2014 8L
14 SAHARA 14/05/2014 8P
15 QUEISHA ANYA DAMANIK 07/08/2014 8L
16 THESIA DEARNI SINAGA 12/09/2013 9P
17 ZIKRUL RAMADHAN PURBA 17/07/2013 9L
18 QORY SANDIORIVA 18/03/2014 8P
19 BELLVANIA RENADA PURBA 17/06/2014 8P
20 PEBRI SAFIRA SINAGA 25/02/2014 8P
21 DESTRADI NURFAHLEVI SARAGIH 01/12/2013 9L
22 ROY FEBRIAN SINAGA 13/02/2014 8L
23 NOVAL RAMADHAN 12/06/2013 9L
24 ATIKA JAHRA 07/08/2014 8P
 25

KELAS 3
1 AZRIL ZULHAFIS DAMANIK 01/07/2013 9L
2 FADHLY 21/06/2013 9L
3 NURUL HADIL SARAGIH 22/03/2013 9L
4 MISHEL LEWIS DAMANIK 31/05/2012 10 L
5 RAYFAN GANDARA SINAGA 18/03/2012 10 P
6 DWI AYUNINGTIAS 16/01/2013 9P
7 YOSEFA YEMIMA SARAGIH 11/08/2013 9P
8 SARI HARTANI SARAGIH 16/06/2013 9P
9 ROMA ULITA SILALAHI 08/11/2012 10 P
10 REGINA CLARISA SARAGIH 10/06/2013 9P
11 RARA NOVITA 20/11/2012 10 P
12 NURUL LIANDA SARI BARUS 15/06/2013 9P
13 NIKITA CLAUDIA 13/11/2012 10 P
14 NASRIL 06/01/2013 9L
15 MAULINA DAMANIK 27/12/2012 10 P
16 MAURA SINAGA 15/12/2012 10 P
17 MARWAH SINAGA 15/12/2012 9P
18 KHAIRUNIZAM 04/05/2013 9L
19 JONATAN SIDAURUK 21/03/2013 9L
20 ELRIZA MELODY PURBA 09/07/2013 9P
21 BAYU PRATAMA 24/03/2013 9L
22 AYUMI PRILIA DAMANIK 06/07/2013 9P
23 ARINI PUTRI RAJOHI SARAGIH 21/04/2013 9P
24 ALDIANO NUGRAHA 11/01/2013 9L
25 ALVIAN 28/11/2012 10 L
26 LILA DAMANIK 02/06/2010 12 P
27
28
KELAS 4
1 KESIA LORENJA SARAGIH 11/07/2011 11 P
2 REHAN 05/10/2011 11 L
3 M.WALIYTUDIN NURHIDAYAT 02/04/2011 11 L
4 RAFAEL CRISTOPEL SINAGA 17/05/2012 10 L
5 FEBIAN ARIFKA BARUS 01/02/2010 12 L
6 JUVITA FELINSYAH DAMANIK 15/04/2012 10 P
7 SAHMAYANTI SINAGA 26/01/2012 10 P
8 AZURA NUR HASANAH 22/09/2011 11 P
9 FIQRI GILANG RAMADHAN SINAGA 17/08/2012 10 L
10 HERLIANA SIDAURUK 18/11/2011 11 P
11 TRY YONA DAMANIK 29/12/2011 11 P
12 BELLA ANGELIKA SARAGIH 14/11/2012 10 P
13 ANGGI PRATIWI PURBA 17/12/2011 11 P
14 HESKIEL SARAGIH 16/04/2012 10 L
15 YUDA ANUGRAH FEBRIAN 16/02/2012 10 L
16 CHAIRIL AKBAR SARAGIH 26/04/2012 10 L
17 ANUGRAH PIRMANSYAH 07/11/2011 11 L
18 MARISKA SINAGA 22/01/2012 10 P
19 CIKA APRILIA PURBA 16/04/2012 10 P
20 ELPIDA MARCHILLA DAMANIK 04/03/2012 10 P
21 RISKY HARDIAN PRATAMA 04/02/2012 10 L
22 ELPINA DAMANIK 05/08/2009 13 P
23 JON PREDI DAMANIK 08/04/2012 10 L
24 SESAR RIFALDO PURBA 06/01/2012 10 L
25 ARGA PURBA 07/07/2012 10 L
26 JUNIARMAN DAMANIK 08/06/2011 11 L

KELAS 5
1 JHON RADO VALENTINO 14/02/2012 10 L
2 JOY AMANDA SUMBAYAK 15/03/2011 11 L
3 MA BAHY DAMANIK 24/06/2011 11 L
 4 KEYLANI ANASTASYA PURBA 13/05/2011 11 P
5 NURIADI SARAGIH 22/03/2009 13 L
6 FAHRURROZI 28/01/2011 11 L
7 ALECIA ANJANI SIPAYUNG 20/01/2011 11 P
8 ARSYA NABILA DAMANIK 14/07/2011 11 P
9 JENNI RAHMASARI SINAGA 26/01/2012 10 P
10 NHENDRA KRISTIAN SARAGIH 25/05/2011 11 L
11 BUNGA RIAH PURBA 29/11/2010 12 P
12 MARTIN PRATAMA DAMANIK 29/08/2011 11 L
13 ALVINO 23/11/2012 10 L
14 JICKRY IRVANDI SARAGIH 17/07/2011 11 L
15 SATRIA SURAMANA TANJUNG 17/05/2011 11 L
16 HANDRIAN SINAGA 12/08/2010 12 L

KELAS 6
1 KHARISMAHANI LASMARANTA SARAGIH 16/09/2010 12 P
2 ALEX ANDREA 20/11/2008 14 L
3 GILANG PRAYOGA 11/02/2010 12 L
4 M.FAHMI 24/08/2010 12 L
5 FERDI JONATAN ZEBUA 05/02/2010 12 L
6 BAIHAQI 06/10/2009 13 L
7 VIKA SARTIKA DAMANIK 04/06/2010 12 P
8 JEKTRONALDO SILALAHI 10/10/2008 14 L
9 YABES CRISTIAN F SINAGA 09/11/2010 12 L
10 CRISNOVEL DAMANIK 13/07/2009 13 L
11 ALBERT FRANSISCO DAMANIK 20/02/2010 12 L
12 MELFRI SYAHPUTRA SARAGIH 19/04/2010 12 P
13 EDY PRANATA 01/12/2009 13 L
14 NUR FADILA DAMAIK 31/30/2010 12 P
15 ESYIA YUNI ISAFIRA PURBA 27/06/2014 8P
16 MEYRA YOHANA SARAGIH 13/05/2010 12 P
17 IMELDA YAPINE SINAGA 21/04/2010 12 P
18 AULIA APRI YANTI 01/04/2010 12 P
19 MUHAHMMAD FAHMI 24/08/2010 12 L
20
umlah vaksin (vial) dan logistik yang digunakan
Jenis logistik OPV IPV DPT-HB-HIB
Jumlah

Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
 FORMAT PENCATATAN HASIL PELAYANAN

Nama orang tua Alamat No.Hp NIK ANAK

f g h i

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 Pelarut Campak Rubela Dropper
CAMPAK RUBELA

olom keterangan
 Nama petugas :
Puskesmas :
Kabupaten :

Imunisasi Kejar
(Ya = 1, Tidak=0) Ket** (bila anak
mendapatkan dosis
kedua/keetiga/keempat
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ADS 0,5 ML ADS 5 ML Safety Box Pen Marker
Posyandu/Pos Layanan BIAN lainnya SD TIGA LAMA
Desa/kelurahan : PANE RAYA
Tanggal : 10 JUNI 2022

Jenis Kelamin
No. NAMA ANAK Tgl lahir Umur
(L/P)

a b c d e
KELAS 1
1 ANDIKA SYAHPUTRA SARAGIH 06/08/2015 7L
2 AHMAT AL FIKRI 01/10/2014 8L
3 AKBAK ANTARIKSA 10/04/2014 8L
4 AZKIA SAUFA BILOIS DAMANIK 29/08/2014 8P
5 ABYAN NANDANA 06/05/2014 8P
6 CINDRA PORDOMUAN L
7 ADINDA SYAKIRA 01/10/2014 8P
8 FERMANDO DAMANIK 16/08/2014 8L
9 MUHAMAD REHAN 31/30/2015 7L
10 MUHAMAD ZAKWAN LLUFTI 12/12/2012 10 L
11 REHAN TURNIP 14/06/2015 7L
12 HARIANDINO 31/30/2013 9L
13 FAHRIANDO SARAGIH 04/08/2016 6L
14 KEYZA RAMADHANI SINAGA 02/07/2015 7L
15 YESI OKTAVIA SARAGIH 27/10//2014 8L
16 MUHAMMAD YUDA 24/12/2014 8L
17 MUHAMMAD DIRGA 27/02/2015 7L
18 RISKI AWAN SARAGIH 09/05/2015 7L
19 DAROZA NURHASIMA 01/01/2015 7P
KELAS 2
1 HENDRA PRA YOGA 21/02/2014 8L
2 HENDRA PRA YOGI 21/02/2015 8L
3 EVARINA PURBA 24/07/2013 9P
4 JUNIOR SINAGA 15/09/2013 9L
5 LIZA AFRILIA SARAGIH 07/04/2014 8P
6 ANANDA SAPUTRA TANJUNG 31/07/2014 8L
7 FAZAR DAMANIK 09/06/2014 8L
8 SASKIA PEBIYOLA DAMANIK 09/04/2014 8P
9 SURYA WARDANA 10/06/2014 8L
10 ZIDAN PRATAMA 07/11/2013 9L
11 MIKA ANJANI PURBA 13/10/2013 9P
12 MUHAMMAD ALIFAHMI 19/09/2013 9L
13 IRFANDI PURBA 30/12/2013 9L
14 KHANZA SYAKIRA DAMANIK 31/07/2014 8P
15 NURHASANAH YASTRIB PURBA 17/01/2014 8P
16 NURUL MARDIAH 03/06/2014 8P
17 NAILA SYAKIRAH 23/02/2014 8P
18

KELAS 3
1 ADIBA FAIZA SARAGIH 19/06/2013 9P
2 ADRIANSYAHPITRA SARAGIH 23/08/2012 10 L
3 AKBAR MAULANA 28/02/2012 10 L
4 AKIFA DAFIYA HASNA 24/09/2013 9P
5 ANUGRAH RAMADAN 31/07/2012 10 L
6 BELLA SYAFIRA SARAGIH 02/12/2012 10 P
7 DINO AGATHA UMAR 04/08/2013 9L
8 FAREL YUDA HERLAMBANG PURBA 24/01/2013 9L
9 FERDY ANANTA 9/05/2013 9L
10 HAFIZA RAMAYANI 07/07/2013 9P
 11 HANUN ADILA 24/02/2013 9P
12 IBRAHIM MOVIC 24/04/2013 9L
13 INDAH PUSPITA SARI 7/08/0213 9P
14 JAN YOGI TRIYANDI SARAGIH 12/08/2013 9L
15 JIHAN AULIA 1/09/2013 9P
16 KAKA NIKITA SIPAYUNG 08/08/2013 9P
17 KARIN AMELIA SIDAURUK 28/10/2010 12 P
18 M.YUNUS PAZRI SARAGIH 17/09/2013 9L
19 M.AKBAR 06/03/2013 9L
20 NUR SOHIBA 09/09/2013 9P
21 RADIKA WARDO 13/03/2013 9L
22 RASTI TURNIP 18/08/2011 11 P
23 REFAN DIYEGO PUTRA 02/11/2011 11 L
24 SALSA NABILA SIDAURUK 05/05/2012 10 P
25 SYAKINA HERFIZA KOTO 08/06/2013 9P
26 WAHYU SYAHPUTRA 20/01/2013 9L
27 ZIKRI ARITOUS SARAGIH 10/02/2012 10 L

KELAS 4
1 ALFARO GAVRIEL SINAGA 15/05/2012 10 L
2 ARYA RAMADHAN 13/08/2012 10 L
3 CRISTYHANA SIANGA 21/05/2012 10 P
4 DWI NURAINI PURBA 09/05/2012 10 P
5 ELVI BALI SARA DAMANIK 25/07/2012 10 P
6 FAJAR KUSUMA 15/05/2011 11 L
7 FEBI SABRANI DAMANIK 20/02/2012 10 P
8 HORAS INSANA SINAGA 24/04/2012 10 P
9 HORAS INSANI SIANG 24/04/2012 10 L
10 JENRIANDO PURBA 22/02/2011 11 L
11 KELVIN REVALDI PURBA 31/10/2012 10 L
12 LIDYA OKTAVIA DAMANIK 12/01/2012 10 P
13 MHD PADLY SYAPUTRA SARAGIH 19/07/2012 10 L
 14 MDH ALFAINDA TANJUNG 11/11/2011 11 L
15 NADIRA 29/05/2012 10 P
16 NELLA MUTIA LESTARI SARAGIH '04/06/0212 10 P
17 NOVITA SARI DAMANIK 02/03/2012 10 P
18 PIOLA ANDYANI PIRBA 29/11/2011 9P
19 RAFA ALPAJI 15/02/2012 10 L
20 RAFA DAMANIK 21/07/2011
21 RAFIKA HABNI LUBIS 14/11/2011 11 L
22 REFAN ARDIANSYAH SINAGA 21/09/2011 11 L
23 RIDHAO SYAH PUTRA HALOHO 08/05/2011 11 L
24 SUCI RAMAYANI SARAGIH 10/08/2012 11 P
25 TANIA ENJELIKA DAMANIK 04/08/2012 10 P
26 ZILA ALIKHA DENDA PURBA 01/08/2012 10 L

KELAS 5
1 ABABIL 15/09/2011 11 L
2 AHMAD FAUJI DAMANIK 06/01/2010 12 L
3 ALYA DAMANIK 19/09/2010 12 P
4 ANANDA FUZI AULIA KOTO 04/06/2011 11 P
5 ANDARTA SARAGIH 28/07/2011 11 L
6 AZRIL PRAYUDA 21/03/2011 11 L
7 DIMAS SAPUTRA 04/07/2010 12 L
8 EDUARMAN PURBA 03/12/2011 11 L
9 ESTER KASIH SIANGA 26/01/2011 11 P
0 FIRDAYANI SARAGIH 29/08/2011 11 P
10 FITRI RAHANUM 25/07/2011 11 P
11 GRESIA TIOVANIA PURBA 15/09/2010 12 P
12 HERNA LIANA DAMANIK 15/09/2010 12 P
13 HERNA LIANTRI DAMANIK 20/12/2010 12 P
14 IKBAL MAULANA 09/02/2009 13 L
15 JOKO IRWANSYAH 25/05/2011 11 L
16 KIANSAH PRATAMA SARAGIH 08/01/2011 11 L
 17 MHD RENDY DAMANIK 04/05/2011 11 L
18 NENI ARIANI SARAGIH 06/10/2010 12 P
19 OKTA ADELIA SARAGIH 30/04/2011 11 P
20 RAFI JONANDA DAMANIK 02/07/2011 11 L
21 ROYHAN 24/02/2011 1L
22 SULAPAH NUR JIHAN P 08/07/2010 12 P
23 VITA PUTRI CAHAYA 24/08/2009 13 P
24 WANDA SAPUTRA 19/07/2011 11 L
25 WITRI WIDAYATI 31/01/2011 11 P

KELAS 6
1 ADELIA HASANAH SARAGIH 15/07/2011 11 P
2 ALLEA AZZURA SARAGIH 01/08/2010 12 P
3 BILQIS SELVIANI PURBA 04/08/2010 12 P
4 BOY ALFA RIZKI 17/03/2010 12 L
5 CICI KHAIRONI DAMANIK 24/12/2009 13 P
6 DAMRA DAMANIK 13/12/2010 12 L
7 DARA KHADIJAH 10/08/2010 12 P
8 DONI ERWANDO SARAGIH 13/04/2010 12 L
9 ELLYSIA SARAGIH 08/06/2010 12 P
10 ELSA TRIAFRINA PURBA 04/04/2010 12 P
11 ERWANDI FERDIANSYAH PURBA 02/10/2008 14 L
12 HARDIAMAN 06/04/2008 14 L
13 IFNU PRAYOGA 06/11/2008 14 L
14 MHD TORIQ ALFA 18/10/2010 12 L
15 NICOL OWEN AULIA PURBA 07/07/2008 14 L
16 RAMADANI PURBA 10/04/2011 11 L
17 RIDHOL PURBA 06/04/2010 12 P
18 RISNAWATI TURNIP 17/05/2009 13 L
19 ROY EFENDI DAMANIK 11/03/2010 12 L
20 SATRIO ALPIANSYAH 13/12/2008 14 P
21 SELLA OKTAVIA SARAGIH 05/10/2010 12 P
 22 SEPTI ANGRIANI PURBA 17/09/2010 12 P
23 SITI NURHAYATI 07/03/2010 12 L
24 YOSE ONRIEL PURBA 05/01/2010 12 P
25 ZENI ADINDA PUTRI LUBIS 28/01/2010 12 P
26 ZIVANA SARAH UTAMI 12/12/2012 10 P
27 JESIKA SINAGA 28/05/2010 12 P

umlah vaksin (vial) dan logistik yang digunakan

Jenis logistik OPV IPV DPT-HB-HIB
Jumlah

Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
 FORMAT PENCATATAN HASIL+A1:O1054 PELAYANAN

Nama orang tua Alamat No.Hp NIK ANAK

f g h i

WINDAYANI TIGA LAMA 082361783140 1208070606152001

PAINAH DAMANIK TIGA LAMA 082361783140 1208070110140001
DAMERITA DAMANIK TIGA LAMA 082361783140 1210091004140001
ROSMINARIA PURBA TIGA LAMA 082361783140 1208076908140001
SUMARDI TIGA LAMA 082361783140 1208076051430003
TIGA LAMA 082361783140 0000000000000000
DELIANA SARAGIH TIGA LAMA 082361783140 1208070110060003
MURNIATI TIGA LAMA 082361783140 1205071608140001
FERLINAWATI TIGA LAMA 082361783140 1208073103150001
ROSMAWATI TIGA LAMA 082361783140 1209151212120001
SANTY TIGA LAMA 082361783140 1208072707170001
SUSILAWATI TIGA LAMA 082361783140 1208073103130002
HERLINA SARAGIH TIGA LAMA 082361783140 1208070408162001
ERMINA TIGA LAMA 082361783140 1208074207150002
ERPESENI SARAGIH TIGA LAMA 082361783140 1208076710140001
NURSILA TIGA LAMA 082361783140 1208072812140002
ARBAIYAH TIGA LAMA 082361783140 1208072702152001
LILI SUNDARI TIGA LAMA 082361783140 1208150805151002
LIANA TAMBUNAN TIGA LAMA 082361783140 1208074101152001
HASRA WALIA SARAGIH TIGA LAMA 082277564473 1208072102140001
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ROSLIATI SARAGIH TIGA LAMA 082277564473 1208076407130001
DEWI PUTRI SARAGIH TIGA LAMA 082277564473 1208071509130001
NURAINI DAMANIK TIGA LAMA 082277564473 1208074704140001
HARLINA DAMANIK TIGA LAMA 082277564473 1208073107140001
HELMINA SUSANTRI PURBA TIGA LAMA 082277564473 1208070906140001
IRMA PASKA PURBA TIGA LAMA 082277564473 1208074904140001
KARNIATI TIGA LAMA 082277564473 1208071006140001
NOVI RESDAYANTI PURBA TIGA LAMA 082277564473 1208070711130001
MARIANI SARAGIH TIGA LAMA 082277564473 1208075310130001
DEDE ISNANI SITIO TIGA LAMA 082277564473 1208071909130001
HASIANI SARAGIH TIGA LAMA 082277564473 1208073012132001
VIKA HANRIANI PURBA TIGA LAMA 082277564473 1208077107140001
ERNA ROSIDA DAMANIK TIGA LAMA 082277564473 1208075701140001
SUNARTI TIGA LAMA 082277564473 1208074306142001
SITI AISYAH SARAGIH TIGA LAMA 082277564473 1271056302140001

SUSI SUSANTI DAMANIK TIGA LAMA 081264847187 1208075906130001

WINDAYANI TIGA LAMA 081264847187 1208072308120001
SUSANTI TIGA LAMA 081264847187 1208072802120001
HETTY SURYANA PURBA TIGA LAMA 081264847187 1208076409130001
SURYANI TIGA LAMA 081264847187 1208073107120001
MARIYA TIGA LAMA 081264847187 1208074212122001
NINGSIH AWATI TIGA LAMA 081264847187 1208070408130001
KUSMAWATI HANDAYANI TIGA LAMA 081264847187 1208072401130001
INTAN KUMALA TIGA LAMA 081264847187 1208070905130003
YUSNANI TIGA LAMA 081264847187 1208074707130001
RIJAH PAHLEPI TIGA LAMA 081264847187 1208076402130001
SUMIATI TIGA LAMA 081264847187 1208072404130001
SUARTINI TIGA LAMA 081264847187 1208071208130001
DAMAYANTI PURBA TIGA LAMA 081264847187 1208074109130001
ROSMINI TIGA LAMA 081264847187 1208074808130001
ESRA YUSNIDA DAMANIK TIGA LAMA 081264847187 1208074808130000
TIGA LAMA 081264847187 1208076810110001
LIANA TAMBUNAN TIGA LAMA 081264847187 1209151709130001
NURYATI TIGA LAMA 081264847187 1208070603130001
ISMAWATI TIGA LAMA 081264847187 1208074909130001
SAURMN IDA TAMBUNAN TIGA LAMA 081264847187 1208071303130001
SUSILAWATI TIGA LAMA 081264847187 1208075808110001
HOTNAULI SINAGA TIGA LAMA 081264847187 1208070211120001
JULIANTI TIGA LAMA 081264847187 1208074505120001
MIRNA TIGA LAMA 081264847187 1208075806130001
NIRWANA SINAGA TIGA LAMA 081264847187 1208072001130001
ROSMIANI SINAGA TIGA LAMA 081264847187 1208071002122001

ROSMIDA TIGA LAMA 082272731859 1208071505120002

SRI HIJRIATI PURBA TIGA LAMA 082272731859 1208071308120001
HERMAWATI SARAGIH TIGA LAMA 082272731859 1208076105120002
SUSILAWATI TIGA LAMA 082272731859 1208074905120002
SURIATUN TIGA LAMA 082272731859 1208076509120002
PONIEM SINAGA TIGA LAMA 082272731859 1208071505110003
HOTMAIDA MARPAUNG TIGA LAMA 082272731859 1208076002120001
ROSMILA PURBA TIGA LAMA 082272731859 1208072404120002
ROSMILA PURBA TIGA LAMA 082272731859 1208072404120001
MARIANI SARAGIH TIGA LAMA 082272731859 1208072202110002
HELMINAWATI DAMANIK TIGA LAMA 082272731859 1208073110122001
DIRON SINAGA TIGA LAMA 082272731859 1208075201120003
SUMIATI SINAGA TIGA LAMA 082272731859 1218081907120001
HARLIUNA DAMANIK TIGA LAMA 082272731859 1208071111110001
PAINAH DAMANIK TIGA LAMA 082272731859 1208076905120001
DAMAYANTI PURBA TIGA LAMA 082272731859 1208074406120001
SITI AMINAH TIGA LAMA 082272731859 1208074203120001
KAMELINA SARAGIH TIGA LAMA 082272731859 1208076911110001
LILI SUNDARI N TIGA LAMA 082272731859 1208071502120001
MARLINA SANTI S TIGA LAMA 082272731859 1209232107510004
NURMAIATI TIGA LAMA 082272731859 1208075411110001
REMLI PURNAMA PURBA TIGA LAMA 082272731859 1208072109110004
MARLINDA SARAGIH TIGA LAMA 082272731859 1208070805120002
DAMAYANI PURBA TIGA LAMA 082272731859 1208075012110002
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NURHAYATI SINAGA TIGA LAMA 082272731859 1208074108120002

SITI SUARNI TIGA LAMA 081375223297 1208075507110001

SAMLIATI SINAGA TIGA LAMA 081375223297 1208074108100001
ROSMINARIA PURBA TIGA LAMA 081375223297 1208074408100001
MIRNA TIGA LAMA 081375223297 1208071703100001
TETTY SARMAULINA DAMANIK TIGA LAMA 081375223297 1208076412090002
HASIDAWANI DAMANIK TIGA LAMA 081375223297 1208071312100001
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APRINA PURBA TIGA LAMA 081375223297 1208074806100002
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KARNIATI TIGA LAMA 081375223297 1208070210080002
HETTY KASMARIA NAINGGOLAN TIGA LAMA 081375223297 1208071704060001
FERNILAWATI PURBA TIGA LAMA 081375223297 1208070611080001
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ISMAWATI TIGA LAMA 081375223297 1208071810100001
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HERMINA SUSANTRI PURBA TIGA LAMA 081375223297 1208070608100002
SUSILA WATI TIGA LAMA 081375223297 1208075705090002
ROSNAULI SINAGA TIGA LAMA 081375223297 1208071103100003
IRMA PASKA PURBA TIGA LAMA 081375223297 1208071312080002
ETI SUHENTI TIGA LAMA 081375223297 1208074510100001
ERISNAWATI DAMANIK TIGA LAMA 081375223297 1208075709000003
TIGA LAMA 081375223297 1210094807100002
SUPIA TIGA LAMA 081375223297 1208074703100002
RINA TIGA LAMA 081375223297 1208070501100002

SEMMINARIA SINAGA TIGA LAMA 083198229210 1208075507110001

SUSI SUSANTI SARAGIH TIGA LAMA 083198229210 1208074108100001
ERNA ROSIDA DAMANIK TIGA LAMA 083198229210 1208074408100001
KASNIWATI TIGA LAMA 083198229210 1208071703100001
SITI AMINAH TIGA LAMA 083198229210 1208076412090002
ROHENNI PURBA TIGA LAMA 083198229210 1208071312100001
MULIANA TIGA LAMA 083198229210 1208075008100001
ERMINA TIGA LAMA 083198229210 1208071304100002
YANTI NARIA PURBA TIGA LAMA 083198229210 1208074806100002
ARIASMI SARAGIH TIGA LAMA 083198229210 1208074404100001
KUSMAWATI HANDAYANI TIGA LAMA 083198229210 1208070210080002
SUMINI TIGA LAMA 083198229210 1208071704060001
PAINAH DAMANIK TIGA LAMA 083198229210 1208070611080001
HASRA WALIA SARAGIH TIGA LAMA 083198229210 1208071810080001
TIGA LAMA 083198229210 1208070707080001
TIGA LAMA 083198229210 1208071004110002
LASMA FILTERIA SITUMORANG TIGA LAMA 083198229210 1208070608100002
SUSILAWATI TIGA LAMA 083198229210 1208075705090001
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ARMINAH SARAGIH TIGA LAMA 083198229210 1208071312080002
ENI KUSRINI TIGA LAMA 083198229210 1208074510100001
ESDAYANI SARAGIH TIGA LAMA 083198229210 1208076709000003
MESWATI SARAGIH TIGA LAMA 083198229210 1208074703100002
RITA OKTAVIANA PURBA TIGA LAMA 083198229210 1208070611000002
HOTNAULI SINAGA TIGA LAMA 083198229210 1208076801100002
SANTY TIGA LAMA 083198229210 1209154906100001
DEWI PUTRI SARAGIH TIGA LAMA 083198229210 1208071509130001
 Pelarut Campak Rubela Dropper
CAMPAK RUBELA

olom keterangan
 Nama petugas :
Puskesmas :
Kabupaten :

Imunisasi Kejar
(Ya = 1, Tidak=0) Ket** (bila anak
mendapatkan dosis
kedua/keetiga/keempat
Campak Rubela
NIK Ibu OPV/Penta saat BIAN,
(Ya=1, Tidak=0)
maka tetap dicatat namun
OPV IPV DPT-HB-Hib tidak dimasukkan sebagai
cakupan BIAN)

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ADS 0,5 ML

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Posyandu/Pos Layanan BIAN lainnya PAUD DESA SIAGA
Desa/kelurahan : PANEI RAYA
Tanggal : 10 JUNI 2022

Jenis Kelamin
No. NAMA ANAK Tgl lahir Umur
(L/P)

a b c d e
1 SYAKILA DAMANIK 03/10/2015 7P
2 ADINDA JAN HAZZELA 06/01/2016 6P
3 JULIOWIRDANA ASKA SARAGIH 12/08/2016 6L
4 NOVITA SARI SINAGA 10/05/2016 6P
5 JOVANKA THERESIA PURBA 20/09/2016 6P
6 JEVANA IRAMOTHI NATALIA PURBA 25/12/2017 5P
7 ARTHUR JHON RAJOHI SARAGIH 10/05/2016 6L
8 ZIDAN AQMAL SINAGA 18/01/2016 6L
9 HARAPANDO SARAGIH 16/05/2016 6L
10 HARAPIANDI SARAGIH 16/05/2016 6L
11 ANJU PRATAMA DAMANIK 08/11/2015 7L
12 WILLCAN AGUSTEIS GIANTARA PURBA 18/08/2016 6L
13 FADHILA ZAHRA PURBA 07/05/2016 6P
14 LINTANG KHADIJAH 04/07/2016 6P
15
16
umlah vaksin (vial) dan logistik yang digunakan
Jenis logistik OPV IPV DPT-HB-HIB
Jumlah

Catatan
* Tuliskan alasan jika anak tidak bisa diimunisasi dan rencana jadwal pemberian imunisasi susulan pada kolom keterangan
 FORMAT PENCATATAN HASIL+A1:O1054 PELAYANAN

Nama orang tua Alamat No.Hp NIK ANAK

f g h i
SUMARNI SARAGIH PANEI RAYA 081260890570 1208074310152001
AYU LESTARI PANEI RAYA 081261256285 1208074601162001
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DAMAYANI PURBA PANEI RAYA 083164589152 1208071605162001
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WILDA RIANA DAMANIK PANEI RAYA 085262313958 1208071808160001
RAMNAH PANEI RAYA 085296033173 1208074705160001
MULIANA PANEI RAYA 085362221692 1208074407162001
 Pelarut Campak Rubela Dropper
CAMPAK RUBELA

olom keterangan
 Nama petugas RONAULI DAMANIK & LINCE R SARAGIH
Puskesmas SINDAR RAYA
Kabupaten SIMALUNGUN

Imunisasi Kejar
(Ya = 1, Tidak=0) Ket** (bila anak
mendapatkan dosis
kedua/keetiga/keempat
Campak Rubela
NIK Ibu OPV/Penta saat BIAN,
(Ya=1, Tidak=0)
maka tetap dicatat namun
OPV IPV DPT-HB-Hib tidak dimasukkan sebagai
cakupan BIAN)

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