Form 10 29012022
Form 10 29012022
Form 10 29012022
Kabupaten/Kota
Provinsi
Hari, Tanggal
No No. Tiket
1 P-13HA4PLD
2 Q-002K20HZ
3 UU-005JR3A
4 Q-002D0M4S
5 P-1JTK8E1V
6 Q-002E0KPU
7 P-3NDK1GUV
8 P-4ULBSEQ3
9 Q-002K4DC3
10 q-001WENYK
11 MANUAL
12 U-0000LXWM
13 S-12237356
14 Q-002K341Y
15 Q-002HHWA1
16 P-107G4HFV
17 Q-002BLROP
18 Q-002G511T
19 P-173VXVZI
20 Q-002AXI8S
21 P-17RIL9MX
22 Q-002HRIXE
23 Q-002G59IB
24 Q-002CCKUU
25 Z-000HFC9K
26 Q-000EFUD7
27 P-1KXRFHZ0
28 P-1FYDTTF1
29 Q-002GAGW1
30 P-2S06FJKZ
31 P-2LGNK5P5
32 P-2IEOMJZN
33 P-2HLJ5WVW
34 Z-000DHNCW
35 P-3OWVGSYM
36 P-3V8EJJE1 :
37 P-3V4KIILF
38 P-5FFBO11N
39 P-2SUW9N1R
40 P-0BJKXHU2
41 P-WNKLKQ5S
42 Q-001MGZRM
43 Q-002G92XE
44 P-13WO9CXN
45 Q-002GXLGT
46 Q-002DNF09
47 Q-002DNH06
48 Q-002AX7TJ
49 Q-002K406M
50 P-1AVAP5WL
51 P-QW5IXZFC
52 P-L43XI58B
53 P-1ON9VJ8N
54 P-XE2BPEK9
55 P-1Q7GWBBN
56 Q-002CZ6H5
57 Q-002K4D39
58 P-1THP5QG3
59 Q-002K4D1V
60 S-15A709B7
61 P-28RDGAUD
62 P-2AFLWOXN
63 P-1COD6OWX
64 P-3BTVJZME
65 P-342NEGGP
66 Q-002K338K
67 P-2Z999R0U
68 UL-003MR55
69 P-2S06FJKZ
70 Q-002HKVPH
71 P-3J5IS0ZF
72 P-4OMSPZ2L
73 P-4FMLKVLI
74 P-4GNNND0O
75 P-44RKYGRM
76 Q-001AO1OG
77 Q-000ZD9JM
78 P-483QBACV
79 P-5UWV5S0Y
80 P-57GDI9DZ
81 Y-012ZABQY
82 Q-001GDIDG
83 Q-002GAYQQ
84 Z-000FNLOC
Keterangan
* Pekerjaan dikelompokkan menjadi:
A = Petugas Medis dan Non Medis di Fasilitas Pelayanan Kesehatan
B = Petugas pelayanan publik yang berhadapan langsung dengan masyarakat
C = Administrator Pemerintahan
D = Lainnya
E = Tidak Bekerja
NIK
6372061404820002
6305044904920003
6372066707780002
6303054912710002
6303054304080001
3328110601960004
6401074510000001
6303056004010007
6304031307020001
6372062807020002
6303051602990002
6372066212770001
6372025403650001
6372065511860004
6307046708880001
6372036909100001
6372024207750004
6372066705690001
6372060307610001
6303083112770019
6372054708150001
6372061505790004
6372065101800001
6372060704870001
6372062903550001
3173016504031003
6372064107110001
6372060410100001
6371037003000009
6303050109150005
6372065810640001
6303056908910004
6372061202120002
3510032006600024
6372024405130001
6372065111140002
6372066704130001
6303122312150001
6372064502100003
6372064309100001
6372064807120001
6372066002800002
6372066506610001
6372062504100002
6372062010660002
6372065503700002
6372066706700002
6303084108810002
6372060304740002
6372062607150001
6372065108110001
6372061812150002
6372065411120002
6372025107120001
6372056304100001
6372064604750004
6307021205800003
6372020403150003
6303124107940095
6372060911980002
6302096506950002
6372055511150002
6372050201160000
6371042108110003
6372062302140001
6372053112900001
6372054107150003
6372060103530002
6303050109150005
6304166506970001
6303030309910001
6372061803150001
6310066201820001
6372062903920002
6372067005150001
6303055304760006
6302201011000002
6311066110130001
6471060202150003
6372066601150001
6471052404620003
6309042302010005
6372066711090001
6372062404750004
Kelompok Umur:
12-17
18-30
31-45
46-59
≥ 60 tahun
Total
Pekerjaan:
A
B
C
D
E
Total
: BANJARBARU SELATAN
: BANJARBARU
: KALIMANTAN SELATAN
: 29 JANUARI 2022
Jenis
Nama Penerima Vaksin Pekerjaan*
Kelamin
MUTHMAINNAH, DR P NAKES
JUMIANUR P M.UMUM
MASLIANA P M.UMUM
MAIRIDAH P M.RENTAN
SALMIAH P M.UMUM
RAHIMAH P M.RENTAN
TOHARI L LANSIA
MARIANA P LANSIA
M.RAFI L ANAK
SUSILAWATI P RENTAN
SIPAH P UMUM
RUDI L UMUM
FATIMAH P UMUM
ALHAYAT L UMUM
AWALIAH P UMUM
***Merek Vaksin
A = Sinovac
B = Lainnya (Mohon disebutkan jenis vaksin yang diterima Puskesmas/Faskes)
Umur
Tanggal Lahir Kelompok Umur
(6 sd ≥ 60 tahun)
14/04/1982 40 31-45
09/04/1992 30 18-30
27/07/1978 44 31-45
09/12/1971 50 46-59
03/04/2008 14 12-17
06/01/1996 26 18-30
05/10/2000 22 18-30
20/04/2001 21 18-30
13/07/2002 20 18-30
28/07/2002 20 18-30
16/02/1999 23 18-30
22/12/1977 44 31-45
14/03/1965 57 46-59
15/11/1986 36 31-45
27/08/1988 34 31-45
29/09/2010 12 12-17
02/07/1975 47 46-59
27/05/1969 53 46-59
03/07/1961 61 ≥60
31/12/1977 44 31-45
07/08/2015 7 6-11
15/05/1979 43 31-45
11/01/1980 42 31-45
17/04/1987 35 31-45
29/03/1955 67 ≥60
25/04/2003 19 18-30
01/07/2011 11 6-11
04/10/2010 12 12-17
30/03/2000 22 18-30
01/09/2015 7 6-11
18/10/1964 58 46-59
27/08/1991 31 31-45
12/02/2012 10 6-11
20/06/1960 62 ≥60
04/05/2013 9 6-11
11/11/2014 8 6-11
27/04/2013 9 6-11
23/12/2015 6 6-11
05/02/2010 12 12-17
03/09/2010 12 12-17
08/07/2012 10 6-11
20/02/1980 42 31-45
25/06/1961 61 ≥60
25/04/2010 12 12-17
10/20/1967 55 46-59
15/03/1970 52 46-59
6/27/1970 52 46-59
01/08/1981 41 31-45
4/3/1974 48 46-59
26/07/2015 7 6-11
11/08/2011 11 6-11
18/12/2015 6 6-11
14/11/2012 10 6-11
11/07/2012 10 6-11
23/04/2010 12 12-17
4/6/1975 47 46-59
12/05/1980 42 31-45
04/03/2015 7 6-11
01/07/1994 28 18-30
09/11/1998 24 18-30
25/06/1995 27 18-30
15/11/2015 7 6-11
02/01/2016 6 6-11
21/08/2011 11 6-11
23/02/2014 8 6-11
30/12/1990 31 31-45
01/07/2015 7 6-11
01/03/1953 69 ≥60
01/09/2015 7 6-11
25/08/1997 25 18-30
03/09/1991 31 31-45
18/03/2015 7 6-11
22/01/1982 40 31-45
29/03/1992 30 18-30
30/05/2015 7 6-11
13/04/1976 46 46-59
10/11/2000 22 18-30
21/10/2013 9 6-11
02/02/2015 7 6-11
26/01/2015 7 6-11
4/24/1962 60 ≥60
23/02/2001 21 18-30
27/11/2009 13 12-17
24/04/1975 47 46-59
0
84
0
84
83
38
121
FORMAT PENCATATAN PELAKSANAAN VAKS
TINGKAT PUSKESMAS/FASYANKES/POS
JL.PANDAWA GT.PAIKAT
BANJARBARU
PAGEDANGAN 13
BANJARBARU
BANJARBARU
JL. PENMAS TANI IV, RT. 01, RW. 01. KAHAKAN, BATU BENAWA
JL. RP. SOEPARTO KOMP. MERATUS NO. 72, RT. 05, RW. 05. MENTAOS
Pekerjaan
A
B
C
D
E
Total
KSANAAN VAKSINASI COVID-19
ASYANKES/POS VAKSINASI
Kelas No. Hp
BPJS PBI
085332926368
085248025820
081361070907
085100321757
083150186982
085226243323
085248569136
083155813483
085654876305
08115163528
0855156814746
085248031337
082347467550
085246007982
'085249911745
085391460190
087781943890
082251469591
083155624131
081254355030
B4 081275264646
081933887127
087719198128
085248676444
081349431609
082353417223
5 081257337277
5 087772233221
083141497260
081348742727
0895402735200
082256028012
4 087743630715
082150646096
3 085389372887
1 085389372887
3 08152122497
B 081998007369
081933848048
5 082149423178
4 085248068124
085248068124
085251184965
KLS VI A 085386789018
085391355998
085251269919
087811166816
082250657069
081348966522
082154015408
KLS 3A 082148361444
B4 081258347903
KLS 3B 081278983156
KLS 4A 081251711983
KLS 6A 081278983156
08125092396
085251562268
B 08125025271
085933841001
085754061206
083143651369
B4 081351340833
B4 081289614014
KLS 5 082153662153
KLS 1 081250534574
081574266416
B BULAN 085391112731
081349755935
B4 081348742727
087724088098
085248569136
B 085754088019
083141577494
082252148289
081250515131
081349544405
082252250423
085386299911
082152572609
082136299989
082154589499
081210260682
087851747062
081349317921
0
0
0
0
0
0
rtaan BPJS (tulis 'Ya' pada kolom yang sesuai)
Tanggal Screening
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29-01-2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
YA 29/01/2022
Dosis I
Nama/Jenis/Merek Vaksin***
Tanggal Pemberian
No. Batch
Vaksinasi
COVID-19
Vaccine Pfizer 29-01-2022 FL4789
COVID-19
Vaccine Pfizer 1/8/2022 FL4789
COVID-19
3/26/2021 24001321
Vaccine Pfizer
COVID-19
12/23/2021 FK9707
Vaccine Pfizer
COVID-19
Vaccine Pfizer 29-01-2022 FL4789
COVID-19
12/24/2021 SDHJ6
Vaccine Pfizer
COVID-19
Vaccine Pfizer 29-01-2022 FL4789
COVID-19
Vaccine Pfizer 29-01-2022 FL4789
COVID-19
1/8/2022 FL4789
Vaccine Pfizer
COVID-19
11/27/2021 FL7649
Vaccine Pfizer
COVID-19
Vaccine Pfizer
COVID-19
2/24/2021 202009007
Vaccine Pfizer
COVID-19
Vaccine Pfizer 29-01-2022 FL4789
COVID-19
1/8/2022 FL4789 B
Vaccine Pfizer
COVID-19
12/30/2021 FL4789
Vaccine Pfizer
Tanggal Pemberian
No. Serial No. Batch
Vaksinasi
29-01-2022 FL4789
4/22/2021 24001321
29-01-2022 FL4789
29-01-2022 FL4789
29-01-2022 FL4789
29-01-2022 FL4789
3/10/2021 202009007
29-01-2022 FL4789
29-01-2022 FL4789
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29-01-2022 202111227F
29/01/2022 202111227F
29/01/2022 202111227F
29/01/2022 202111227F
29/01/2022 202111227F
29/01/2022 FL4789
29/01/2022 202111227F
29/01/2022 FL4789
29/01/2022 FL4789
29/01/2022 FL4789
4/29/2021 24001321
1/29/2022 202111227F
1/29/2022 202111227F
1/29/2022 202111227F
1/29/2022 202111227F
1/29/2022 202111227F
1/29/2022 FL4789
2
Keterangan
(Ditunda/Tidak Diberikan/Lanjut)
No. Serial
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 2
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 2
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 2
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 1
VAKSIN 2
VAKSIN 2
VAKSIN 2
FORMAT REKAPITULASI PELAKSANAAN VAKSINASI COVID-19
TINGKAT PUSKESMAS/FASYANKES…………
Nama Puskesmas/Fasyankes/Pos :
Kabupaten/Kota :
Provinsi :
# % # % # % # % # % # % # % # % # % # % #
Sasaran
Tahap 1 Tahap 2
Puskesmas/Fasyankes/
NO
Pos Vaksinasi
SDM Kesehatan Lansia
TOTAL 0 0
RIAN PELAKSANAAN VAKSINASI COVID-19
T KABUPATEN/KOTA
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 0 #DIV/0! 0 #DIV/0! 0
enerima Vaksin Dosis 1 Tunda Vaksin Dosis 1
Total Tunda Dosis
Tahap 2 I Tahap 1 Tahap 2
(Semua Tahapan)
Lansia Pelayan Publik SDM Kesehatan Lansia
% # % # % # % #
% # % # % # % # %
# % # % # % # % # %
# % # % # % # % # %
Vaksin Covid-19 BF
(Multi Dose Vial)
Provinsi
Hari, Tanggal
Sasaran
Tahap 1 Tahap 2
NO Kabupaten/Kota
SDM Kesehatan Lansia
TOTAL 0 0
APITULASI HARIAN PELAKSANAAN VAKSINASI COVID-19
TINGKAT PROVINSI
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 #DIV/0! #DIV/0!
0 0 0 #DIV/0! 0 #DIV/0!
SI COVID-19
# % # % # % # %
# % # % # % # % # %
# % # % # % # % # %
# % # % # % # % # %
Vaksin Covid-19 BF
(Multi Dose Vial)