1.

Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 V 3 4 5 6
6 5 0 3 0 2 2 Bulan : 2022
NAMA FASKES/ PKM NUNUKAN TIMUR 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN SUMBER ALOKON

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
STATUS PESERTA KB

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN
ISTRI

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN
PENCABUTAN

PENCABUTAN

KEGAGALAN
PEMBERIAN/

KOMPLIKASI
NAMA SUAMI

OPERATIF/

LAINNYA
TANGGAL

MANDIRI
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

BERAT
LAHIR

(Kode)

TIDAK

APBN

APBD
DAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 01-Feb-2022 ARDI 6 4 0 5 0 2 1 2 3 0 9 8 0 0 0 3 NURFATIKA 12-Mar-1998 JL. GANG DELIMA 1 0 1 0 6 1 0 0 1 0 0 0

2 01-Feb-2022 JULKARNAIN 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 IRA ROYATI 11-Feb-1990 J.PASAR BARU 3 1 0 0 2 1 0 0 1 0 0 0

3 03-Feb-2022 Muhammad ahmad 6 4 0 5 0 2 5 5 0 8 7 6 0 0 0 5 Norhayati 05-Aug-1976 JL.mandor beddu 3 1 0 0 2 1 0 0 1 0 0 0

4 07-Feb-2022 JAYA 6 4 0 5 0 2 5 0 1 0 9 4 0 0 0 3 NURAINI 05-Oct-1994 JL. PATTIMURA 2 1 0 0 2 0 0 1 1 0 0 0

5 08-Feb-2022 ISWANDI 6 4 0 5 0 2 5 0 0 2 9 3 0 0 0 5 HAYATI 05-Feb-1993 TIEN SOEHARTO 1 1 1 0 8 1 0 0 1 0 0 0

6 12-Feb-2022 LANYANYA 7 3 7 2 0 3 4 2 0 2 8 1 0 0 0 6 ROSNIDAR 02-Feb-1981 JL. DAENG TOBA 3 1 0 0 2 1 0 0 1 0 0 0

7 14-Feb-2022 bernadus 6 4 0 5 0 1 4 7 0 1 8 6 0 0 0 1 dina 07-Jan-1986 jl. kampung rambutan 1 0 1 0 4 1 0 0 1 0 0 0

8 15-Feb-2022 ALIMIN 6 4 0 5 0 2 5 4 0 1 9 8 0 0 0 2 DEWI ALFINA 04-Jan-1998 J. LUMBA-LUMBA 1 1 1 0 8 1 0 0 1 0 0 0

9 20-Feb-2022 ANDI ILHAM RIFKI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 RITA 01-Jun-1993 JL. TIEN SOEHARTO 3 1 0 0 2 0 0 1 1 0 0 0

10 21-Feb-2022 TANPA NAMA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NINGSIH 01-Jun-1989 JL. TVRI 3 1 0 0 2 1 0 0 1 0 0 0

11 24-Feb-2022 DARWIS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ROSNA 01-Jun-1987 JL.TIEN SOEHARTO 3 1 0 0 2 0 0 1 1 0 0 0

12 26-Feb-2022 EDI 6 4 0 5 0 2 5 4 0 4 8 7 0 0 0 6 NURHAYATI 04-Apr-1987 JL.TIEN SOHARTO 3 1 0 0 2 1 0 0 1 0 0 0

13 27-Feb-2022 ANTO 6 4 0 5 0 2 4 5 0 4 8 4 0 0 0 6 SUNARTI 05-Apr-1984 JL.PASAR BARU 2 0 0 0 4 1 0 0 1 0 0 0

14 27-Feb-2022 LANGANGA 6 4 0 5 0 2 4 6 0 5 8 5 0 0 0 8 SITI HALIJA 06-May-1985 JL.CIK DITIRO 3 1 0 0 2 1 0 0 1 0 0 0

15 01-Mar-2022 andi arifah 7 3 1 4 0 5 5 6 0 8 8 8 0 0 0 2 santi 11-Aug-1988 manunggal bakti 082248840050 1 1 1 0 8 1 0 0 1 0 0 0

16 01-Mar-2022 Rizal 7 3 1 4 0 7 4 1 0 7 9 8 0 0 9 8 Sri rahayu 31-Oct-2000 pasar baru 085298482817 3 1 0 0 2 1 0 0 1 0 0 0

17 01-Mar-2022 Sudarmono 6 4 0 5 0 2 6 8 0 6 9 2 0 0 0 2 Nasti 28-Jun-1992 tien sooeharto 089628259161 3 1 0 0 2 1 0 0 1 0 0 0

18 01-Mar-2022 Abu alias 6 4 0 5 0 2 4 5 5 0 8 8 4 0 0 0 Rosmiati 05-Aug-1984 pangkalann porsas 085246116743 3 1 0 0 2 1 0 0 1 0 0 0

19 01-Mar-2022 Amir 6 4 7 2 0 4 4 6 0 8 9 5 0 0 0 2 Misna 06-Aug-1995 pasar baru 082255585546 3 1 0 0 2 1 0 0 1 0 0 0

20 01-Mar-2022 andi arifah 6 4 0 5 6 2 6 2 1 1 9 0 0 0 0 1 satriani 11-Aug-1988 manungga bakti 7314055608880002 1 1 1 0 8 1 0 0 1 0 0 0

21 01-Mar-2022 suharman 6 4 0 5 0 2 5 1 1 1 8 2 0 0 0 3 rosmani 11-Nov-2022 pasar baru 085248858083 3 1 0 0 2 1 0 0 1 0 0 0

22 01-Mar-2022 Baharuddin 6 4 0 5 0 2 6 7 1 2 7 5 0 0 0 1 Nurhana ekawati 27-Dec-1975 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 1

23 01-Mar-2022 irtan 7 6 0 4 0 2 4 4 0 7 9 4 0 0 0 5 nuraisha 04-Apr-1991 pasar baru 085343605662 3 1 0 0 2 1 0 0 1 0 0 0

24 04-Mar-2022 paskore 6 4 0 5 0 2 6 5 0 8 0 1 0 0 0 6 mastura 25-Aug-2021 pasar baru 6405026508010006 3 1 0 0 2 1 0 0 1 0 0 0

25 04-Mar-2022 amirudin 6 4 0 5 0 2 4 8 0 9 9 7 0 0 0 1 fitri rahayu 08-Sep-1997 tien soeharto 082331466367 3 1 0 0 1 0 0 1 0 0 0

26 04-Mar-2022 ferdiansysh 5 3 0 2 2 0 5 4 0 4 8 2 0 0 0 1 mery nomleni 15-May-1984 pasar baru 082358278413 3 1 0 0 2 1 0 0 1 0 0 0

27 04-Mar-2022 zulkipli 6 4 8 5 0 8 6 5 0 7 8 9 0 0 0 1 amera 25-Jul-1989 antasari 0822450142993 2 1 0 0 8 1 0 0 1 0 0 0

28 16-Mar-2022 mohammad rifat 3 5 2 1 1 3 4 9 0 9 9 2 0 0 0 2 dewi estari 09-Sep-1992 pasar baru 085312589596 3 1 0 0 2 1 0 0 1 0 0 0

29 16-Mar-2022 Sumardiansyah 6 4 0 5 0 2 5 0 2 5 0 1 1 9 1 0 Ririn indriyani 10-Mar-1991 tien soeharto 085349783330 3 1 0 0 2 1 0 0 1 0 0 0

30 18-Mar-2022 Jeri gregorius 5 3 0 7 0 9 5 3 0 4 8 4 0 0 0 1 Paulina emirens 13-Apr-1984 daeng toba 085243495866 3 0 0 0 6 1 0 0 1 0 0 0

31 22-Mar-2022 Ali marusu 5 3 0 6 0 3 4 7 0 8 7 5 0 0 0 1 Kamriyati hisyam 07-Aug-1975 Arif rahman hakim 082354824860 3 1 0 0 2 1 0 0 1 0 0 0

32 26-Mar-2022 Dulah 3 5 2 2 0 9 4 6 0 9 7 0 0 0 0 2 Djemani 06-Sep-1970 Bhayangkara 082256633636 3 1 0 0 2 0 1 0 1 0 0 1

33 26-Mar-2022 Simon Sory 6 4 0 5 0 2 4 8 0 7 8 6 0 0 0 4 Nuraini 08-Jul-1978 muhamaad hatta 081350194930 1 0 1 0 6 1 0 0 1 0 0 0

34 26-Mar-2022 Bambang nurhadi 7 3 1 4 0 3 4 7 1 0 9 6 0 0 0 2 Priske ayu lestari 07-Oct-1996 tien soeharto 085257777658 1 0 1 0 6 1 0 0 1 0 0 0

35 26-Mar-2022 Syarif 6 4 0 5 0 2 6 9 0 9 9 0 0 0 0 5 Darmiah 29-Sep-1996 cik di tiro 1 0 1 0 6 1 0 0 1 0 0 0

36 26-Mar-2022 A M Tahir 6 4 0 5 0 2 6 9 0 8 9 9 0 0 0 4 Wydiya Agustina 26-Sep-1989 Tien soeharto 082151337350 1 0 1 0 6 1 0 0 1 0 0 0

37 28-Mar-2022 Sapri 6 4 0 5 0 2 5 9 0 9 8 0 0 0 0 2 Nakira 19-Sep-1988 manunggal bakti 082457672322 3 0 0 0 6 1 0 0 1 0 0 0

38 28-Mar-2022 Abdu 6 4 0 5 0 2 4 4 0 9 8 5 0 0 0 3 Sitti puliana 04-Sep-1985 tie soeharto 3 0 0 0 4 1 0 0 1 0 0 1

39 28-Mar-2022 Amar 6 4 0 5 0 2 4 2 0 3 8 7 0 0 0 1 Sulistriya 02-Mar-1982 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 1

40 28-Mar-2022 Amiin 6 4 0 5 0 2 7 1 1 0 0 0 0 0 0 3 Ira royati 31-Oct-2006 pasar baru 089518041851 3 1 0 0 2 1 0 0 1 0 0 0

41 01-Apr-2022 Baharudin 6 4 7 3 0 2 5 5 1 2 8 8 0 0 0 5 Nur indah 15-Dec-1988 gang kakap 3 0 0 0 4 0 1 0 1 0 0 1

42 06-Apr-2022 Sapri 6 4 0 5 0 2 5 9 0 9 8 0 0 0 0 2 Nakira 19-Sep-1980 Manunggal bakti 082157672322 2 1 0 0 8 1 0 0 1 0 0 0

43 07-Apr-2022 Lahyahya 7 3 7 2 0 3 4 2 0 2 8 1 0 0 0 6 Rosnidar 02-Feb-1981 Daeng toba 3 1 0 0 2 1 0 0 1 0 0 0

44 07-Apr-2022 Hendrik 7 3 0 8 1 1 4 1 0 6 8 8 0 0 0 5 Hasriani 01-Jun-1988 cik di tiro 1 0 1 0 6 1 0 0 1 0 0 0

45 09-Apr-2022 Abdul ghofur 6 4 0 5 0 3 5 7 1 9 7 8 0 0 0 1 Lily triana 17-Oct-1978 pageran antasari 091255647857 3 0 0 0 4 1 0 0 1 0 0 0

46 12-Apr-2022 Joni grogorius 5 3 0 7 0 9 5 3 0 4 8 9 0 0 0 1 Paulina Emeren siana 13-Apr-1984 gang toba 085242495866 1 1 1 0 2 1 0 0 1 0 0 0

47 14-Apr-2022 Suryadi 6 4 0 5 0 2 4 2 0 1 8 9 0 0 0 1 Ningsih 02-Jan-1989 TVRI 085248876527 3 1 0 0 2 1 0 0 1 0 0 0

48 18-Apr-2022 Edi 6 4 0 5 0 2 5 4 0 4 8 7 0 0 0 6 Nurhayati 14-Apr-1987 tien soeharto 085335326129 3 1 0 0 2 2 1 0 0 1 0 0 0

49 18-Apr-2022 Muh Jumail 6 4 0 5 0 2 4 8 0 2 8 2 0 0 0 1 Kartini 08-Feb-1982 kampung rambutan 082352825951 4 0 0 0 8 0 0 0 0 0 0 0

50 20-Apr-2022 Lajagung 6 4 0 5 0 2 4 6 0 5 8 5 5 0 0 0 Siti khalija 06-May-2000 cik di tiro 082345769660 3 1 0 0 2 1 0 0 1 0 0 0

51 20-Apr-2022 Amie 6 4 0 5 0 2 4 5 0 4 8 4 0 0 0 6 Sunarti 05-Apr-1984 pasar baru 085246063570 3 1 0 0 2 1 0 0 1 0 0 0

52 20-Apr-2022 Darwis 7 3 7 2 0 3 5 0 0 6 8 7 0 0 1 4 Rosna 10-Jun-1987 tien soeharto 082111707118 3 1 0 0 2 1 0 0 1 0 0 0

53 26-Apr-2022 Edy 7 2 7 1 0 1 6 7 0 3 0 0 0 0 0 2 Siti Wirna 27-Mar-2000 cik di tiro 081257217120 3 0 0 0 4 1 0 0 1 0 0 0

54 01-Jun-2022 Mustakim 6 4 0 5 0 9 5 8 1 0 8 7 0 0 0 2 Haslinda 18-Oct-1987 gangbdamai 3 0 0 0 4 1 0 0 1 0 0 0

55 01-Jun-2022 Muhammad amri 6 5 0 2 0 2 5 3 0 7 7 7 0 0 0 2 Rosalinda 13-Jul-1977 kmpung rambutan 3 0 0 0 4 1 0 0 1 0 0 0

56 01-Jun-2022 Baharuddin 6 4 0 5 0 2 7 0 1 1 0 3 0 0 0 2 Fiska 11-Jan-2003 cik di tiro 082150751944 3 0 0 0 1 0 0 1 0 0 0

57 01-Jun-2022 Rizal 6 5 0 3 1 3 5 6 0 9 7 3 0 0 0 1 Jusdiana 16-Sep-1973 Pangkalan Porsas 082347526517 2 1 0 0 2 1 0 0 1 0 0 0

58 01-Jun-2022 Irfan 7 6 0 4 0 2 4 9 0 7 9 4 0 0 0 5 Nur aisha 11-Jan-1991 tien soeharto 085343605662 3 1 0 0 2 1 0 0 1 0 0 0

59 01-Jun-2022 suharman 6 4 0 5 0 2 5 1 1 1 8 2 0 0 0 3 rosmani 11-Jun-1982 pasar baru 3 1 0 0 2 1 0 0 1 0 0 0

60 01-Jun-2022 Muhamad Ahmad 6 4 0 5 0 4 5 5 0 8 7 6 0 0 0 5 Norhayati 15-Aug-1976 Mandor beddu 3 1 0 0 2 1 0 0 1 0 0 0

61 01-Jun-2022 Edy 7 2 7 1 0 1 6 7 0 3 0 0 0 0 0 2 Siti wirnachrina 07-Mar-2000 cik ditiro 3 0 0 0 4 1 0 0 1 0 0 0

62 01-Jun-2022 Bahar 7 3 7 1 1 0 4 6 0 6 8 0 0 0 0 2 Nurhaeni 26-Jun-1980 cik di tiro 081247774309 3 1 0 0 2 1 0 0 1 0 0 0

63 01-Jun-2022 Sudarwin 6 4 0 5 0 2 5 9 1 0 9 2 0 0 0 2 Sinta mandasari 19-Oct-1992 mulawarman 3 1 0 0 2 1 0 0 1 0 0 0

64 01-Jun-2022 Sultan 6 4 0 5 0 9 6 2 1 0 8 1 0 0 0 1 Hasnawati 12-Oct-1981 Pesantren hidayatullah 3 0 0 0 6 1 0 0 1 0 0 0

65 03-Jun-2022 Aidil 6 4 0 5 0 2 4 2 2 0 3 8 7 0 0 0 Sulistriya wahyuni 29-Jun-1989 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 0

66 03-Jun-2022 Amiruddin 6 4 0 5 0 2 4 8 0 9 9 7 0 0 0 1 Fitri rahayu 08-Sep-1997 tien soeharto 3 1 0 0 2 1 0 0 1 0 0 0

67 03-Jun-2022 Herman 6 4 0 5 0 2 4 4 0 3 9 1 0 0 0 6 Karmila 04-Mar-1991 cik di tiro 3 1 0 0 2 1 0 0 1 0 0 0

68 04-Jun-2022 Immran 7 3 0 8 0 7 6 7 0 6 9 1 0 0 9 1 Musdaifah 27-Jun-1991 pasar baru 3 0 0 0 6 1 0 0 1 0 0 0

69 13-Jun-2022 Abdul alias 6 4 0 5 0 2 4 5 0 8 8 4 0 0 0 1 Rosmiati 05-Aug-1984 Pangkalan 3 1 0 0 2 1 0 0 1 0 0 0

70 13-Jun-2022 Sapri 7 3 0 7 0 3 4 1 0 1 9 3 0 0 0 8 Nursyafika 01-Jan-1993 Pangkalan 4 1 0 0 8 0 0 0 0 0 0 0

71 13-Jun-2022 Sudrmoko 6 4 0 5 0 2 6 8 0 6 9 2 0 0 0 2 Nasti 21-Jun-1992 tien soeharto 3 1 0 0 2 1 0 0 1 0 0 0

72 15-Jun-2022 SYARIFUDDIN 7 3 0 2 0 6 6 5 0 5 8 5 0 0 0 2 SUHARNI 25-May-1985 MANUNGGAL BAKTI 3 1 0 0 2 1 0 0 1 0 0 0

73 17-Jun-2022 Ilhamm 6 4 0 5 0 2 4 4 0 9 8 5 0 0 0 3 Sitti Puliati 04-Sep-1985 Tien soeharto 085246663365 3 0 0 0 4 1 0 0 1 0 0 0

74 17-Jun-2022 Muhammad arif 6 4 0 5 0 2 4 5 0 9 0 4 0 0 0 1 Asmawati 05-Sep-2004 kampung rambutan 2 0 0 0 4 1 0 0 1 0 0 0

75 19-Jun-2022 Andi arifudin 6 4 0 5 0 2 6 3 1 0 8 2 0 0 0 2 Rasidah 23-Oct-1982 pasar baru 1 0 1 0 6 1 0 0 1 0 0 0

76 19-Jun-2022 Zullpadi 6 4 0 5 0 2 6 7 0 4 9 7 0 0 0 4 Susanti 27-Apr-1997 pasar baru 1 0 1 0 6 1 0 0 1 0 0 0

77 20-Jun-2022 Rizal 7 3 1 4 0 7 4 1 0 7 9 8 0 0 0 8 Sri rahayu 10-Jul-1998 pasar baru 3 1 0 0 2 1 0 0 1 0 0 0

78 22-Jun-2022 Wahyudin 7 3 7 2 0 3 5 2 0 8 9 8 0 0 0 1 Alfiana 12-Aug-1998 tien soeharto 1 1 1 0 2 1 0 0 1 0 0 0

79 22-Jun-2022 ah yahya 7 3 7 2 0 3 4 2 0 2 8 1 0 0 0 6 Rosnidar 02-Feb-1981 Daeng toba 3 1 0 0 2 1 0 0 1 0 0 0

80 23-Jun-2022 Sabri 6 4 0 5 0 2 4 1 0 8 9 6 0 0 0 1 Ria agraini 01-Aug-1996 Patimura 1 0 1 0 6 1 0 0 1 0 0 0

81 01-Jul-2022 Suriadi 6 4 0 5 0 2 4 2 0 1 8 9 0 0 0 1 Ningsih 20-Jan-1989 TVRI 3 1 0 0 2 1 0 0 1 0 0 0

82 01-Jul-2022 Amir 6 4 0 5 0 2 4 5 0 4 8 4 0 0 0 6 Sunarti 05-Apr-1984 pasar baru 3 1 0 0 2 1 0 0 1 0 0 0

83 01-Jul-2022 Syarifuddin 6 4 0 5 0 2 6 6 0 6 9 0 0 0 0 1 Fitriyanti 23-Jun-1996 Manunggal bakti 1 1 1 0 2 1 0 0 1 0 0 0

84 01-Jul-2022 Rudianto 6 4 0 5 0 2 6 5 0 2 8 9 0 0 0 2 Syariani 25-Feb-1989 mohammad hatta 2 1 0 0 2 1 0 0 1 0 0 0

85 06-Jul-2022 Jeri Tregorius 5 3 0 7 0 9 5 2 0 4 8 9 0 0 0 1 Pauina emironsius 13-Apr-1984 daeng toba 3 1 0 0 2 1 0 0 1 0 0 0

86 10-Jul-2022 Abdullah 6 4 0 5 0 2 4 6 0 5 8 5 8 0 0 8 Sitti halija 06-May-1985 Cik di tiro 3 1 0 0 2 1 0 0 1 0 0 0

87 27-Jul-2022 Karno 7 3 0 2 0 6 4 5 0 5 8 3 0 0 0 1 Kartini 05-May-1983 pasar baru 3 1 0 0 2 1 0 0 1 0 0 0

88 29-Jul-2022 Moch Ahmad 6 4 0 5 0 2 5 5 0 8 7 6 0 0 0 5 Norhayati 15-Aug-1976 Mandor beddu 3 1 0 0 2 1 0 0 1 0 0 0

89 29-Jul-2022 Saipul 6 4 0 5 0 2 5 2 1 2 9 3 0 0 0 3 Siti Fatimah 12-Dec-1990 mohammad hatta 4 1 0 0 8 0 0 0 0 0 0 0

90 01-Aug-2022 Miftahuddin Adam 7 3 1 2 0 4 6 2 0 4 9 4 0 0 0 2 YUSRIANI 23-Apr-1994 PANGKALAN 3 1 0 0 2 1 0 0 1 0 0 0

91 01-Aug-2022 Zubain 7 4 0 5 0 9 6 4 0 6 8 4 0 0 0 2 Dewi yanti 24-Jun-1989 pasar baru 1 0 0 0 6 1 0 0 1 0 0 0

92 01-Aug-2022 Simon silli 6 4 0 5 0 2 6 1 0 4 7 9 0 0 0 5 Kartina 21-Apr-1979 persemaian 3 1 0 0 2 0 0 1 1 0 0 0

93 01-Aug-2022 Jusman 6 4 0 5 0 2 5 6 0 7 9 2 0 0 0 3 Sabariah 16-Jul-1992 pasar baru 081253455555 3 0 0 0 1 0 0 1 0 0 0

94 01-Aug-2022 Marno 3 5 0 2 1 6 5 0 0 6 7 7 0 0 0 2 Yati 22-Jun-1977 Imam Bonol 3 1 0 0 2 1 0 0 1 0 0 0

95 01-Aug-2022 6 4 0 5 0 2 4 9 0 9 8 5 0 0 0 3 Siti puliani 04-Sep-1985 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 0

96 01-Aug-2022 Muh Anur 6 5 0 3 0 2 5 3 0 7 7 7 0 0 0 2 Rosalinda 13-Jul-1977 Kampung Rambutan 3 0 0 0 4 1 0 0 1 0 0 0

97 01-Aug-2022 Hamzah 6 4 0 5 0 2 4 2 1 1 8 4 0 0 0 2 Ervina 08-Nov-1984 Arief Rahman Hakim 1 1 1 0 2 1 0 0 1 0 0 0

98 01-Aug-2022 Irfan 7 6 0 4 0 7 5 1 0 1 1 9 1 0 0 0 Nur Aisha 11-Jan-1991 tien soeharto 3 1 0 0 2 1 0 0 1 0 0 0

99 04-Aug-2022 Bahar 7 3 7 1 1 0 4 6 0 6 8 0 0 0 0 2 Nurhuneni 21-Jun-1980 Cik di tiro 081347774309 3 1 0 0 2 1 0 0 1 0 0 0

100 04-Aug-2022 Baharudin 6 4 0 5 0 2 4 1 0 7 7 8 0 0 0 9 Nasriah 01-Jul-1978 pasar baru 3 0 0 0 4 1 0 0 1 0 0 0

101 04-Aug-2022 Aidi 6 4 0 5 0 2 1 2 0 3 9 8 0 0 0 3 Nur Fatihah 12-Mar-1998 Gang Delima 3 1 0 0 2 1 0 0 1 0 0 0

102 04-Aug-2022 Dominggus 7 3 2 6 1 4 4 8 0 2 0 2 0 0 0 2 Monica Bila 08-Dec-2002 Lumba Lumba 3 0 0 0 1 0 0 1 0 0 0

103 23-Aug-2022 6 4 0 5 0 2 6 7 1 2 7 5 0 0 0 1 Nurhana 27-Dec-1975 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 0

104 23-Aug-2022 6 4 0 5 0 2 4 2 0 3 8 7 0 0 0 1 Sulistriya 02-Mar-1987 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 0

105 01-Sep-2022 Muh Amir 6 5 0 3 0 2 5 3 0 7 7 7 0 0 0 2 Rosalinda 13-Jul-1977 kampung rambutan 3 0 0 0 4 1 0 0 1 0 0 1

106 05-Sep-2022 Abdul alias 6 4 0 5 0 2 4 5 0 8 8 4 0 0 0 1 Rosmiati 15-Aug-1984 pangkalan hj muctar 085246116743 3 1 0 0 2 1 0 0 1 0 0 0

107 05-Sep-2022 Irwan 6 4 0 5 0 2 6 2 1 2 9 1 0 0 0 3 Nurlina 12-Dec-1991 kampun rambtan 082213505162 1 1 1 0 8 1 0 0 1 0 0 0

108 07-Sep-2022 Sulaiman 7 3 7 2 0 4 4 5 0 6 8 1 0 0 0 4 Kasmia 06-Jun-2000 Cik di tiro 0852146029175 1 0 0 1 6 1 0 0 1 0 0 0

109 07-Sep-2022 Syarifudin 7 3 0 2 0 6 6 5 0 5 8 5 5 0 0 0 Suharni 25-May-1985 Manunggal bakti 085349900319 3 1 0 0 2 1 0 0 1 0 0 0

110 09-Sep-2022 Sumardiansyah 6 4 0 5 0 2 5 0 1 1 9 1 0 0 0 3 Ririn 10-Nov-1991 tien soeharto 085349783330 2 0 0 0 4 1 0 0 1 0 0 0

111 22-Sep-2022 Jusman 6 4 0 5 0 2 5 6 0 7 9 2 0 0 0 3 Sabariah 16-Jul-1992 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

112 22-Sep-2022 Baharuddin 6 4 0 5 0 2 6 7 1 2 7 5 0 0 0 1 Nurhana ekawati 27-Dec-1975 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 1

113 22-Sep-2022 Aidil 6 4 0 5 0 2 4 2 0 3 8 7 0 0 0 1 Sulistriya 02-Mar-1987 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 0

114 22-Sep-2022 Baharudin 6 4 0 5 0 2 4 1 0 7 7 8 0 0 0 9 Nasita 01-Jul-1978 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

115 22-Sep-2022 Ilham 6 4 0 5 0 2 4 4 0 9 8 5 0 0 0 3 Siti puliati 04-Sep-1985 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 0

116 23-Sep-2022 Samsumar 7 3 0 8 0 9 6 1 0 7 8 9 0 0 0 1 Jumriati 21-Jul-1989 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

117 23-Sep-2022 Lanyanya 7 3 7 2 0 3 4 2 0 2 2 8 1 0 0 0 Rosnidar 02-Jun-1981 Daeng toba 3 1 0 0 2 1 0 0 1 0 0 0

118 28-Sep-2022 Suriadi 6 4 0 5 0 2 4 2 0 1 8 9 0 0 0 1 Ningsih 02-Jan-1989 TVRI 3 1 0 0 2 1 0 0 1 0 0 0

119 28-Sep-2022 Jeri Gregorius 5 3 0 7 0 9 5 3 0 4 8 9 0 0 0 1 Paulina E 13-Apr-1984 gang toba 3 1 0 0 2 1 0 0 1 0 0 0

120 30-Sep-2022 Jusman 6 4 0 5 0 2 5 6 0 7 9 2 0 0 0 3 Sabariah 16-Jul-1992 pasar baru 3 0 0 0 4 1 0 0 1 0 0 0

121 01-Oct-2022 Sultan 6 4 0 5 0 9 5 2 1 0 8 1 0 0 0 1 Hasnawati 12-Oct-1981 Pesantrenn 3 0 0 0 6 1 0 0 1 0 0 0

122 01-Oct-2022 Bernadus 6 4 0 5 0 1 4 7 0 1 8 6 0 0 0 1 DIANA 07-Jan-1986 Pesantren 3 0 0 0 4 1 0 0 1 0 0 1

123 01-Oct-2022 Muliadi 6 4 0 5 0 2 4 1 0 3 9 2 0 0 0 1 Irmayana 10-Mar-1992 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

124 01-Oct-2022 Serman 7 3 1 5 1 1 6 0 0 8 9 4 0 0 0 5 Verawati 20-Jun-1994 pasar baru 1 1 1 0 3 1 0 0 1 0 0 0

125 01-Oct-2022 Samsumar 7 3 0 8 0 9 6 1 0 7 8 9 0 0 0 1 Jumriati 21-Jul-1989 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

126 04-Oct-2022 Rudianto 6 4 0 5 0 2 6 5 0 2 8 9 0 0 0 2 Syahriani 25-Feb-1989 mohammad hatta 2 1 0 0 8 1 0 0 1 0 0 0

127 04-Oct-2022 Syarifuddin 6 4 0 5 0 2 6 6 0 6 9 0 0 0 0 1 fitri yanti 23-Jun-1996 manunggal bakti 3 1 0 0 2 1 0 0 1 0 0 0

128 10-Oct-2022 Heri hasbudi 6 5 0 3 0 2 5 0 1 0 7 8 0 0 0 1 Hamsinah 10-Oct-1978 pasar baru 1 1 0 0 3 1 0 0 1 0 0 0

129 10-Oct-2022 Amir 6 4 0 5 0 2 4 5 5 0 4 8 4 0 0 0 Sunarti 05-Apr-1984 pasar baru 3 1 0 0 2 1 0 0 1 0 0 0

130 11-Oct-2022 Lajagung 6 4 0 5 0 2 4 6 0 5 8 5 0 0 0 8 Siti khalia 06-May-1985 Cik di tiro 3 1 0 0 2 1 0 0 1 0 0 0

131 18-Oct-2022 Simon sony 6 4 0 5 0 2 4 8 0 7 8 6 0 0 0 4 Nuraini 08-Jul-1986 mohammad hatta 2 1 0 0 8 1 0 0 1 0 0 0

132 18-Oct-2022 Alimudin 1 8 7 1 1 9 4 6 0 7 8 9 0 0 0 1 Dewi anindri 06-Jul-1989 mohammad hatta 2 1 0 0 8 0 0 1 1 0 0 0

133 21-Oct-2022 Muhammad akbar 6 4 0 5 0 2 5 5 0 8 7 6 0 0 0 5 Norhayati 15-Aug-1976 mandor beddu 3 1 0 0 2 1 0 0 1 0 0 0

134 21-Oct-2022 Darwis 7 3 7 2 0 3 5 0 0 6 8 7 0 0 1 4 Rosna 10-Jun-1987 tien soeharto 3 1 0 0 3 1 0 0 1 0 0 0

135 25-Oct-2022 Baharudin 6 4 0 5 0 2 4 1 0 7 7 8 0 0 0 9 Nasria 01-Jul-1978 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

136 25-Oct-2022 aidil 6 4 0 5 0 2 4 2 0 3 8 7 0 0 0 1 Sulistriya 26-Mar-1987 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 1

137 25-Oct-2022 Jusman 6 4 0 5 0 2 5 6 0 7 9 2 0 0 0 3 Sabariah 16-Jul-1992 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

138 25-Oct-2022 Baharuddin 6 4 0 5 0 2 6 7 1 2 7 5 0 0 0 1 Nurhana ekawati 27-Dec-1975 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 1

139 25-Oct-2022 Ilham 6 4 0 5 0 2 4 4 0 9 8 5 0 0 0 3 Siti puliati 04-Sep-1985 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 1

140 25-Oct-2022 Sumardiansyah 6 4 0 5 0 2 5 0 1 1 9 1 0 0 0 3 Ririn 10-Nov-1991 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 1

141 26-Oct-2022 Muh amir 6 5 0 3 0 2 5 3 0 7 7 7 0 0 0 2 Rosalinda 13-Jul-1977 kampung rambutan 3 0 0 0 4 1 0 0 1 0 0 1

142 27-Oct-2022 Bahar 7 3 7 1 1 0 4 6 0 6 8 0 0 0 0 2 Nurhunaeni 26-Jun-1980 Cik di tiro 3 1 0 0 2 1 0 0 1 0 0 0

143 28-Oct-2022 Edy 7 2 7 1 0 1 6 7 0 3 0 0 0 0 0 2 Siti wirna 07-Mar-2009 Cik di tiro 3 0 0 0 4 1 0 0 1 0 0 1

144 28-Oct-2022 Rizal 6 5 0 3 1 3 5 6 0 9 7 3 0 0 0 1 Jusdiana 16-Sep-1973 porsas 3 0 0 0 4 1 0 0 1 0 0 1

145 28-Oct-2022 Baharuddin 6 4 7 3 0 2 5 5 1 2 8 8 0 0 0 5 Nurindah 15-Dec-1980 kakap 3 0 0 0 4 1 0 0 1 0 0 1

146 31-Oct-2022 Aidil 6 4 0 5 0 2 1 2 0 3 9 8 0 0 0 3 Nurfatihah 02-Mar-1998 gang delima 3 1 0 0 2 1 0 0 1 0 0 0

147 31-Oct-2022 Dominggus 7 3 2 6 1 4 4 8 0 2 0 2 0 0 0 2 Monica Bilo 08-Feb-2002 Lumba-lumba 3 1 0 0 3 1 0 0 1 0 0 0

148 01-Dec-2022 Syarifuddin 7 3 0 2 0 6 6 5 0 5 8 5 0 0 0 2 Suharni 01-Jan-1985 manunggal bakti 2 1 0 0 8 1 0 0 1 0 0 0

149 01-Dec-2022 Muh amri 6 5 0 3 0 2 5 3 0 7 7 7 0 0 0 2 Rosalinda 03-Jul-1977 kampung rambutnn 1 1 0 1 8 1 0 0 1 0 0 0

150 01-Dec-2022 Dedi 6 5 0 3 0 2 5 3 0 6 9 2 0 0 0 1 Ike juniarti 13-Jun-1992 Cik di tiro 3 1 0 0 3 1 0 0 1 0 0 0

151 01-Dec-2022 Muliadi 6 4 0 5 0 2 4 1 0 3 9 2 0 0 0 1 Irma yana 10-Mar-1992 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

152 01-Dec-2022 Irfan 7 6 0 4 0 7 5 1 0 1 9 1 0 0 0 1 Nur aisha 11-Jan-1991 Tien suharto 3 1 0 0 3 1 0 0 1 0 0 0

153 01-Dec-2022 Edy 7 2 7 1 0 1 6 7 0 3 0 0 0 0 0 2 Siti wirna 07-Mar-2000 Cik di tiro 3 0 0 0 4 1 0 0 1 0 0 1

154 01-Dec-2022 Anhar 7 3 1 5 0 5 4 6 0 9 8 6 0 0 0 2 Hasna 06-Feb-1986 lumba lumba 3 1 0 0 3 1 0 0 1 0 0 0

155 01-Dec-2022 Jarwo 6 4 0 5 0 2 4 2 0 5 8 3 0 0 0 4 Jawariah 01-Jan-1978 Cik di tiro 3 0 0 0 4 1 0 0 1 0 0 1

156 01-Dec-2022 Yusuf 6 4 0 5 0 2 7 0 0 5 8 2 0 0 0 2 Fitri 30-May-1982 pasar baru 3 1 0 0 8 1 0 0 1 0 0 0

157 01-Dec-2022 Marno 3 5 0 2 1 6 5 0 0 6 7 7 8 0 0 2 Yati 10-Jun-1977 Imam bonjoll 3 1 0 0 3 1 0 0 1 0 0 0

158 01-Dec-2022 Muc Nuh 6 4 0 5 0 2 6 7 0 2 8 8 0 0 0 2 Hawati 27-Feb-1988 imam bonjol 1 1 1 0 8 1 0 0 1 0 0 0

159 01-Dec-2022 Ferdiansyah 5 3 0 2 2 0 5 4 0 4 8 2 0 0 0 1 Merry namlen 15-May-1984 pasar baru 3 1 0 0 3 1 0 0 1 0 0 0

160 01-Dec-2022 Hidayat 7 2 0 3 0 6 4 1 0 7 9 1 0 0 5 9 Nur milan 27-Jul-1989 pasar baru 3 1 0 0 3 1 0 0 1 0 0 0

161 12-Dec-2022 Amir 7 3 7 2 0 3 5 2 2 0 8 9 8 0 0 0 Alfiana 12-Aug-1998 tien soeharto 1 0 0 1 4 1 0 0 1 0 0 0

162 12-Dec-2022 Adi 6 5 0 3 1 3 5 6 0 9 7 3 0 0 0 1 Jusdiana 16-Sep-1973 porsas 3 1 0 0 3 1 0 0 1 0 0 0

163 20-Dec-2022 Suriadi 6 4 0 5 0 2 4 9 0 7 9 7 0 0 0 3 Ningsy 09-Apr-1997 pasar baru 3 1 0 0 3 1 0 0 1 0 0 0

164 20-Dec-2022 Baharuddin 6 4 0 5 0 2 4 1 0 7 7 8 0 0 0 9 Nasria 01-Jul-1978 pasar baru 3 0 0 0 4 1 0 0 1 0 0 0

165 24-Dec-2022 Forka ariin 7 4 0 3 2 7 4 7 0 7 9 3 0 0 0 3 Wa ode aju 07-Jul-1993 manunggal bakti 1 1 1 0 8 1 0 0 1 0 0 0

166 29-Dec-2022 Abu alias 6 4 0 5 0 2 4 5 0 8 8 4 0 0 0 1 rosmiati 05-Aug-1984 porsas 3 1 0 0 3 1 0 0 1 0 0 0

167 30-Dec-2022 Edy 7 2 7 1 0 1 6 7 0 3 0 0 0 0 0 2 Siti wirna 07-Mar-2000 Cik di tiro 3 0 0 0 4 1 0 0 1 0 0 1

168 30-Dec-2022 Bernadus 6 4 0 5 0 1 4 7 0 1 8 6 0 0 0 1 Dina 07-Jan-1986 Pesantren 3 0 0 0 4 1 0 0 1 0 0 1

169 30-Dec-2022 Baharuddin 6 4 7 3 0 2 5 5 1 2 8 8 0 0 0 5 Nur indah 15-Dec-1980 gang kakap 3 0 0 0 4 1 0 0 1 0 0 1

170 30-Dec-2022 Baharuddin 6 4 0 5 0 2 6 7 1 2 7 5 0 0 0 1 Nurhana ekawati 27-Dec-1975 tien soeharto 3 0 0 0 4 1 0 0 1 0 0 1

171 30-Dec-2022 Anwar 7 3 7 2 0 4 5 1 0 1 9 2 0 0 0 3 Siska 01-Jan-1996 Cik di tiro 3 0 0 0 4 1 0 0 1 0 0 1

172 30-Dec-2022 Jusman 6 4 0 5 0 2 5 6 0 7 9 2 0 0 0 3 Sabariah 16-Jul-1992 pasar baru 3 0 0 0 4 1 0 0 1 0 0 1

1) Keterangan Kode

STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi

2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA CENTANG (V)
1. Petugas Entri Lamp.R/I/KB/20
Data LAMPIRAN R/I/KB/20 Lembar 6

1 2 3 4 5 6
6 5 0 3 0 2 2 Bulan : 2022
NAMA FASKES/ PKM NUNUKAN TIMUR 7 8 9 10 11 V
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

RINGKASAN HASIL PELAYANAN KB

PESERTA KB BARU (PB) PESERTA KB ULANGAN PELAYANAN KASUS

PEMBERIAN
PEMBERIAN INFORMED PB DAN KESERTAAN JKN INFORMED CONSENT
METODE
NO. CONSENT (Untuk Peserta KB
KONTRASEPSI
(Untuk PB) PB PASCA PB PASCA Ulangan) PELAYANAN ULANG KOMPLIKASI BERAT
GANTI CARA PENCABUTAN KEGAGALAN
PERSALINAN KEGUGURAN
PB JKN PB NON JKN TOTAL PB

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
2 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
3 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
4 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
5 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
6 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
7 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
8 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
9 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
10 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
11 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
12 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
13 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
14 KONDOM 0 0 0 0 0 0 0 0 1 0 0
15 SUNTIKAN 1 1 0 1 1 0 0 0 0 0 0
16 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
17 PIL 0 0 0 0 0 0 0 0 1 0 0
18 PIL 0 0 0 0 0 0 0 0 1 0 0
19 PIL 0 1 0 1 1 0 0 0 0 0 0
20 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
21 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
22 KONDOM 0 1 0 1 1 0 0 0 0 0 0

JUMLAH 14 27 0 27 22 0 84 12 130 2 2 0

03 - NUNUKAN , 02-January-2023
Pimpinan Faskes KB/Jaringan/Jejaring*

dr. Eka Aprina Lestrai

( .................................................................................................)
198504232014122001

NIP/NRP
* Coret yang tidak perlu