BALITA

PEREMPUAN
LAKI-LAKI
ANAK KE-

NO. KK
TTL
NO

NIK
(1) (2) (3) (4) (4) (5) (6)
1 1 BANDUNG 17-02-2019 1 3278060502180000 3278061702190002
2 2 TASIKMALAYA 10-07-2018 1 3278061201120004 3278065007180004
3 1 TASIKMALAYA 17-08-2016 1 3278062712100060 3278061708160002
4 1 TASIKMALAYA 26-09-2019 1 3278062008180009 3278062609190002
5 3 TASIKMALAYA 09-12-2018 1 327806060602090012 3278060912180002
6 1 TASIKMALAYA 12-02-2016 1 3278063108160002 3278065202160001

7 2 TASIKMALAYA 06-07-2016 1 3278062608160001 3206374607160001

8 2 TASIKMALAYA 12-03-2017 1 3278062611070009 3278061203170001
9 1 TASIKMALAYA 29-03-2019 1 3278060406180011 3278062903190001
10 2 TASIKMALAYA 16-04-2019 1 3278062801190000 3278061604190002
11 2 TASIKMALAYA 23-01-2019 1 3278062802190006 3278062301190001
12 2 TASIKMALAYA 29-09-2019 1 3278062505070013 3278062909190002

13 2 TASIKMALAYA, 03-12-2015 1 3278062702140009 3278064312150001

14 2 TASIKMALAYA, 10-01-2018 1 3278060507120005 3278061001180002
15 1 TASIKMAALYA, 18-06-2019 1 3278060905180012 327806580619002
16 1 TASIKMALAYA, 28-12-2016 1 327806030816005 327806812160001
17 1 TASIKMALAYA, 04-12-2014 1 3278060210120002 3278064212140002
18 2 TASIKMALAYA, 27-11-2016 1 3278061612100023 3278066711160002
19 1 TASIKMALAYA, 25-10-2018 1 3278060108180011 3278062510180001
20 1 1
21 1 TASIKMALAYA, 27-11-2018 1 327806060218006 3278062711180002
22 1 TASIKMALAYA, 01-06-2017 1 3278061003160007 3278064106170003
23 1 TASIKMALAYA, 02-07-2014 1 3278060606140004 3278064207140001
24 2 TASIKMALAYA, 16-03-2018 1 3278062501110010 3278061603180002
 25 3 TASIKMALAYA, 16-05-2015 1 3278051201110026 3278061605150002
26 2 TASIKMALAYA, 11-01-2014 1 3278061111100006 32780611O1140001
27 2 TASIKMALAYA, 31-03-2018 1 32780660408140001 3278067103180001

28 1
29 1
30 1
31 1
32 1
33 1
34 1

35 2 TSM,10-12-19 1 3278061102110006
36 2 TSM,9-07-2019 1 3278063012120003
37 3 TSM,17-07-2019 1 3278062506080112 3278060302720011
38 2 TSM,28-02-2018 1 3278060201180009 3278062802180001
39 4 TSM,23-02-2018 1 327806271210004 3278066302180001
40 2 TSM,17-12-2015 1 3278062707110008
41 1 TSM,16-06-2017, 1 3278061302170009 3278065606170001
42 2 TSM,21-02-2017 1 3278062712100054
43 2 TSM,07-04-2016 1 3278061601100009 3278060704160001
44 3 TSM,08-01-2018 1 3278062102120017 3278064801160002
45 4 TSM,01-10-19 1 3278062910130002
46 3 TSM,09-10-15 1 3278062910130002
47 1 TSM,5-08-2015 1 3278060606140002 3278064508150001
48 TSM,03-02-2018 1 3278060201180009 3278060302150003
49 1
50 1
51 1
52 1
53 1
54 1

28 26

Keterangan :
Kolom 11 : Jika Ayah tidak ada, maka diisikan nama Ibu
Kolom 12 : Jika Ayah tidak ada, maka diisikan NIK Ibu
Kolom 13 : Jika Ayah tidak ada, maka diisikan No. Telp./HP Ibu
 FORMULIR PENCATATAN PEMANTAUAN PERTUMB
SURVEI MAWAS DIRI PRAKTIK KERJA LAPANGAN (PK
UNIVERSITAS BHAKTI KENCANA TASIKMA

AYAH

KEPEMILIKAN BUKU
BB LAHIR
NAMA ANAK

KIA/KMS
2500-4000 gr

NAMA
IMD
<2500 gr

>4000 gr

NIK
(7) (8) (9) (10) (11) (12)
MOCH ALFA RIZKI KURNIA 1 1 1 ARIEP RIZAL HILMAN 3278060601910005
ALFIRA ADEEVA AFSHEEN MYSHA 1 1 1 HENDRI 3278060509840007
ADITIA RAHMAN 1 1 1 MARTIN SUTISNA 3173083103870008
FADHIL FAUZI RASYID 1 1 1 YANA FAUZI 3205071708910003
MUHAMMAD SURYA AL FATIH 1 1 1 SAID 3278061606790010
BINTARI 1 1 1 SUGIH RAHAYU 3278063108160002

MUTIARA INARA RATNASIH 1 1 1 AA MULYANA, SE 3206370201810001

NAUFAL AFKAR 1 1 1 AJAT SUDRAJAT 3278060811820005

AKBAR RIZKY RAMDANI 1 1 1 DIKI RAMDANI 3278060103950012

GHAVIN MALIK AL IRWANA 1 1 1 IMAM IRWANA 3278061905890007

MUHAMMAD AZKI FIRMANSYAH 1 1 1 ADE IRMAN 3206240107840191

M. SYAFIQ SYAHRUL SHAFR 1 1 1 WAWAN GUNAWAN 3278062701630003

ALVIA AZAHRA SABELA 1 1 1 IMAN NUGRAHA 3278102108830002

RIFQI FADHIL IBRAHIM
KANAYA AULIA PUTRI
ANANDI PUTRI
ADE LISA AULIA N
AQILA DINAYA FIRZYAH
AKBAR MUHAMMAD PUTRA B
AISYAH F
M ADITYA ZAENAL MUTTAQIN
RAISYA AULIA AZKADINA
IRMA NUR RAHMAWATI
MUHAMMAD ARSYAD SOFYAN N
1 1 1 AGUS RONI 327806230884005
1 1 1 DONI ROMDONI 3206220107910083
1 1 1 RANDI 327806240680005
1 1 1 EMUH MUHTAR 3278061003920012
1 1 1 FIRMANSYAH 3278060506830020
1 1 1 AWALUDIN GENTUR BINEKAS 3278060610920003
1 1 1
1 1 1 - -
1 1 ARI SAMBARI 3278064106170003
1 SONY SONJAYADI 3207022010890003
1 1 1 YAYAN NURJAMAN 3278061603180002
MUHAMMAD HASBI A 1 1 1 ADE ANWARUDIN 3278061605150002
ADIN RIFKI BARKAH 1 1 1 WARNI JUARNI 3278061101140001
AZIZA RASYIDA ZUHIDA 1 1 IRFAN MAULANA 3278067103180001

ZAHRA 1 1 1
ADITYA 1 1 1 DONI
RISKA 1 1 1
RINA 1 1 1
RAFKA 1 1 1
ARKANA 1 1 1
ALFINO 1 1 1

Mochamad farel 1 1 2 Fauzi 3278061801860005

Arzan 1 1 1 Asep Doni 3278060603890016

M.Irfan 1 1 1 Miming 3278060302720011

Farhan 1 1 2 Guntur 3278061204880008

Lepina 1 1 2 Jeni 3278060607750010

Zilla 1 1 1 Deden 3278062705890012

Naura 1 1 2 Yanto 3278060903910009

Nurma 1 1 1 Habib 3278061809800007

Zaidan 1 1 1 Lukman 3278061704860014

Fika 1 1 1 Masrul 3278061009800023

Rafa 1 1 1 Aceng 3278061602830006

Syakira 1 1 1 Aceng 3278061602830006

Salwa 1 1 1 Iman 3278060807870009

M.Febriansyah 1 1 1 Guntur 3278061204880008

SASKIYAPUTRI 1 1 1
SITI AINUR R 1 1 1
MUHAMAD ALFIANDO F 1 1 1
FATHIR KYAR 1 1 1
DINDA SAFITRI 1 1 1
RAFKA SYAKUILJ 1 1 1

2 52 0 53 55
TUMBUHAN BALITA
AN (PKL) KOMUNITAS
IKMALAYA

AYAH STUNTING

BB (KG) PB / TB (CM)

TGL PENGUKURAN

CARA UKUR
ALAMAT
NO. TLP

SGT KURUS

NORMAL

NORMAL
RW

SANGAT
PENDEK

PENDEK
GEMUK
RT

KURUS
(13) (14) (15) (16) (17) (18) (19) (20)
KUDANG 2 3 8 JANUARI 2020 1 0 1
KUDANG 2 3 8 JANUARI 2020 1 0 1
KUDANG 2 3 8 JANUARI 2020 1 1 1
KUDANG 2 3 8 JANUARI 2020 1 0 1
KUDANG 2 3 8 JANUARI 2020 1 0 1
KUDANG 2 3 8 JANUARI 2020 1 1 1

SINDANG SARI 4 3 9 JANUARI 2020 1 1 1

SINDANG SARI 4 3 9 JANUARI 2020 1 1 1
SINDANG SARI 4 3 9 JANUARI 2020 1 0 1
SINDANG SARI 4 3 9 JANUARI 2020 1 0 1
SINDANG SARI 4 3 9 JANUARI 2020 1 0 1
SINDANG SARI 4 3 9 JANUARI 2020 1 0 1
0
KP KUDANG 1 3 12/19/2019 1 1 1
KP KUDANG 1 3 12/19/2019 1 1 1
KP KUDANG 1 3 12/19/2019 1 1 1
KP KUDANG 1 3 12/19/2019 1 1 1
KP KUDANG 1 3 12/19/2019 1 1 1
KP KUDANG 1 3 12/19/2019 1 1 1
KP KUDANG 1 3 12/19/2019 1 1 1
1 3 1 1 1
- SINDANGSARI 5 3 12/19/2019 1 1
SINDANGSARI 5 3 12/19/2019 1 1 1
SINDANGSARI 5 3 12/19/2019 1 1 1
SINDANGSARI 5 3 12/19/2019 1 1 1
SINDANGSARI 5 3 12/19/2019 1 1 1
SINDANGSARI 5 3 12/19/2019 1 1 1
SINDANGSARI 5 3 12/19/2019 1 1 1

4 3 12/19/2019 1 1 1
4 3 1 1 1
4 3 1 1 1
4 3 1 1 1
4 3 1 1 1
4 3 1 1 1
4 3 1 1
0
Kudang 3 3 1/9/2029 1 0 1
Kudang 3 3 1/9/2020 1 0 1
Kudang 3 3 1/9/2020 1 0 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 0 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 1 1
Kudang 3 3 1/9/2020 1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1 1

0 4 48 1 42 1 7 45
 ASI EKSKLUSIF VITAMIN A

UMUR 0 BLN

UMUR 1 BLN

UMUR 2 BLN

UMUR 3 BLN

UMUR 4 BLN

UMUR 5 BLN

FEBRUARI

AGUSTUS
(21) (22) (23) (24) (25) (26) (27) (28)
1 1 1
1 1 1
1 1 1
1
1 1 1
1 1 1

1 1 1

1 1

1 1

1 1
0 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1 1 1 1 1
1
1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1

1 1 1
1 1 1
1 1 1
1 1 1
1 1 1
1 1

0 0 0
1 1 1
1 1 1
0 0 0 0 0 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1
1 1 1
1 1
1 1 1
1 1 1
1 1 1
1 1 1
25 25 25 23 22 43 47 43