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FORMULIR LAPORAN RUTIN BULANAN IMUNISASI

PUSKESMAS : DANA MULYA


BULAN : JULI
TAHUN : 2023

IMUNISASI RUTIN
SASARAN IMUNISASI DASAR (BAYI 0 - 11 BULAN ) BADUTA 18 - 24 BULAN IMUNISASI WUS
RUTIN
CAMPAK CAMPAK
No Nama Desa / kel BAYI BADUTA BUMIL HBO BCG POLIO 1 DPT 1 POLIO 2 PCV 1 RV 1 DPT 2 POLIO 3 PCV 2 RV 2 DPT 3 POLIO 4 IPV 1 RV 3 IPV 2 IDL PCV 3 DPT 4 LENGKAP Td Td Td Td
1 2
(BAYI &
L P L P P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P BADUTA) 1 2 3 4

1 SUMBER REJEKI 10 8 17 16 20 2 1 2 1 2 1 0 2 0 2 0 2 0 0 2 2 2 2 2 2 0 0 2 4 2 4 2 4 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 2

2 DANA MULYA 10 8 19 17 20 1 2 1 2 1 2 0 2 0 2 0 2 0 0 1 0 1 0 0 1 0 0 2 1 2 1 2 1 0 0 0 0 0 0 0 0 0 0 1 2 0 3 1 0 0 3

3 NUNGGAL SARI 10 10 21 20 23 1 0 1 0 1 0 1 0 1 0 1 0 0 0 1 2 1 2 1 2 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 2 3 0 0 0 1

4 SUMBER MULYA 10 8 14 13 20 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 4 0 4 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 3

5 WANA MUKTI 9 10 19 19 20 0 1 0 1 0 1 2 0 2 0 2 0 0 0 2 1 2 1 2 1 0 0 3 2 3 2 4 0 0 0 1 0 1 0 2 0 0 0 0 0 0 0 0 0 0 1

6 RAWA BANDA 10 10 21 16 23 1 1 1 1 1 1 2 2 2 2 2 2 0 0 4 0 4 0 4 0 0 0 1 0 1 0 0 0 0 0 2 2 2 2 4 0 0 1 3 1 3 4 2 0 0 2

7 RUKUN MAKMUR 9 10 20 21 20 1 1 1 1 1 1 2 1 2 1 2 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 2 1 2 5 0 0 0 0 0 0 0 0 0 0 1

8 BUDI ASIH 10 8 21 22 20 3 2 3 2 3 2 0 2 0 2 0 2 0 0 0 1 0 1 0 1 0 0 1 1 1 1 2 1 0 0 2 0 2 0 2 0 0 1 1 2 1 3 1 0 0 2

9 MAJATRA 10 10 18 19 22 2 2 2 2 2 2 0 1 0 1 0 1 0 0 1 0 1 0 1 0 0 0 0 2 0 2 0 2 0 0 1 1 1 1 2 1 0 1 2 0 1 3 0 0 0 2

10 WONOSARI 10 9 19 20 20 0 0 0 0 0 0 3 0 3 0 3 0 0 0 0 1 0 1 0 0 0 0 1 1 1 1 2 1 0 0 1 0 1 0 1 0 0 3 1 3 0 3 1 0 0 3

11 PUSKESMAS 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

98 91 189 183 208 11 11 11 11 11 11 10 10 10 10 10 10 0 0 12 7 12 7 11 7 0 0 16 12 16 12 19 10 0 0 7 6 8 5 17 1 0 6 8 9 7 19 6 0 0 20


TOTAL
189 372 208 22 22 22 20 20 20 0 19 19 18 0 28 28 29 0 13 13 17 1 14 16 19 6 0 0 20
IMUNISASI RUTIN
WUS
Td

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