Lampiran 3

FORMULIR PEMANTAUAN PERTUMBUHAN BALITA DI POSYANDU

Provinsi : LAMPUNG Nama Posyandu : MELATI

Kabupaten/Kota : LAMPUNG TIMUR Bulan :
Puskesmas/Kecamatan : BATANGHARI Tahun :
Desa/Kelurahan : BANARJOYO

Berat Badan
Jenis No Kartu NIK (Nomor Induk
No Anak Ke Tanggal Lahir Kelamin Nama Anak (BB) Lahir
Keluarga Kependudukan) (Kg)

(1) (2) (3) (4) (5) -6 (7) (8)

1 2 18/07/2018 P 1807061807180003 MUTSANNA AL-HARIS 2,9
2 1 13/07/2018 P 1807065307180001 KARINA LUTFATUL H 2,5
3 2 17/06/2018 L 1807061706180001 MOH ALFATIH 2,4
4 2 18/07/2018 P 1807061807180002 CANDY VERORA 3,1
5 2 7/10/2018 P 1807065007180001 ANIS ADILA 2,6
6 1 26/04/2018 P 1807066604180001 AFIYA GHINA F. 3,4
7 1 20/03/2018 L 1807062003180002 MOH. ASROFIL AKMAL 2,6
8 1 20/03/2018 L 1807062003180001 RAFARDAN HASROMO 2,9
9 1 2/5/2018 L 1807060502180002 ZUBAIR MUZZAMIL 3,0
10 1 25/01/2018 P 1807066501180001 MIKAYLA SIBITA 2,9
11 1 19/11/2017 P 1807065911170001 AQILA RIZKI 2,8
12 1 19/11/2017 P 1807065911170001 ASYIFA KHAIRUNISA 2,4
13 3 5/11/2017 P 1807064511170003 ARSYLA NAURA N. 2,3
14 2 9/27/2017 P 1807066709170001 EHELCIA AFIQA 3,2
15 2 8/2/2017 L 1807060208170002 PUTRA KENZI P. 3,1
16 2 6/18/2017 L 1807061806170001 GIBRAN REZEQ 3,0
17 2 5/31/2017 P 1807067105170001 ZULVIA RANADANIA 3,4
18 1 3/23/2017 L 1807062303170001 DAFA RAFIF ARKAN 3,3
19 1 2/9/2017 L 1807060902170001 ABHI EFANUR IQBAL 3,5
20 1 2/3/2017 P 1807064302170001 ARLIN MEDINA TANTRI 3,2
21 1 12/19/2016 L 1971061912160001 ALVIN KURNIAWAN 3,6
22 1 27/12/2016 P 1807066712160001 ADELIA FAHRANISA 2,7
23 1 8/20/2016 L 1807062008160002 FIRLY ADIYAKSA 2,9
24 2 10/4/2016 L 1807060410160001 NAWAB HAMDAN S. 2,8
25 1 6/10/2016 P 1807064610160002 AURA MAULIDA 3,1
26 1 25/09/2016 L 1807062509160001 MOH. ZAFRAN ABDILAH 3,2
27 1 3/23/2017 L 1807062303170001 MOH. DAFA FATURAHMAN 2,9
28 1 5/18/2016 L 1807061805180001 ALIF DWIKA PUTRA 2,4
29 3 24/05/2016 L 1807062405160001 DESWA DWI SAPUTRA 2,4
30 1 4/1/2015 L 1807060104150001 MOH. IMAM RIDHO 2,8
31 2 8/4/2016 P 1807064804160002 ADIVA AYUNDIA INARA 3,5
 32 1 4/12/2016 P 1807061204160003 ALEXI 3,1
33 1 12/3/2016 P 1807065203160001 GANDIS LUHUNG 2,6
34 1 5/2/2016 P 1807064205160002 ALIA MUNAWAROH 2,7
35 2 13/01/2016 P 1807065301160002 AISYA ALIFA 3,1
36 2 22/1/2016 P 1807066201160002 LATIFATUN NIKMAH 3,3
37 2 12/1/2015 P 1807064112150001 DELLA FIRNANDA 3,5
38 2 12/1/2015 L 1807060112150001 DAVA FIRNANDO 2,3
39 2 9/3/2015 P 1807064309150001 ARAJWA NADIA 2,2
40 2 8/3/2015 P 1807061308150001 JAMALUDDIN 2,7
41 2 8/3/2015 P 1807065308150002 JANALIYIAH 3,6
42 3 3/6/2015 L 1807060306150001 AZKA GILANG PRATAMA 3,1
43 3 9/8/2015 P 1807064908150002 SYAKILA ATMARINI 3,0
44 1 4/7/2015 L 1807060704150003 AZKA ALDRIK ABQORI 3,0
45 1 3/7/2015 L 1872010703150001 MOH. ZAKI ISHAM 2,6
46 1 11/16/2014 P 1807061611140002 GEIZA DIVA 2,9
47 1 2/16/2016 L 1807061602160002 ANAN FARHAN 3,3
48 2 12/29/2014 P 1807066912140001 BILQIS ASNI SAFIRA 3,2
49 2 9/30/2014 P 1807067009140001 BILQIS AMANDA PUTRI 2,4
50 1 9/14/2014 L 1807061409140001 FARHAN ARFINDO 2,6
51 2 9/7/2014 P 1807064709140001 VERLIN AZAHRA 2,8
52 1 9/7/2014 L 1807060907140001 MOH. ABIDZAR 3,6
53 2 7/2/2014 P 1807064207140001 ARIN ZULIA A. 3,8
54 1 5/22/2014 P 1807066205140001 MEIZA FAHRADISA 2,6
55 2 3/12/2014 L 1807061203140001 REZA AL-KAUTSAR 2,7
56 1 6/29/2014 P 1807066906140002 AQILA AL-FATH 3,1
57 2 11/4/2018 P AYRA MISHA ANJANI 2.5
58 1 1/18/2019 P RAISA SABRINA F 3.1
59 3 9/25/2018 L 1807062509180001 MOH SAFTA ASRI N 3
60 2 6/16/2018 P 1807065606180001 ARUM AZZAHWA 3.2

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
Kepemilikan IMD
Buku 1=YA, No Tlp/ Tgl
KIA/KMS 2=Tidak Nama Ayah NIK Ayah Alamat RT RW
HP Ayah Pengukuran
1=YA,
2=Tidak

(9) (10) (11) -12 (13) (14) (15) (16) (17)

1 1 SAHIRIN Banarjoyo 2/12/2019
1 1 SUHARTONO Banarjoyo 2/12/2019
1 1 MINARKO 1807061001840004 Banarjoyo 2/12/2019
1 1 CIPTO HANDOKO Banarjoyo 2/12/2019
1 1 ANDRI Banarjoyo 2/12/2019
1 1 FEBRI HERIYANTO Banarjoyo 2/12/2019
1 1 RAHMAT Banarjoyo 2/12/2019
1 1 FITRAH HASTOMO Banarjoyo 2/12/2019
1 1 FEBRIYANTO Banarjoyo 2/12/2019
1 1 TIAS Banarjoyo 2/12/2019
1 1 AFRIZAL Banarjoyo 2/12/2019
1 1 MUSTAR AMIN Banarjoyo 2/12/2019
1 1 MARYONO Banarjoyo 2/12/2019
1 1 RUDIYANTO Banarjoyo 2/12/2019
1 1 ALEX Banarjoyo 2/12/2019
1 1 RISMANTO Banarjoyo 2/12/2019
1 1 ANWAR SAIDI 1807061406770001 Banarjoyo 2/12/2019
1 1 SUDI Banarjoyo 2/12/2019
1 1 EKO 1807060708790003 Banarjoyo 2/12/2019
1 1 BAYU 1807063101900005 Banarjoyo 2/12/2019
1 1 AAN Banarjoyo 2/12/2019
1 1 SUTOYO Banarjoyo 2/12/2019
1 1 SAIUN Banarjoyo 2/12/2019
1 1 SOFYAN ARIF 1807061407830002 Banarjoyo 2/12/2019
1 1 EKO Banarjoyo 2/12/2019
1 1 KIKI Banarjoyo 12 2/12/2019
1 1 RAJIM Banarjoyo 11 2/12/2019
1 1 SUDIARTO Banarjoyo 2/12/2019
1 1 DEDI Banarjoyo 12 2/12/2019
1 1 EKA SAPUTRA Banarjoyo 2/12/2019
1 1 MANTO Banarjoyo 2/12/2019
1 1 SIDIK PURNOMO Banarjoyo 2/12/2019
1 1 SUBAR Banarjoyo 9 2/12/2019
1 1 SOFIAN ARIF Banarjoyo 11 2/12/2019
1 1 MARIYANTO Banarjoyo 2/12/2019
1 1 KOMARUDIN Banarjoyo 2/12/2019
1 1 NOLA Banarjoyo 2/12/2019
1 1 NOLA Banarjoyo 2/12/2019
1 1 PURNOMO Banarjoyo 2/12/2019
1 1 AHMAD SUJAI Banarjoyo 2/12/2019
1 1 AHMAD SUJAI Banarjoyo 2/12/2019
1 1 SOLIKIN Banarjoyo 2/12/2019
1 1 SUHARMADI Banarjoyo 2/12/2019
1 1 RONI Banarjoyo 2/12/2019
1 1 AGUS S Banarjoyo 2/12/2019
1 1 YULI EFREDI Banarjoyo 2/12/2019
1 1 ASRORI MUJIT Banarjoyo 10 5 2/12/2019
1 1 ASRAT RIANTO 1807062705770002 Banarjoyo 2/12/2019
1 1 EDI Banarjoyo 2/12/2019
1 1 DIAN Banarjoyo 2/12/2019
1 1 HANDOYO Banarjoyo 2/12/2019
1 1 SUDI Banarjoyo 2/12/2019
1 1 SUMADI Banarjoyo 2/12/2019
1 1 PANDI Banarjoyo 2/12/2019
1 1 ANWAR SAIDI Banarjoyo 2/12/2019
1 1 HARY Banarjoyo 2/12/2019
1 1 JONI 1807060808810007 Banarjoyo 2/12/2019
1 1 ENI KUSNIATI Banarjoyo 12 6 2/12/2019
1 1 ASRAT RIANTO 1807062705770002 Banarjoyo 2/12/2019
1 1 MENIK PURWANINGS1807961304880008 Banarjoyo 2/12/2019
 ASI EksklusifF1=YA, 2=Tidak
Panjang Cara Ukur Vitamin A Vitamin A
Badan/ 1=Telenta Februari Agustus
BB (kg) umur 0 umur 1 umur 2 umur 3 umur 4 umur 5
Tinggi ng 1=YA 1=YA
Badan (cm) 2=Berdiri bln bln bln bln bln bln 2=Tidak 2=Tidak

(18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28)
8.5 65 1 1 1 1 1 1 1 1 -
7.3 68 1 1 1 1 1 1 1 1 -
7.5 67 1 1 1 1 1 1 1 1 -
9 66 1 1 1 1 1 1 1 1 -
7.9 65 1 1 1 1 1 1 1 1 -
10.8 74 1 1 1 1 1 1 1 1 -
8.7 75 1 1 1 1 1 1 1 1 -
9.9 77 1 1 1 1 1 1 1 1 -
10 75 2 1 1 1 1 1 1 1 -
10 73 2 1 1 1 1 1 1 1 -
9.8 72 2 1 1 1 1 1 1 1 -
8.5 72 2 1 1 1 1 1 1 1 -
10.3 73 2 1 1 1 1 1 1 1 -
8.9 78 2 1 1 1 1 1 1 1 -
11.8 81 2 1 1 1 1 1 1 1 -
11 79 2 1 1 1 1 1 1 1 -
9.8 78 2 1 1 1 1 1 1 1 -
9.5 81 2 1 1 1 1 1 1 1 -
11.7 87 2 1 1 1 1 1 1 1 -
11.4 106 2 1 1 1 1 1 1 1 -
12.6 85 2 1 1 1 1 1 1 1 -
8.5 86 2 1 1 1 1 1 1 1 -
11 85 2 1 1 1 1 1 1 1 -
13 87 2 1 1 1 1 1 1 1 -
12.7 88 2 1 1 1 1 1 1 1 -
12.3 88 2 1 1 1 1 1 1 1 -
15.8 95 2 1 1 1 1 1 1 1 -
13 92 2 1 1 1 1 1 1 1 -
13.5 89 2 1 1 1 1 1 1 1 -
13.9 104 2 1 1 1 1 1 1 1 -
12 88 2 1 1 1 1 1 1 1 -
14 87 2 1 1 1 1 1 1 1 -
13 88 2 1 1 1 1 1 1 1 -
11.2 88 2 1 1 1 1 1 1 1 -
15 93 2 1 1 1 1 1 1 1 -
11.5 88 2 1 1 1 1 1 1 1 -
13 90 2 1 1 1 1 1 1 1 -
17.2 95 2 1 1 1 1 1 1 1 -
11.7 94 2 1 1 1 1 1 1 1 -
12 94 2 1 1 1 1 1 1 1 -
12.3 94 2 1 1 1 1 1 1 1 -
13.9 99 2 1 1 1 1 1 1 1 -
11.7 91 2 1 1 1 1 1 1 1 -
11.8 99 2 1 1 1 1 1 1 1 -
15 101 2 1 1 1 1 1 1 1 -
19 108 2 1 1 1 1 1 1 1 -
17.2 107 2 1 1 1 1 1 1 1 -
13.5 100 2 1 1 1 1 1 1 1 -
15.2 103 2 1 1 1 1 1 1 1 -
17.2 105 2 1 1 1 1 1 1 1 -
12.2 97 2 1 1 1 1 1 1 1 -
15.8 110 2 1 1 1 1 1 1 1 -
15.5 96 2 1 1 1 1 1 1 1 -
14 100 2 1 1 1 1 1 1 1 -
13 105 2 1 1 1 1 1 1 1 -
20 111 2 1 1 1 1 1 1 1 -
5.8 62 2 1 1 1 1 1 1 1 -
4.2 45 2 1 1 1 1 1 1 1 -
2 1 1 1 1 1 1 1 -
2 1 1 1 1 1 1 1 -
Lampiran 3
FORMULIR PEMANTAUAN PERTUMBUHAN BALITA DI POSYANDU

Provinsi : LAMPUNG Nama Posyandu : LESTARI

Kabupaten/Kota : LAMPUNG TIMUR Bulan :
Puskesmas/Kecamatan : BATANGHARI Tahun :
Desa/Kelurahan : BANARJAYA

Berat
Jenis No Kartu NIK (Nomor Induk
No Anak Ke Tanggal Lahir Kelamin Nama Anak Badan (BB)
Keluarga Kependudukan) Lahir

(1) (2) (3) (4) (5) (6) (7) (8)

1 1 25/02/2018 P 1801066502180001CALISTA NINDYA AZZAHRA 2,3
2 1 3/11/2018 L 1807061103180002YUSUF RAQILA 2,2
3 1 17/06/2014 L 1807061706140002A. GIBRAN RAMADAN 3,1
4 1 5/23/2014 P 1807066305140001ERSA MAIA ZULAIKA 2,9
5 1 6/19/2014 L 1807061906140001ABIYAN LIONEL 3,6
6 1 8/4/2014 P 1807060408140001JESIKA SYAKILLA 2,7
7 2 6/30/2014 P 1807067006140001NAURA ANINDITA 2,8
8 2 28/12/2014 L 1807062812140001IBRAHIM NAZIRAL 2,4
9 1 26/02/2015 P 1807066602150007KRISTABEL 3,1
10 1 1/7/2015 L 1807060701150001ABIZARULLOH WAZALLA M. 3,2
11 1 2/1/2015 L 1807060102150001ABRIZAM REYNAN 2,9
12 2 4/4/2015 P 1807064404150001NADIRA TIFANI 2,6
13 1 4/11/2015 L 1807061104150001NICO WILIAM 2,9
14 1 9/7/2015 P 1807064907150004INTAN 2,8
15 3 7/22/2015 P 1807066207150001NAFILA SAFA AZZAHRA 3,6
16 1 11/10/2014 P 1807061211140002IYAS WIDYA 3,1
17 1 12/25/2015 L 1807062512150001ASIAM KHOIRUL ANAM 3,2
18 1 5/3/2016 L 1807064305160001SHANG HIYANG FARASTA 3,7
19 1 14/01/2016 L 1807061401160001ASKHA RASYID 2,1
20 1 2/1/2016 L 1807060201160002BRAMANTIO FATHUL A. 2,7
21 1 2/18/2016 L 1807061802160001RIZKI ALDO SAPUTRA 2,8
22 2 2/12/2016 L 1807061202160001IRFAN ASSRAF ZAFFRAN 2,5
23 2 6/9/2016 L 1807060906160001DANISH ALFAHRIZZI 3,0
24 2 18/09/2016 P 1807065808160001CAHYASIA AGUSTIN 3,1
25 1 8/13/2016 P 1807061308160001ARDANTA FAIZA 3,1
26 1 9/15/2016 P 1807065509160003RAINA RAISYA ARDANI 3,5
27 1 10/13/2016 L 1807061310160001REYNAN FAHMI FAIZUL I. 2,9
28 1 1/4/2017 L 1807060401170001IZZAM ARKHA WAHYUDI 2,4
29 1 10/4/2016 P 1807060410160001SHAQUEENA KIRANA S. 2,6
30 1 12/9/2016 P 1807064912160001ALZENA AZKIA RUSMALA 2,4
31 1 1/2/2017 L 1807060201170006DAFFA MAULANA 3,5
 32 2 12/24/2016 P 1807066412160001SYAKILA AZZAHRA HAFIZA 3,1
33 1 27/12/2016 P 1807066912160002INDANI SAFIRA ZAHRA 3,1
34 1 4/3/2017 P 1807064304170003AZZIAH NUR FADILLAH 3,2
35 1 8/14/2015 P 1807065408150002NAZWA 3,2
36 1 5/4/2017 L 1807060405170002M. MEYRIFAT ALFARIZKY 3,7
37 1 6/11/2017 L 1807061106170002RAMADANI HAQIQI A. 2,8
38 1 27/05/2017 P 1807066705170001AZELA RAMADANI 2,8
39 1 25/12/2015 P 1807066512150001KEREL 2,3
40 1 6/14/2017 P 1807065406170001AQILA FARIZA MUFIA 2,6
41 2 8/14/2017 L 1807066408170001QIANDRA SHANUM ARGANI 2,5
42 2 11/9/2017 L 1807061109170001KELVIN ARDANA PUTRA 2,9
43 2 8/31/2017 L 1807063108170001ALKA DAWA RAMA 2,4
44 3 12/12/2017 L 1807061212170002FAHREYZA NAZIRUL 2,4
45 1 10/25/2016 P 1807066510160003REVALINA RAYA TAVIZHA 3,1
46 1 21/02/2018 L 1807062102180001AGNAN 3,1
47 1 4/3/2018 P 1807064304180001TALITA DINDA 3,4
48 1 5/23/2018 L 1807062805180002ARKA SAID RAMADAN 2,5
49 1 12/5/2017 L 1807060512170001FIRZA ALFAREZA 2,4
50 1 6/23/2018 P 1807066306180001REVINA ASKAYRA 2,3
51 1 6/24/2018 L 1807062406180001ARIF MAULANA 2,3
52 1 1/12/2018 P 1807065201180001SHARLA ABIDAH SAHIRA 2,9
53 1 11/2/2017 L 1807060211170001ARSYA DAVINO MORATA 2,6
54 2 12/4/2017 L 1807061204170001SYAMIL HISYAM ALFARIQ 3,1
55 2 29/04/2014 P 1807066904140002JIHAN KAILA 3,1
56 1 10/16/2018 p 1807065610180001ken hena azahra 2,8
57 3 10/12/2018 L 1807061210180001m arsyad siswoyo 2,9
58 2 10/30/2018 L 1807063010180001lugas okta s 3,1

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
Kepemilik IMD
an Buku 1=YA, No Tlp/
KIA/KMS 2=Tidak Nama Ayah NIK Ayah Alamat RT RW
HP Ayah
1=YA,
2=Tidak

(9) (10) (11) -12 (13) (14) (15) (16)

1 1 TUTUR 18070607047680007 Banarjoyo
1 1 GUNAWAN 3603121506830021 Banarjoyo
1 1 ISMAIL Banarjoyo
1 1 SUPARYO Banarjoyo
1 1 ABDULAH Banarjoyo
1 1 AMIN Banarjoyo
1 1 WAWAN Banarjoyo
1 1 SIGIT Banarjoyo
1 1 DWI GRAJITO Banarjoyo
1 1 LIYAN Banarjoyo
1 1 SIYO ANDRIYANTO 1807061204910003 Banarjoyo
1 1 ANGGA APRIAN 180761504850002 Banarjoyo
1 1 WINARNO 1807052606830004 Banarjoyo
1 1 MUSLIM TIAR 180706550380002 Banarjoyo
1 1 AHMAD 1807060107920023 Banarjoyo
1 1 HARIS SETIADI 1807063011850001 Banarjoyo
1 1 EKO YULIYANTO 1807060102100020 Banarjoyo
1 1 PUPUT Banarjoyo
1 1 IWAN 1807062006910010 Banarjoyo
1 1 YUNIZAR 1807060706750000 Banarjoyo
1 1 MUJIANTO 1807062706740001 Banarjoyo
1 1 WIYONO Banarjoyo
1 1 SARIMIN Banarjoyo
1 1 YUDI SETIAWAN Banarjoyo
1 1 ARIF 1802230306890000 Banarjoyo
1 1 SUYOTO Banarjoyo
1 1 ARI SUSANTO 1807062502860002 Banarjoyo
1 1 AGUS WAHYUDI 1807062608810004 Banarjoyo
1 1 JEFRI 1807062608830004 Banarjoyo
1 1 WAHYU 1807062606830004 Banarjoyo
1 1 BASUKI 180706503800003 Banarjoyo
1 1 FIRDAUS 1807052302790001 Banarjoyo
1 1 MUSLIM TIAR 180706050380002 Banarjoyo
1 1 TRI PURWANTO 1807061006670002 Banarjoyo
1 1 MUKMIN 1807061001730001 Banarjoyo
1 1 HERU 1807062708860001 Banarjoyo
1 1 CANDRA IRAWAN 1807062304910003 Banarjoyo
1 1 KURNIAWAN Banarjoyo
1 1 ARIF Banarjoyo
1 1 DEDI PRIYATNA 1807061605930002 Banarjoyo
1 1 TRI ADIWIBOWO 1807061805900004 Banarjoyo
1 1 IMAM SAFEI 1807061010930010 Banarjoyo
1 1 ERWIN KURNIAWAN 1807062604820004 Banarjoyo
1 1 AHMAD YULI 1807170612170002 Banarjoyo
1 1 WIDAKIR 1807062503790008 Banarjoyo
1 1 ARIF Banarjoyo
1 1 DWI HANDOKO 1807060105850001 Banarjoyo
1 1 MARNO 1807060310660001 Banarjoyo
1 1 ARIS AFRIZAL 177104070480004 Banarjoyo
1 1 WIDODO 1807060103820003 Banarjoyo
1 1 ERIS 1807062703820002 Banarjoyo
1 1 PRAYOGA Banarjoyo
1 1 KRISTIANTO Banarjoyo
1 1 AGUS IRAWAN Banarjoyo
1 1 DAYAT Banarjoyo
1 1 adi saputra 1807061011940001 Banarjoyo
1 1 purnomo s 1807060705740003 Banarjoyo
1 1 agus rumanto 1807061708770013 Banarjoyo
 ASI EksklusifF1=YA, 2=Tidak
Panjang Cara Vitamin A
Badan/ Ukur
Tgl 1=Telent umur 0 umur 1 umur 2 umur 3 umur 4 umur 5 Februari
Pengukuran BB (kg) Tinggi 1=YA
Badan ang bln bln bln bln bln bln 2=Tidak
(cm) 2=Berdiri

(17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27)
2/4/2019 7.9 68 1 1 1 1 1 1 1 1
2/4/2019 8.6 68 1 1 1 1 1 1 1 1
2/4/2019 16.5 107 1 1 1 1 1 1 1 1
2/4/2019 13.4 99 1 1 1 1 1 1 1 1
2/4/2019 19.5 109 1 1 1 1 1 1 1 1
2/4/2019 16 108 1 1 1 1 1 1 1 1
2/4/2019 22.1 112 1 1 1 1 1 1 1 1
2/4/2019 15.3 103 1 1 1 1 1 1 1 1
2/4/2019 13 99 2 1 1 1 1 1 1 1
2/4/2019 13.2 100 2 1 1 1 1 1 1 1
2/4/2019 13.6 102 2 1 1 1 1 1 1 1
2/4/2019 14.7 103 2 1 1 1 1 1 1 1
2/4/2019 15.5 104 2 1 1 1 1 1 1 1
2/4/2019 22.5 111 2 1 1 1 1 1 1 1
2/4/2019 11.4 90 2 1 1 1 1 1 1 1
2/4/2019 16.5 101 2 1 1 1 1 1 1 1
2/4/2019 11.7 92 2 1 1 1 1 1 1 1
2/4/2019 11.5 89 2 1 1 1 1 1 1 1
2/4/2019 12.5 98 2 1 1 1 1 1 1 1
2/4/2019 12.2 86 2 1 1 1 1 1 1 1
2/4/2019 12.3 89 2 1 1 1 1 1 1 1
2/4/2019 12.7 90 2 1 1 1 1 1 1 1
2/4/2019 13.1 89 2 1 1 1 1 1 1 1
2/4/2019 10.5 85 2 1 1 1 1 1 1 1
2/4/2019 13 89 2 1 1 1 1 1 1 1
2/4/2019 10.2 85 2 1 1 1 1 1 1 1
2/4/2019 10.9 87 2 1 1 1 1 1 1 1
2/4/2019 13.8 89 2 1 1 1 1 1 1 1
2/4/2019 10.2 84 2 1 1 1 1 1 1 1
2/4/2019 14.3 91 2 1 1 1 1 1 1 1
2/4/2019 13.4 88 2 1 1 1 1 1 1 1
2/4/2019 13.6 87 2 1 1 1 1 1 1 1
2/4/2019 13 87 2 1 1 1 1 1 1 1
2/4/2019 9 82 2 1 1 1 1 1 1 1
2/4/2019 12.3 92 2 1 1 1 1 1 1 1
2/4/2019 10.3 82 2 1 1 1 1 1 1 1
2/4/2019 9.8 80 2 1 1 1 1 1 1 1
2/4/2019 10 80 2 1 1 1 1 1 1 1
2/4/2019 12.5 85 2 1 1 1 1 1 1 1
2/4/2019 9.5 80 2 1 1 1 1 1 1 1
2/4/2019 10.5 80 2 1 1 1 1 1 1 1
2/4/2019 9.2 73 2 1 1 1 1 1 1 1
2/4/2019 10 82 2 1 1 1 1 1 1 1
2/4/2019 9 76 2 1 1 1 1 1 1 1
2/4/2019 11.2 88 2 1 1 1 1 1 1 1
2/4/2019 9.5 85 2 1 1 1 1 1 1 1
2/4/2019 7.7 68 2 1 1 1 1 1 1 1
2/4/2019 8.9 71 2 1 1 1 1 1 1 1
2/4/2019 10.8 74 2 1 1 1 1 1 1 1
2/4/2019 7.9 65 2 1 1 1 1 1 1 1
2/4/2019 6.5 65 2 1 1 1 1 1 1 1
2/4/2019 8 67 2 1 1 1 1 1 1 1
2/4/2019 9 77 2 1 1 1 1 1 1 1
2/4/2019 8.5 86 2 1 1 1 1 1 1 1
2/4/2019 14.5 99 2 1 1 1 1 1 1 1
2/4/2019 7 65 2 1 1 1 1 1 1 1
2/4/2019 6.6 67 2 1 1 1 1 1 1 1
2/4/2019 6.9 68 2 1 1 1 1 1 1 1
Vitamin A
Agustus
1=YA
2=Tidak

(28)
-
-
-
-
-
-
-
-
-
-
-
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Lampiran 3
FORMULIR PEMANTAUAN PERTUMBUHAN BALITA DI POSYANDU

Provinsi : LAMPUNG Nama Posyandu : MAWAR

Kabupaten/Kota : LAMPUNG TIMUR Bulan :
Puskesmas/Kecamatan : BATANGHARI Tahun :
Desa/Kelurahan : BANARJAYA

Jenis No Kartu NIK (Nomor Induk Berat Badan

No Anak Ke Tanggal Lahir Kelamin Nama Anak
Keluarga Kependudukan) (BB) Lahir

(1) (2) (3) (4) (5) -6 (7) (8)

1 1 10/08/2018 P 1801066502180001 MAWAR NAJWA CAHYA 3,4
2 1 24/08/2018 L 1807062408180002 ABBAD MALIK AHMAD 2,4
3 1 22/07/2018 P 1807066207180001 SEVANIA NUR HANIFAH 3,1
4 1 6/30/2018 P 1807065007180003 FRALIESHA PUTRI A 2,3
5 1 30/06/2018 P 1807067006180001 KHANZA KHALISA PUTRI 2,8
6 2 19/04/2018 L 1807061904180002 RUZAIN ANWAR 3,1
7 2 4/2/2018 L 1807060204180001 DANIS FATIH RAHMAT 3,1
8 2 3/1/2018 L 1802080103180003 KEVIN RASYA SETIAWAN 3,0
9 2 15/02/2018 P 1807065502180001 HANIN AKIRA MAULANA 2,5
10 2 15/02/2018 L 1807061502180001 HANAN AT-TAQI MAULANA 2,8
11 2 4/11/2017 L 1807065104170001 YUMNA AZKAYRA M 3,6
12 1 02/06/2018 L 1807060602180001 FAEZYA ALFINO F 3,4
13 1 24/12/2017 P 1807066412170002 NAFISA DIVIA A 3,2
14 1 24/08/2015 L 1807062408150004 KIKO ALBIAN 2,3
15 1 23/01/2018 L 1807062301180004 ALBARI GANIYU R 2,4
16 1 13/03/2016 L 1802051303160001 RIDWAN HILMY A 2,4
17 3 18/10/2017 P 1807065810170001 AIRA MIZHA 2,8
18 1 14/10/2017 L 1807061410170001 RAIHAN MUAFI 2,6
19 1 15/11/2017 P 1807066504170001 KEYSA APRILIA 3,6
20 1 11/05/2017 L 1807060511170001 NOVAL ANGGA PRATAMA 3,1
21 1 20/04/2017 L 1807062004170002 RESTU NABIL M 2,6
22 1 21/08/2017 L 1807062108170001 KEMAS ARTHA WARDANU 2,8
23 1 04/12/2017 P 1807045204170003 SALMA APRILIA 2,9
24 2 12/01/2014 P 1802050112140001 HABIB DANISH FAIZAH 3,1
25 2 05/01/2017 L 1807060105170001 M FATTAN AL RIZKI 3,4
26 2 13/05/2017 L 1807061305170001 PRANAJA RASYA A 3,6
27 2 29/03/2017 L 1807062903170001 ABI FAIZ ALGAZALI 3,0
28 2 26/12/2017 L 1807062612170001 FARHAN SAPUTRA 3,1
29 2 20/12/2016 P 1807062012160003 AYSHA SHAREE FA.D 3,1
30 2 28/01/2017 P 1807066801170001 KANZIA NALA A 2,5
31 3 30/01/2017 P 1807067001170001 NAFISA ARSITA DEWI 2,6
32 3 11/07/2016 P 1807064711160001 AQILA SALSABILA 2,4
33 1 18/04/2015 P 1807061804150002 DEVIKA MUTIARA Y 2,8
34 1 09/11/2014 L 1807062109160003 ABIZAR ALBI P 2,8
35 1 21/09/2016 P 1807062109160002 ASSHIHA KINAN 2,6
36 1 22/09/2016 L 1807062209160001 LUKMAN NUR HAKIM 2,5
37 1 15/06/2016 L 1807061506160002 RAKA MAULANA 2,8
38 1 25/04/2016 P 1807066504160001 ANE FITRI KHOIRIYAH 2,4
39 1 28/03/2016 L 1807062803160001 GIBRAN CAHYA P 3,1
40 1 24/02/2016 L 1807062402160001 VIRZAN RASKA ADRIAN 3,6
41 1 17/02/2016 L 1807061702160001 M AQIEL PRATAMA 3,1
42 1 20/12/2015 L 1807062012150001 RENAN FIDELIO 3,5
43 1 04/05/2016 P 1807064504160002 AUREL SINEKA 3,7
44 1 24/09/2015 L 3302200910150001 AZIZ AQILA PRADIPTA 3,2
45 1 08/09/2015 P 1807066409150001 ALYA NABILAH 3,1
46 1 08/09/2015 L 1807060908150001 M DAMAR ASSIDIQ 2,7
47 1 25/07/2015 L 1807062507150001 ASKA ALDRIK A 2,4
48 3 02/07/2015 L 1872040207150003 REHANSYAH DIRGANTARA 2,4
49 1 08/08/2016 P 1807064808160002 FITRI RAHMA KAMILA 2,7
50 1 08/08/2016 P 1807064808160002 YULIA RAHMA KAMILA 3,1
51 1 30/05/2015 L 1807067005150002 DAMIA ALESYA MAULANA 3,8
52 2 08/06/2015 P 1807060806150001 ASKA ANUNG 3,6
53 1 21/05/2015 P 1807061604150001 KAYLA MELA SEVANIA 2,7
54 1 16/04/2015 L 1807061604150001 FARID AKBAR NUR D 2,6
55 1 18/04/2015 L 1807061804150001 GATRA HUSNAN 2,9
56 1 07/02/2015 L 1807060702150001 AHMAD FARID M 3,8
57 1 22/12/2014 L 1807062212140002 GILANG AYASHY 3,7
58 2 22/12/2014 P 1807056212140001 KAELA AFIFAH 3,1
59 2 08/11/2014 L 1807060811140003 WIRA BUMI SUJANA 2,4
60 2 11/11/2014 L 1807061111140001 MICO Y 2,7
61 2 14/10/2014 L 1807061410140002 ALBI LUTHFI FAHRI 2,8
62 2 01/07/2014 L 1807060107140003 ABDUSSALAM ARRODHIN 2,7
63 2 20/07/2014 L 1807062007140001 IQBAL 2,9
64 2 12/05/2014 P 1807065205140005 CHUT QUEENERA 3,5
65 2 11/03/2014 L 1807061103140002 MIFTAHUL KHOLIS 2,5
66 1 13/03/2014 L 1807061303140002 VINO PRASETYO 2,9
67 1 30/08/2016 P 1807066008160001 FAQIHA AYUDIA KARLA 3,0
68 3 23/11/2017 P 1807066311170001 FATHIRA ARSYLA YASMIN 3,1
69 1 12/25/2018 p 1807066512180003 ANINDIRA MERLIANA P 2.6
70 1 1/13/2019 L 187201180190001 ARFAN HAFIDZ A.F 3.1
71 1 1/20/2019 L ABIDZAR KHALID F 2.8
72 2 1/10/2019 P ALIKA 3.2
73 1 11/3/2018 P ERVINA LATIFAH S 3.3
74 1 10/4/2018 L 1807060410180001 M RAJENDRA ARSABIAN 2.5
75 1 10/10/2018 L ALGIS GILANG FITER P 2.5
76 3 11/14/2018 L WIRA MAHENDRA 2.9
 77 1 12/16/2018 L RIZKY YOFA ERNANDO 3.1

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
Kepemilikan IMD
Buku 1=YA, No Tlp/ Tgl
KIA/KMS 2=Tidak Nama Ayah NIK Ayah Alamat RT RW
HP Ayah Pengukuran
1=YA,
2=Tidak

(9) (10) (11) -12 (13) (14) (15) (16) (17)

1 1 MARWANTO Banarjoyo 2/8/2019
1 1 NURUL RAHMAN A Banarjoyo 2/8/2019
1 1 SUKADI Banarjoyo 2/8/2019
1 1 MUJIANTO 1807060806800003 Banarjoyo 2/8/2019
1 1 WIDODO Banarjoyo 2/8/2019
1 1 TRIANTO 1807062107730002 Banarjoyo 2/8/2019
1 1 ERWIN SYAHPUTRA Banarjoyo 2/8/2019
1 1 YONGKI SETIAWAN 1802080606920003 Banarjoyo 2/8/2019
1 1 RISKA Banarjoyo 2/8/2019
1 1 RISKA Banarjoyo 2/8/2019
1 1 DORES MANSYAH 1611021610930001 Banarjoyo 2/8/2019
1 1 SUMARDI Banarjoyo 2/8/2019
1 1 EDI SUSANTO 1807061009770002 Banarjoyo 2/8/2019
1 1 TRIAN GATAMA 1807060606890004 Banarjoyo 2/8/2019
1 1 RENDI RENALDI 1807061001950004 Banarjoyo 2/8/2019
1 1 SUHERLAN Banarjoyo 2/8/2019
1 1 SUPRISNUS HANTORO Banarjoyo 2/8/2019
1 1 SARINO Banarjoyo 2/8/2019
1 1 TRIANTO Banarjoyo 2/8/2019
1 1 PITOYO Banarjoyo 2/8/2019
1 1 UNTUG WIDODO Banarjoyo 2/8/2019
1 1 AGUS SUMANTO Banarjoyo 2/8/2019
1 1 PRAYOGA Banarjoyo 2/8/2019
1 1 SUHERLAN Banarjoyo 2/8/2019
1 1 SUWARDI Banarjoyo 2/8/2019
1 1 HENDRI PRIYANTO Banarjoyo 2/8/2019
1 1 BAYU EKA Banarjoyo 2/8/2019
1 1 HENDRA RUKMANA 1807061602910001 Banarjoyo 2/8/2019
1 1 HANTO Banarjoyo 2/8/2019
1 1 EKO RIKI S Banarjoyo 2/8/2019
1 1 IMAM S Banarjoyo 2/8/2019
1 1 SUKARYANTO Banarjoyo 2/8/2019
1 1 FERIZA INGKAN Banarjoyo 2/8/2019
1 1 TONI Banarjoyo 2/8/2019
1 1 SETIO JATMIKO 1872042907880002 Banarjoyo 2/8/2019
1 1 HAMDAN Banarjoyo 2/8/2019
1 1 PONIDI Banarjoyo 2/8/2019
1 1 TOTOK Banarjoyo 2/8/2019
1 1 TEGUH TRI H Banarjoyo 2/8/2019
1 1 YADI Banarjoyo 7 4 2/8/2019
1 1 DENI ARYADI Banarjoyo 2/8/2019
1 1 TRIONO Banarjoyo 7 4 2/8/2019
1 1 SUSIANTO Banarjoyo 2/8/2019
1 1 SUIS Banarjoyo 2/8/2019
1 1 MUJIANTO Banarjoyo 7 4 2/8/2019
1 1 RAFIQ Banarjoyo 5 4 2/8/2019
1 1 RIO Banarjoyo 5 4 2/8/2019
1 1 FAUZY Banarjoyo 7 4 2/8/2019
1 1 TEGUH Banarjoyo 8 4 2/8/2019
1 1 TEGUH Banarjoyo 8 4 2/8/2019
1 1 RISKA Banarjoyo 5 4 2/8/2019
1 1 SUMINTO Banarjoyo 8 4 2/8/2019
1 1 TRIANTO Banarjoyo 7 4 2/8/2019
1 1 SOLIKUN Banarjoyo 7 4 2/8/2019
1 1 RUDI SUSANTO Banarjoyo 7 4 2/8/2019
1 1 HERMAN Banarjoyo 8 4 2/8/2019
1 1 UNTORO Banarjoyo 2/8/2019
1 1 KARSIM Banarjoyo 2/8/2019
1 1 RENDRA K Banarjoyo 2/8/2019
1 1 YUDI Banarjoyo 2/8/2019
1 1 TUKIJO Banarjoyo 2/8/2019
1 1 IMAM Banarjoyo 2/8/2019
1 1 PERI Banarjoyo 2/8/2019
1 1 ADVENT Banarjoyo 2/8/2019
1 1 SUNGKONO Banarjoyo 2/8/2019
1 1 SUPARYONO Banarjoyo 2/8/2019
1 1 ICHYAR HAAQ Banarjoyo 2/8/2019
1 1 ICHYAR HAAQ Banarjoyo 2/8/2019
1 1 TRIYANTO 1807060507940003 Banarjoyo 2/8/2019
1 1 ARI SETIAWAN Banarjoyo 2/8/2019
1 1 RIVAUDIN 3201012312910005 Banarjoyo 2/8/2019
1 1 DWI SISWANTO 1807062911870001 Banarjoyo 2/8/2019
1 1 KOKO HERU 1807066911930001 Banarjoyo 2/8/2019
1 1 ANODYA Banarjoyo 2/8/2019
1 1 BUDI FITER W 1807061010940004 Banarjoyo 2/8/2019
1 1 DENI 1807060301810003 Banarjoyo 2/8/2019
1 1 YOGA 1807065306970004 Banarjoyo 2/8/2019
 ASI EksklusifF1=YA, 2=Tidak
Panjang Cara Ukur Vitamin A Vitamin A
Badan/ 1=Telenta Februari Agustus
BB (kg) umur 0 umur 1 umur 2 umur 3 umur 4 umur 5
Tinggi ng 1=YA 1=YA
Badan (cm) 2=Berdiri bln bln bln bln bln bln 2=Tidak 2=Tidak

(18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28)
6,5 60 1 1 1 1 1 1 1 1 -
8,7 67 1 1 1 1 1 1 1 1 -
7,8 68 1 1 1 1 1 1 1 1 -
7,2 63 1 1 1 1 1 1 1 1 -
6,5 64 1 1 1 1 1 1 1 1 -
11,3 72 1 1 1 1 1 1 1 1 -
7,7 72 1 1 1 1 1 1 1 1 -
8,8 75 2 1 1 1 1 1 1 1 -
7,4 69 2 1 1 1 1 1 1 1 -
9 69 2 1 1 1 1 1 1 1 -
10,1 83 2 1 1 1 1 1 1 1 -
10,3 75 1 1 1 1 1 1 1 1 -
7,6 73 2 1 1 1 1 1 1 1 -
14,1 95 2 1 1 1 1 1 1 1 -
9,2 73 2 1 1 1 1 1 1 1 -
12,5 92 2 1 1 1 1 1 1 1 -
8,3 75 2 1 1 1 1 1 1 1 -
11,2 80 2 1 1 1 1 1 1 1 -
11,2 78 2 1 1 1 1 1 1 1 -
8,4 79 2 1 1 1 1 1 1 1 -
12 80 2 1 1 1 1 1 1 1 -
9,8 78 2 1 1 1 1 1 1 1 -
10 85 2 1 1 1 1 1 1 1 -
13,5 99 2 1 1 1 1 1 1 1 -
9,5 79 2 1 1 1 1 1 1 1 -
12,1 84 2 1 1 1 1 1 1 1 -
9,6 83 2 1 1 1 1 1 1 1 -
8,1 73 2 1 1 1 1 1 1 1 -
12 85 2 1 1 1 1 1 1 1 -
9,8 90 2 1 1 1 1 1 1 1 -
9,7 83 2 1 1 1 1 1 1 1 -
8,9 83 2 1 1 1 1 1 1 1 -
10 89 2 1 1 1 1 1 1 1 -
15,2 101 2 1 1 1 1 1 1 1 -
12,5 86 2 1 1 1 1 1 1 1 -
16 97 2 1 1 1 1 1 1 1 -
11 89 2 1 1 1 1 1 1 1 -
11,7 89 2 1 1 1 1 1 1 1 -
10,6 90 2 1 1 1 1 1 1 1 -
10,4 89 2 1 1 1 1 1 1 1 -
11,5 91 2 1 1 1 1 1 1 1 -
12 95 2 1 1 1 1 1 1 1 -
20 85 2 1 1 1 1 1 1 1 -
13,3 93 2 1 1 1 1 1 1 1 -
12 95 2 1 1 1 1 1 1 1 -
13,8 97 2 1 1 1 1 1 1 1 -
13,7 94 2 1 1 1 1 1 1 1 -
14 94 2 1 1 1 1 1 1 1 -
12,4 95 2 1 1 1 1 1 1 1 -
12,5 95 2 1 1 1 1 1 1 1 -
12,7 95 2 1 1 1 1 1 1 1 -
12,2 97 2 1 1 1 1 1 1 1 -
14 94 2 1 1 1 1 1 1 1 -
18,5 103 2 1 1 1 1 1 1 1 -
13,2 99 2 1 1 1 1 1 1 1 -
14,5 96 2 1 1 1 1 1 1 1 -
20 107 2 1 1 1 1 1 1 1 -
15,7 103 2 1 1 1 1 1 1 1 -
15 100 2 1 1 1 1 1 1 1 -
11 95 2 1 1 1 1 1 1 1 -
15,6 101 2 1 1 1 1 1 1 1 -
22 108 2 1 1 1 1 1 1 1 -
14,7 99 2 1 1 1 1 1 1 1 -
15 100 2 1 1 1 1 1 1 1 -
14,8 102 2 1 1 1 1 1 1 1 -
17,3 109 2 1 1 1 1 1 1 1 -
12 85 2 1 1 1 1 1 1 1 -
10 74 2 1 1 1 1 1 1 1 -
4.4 50 2 1 1 1 1 1 1 1 -
4 50 2 1 1 1 1 1 1 1 -
3.2 48 2 1 1 1 1 1 1 1 -
4.2 50 2 1 1 1 1 1 1 1 -
4.2 56 2 1 1 1 1 1 1 1 -
5.5 58 2 1 1 1 1 1 1 1 -
6.4 61 2 1 1 1 1 1 1 1 -
6.3 56 2 1 1 1 1 1 1 1 -
4.6 55 2 1 1 1 1 1 1 1 -
Lampiran 3
FORMULIR PEMANTAUAN PERTUMBUHAN BALITA DI POSYANDU

Provinsi : LAMPUNG Nama Posyandu : KENANGA

Kabupaten/Kota : LAMPUNG TIMUR Bulan :
Puskesmas/Kecamatan : BATANGHARI Tahun :
Desa/Kelurahan : BANARJAYA

Jenis No Kartu NIK (Nomor Induk Berat Badan

No Anak Ke Tanggal Lahir Kelamin Nama Anak
Keluarga Kependudukan) (BB) Lahir

(1) (2) (3) (4) (5) (6) (7) (8)

1 2 5/28/2018 P 1807066805180001 ARSYLA ASKA DINA 3,8
2 1 6/4/2018 L 1807060406180001 PUTRA RAHMADAN 2,7
3 1 7/3/2018 P 1807064307180001 ALIYA ELFIANI 2,7
4 1 1/16/2018 L 1807061601180001 ARIF ZIKRIANSYAH 2,4
5 1 2/20/2018 P 1807066002180001 ANIS ANGGRAINI 2,3
6 1 7/11/2018 L 1807061107180001 EKSA FARLOS AL 2,9
7 1 1/26/2018 L 1807062601180001 INDRA ARKANA 2,8
8 1 6/25/2018 L 1807062506180002 ADIKA DWI SAPUTRA 2,8
9 1 3/8/2018 L 1807060803180001 ASKA ARDIAN 2,7
10 3 4/23/2017 L 1807062304170001 M. ARYA CANDRA 2,3
11 1 6/30/2017 P 1807067006170001 SHERIL ALISIA PUTRI 3,1
12 1 3/21/2017 L 1807062104170001 A. KHOIRUL ANAM 3,1
13 2 8/18/2017 L 1807065808170001 NAURA WAHYU M. 3,8
14 2 1/4/2018 L 1807062204150002 DEVIN PUTRA DEPRATAMA 3,4
15 2 12/7/2017 L 1807060712170001 DAVIAN HALIF 2,6
16 2 2/19/2017 L 1807061902170001 UBAIDA RAHMAN H.G 2,8
17 2 5/27/2017 L 1807062705170001 N. RAHMADAN MUBAROK 2,9
18 2 5/23/2017 P 1807066305170001 AFIFA DWI CAHYANI 2,7
19 1 5/8/2017 P 1807064805170001 KHAMILA KHOIRUNISA 2,6
20 1 7/27/2015 P 1807066710150001 ZAIDATUL KAROMAH 2,9
21 1 4/20/2015 P 1807066004150001 ADYA DWI AZZAHRA 3,0
22 1 8/5/2017 P 1807064508170001 GISEL KORNELIA E 3,0
23 1 10/21/2015 L 1807062110150001 CAHYA ARIFIN 2,6
24 1 10/10/2016 P 1807065010160001 BILQIS MUTIA 3,2
25 1 7/24/2016 L 1807066407160001 BERIL 2,6
26 2 6/16/2016 L 1807061606160001 ARLAN DWI RAHMADAN 3,0
27 1 10/19/2016 P 1807065910160001 RAHMAWATI 3,0
28 1 8/25/2016 L 1807062508160002 ARFIENDO ALBI F. 3,6
29 3 1/14/2015 L 1807061401150001 M FAHMI ZEIN 2,4
30 1 1/19/2017 L 1807061901170001 ASKA AFRIZALAL GOZALI 2,9
31 1 11/2/2016 L 1807060211160001 LITFI ALBI AL FAKIH 2,6
 32 1 5/30/2014 P 1807067005140001 SAILA NAJWA S. 2,8
33 1 5/12/2014 P 1807065205150007 INKA MUTIARA C. 2,3
34 1 1/10/2016 P 1807065001160001 ZAHRATUN NAJWA 2,5
35 1 4/24/2014 P 1807066804140004 FATIMAH AZAHRA 3,2
36 1 5/26/2015 P 1807066406150002 ERLIN MICHELINA 3,5
37 1 6/20/2015 L 1807062006150003 M. ALFIN RAHMADAN 3,4
38 2 9/20/2014 L 1807063008140001 FAHRI ADIAN AL AIDEN 2,9
39 2 9/1/2017 P 1807064109170001 IDA FANTIKA 2,4
40 2 5/9/2015 L 1807060905150001 M. FAHRO ZIDAN 2,8
41 1 5/18/2016 L 1807061805160002 ARKA RIZKI RAFINDRA 2,5
42 1 6/23/2014 P 1807066306140001 SETIVANI P. ANGGRAINI 3,6
43 3 9/18/2016 P 1807065809160001 NAALA SABILA KHOIRIAH 3,1
44 1 10/7/2015 P 1807064710150001 ALYA FATIMATUS ZAHRA 3,2
45 1 8/4/2015 L 1807060408150002 SYAMIL ZAHRAN AT ZAKI 3,2
46 1 5/16/2014 L 1807061605140001 ALFIN NOVAL ZULFAHMI 2,9
47 1 9/22/2015 P 1807066209150001 AINAYA FATIATUR RAHMA 2,8
48 1 6/7/2015 L 1807070706150002 N. DAFA IBNU HAFIS 2,7
49 1 8/24/2018 L 1807062408180001 FAIQ NIZAR RIFAAH 2,3
50 1 5/9/2018 L 1807060905180001 ATTA ABINAYA 2,5
51 1 5/12/2018 P 1807065105180001 MARWAH LATIFAH 3,0
52 1 8/25/2018 P 1807066508180001 AZZAHRA RADIA ARMIRA 3,1
53 1 4/21/2017 P 1807066104170001 EFELIN KARTIKA N. 3,5
54 1 2/12/2018 P 1807065202180001 FAUZIAH KOTRUN NAJA 3,1
55 1 3/23/2014 P 1807066303140001 GLADIS VIRGINIA A. 2,9
56 1 10/4/2014 P 1807064410140001 ZAHRA LAILA FADILAH 2,5
57 1 1/1/2018 P 1807064101180001 KAILA RIZKI AZALIA 2,4
58 2 11/19/2014 L 1807061911140004 MUHAMAD MUSLIH 2,8
59 2 3/24/2015 P 1807062403150001 SEMANA PRAWIRA 2,9
60 2 4/28/2015 L 1807062004150001 DENANDRA PUTRA W. 2,9
61 2 10/5/2015 P 1807064510150001 KANZA SALSA DAFINA 2,6
62 2 8/2/2017 P 1807064208170002 ALESA ASIFA ZAHRA 3,1
63 1 12/18/2018 L 1807061812180002 arsynio akbar 3,5
64 1 9/17/2018 p 1807061709180001 yasmine detta 3,6
65 2 10/1/2018 L 1807060110180001 RAFI PUTRA WIJAYA 2,8

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
Kepemilikan IMD
Buku 1=YA, No Tlp/ Tgl
KIA/KMS 2=Tidak Nama Ayah NIK Ayah Alamat RT RW
HP Ayah Pengukuran
1=YA,
2=Tidak

(9) (10) (11) -12 (13) (14) (15) (16) (17)

1 1 SIGIT KURNIAWAN 1807063009860003 Banarjoyo 13 7 2/16/2019
1 1 DIMIYATI 1807062708820006 Banarjoyo 15 8 2/16/2019
1 1 MAHMUDIN 1807060707700009 Banarjoyo 16 8 2/16/2019
1 1 HENDRIYANTO 1802012802830007 Banarjoyo 14 7 2/16/2019
1 1 A. GUFRON 1807060802840008 Banarjoyo 15 8 2/16/2019
1 1 RIAN DARWANTO 1807060301950002 Banarjoyo 16 8 2/16/2019
1 1 ARIF BINTORO 1807060908790002 Banarjoyo 13 7 2/16/2019
1 1 EDI SUSANTO 1807060109850003 Banarjoyo 15 8 2/16/2019
1 1 M. SOLIHIN Banarjoyo 13 7 2/16/2019
1 1 LEO CANDRA 1802101311900002 Banarjoyo 13 7 2/16/2019
1 1 ASIF RIFAI 1807061803910002 Banarjoyo 16 8 2/16/2019
1 1 HENDRO W. Banarjoyo 14 7 2/16/2019
1 1 AHMAD WAHYUDI 1807060301830001 Banarjoyo 15 8 2/16/2019
1 1 PURWANTO Banarjoyo 16 8 2/16/2019
1 1 DEDIK SETIAWAN 1807061507850007 Banarjoyo 15 8 2/16/2019
1 1 RUDI HANDOKO 1807061507920004 Banarjoyo 14 7 2/16/2019
1 1 NUR KATAM 1807141810890001 Banarjoyo 15 8 2/16/2019
1 1 NAJMUDIN 1807062711740001 Banarjoyo 15 8 2/16/2019
1 1 M. YAJID Banarjoyo 15 8 2/16/2019
1 1 M. TAUFIQ Banarjoyo 13 7 2/16/2019
1 1 N. KOSING 1807061010800001 Banarjoyo 13 7 2/16/2019
1 1 DWI RANGGA O. 1807063110920006 Banarjoyo 15 8 2/16/2019
1 1 MUJIANTO 1807060207730002 Banarjoyo 14 7 2/16/2019
1 1 SUGIMAN 3174101707740006 Banarjoyo 14 7 2/16/2019
1 1 MESRAN Banarjoyo 14 7 2/16/2019
1 1 DODI HARMOKO 1807060808830001 Banarjoyo 15 8 2/16/2019
1 1 SAMSUDIN 1807061908740004 Banarjoyo 16 8 2/16/2019
1 1 YUDI KURNIAWAN 1807063001950001 Banarjoyo 13 7 2/16/2019
1 1 ANDI SAPUTRA Banarjoyo 14 7 2/16/2019
1 1 YUDI TRIATMOJO 1807061909820004 Banarjoyo 13 7 2/16/2019
1 1 NUR MUSLIM 1807063006780001 Banarjoyo 15 8 2/16/2019
1 1 TRISTIAWAN 180706641280001 Banarjoyo 16 8 2/16/2019
1 1 SUPARWOTO Banarjoyo 14 7 2/16/2019
1 1 A. NAWAWI Banarjoyo 15 8 2/16/2019
1 1 TOMI FEBRIANTO Banarjoyo 16 8 2/16/2019
1 1 RUDI SUHARTONO Banarjoyo 13 7 2/16/2019
1 1 SAJITU Banarjoyo 15 8 2/16/2019
1 1 DIKA FITRIADI 1807060405900007 Banarjoyo 13 7 2/16/2019
1 1 TAMIS UZAKI 1807060303720002 Banarjoyo 13 7 2/16/2019
1 1 ERI SATMOKO Banarjoyo 16 8 2/16/2019
1 1 CONRO SULISTIO Banarjoyo 16 8 2/16/2019
1 1 BUDIANTO 1807061506860004 Banarjoyo 16 8 2/16/2019
1 1 KORIB MUJIB Banarjoyo 15 8 2/16/2019
1 1 SAIFULLAH Banarjoyo 14 7 2/16/2019
1 1 PUTUT HADI SAPUTRO Banarjoyo 16 8 2/16/2019
1 1 NUR. HOLIS 1807062804900005 Banarjoyo 13 7 2/16/2019
1 1 EDI PURWANTO Banarjoyo 15 8 2/16/2019
1 1 IMAM SUNARYO Banarjoyo 16 8 2/16/2019
1 1 YULI SHARTONO 1807060707760001 Banarjoyo 14 7 2/16/2019
1 1 AULIYA ABILAH SUMANTO Banarjoyo 15 8 2/16/2019
1 1 SUMANTO 1807062201830004 Banarjoyo 16 8 2/16/2019
1 1 SUBIANTO 1807060504810003 Banarjoyo 13 7 2/16/2019
1 1 PUJI SANTOSO 1807060503800004 Banarjoyo 15 8 2/16/2019
1 1 BAMBANG RUDIANTO 3671050111890001 Banarjoyo 13 7 2/16/2019
1 1 DWI SETIO Banarjoyo 13 7 2/16/2019
1 1 SIDIK WIDODO 1807060203800004 Banarjoyo 16 8 2/16/2019
1 1 JATO CAHYONO 1807061606810010 Banarjoyo 14 7 2/16/2019
1 1 MAHSUDIN 1807060101700008 Banarjoyo 15 8 2/16/2019
1 1 M. ARIFIN Banarjoyo 14 7 2/16/2019
1 1 NANANG SUKOCO Banarjoyo 16 8 2/16/2019
1 1 GUNADI Banarjoyo 15 8 2/16/2019
1 1 EDI HANDOKO 1807062204940003 Banarjoyo 13 7 2/16/2019
1 1 suryono Banarjoyo 13 7 2/16/2019
1 1 Lilik iswati Banarjoyo 16 8 2/16/2019
1 1 SURATNO 1807060509650001 Banarjoyo 14 7 2/16/2019
 ASI EksklusifF1=YA, 2=Tidak
Panjang Cara Ukur Vitamin A Vitamin A
Badan/ 1=Telenta Februari Agustus
BB (kg) umur 0 umur 1 umur 2 umur 3 umur 4 umur 5
Tinggi ng 1=YA 1=YA
Badan (cm) 2=Berdiri bln bln bln bln bln bln 2=Tidak 2=Tidak

(18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28)
9.1 73 1 1 1 1 1 1 1 1 -
8.7 67 1 1 1 1 1 1 1 1 -
8 61 1 1 1 1 1 1 1 1 -
12.5 72 1 1 1 1 1 1 1 1 -
7.7 70 1 1 1 1 1 1 1 1 -
7.5 70 1 1 1 1 1 1 1 1 -
9.1 71 1 1 1 1 1 1 1 1 -
6.9 70 1 1 1 1 1 1 1 1 -
10 73 2 1 1 1 1 1 1 1 -
10.5 83 2 1 1 1 1 1 1 1 -
9.2 74 2 1 1 1 1 1 1 1 -
12.7 83 2 1 1 1 1 1 1 1 -
8 80 2 1 1 1 1 1 1 1 -
11 73 2 1 1 1 1 1 1 1 -
9.9 72 2 1 1 1 1 1 1 1 -
10.5 82 2 1 1 1 1 1 1 1 -
10.4 78 2 1 1 1 1 1 1 1 -
10.2 76 2 1 1 1 1 1 1 1 -
8.2 88 2 1 1 1 1 1 1 1 -
12.9 93 2 1 1 1 1 1 1 1 -
11.8 93 2 1 1 1 1 1 1 1 -
8.1 79 2 1 1 1 1 1 1 1 -
12.7 100 2 1 1 1 1 1 1 1 -
10.8 82 2 1 1 1 1 1 1 1 -
12.3 86 2 1 1 1 1 1 1 1 -
12.8 89 2 1 1 1 1 1 1 1 -
11.7 85 2 1 1 1 1 1 1 1 -
14 91 2 1 1 1 1 1 1 1 -
14.1 100 2 1 1 1 1 1 1 1 -
13.1 90 2 1 1 1 1 1 1 1 -
111.3 87 2 1 1 1 1 1 1 1 -
15.4 102 2 1 1 1 1 1 1 1 -
12.2 99 2 1 1 1 1 1 1 1 -
12.5 90 2 1 1 1 1 1 1 1 -
21 110 2 1 1 1 1 1 1 1 -
12.7 92 2 1 1 1 1 1 1 1 -
14.1 95 2 1 1 1 1 1 1 1 -
17.3 104 2 1 1 1 1 1 1 1 -
10.5 76 2 1 1 1 1 1 1 1 -
11.7 100 2 1 1 1 1 1 1 1 -
15.2 93 2 1 1 1 1 1 1 1 -
16.1 109 2 1 1 1 1 1 1 1 -
10.5 81 2 1 1 1 1 1 1 1 -
13.2 91 2 1 1 1 1 1 1 1 -
14.4 97 2 1 1 1 1 1 1 1 -
15.5 101 2 1 1 1 1 1 1 1 -
12.5 91 2 1 1 1 1 1 1 1 -
13.4 100 2 1 1 1 1 1 1 1 -
10.6 73 2 1 1 1 1 1 1 1 -
8 74 2 1 1 1 1 1 1 1 -
11.2 73 2 1 1 1 1 1 1 1 -
7 66 2 1 1 1 1 1 1 1 -
10.6 81 2 1 1 1 1 1 1 1 -
8 72 2 1 1 1 1 1 1 1 -
14.3 110 2 1 1 1 1 1 1 1 -
14.9 100 2 1 1 1 1 1 1 1 -
7.5 65 2 1 1 1 1 1 1 1 -
15.5 102 2 1 1 1 1 1 1 1 -
15 S 2 1 1 1 1 1 1 1 -
13.5 95 2 1 1 1 1 1 1 1 -
13.5 95 2 1 1 1 1 1 1 1 -
11 82 2 1 1 1 1 1 1 1 -
6 55 2 1 1 1 1 1 1 1 -
6,9 73 2 1 1 1 1 1 1 1 -
7 70 2 1 1 1 1 1 1 1 -