format c-1 google drive
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form c-1 google driveTRANSCRIPT
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit dataPuskesmas :KABTahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLB
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
Januari 1 120502215001
2 120501115001
3 120501715002
4 120501414001
5 120500215001
6 120500215002
7 120501415002
8 120501115002
9 120502215002
10 120501115003
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11 120501115004
12 120501115005
13 120500815001
14 120500515001
15 120501715003
16 120501715004
17 120501615001
18 120501115006
19 120500115001
20 120501014001
21 120501915001
22 120501915002
23 120501915003
24 120501915004
25 120501915005
26 120501915006
27 120501915007
28 120501915008
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29 120501915009
30 120502115001
31 120502115002
JAN 32 120500215001
JAN 33 120501715001
34 120501715002
35 120501715003
36 120501715004
37 120501715005
38 120501715006
39 120501715007
40 120501715008
JANUARI 41 120501615005
JANUARI 42 120501615006
JANUARI 43 120501615007
JANUARI 44 120502515002
JANUARI 45 120502515003
JAN 46 120501815002
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JAN 47 120501815003
FEBRUARI 1 120500115003
FEBRUARI 2 120500315002
FEBRUARI 3 120500615001
FEBRUARI 4 120500615002
FEBRUARI 5 120500615003
FEBRUARI 6 120500615004
FEBRUARI 7 120500615005
FEBRUARI 8 120500615006
FEB 9 120500715001
FEBRUARI 10 120500515002
FEBRUARI 11 120501415003
FEBRUARI 12 120501115008
FEBRUARI 13 120501115009
FEBRUARI 14 120501115010
FEBRUARI 15 120501115011
FEBRUARI 16 120501115012
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FEBRUARI 17 120501215001
FEBRUARI 18 120501414002
FEBRUARI 19 120501315001
FEBRUARI 20 120501615002
FEBRUARI 21 120501615003
FEBRUARI 22 120501815001
FEBRUARI 23 120501915010
FEBRUARI 24 120501915011
FEBRUARI 25 120501915012
FEBRUARI 26 120501915013
FEBRUARI 27 120501915014
FEBRUARI 28 120502315001
FEBRUARI 29 120502415001
FEBRUARI 30 120502115003
MARET 31 120500115004
MARET 32 120500215003
Maret 0 120500715002
MARET 1 120500515004
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MARET 2 120501415004
MARET 3 120501115013
4 120501115014
5 120501115015
6 120501115016
maret 7 120502515004
8 120502515005
MARET 9 120501415003
MARET 4 120501415004
8 120501615004
9 120501615008
MARET 10 120501815004
MARET 1 120501915015
2 120501915016
3 120501915017
MARET 120501915019
MARET 1 120502015001
2 120502015002
MARET
MARET
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MARET 3 120502115004
Maret 4 120502215003
MARET 5 120502315002
6 120502315003
7 120502315004
8 120502315005
maret 9 120502415002
10 120502415003
11 120502415004
April 12 120501815005
13
14
15
16
17
18
19
20
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21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
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39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
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57
58
59
60
61
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
Ragil Saputra
AISYAH QORRY
AIRWAN HARYADI
HIROMI
RINDI NATASYA
AGUS SWARNO
ALIV ZIDAN
MUH ZEIN ALMA
NAJWA BAHIRA
ALAELATUL IZZA
ALAMAT (Desa/RT/RW) DAN TELP
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ERNA EKAWATI
BASARUDIN
FAIZAL MIFTANUDIN
SUHARYANTO
ANDRE MIKO
SUPRIHADI
BINTANG ARKA
LEVI YANTHO
Yohanes setiawan Purba Ny. Supartinah
SRI WIDATI PARMATO WIYONO
HANI FARIDA NURWAHID / SHOHIR
ANISA MAULIDIA NURWAHID / SHOHIR
IBNU HIBAN MARGONO / BARIYAT
TAUFIK DWI NUGRAHA SARDI / YAMINAH
DANANG DWI KUSHARYANTDANANG DWI KUSH KALAKIJO 07/03 TRIHARJO
TRI ASTUTI PAIBAN / PAINAH
ANANDA SUPAID / SRI AHYUNI
TUKINAH SUHARJO
Pr .Baleasri 09/46 Balecatur Gamping
Modinan sambilegi, Maguwoharjo,DepokKLEPU BENER 01/01 KARANGSARI, KEBUMEN / BERAN LOR RT05 RW 22 TRIDADI SLEMANDUKUH RT05 RW 29 TRIDADI SLEMAN
JOGOKERTEN 02/13 , DOMISILI TEMULAWAK 11/38
SIDOREJO 02/20 CATURHARJO SLEMAN
GABUGAN 05/15 PANDOWOHARJO
KLEBEN 01/24 PANDOWOHARJO
KEPITU TRIMULTO, DOMISILI SIDOREJO CATURHARJO SLEMAN
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ANDRI NUGROHO BUDIONO / TUKIYAH
SIDIQ AGUNG SUNARDI
KEVIN RADITYA UTAMA Bp. UTAMI, NY. SRI LE JENENGAN SUMBERREJO
Muh Fadhil Gatama* (diambil RSKA 45)
AIRWAN HARYADI
ANDRE MIKO
SUPRIHADI
UMAR MTS BABADAN BARU
ANAS MTS BABADAN BARU
YOGI MTS BABADAN BARU
AYUDYA MTS BABADAN BARU
LIA ALVIANA MTSN BABADAN BARU
AURORA KYLA KUSPRIYONO TRI HARYATI
AGHNAZA KELANDRA PRASETYA PUGUH PRASETYO
ARFAIZ AKBAR PRAMADANA BANU ARIF W
MOH. FACHRY AL MAHDALY FAKHRUL ZAIN
YULI HERIANI BERT ARINANDO (SUAMI)
ACHILLES TRISNA NASAID EVAND YOHANSA
KARANGTANJUNG 02/12 PANDOWOHARJO
KARANG METHIKAN RT 2 BANYUREJO
Dukuh IV RT 02/08 Sidomoyo
JAMBUSARI INDAH JL. JAMBU AIR X10 MIDOMARTANI NGEMPLAK SLEMAN DIY
PERUM ATMAJAYA BLOK B1 / 4A NGEMPLAK SLEMAN
NGLINGGAN RT 05/53 WEDOMARTANI NGEMPLAK SLEMAN DIY
KOMP. POLRI GOWOK BLOK E1 211 DEPOK SLEMAN
JALAN PANDEGA SATYA NO 26 D-1 KALIURANG
BENDOSARI RT 04/16 SARIHARJO NGAGLIK SLEMAN YK
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MUH HANIF ABBAD PUTUT SUPRIYADI
Pujianti Bejo rianto
IQBAL HABIBI NURMAN TAUFIK SENTUL SIDOAGUNG
TAKIA ROMI PELANI
KHUZAIFA ALI SAPUTRA ROMI PELANI
AMIRATUN SOLICHA ROMI PELANI
MARWANTI ROMI PELANI
AINI IRVIANISA ANGGRAINI DULJANI
HUSEN dr.FADLI
GENTA SUKARNO JAGALAN RT04 MARGODADI
RISKY FARDAN SAPUTRA MARSIYONO GAMPLONG 3 SB RAHAYU
Kristina Suminarsih (diambil Pleret)** Maguwoharjo
FATIN AQILA EKAWATI
Aulia Hasna Khalilah Sendowo no 40 Sleman
Emanuel CC
Noviana
Parikesit
PERUM SUKOHARJO INDAH BLOK C-26 SUKOHARJO NGAGLIK SLEMAN
Mancasan 01/25 Ambarketawang Gamping
PANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJOPANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJOPANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJOPANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJO
JARAKAN SENDANG REJO MINGGIR
PANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJO
RISKA MARETA
PANDEAN 2 GG KANTIL NO 16 CC
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Fallah Aulia Ruzan
NY. KHALIFAH NUR B (IBU HAMNY. SITI WAHIDAH
AN. IVANKA DEWA
YOPI AGUSTIAN FEBRINAYATI
RENA SUPARDI
Erto Ari Wibowo
MAHATMA JENAR W
EKA NURHAYATI SAMUN / JUMINI
FIRDA ANAZIYAH DENGGUNG 01 / 01 TRIDADI
RINGGA INDRA KUSUMA
ABIAN SHAHZADA EGA.S JUMIRAN / RIYANTI
Yehezkiel Dimas
Nathan arsavin Mujiman/Ana dwi astu
SUNARDI
Widiati Tanjungsari
NURYONO SAPUTRO
Faiz Nur Hasanah SIGIT SURYANTO
FATIHAH N FATHAN BETAAN SUMBERRAHAYU
DUKUHSARI PURWOMARTANI
SUNGGINGAN PERENG PRAMBANAN
PRM CANDI GEBANG EE14 WEDO
MALANGREJO WEDOMARTANI
WIBISONO HERU S / MAHMUDAH
PANGUKAN RT04 RW 10 TRIDADI SLEMAN
SANGGRAHAN 01/22 CATURHARJO
EDY SUHANI / WARSIATI
SARWOKO / DWI ASTUTI
KLONCOMAN PANDOWOHARJO
MURANGAN VIII, RT 04 RW 27 TRIHARJO
Plagrak, Wukirsari, cangkringan
BANJAR PONDOKREJO TEMPEL
DAVID DWI BANYUMENENG RT 12 RW 04 BANYURADEN
GONDANGAN RT 06 RW 14, MARGOMULYO
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Andi Maguwoharjo
Larasati Sekar A SRI WANTI DABAG RT 01/26 CONCAT
Erian Junanda HERI KUNARTO SENGKAN RT 05/09 CONCAT
KHIRAN SUWARNO
RAENAD AQILA SUGIYANTO KAYEN RT 04/44 CONCAT
Monica Eva Sari WALPEN SIPAYUNG
Sukemi Purwaningsih
WIJIONO BENDAN,TIRTOMARTANI
NIA KARENINA NN
TALENTA RAHMA M. JUNI POKOH WEDOMARTANI
GALIH RANGGA ALBARIKO WIDIYANTO
Rohadi JETIS SURUH DONOHAQRJO
NOVILA NEYSA CHOIRURIFA
YASMIN JIHAN KIRANA
AMINAH SUGIYONO
ENANG PURNAMA NGEMPLAK CATURHARJO
TRI NUR BAETI SUKRI
NIRMALA PARAMITA YADI NGEPOS LUMBUNG REJO
WIDORO RT 05/25 NGROPOH, CONCAT
BABARSARI TAMBAK BAYAN CT
FITRIANA HARINI
JL RAYA BOGEM 175 TAMANMARTANI KALASAN SLEMAN
PRM CANDI GEBANG BARU NO 10 WEDO
MARJONO / SUPRIYATUN
SANGGRAHAN 03/23 CATURHARJO
EKO MARYANTO/' RINI WAHYUNINGSIH
MURANGAN VII 02/24, TRIHARJO
TEMULAWAK, 05/37, TRIHARJO
KROMODANGSAN, LUMBUNGREJO
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ANITA SARYANTO PISANGAN, SUBEREJO
Isduwi Ida Haryani Bp. Muhadiyanto Becici Wonokerto Turi
Simdhy YAYASAN AULIA KATEN HARJO BINANGUN
MUH. AZKA ANJAR TURGO GEDE HARJO
APRIYANI WANMEN DEMEN,PAKEMBINANGUN
Azka Aurellio
Zaqi putra praditya Sofian
Davina R Gandung
Anita Putri Sokiman-Hartini
Aurelia Azaah Putri Q Anang Heri P Panggungsari 8/23 no 161
Turgogedhe Harjobinangun
Watuadeg, Wukirsari, Cangkringan
Ngepringan, Wukirsari, Cangkringan
Plagrak, Wukirsari, cangkringan
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA PROVINSI
UMUR
TAHUN
8 9 10 11 12
Sleman (Turi)7.00
DEPOK 2
NGAGLIK 119 TH
KALASAN4
GAMPING 229
GAMPING 244 TH
Depok 13 TH
Depok 27 TH
TURI
Depok 2
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Depok 2
Depok 224 TH
MLATI 114 TH
MOYUDAN18 TH
NGAGLIK 116 TH
NGAGLIK 165 TH
NGEMPLAK 21
DEPOK 27 TH
Gamping 1 Gamping21
Depok 1 Depok34
SLEMAN SLEMAN23
SLEMAN SLEMAN9
SLEMAN SLEMAN3
SLEMAN SLEMAN1
SLEMAN SLEMAN 35.00
SLEMAN SLEMAN24
SLEMAN SLEMAN8
SLEMAN SLEMAN54.00
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SLEMAN SLEMAN14
TEMPEL II TEMPEL20
TEMPEL II TEMPEL5
GODEAN 1 GODEAN1
NGAGLIK 119 TH
NGAGLIK 116 TH
NGAGLIK 165 TH
NGAGLIK 114.00
NGAGLIK 114.00
NGAGLIK 115.00
NGAGLIK 112.00
NGAGLIK 115.00
NGEMPLAK7
NGEMPLAK2
NGEMPLAK5
DEPOK4
DEPOK30
NGAGLIK
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NGAGLIK5
Gamping 1 Gamping26.00
GODEAN 1 GODEAN1.00
MINGGIR MINGGIR
MINGGIR MINGGIR
MINGGIR MINGGIR15
MINGGIR MINGGIR15
MINGGIR MINGGIR5
MINGGIR MINGGIR5
SEYEGAN14.00
MOYUDAN MOYUDAN
26
DEPOK 21
DEPOK 2
DEPOK 221
13
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berbah berbah4.00
KALASAN KALASAN22
PRAMBANAN PRAMBANAN
NGEMPLAK 25.00
NGEMPLAK 2 NGEMPLAK11.00
NGAGLIK 2 NGAGLIK
SLEMAN SLEMAN9
SLEMAN SLEMAN11
SLEMAN SLEMAN3
SLEMAN SLEMAN5
SLEMAN SLEMAN0
PAKEM PAKEM6.00
Cangkringan cangkringan4
2.00
Gamping 1 Gamping22.00
GAMPING 2
SEYEGAN SEYEGAN10.00
MOYUDAN MOYUDAN18.00
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Depok 1 Depok23
DEPOK 2 DEPOK1
DEPOK 2 DEPOK21
DEPOK 2 DEPOK2
DEPOK 2 DEPOK
DEPOK 320.00
DEPOK 351.00
KALASAN KALASAN35.00
KALASAN KALASAN18.00
NGEMPLAK 2 NGEMPLAK6.00
NGEMPLAK 3 NGEMPLAK28.00
NGAGLIK 2 NGAGLIK48
SLEMAN SLEMAN2
SLEMAN SLEMAN2
SLEMAN SLEMAN67
SLEMAN46.00
TEMPEL I TEMPEL26.00
TEMPEL I TEMPEL
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TEMPEL II TEMPEL7.00
TURI TURI7.00
PAKEM PAKEM
PAKEM PAKEM1.00
PAKEM PAKEM14.00
Pakem Pakem
Cangkringan cangkringan3
Cangkringan cangkringan1.5
Cangkringan cangkringan3.00
NGAGLIK 2 Ngaglik10.00
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LAPORAN KASUS CAMPAK INDIVIDU
UMUR TANGGAL MULAI
BULAN SAKIT Rash
13 14 15 16 17 18 19L
3 Jan 2015 5 Jan 2015
4 BL P 01/2/2015 1/6/2015
L 11/6/2014 1/7/2014
P 11/9/2015 1/12/2015
P 11/14/2015 1/14/2015
L 11/12/2015 1/15/2015
L1 kali 1/13/2015 1/14/2015
LTT 1/12/2015 1/14/2015
6 BL P1/13/2015 1/16/2015
5 TH PBELUM 11 Jan 2015 14 Jan 2015
JENIS KELAMIN
DOSIS VAKSINASI CAMPAK
YANG DITERIMA SEBELUM
SAKIT
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
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35 TH PTT 14 Jan 2015 18 Jan 2015
LTT 1/18/2015 1/20/2015
LTT 16 Jan 2015 16 Jan 2015
LTH 2002 21 Jan 2015 26 Jan 2015
L Tidak TahuLUPA 24 Jan 2015 25 Jan 2015
L 1TT 25 Jan 2015 26 Jan 2015
1 L 1### 23 Jan 2015 26 Jan 2015
L Tidak TahuLUPA 23 Jan 2015 27 Jan 2015
LBln April 19 1/3/2015 1/4/2015
P 11/8/2014 1/9/2014 1/9/2014
1 P 1SAAT USIA 9 1/4/2015 1/5/2015 1/5/2015
8 P 2BIAS 2014 5 Jan 2015 6 Jan 2015 6 Jan 2015
9 L 011 Jan 2015 13 Jan 2015 13 Jan 2015
6 L 1UMUR 9 BL 1/18/2015 1/20/2015 1/21/2015
1 L 1
UMUR 9 BL ### 30 Jan 2015 1/26/20153.00 P 1
UMUR 9 BL Jan 8, 2015 Jan 25, 2015 1/26/2015
10.00 L 1UMUR 9 BL 25 Jan 2015 26 Jan 2015 26 Jan 2015
0 P 1UMUR 9 BL 26 Jan 2015 27 Jan 2015 1/27/2015
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10.00 L 1UMUR 9 BL 29 Jan 2015 30 Jan 2015 31 Jan 2015
3.00 L LengkapLUPA 6 Jan 2015 9 Jan 2015 10 Jan 2015
6 L LengkapLUPA 1/24/2015 1/27/2015 1/28/2015
L Tidak TahuLUPA 1/15/2015 1/16/2015
L 16 Jan 2014 7 Jan 2014
L Tidak TahuLUPA 24 Jan 2015 25 Jan 2015
L 1TT 25 Jan 2015 26 Jan 2015
L 1BIAS 25 Jan 2015 26 Jan 2015
L Tidak Tahu22 Jan 2015 27 Jan 2015
L 1BIAS 19 Jan 2015 23 Jan 2015
L 2BIAS 22 Jan 2015 26 Jan 2015
P 1BIAS 29 Jan 2015 30 Jan 2015
P Tidak Tahu03/01/2015 04/01/2015 04/01/2015
L19/07/2014 02/01/2015 04/01/2015 04/01/2015
L22/01/2015 26/01/2015 26/01/2015
L18/01/2015 21/01/2015 21/01/2015
P30/01/2015 31/01/2015 31/01/2015
10 L17/02/2015 07/01/2015 12/01/2015 12/01/2015
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L27/12/2014 01/01/2015 01/01/2015
Plupa 7 Feb 2015 11 Feb 2015
9.00 L 218 BLN 28 Feb 2015 27 Feb 2015
11 P 0BLM ### ###
8 L 0BLM ### ###
P 2BIAS SD ### ###
P Tidak Tahu### ###
6 L 1### ###
6 L 1### ###
P 115 Feb 2015 15 Feb 2015
8.00 L 0BLM WKT 7 Feb 2015 10 Feb 2015
L1 Feb 2015 1 Feb 2015
9.00 P 211/1/2014 ### ### ###
8.00 P 0BELUM ### ###
L Tidak Tahu### ###
P### ### ###
### ###
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10.00 L Tidak Tahu7 Feb 2015 10 Feb 2015
P Tidak TahuTDK INGAT 28 Jan 2015 2 Feb 2015 3 Feb 2015
11 P### 9 Feb 2015 12 Feb 2015 14 Feb 2014
L 1### ###
P 22004 25 Feb 2015 26 Feb 2015
22 Feb 2015 22 Feb 2015
7 L 101 FEB 15 02 FEB 15 4'02 FEB 15
2 P 205 JAN 15 06 JAN 15 06 JAN 15
10 P 108 FEB 15 09 FEB 15 10 FEB 15
2 L 109 FEB 15 11 FEB 15 13 FEB 15
5 L 024 FEB 15 26 FEB 15 26 FEB 15
L 122 Feb 2015 23 Feb 2015 24 Feb 2015
L 1lupa 14/02/2015 16/02/2015 16/02/2016
P21 Feb 2015 26 Feb 2015
P### 27 Mar 2015
7.00 L 0BLM WKTNY 8 Mar 2015 9 Mar 2015
P 2SD ### 26 Mar 2015
P2003 ### 30 Mar 2015
SAAT BIAS 2014
BELUM CUKUP UMUR
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L Tidak Tahu### 17 Mar 2015
6.00 P 1BAYI ### 8 March 2015 ###
L 2SD ### 9 March 2015 ###
P 1BAYI ### 3/16/2015 3/19/2015
10.00 L 13/1/2015 21/03/2015 3/25/2015 3/30/2015
P### 5 March 2015
P Tidak Tahu15maret ### April
P Tidak Tahu13 Mart 201 13 Mart 15 18 Mart 15
P Tidak Tahu17 TAHUN Y 3/27/2015 3/28/2015 3/31/2015
P 15/12/2009 6 Mar 2015 6 Mar 2015
L 0LUPA 3/14/2015 3/17/2015 3/17/2015
L4 Mar 2015 4 Mar 2015
P 12 MARET 15 4 MARET15 4 MARET 15
3 L 115 MARET 1517 MARET15 18MARET 15
3 P Tidak Tahu25 MARET 1527 MARET15 27MARET 15
L Tidak Tahu### 10 Mar 2015
L Tidak TahuLUPA ### 14 Mar 2015
### 18 Mar 2015
SAAT UMUR 9 BL
SAAT UMUR 9 BL
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P 1SD ### 24 Mar 2015
P 215 SEPT 201 ### 3/30/2015 ###
7.00 P 0### 15 Mar 2015
7.00 L 19 BLN ### 24 Mar 2015
P 2SD ### 27 Mar 2015
8.00 L3/17/2015 3/18/2015
L 2LUPA 22/03/2015 24/03/2015 25/03/2015
P 1### 23/03/2015 26/03/2015 27/03/2015
P 2LUPA 25/03/2015 28/03/2015 28/03/2015
LUPA 4/12/2015
Belum
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
SERUM URIN IgM Rubella Isolasi Virus
20 21 22 23 24 25
1/8/2015Negatif Negatif
1/6/2015Negatif Negatif
1/8/2014Negatif Positif
1/13/2015Negatif Negatif
1/14/2015Negatif Negatif
1/15/2015Negatif Negatif
1/16/2015Negatif Negatif
1/19/2015Positive ND
1/19/2015Negatif Negatif
16 Jan 2015Negatif Negatif
TANGGAL PELACAKAN
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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1/20/2015Negatif Negatif
1/21/2015Negatif Negatif
19 Jan 2015Negatif Positif
26 Jan 2015Negatif Negatif
26 Jan 2015Negative Equivocal
28 Jan 2015Negative Negative
29 Jan 2015Negative Negative
28 Jan 2015Positive ND
tdk mau diambil
1/10/2014 1/10/2014Negatif Negatif
1/5/2015 1/5/2015Negatif Negatif
6 Jan 2015 6 Jan 2015Negatif Negatif
13 Jan 2015 13 Jan 2015Negatif Negatif
1/21/2015 1/21/2015Negatif Equivocal
1/26/2015 26 Jan 2015 Negatif Negatif
1/26/2015 1/26/2015Negatif Negatif
26 Jan 2015 26 Jan 2015Negatif Negatif
1/28/2015 30 Jan 2015
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1/31/2015 31 Jan 2015
10 Jan 2015 10 Jan 2015Negatif Negatif
1/28/2015 TIDAK MAU DIAMBIL
1/19/2015Negatif Negatif
8 Jan 2014Negatif Positif
26 Jan 2015Negative Equivocal
28 Jan 2015Negative Negative
30 Jan 2015Negatif Negatif
30 Jan 2015Negatif Negatif
30 Jan 2015Negatif Negatif
30 Jan 2015Negatif Negatif
30 Jan 2015Negatif Negatif
22/01/2015Positif
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Tdk mau diambil
28 Feb 2015Negatif Negatif
tidak diambil
###Negatif Negatif
###Negatif Negatif
###Negatif Negatif
###Negatif Negatif
###Negatif Negatif
16/02/2015,TDK ADA HSL,TDK KIRIM LWT DINAS
23 Feb 2015Negatif Negatif
4 Feb 2015Negatif Positif
### ###Negatif Negatif
###Negatif Negatif
###Negatif Negatif
### ###Negatif Positif
###Negatif Negatif
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11 Feb 2015Negatif Negatif
2 Feb 2015Negatif Negatif
13 Feb 2015Negatif Negatif
###Negatif Negatif
27/02/2015,SAMPEL TDK DIKIRIM
23 Feb 2015Negatif Negatif
04 FEB 15 04 FEB 15Negatif Negatif
06 JAN 15 06 JAN 15Negatif Negatif
10 FEB 15 10 FEB 15Negatif Negatif
13 FEB 15 13 FEB 15Negatif Negatif
27 FEB 15 26 FEB 15Negatif Negatif
24 Feb 2015Negatif Negatif
px menolak diambil darah
27 Feb 2015Negatif Positif
28 Mar 2015Negatif Positif
9 Mar 2015Negatif Negatif
26 Mar 2015Positif Negatif
30 Mar 2015Negatif Negatif
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17 Mar 2015Negatif Negatif
9 March 2015Negatif Negatif Negatif
7 March 2015Negatif Negatif
4/7/2015 3/16/2015Equivocal Negatif
3/25/2015Negatif Negatif
7 March 2015Negatif Positif
19 March 2015Negatif Negatif
18 Mart 15Negatif Negatif
3/31/2015Negatif Negatif
9 Mar 2015 10 Mar 2015Negatif Negatif
3/17/2015Negatif Negatif
7 Mar 2015Negatif Negatif
5 MARET 15 4 MARET 15Negatif Negatif
19 MARET 15 18 MARET 15Negatif Negatif
28 MARET 15 27 MARET 15Negatif Negatif
14 Mar 2015 TDK DIPERIKSA
16 Mar 2015Negatif Negatif
18 Mar 2015Positif
ND
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26 Mar 2015Positif Negatif
Mar 31, 2015 Mar 30, 2015
16 Mar 2015Negatif Negatif
26 Mar 2015Negatif Negatif
28 Mar 2015Negatif Negatif
3/25/2015
26/03/2015
28/03/2015
Tidak Cek
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
Vitamin A PENGIRIM NAMA
26 27 28 29 30
Gamping 1
KINDARNA
KINDARNA
KINDARNA
KINDARNA
KINDARNA
KINDARNA
KINDARNA
KINDARNA
TEMPEL II RETNO I
KEADAAN AKHIR
KLASIFIKASI FINAL
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Y H
Y H CK
Y H CL
Y H CL
Y H CL
Y H CL
Y
H CL
Y H CL
Y H CL
Y H CL
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Y H CL
Y H
Y H
KINDARNA
NGK 1 SITI R
NGK 1 SITI R
NGK 1 SITI R
NGK 1 SITI R
NGK 1 SITI R
T HTIDAK KIRIM SAMPLE/ RASTRI RS JIH
T HTIDAK KIRIM SAMPLE/ RASTRI RS JIH
T HTIDAK KIRIM SAMPLE/ RASTRI RS JIH
T HASTRI RS JIH
T HTIDAK KIRIM SAMPLE/ RASTRI RS JIH
Y HTIDAK KIRIM SAMPLE/ RASTRI RS JIH
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T HTIDAK KIRIM SAMPLE/ RASTRI RS JIH
Y H
YGODEAN 1 PRATIWI
H CLPusk Minggir
Y H NPusk Minggir Dwi Wahyuningsih
Y H NPusk Minggir Dwi Wahyuningsih
Y H NPusk Minggir Dwi Wahyuningsih
Y HPusk Minggir Dwi Wahyuningsih
Y HPusk Minggir Dwi Wahyuningsih
ATTPUROT
Y H CLMOYUDAN TITIK
pleret
Y H NDEPOK II HESTI PANGASTUTI
(diambil Gondokusuman 2)
(diambil Gondokusuman 2)Y H CL
Gondokusuman 2
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(diambil Mantrijeron)T H CL
TARTI PDHI
T H CLSUTARTI PDHI
NGK2
Y H CLKINDARNA
Y H CLKINDARNA
Y H CLKINDARNA
Y H CLKINDARNA
Y H CLKINDARNA
PAKEM
Y H
T H CL Klinik RS Baznas
Y H CLGP 2
Y H CLTP II
Y H CLMOYUDAN TITIK
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Y H CLGondokusuman 2
Y H NDEPOK 2 HESTI PANGASTUTI
Y H NDEPOK 2 HESTI PANGASTUTI
Y H CLDEPOK 2 HESTI PANGASTUTI
Y H CLDEPOK 2 HESTI PANGASTUTI
Y H (diambil Depok 2)
Y Humbulharjo
Y H CLKLS
T H CLRS PANTI RINI RURI
Y H CLNgempla 2 kamto
Y H CLDP II
Y H CLngk 2
T H CLKINDARNA
Y H CLKINDARNA
Y H CLKINDARNA
Aturots
Y H CL
Y H CL
TP I
TP I
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Y H CLTEMPEL II
Y HTuri Sari
Y H CLPAKEM
Y H CLNGK I
Y H CLPAKEM
T H CKP. NUGROHO
Y Hhesti hesti
T Hhesti hesti
T Hhesti hesti
Y H
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TANDA TANGAN
31
1/12/2014
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DARAH TDK DIKIRIMKRN SERUM TDK MENCUKUPI
px menolak diambil darah
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infomasi dari hasil lab
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DI YOGYAKARTATanggal rekam/edit data :Puskesmas : GAMPING 1Tahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120500115XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1 120500115001
2 120500115002
FEBRUARI 3 120500115003
MARET 4 120500115004
April 5 120500115005
6 120500115006
Mei 7 120500115007
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
Yohanes setiawan Purba Ny. Supartinah
MAYANG SERUNGKE GUNARDI
Pujianti Bejo rianto
Widiati Tanjungsari
Suriniati Wandito
Nameliana Hari juniawan
Ummu Rasidah Eko purwanto
ALAMAT (Desa/RT/RW) DAN TELP
Pr .Baleasri 09/46 Balecatur Gamping
Padakan rt 07 rw 22 ambar ketawang
Mancasan 01/25 Ambarketawang Gamping
Pereng kembang 02/ 20 Balecatur Gamping
Sumber gamol balecatur 01/14 balecatur gamping
Watulangkah Ambarketawang Gamping
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
Gamping 1 Gamping
Gamping 1 Gamping
Gamping 1 Gamping
Gamping 1 Gamping
Gamping 1 Gamping
Gamping 1 Gamping
Gamping 1 Gamping
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1521 L
28 P Tidak Tahu
26.00 P
22.00 P
25.00 P
9.50 P
1.00 P
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
Bln April 1994 1/3/2015 1/4/2015 tdk mau diambil
26 Jan 2015 29 Jan 2015
lupa 7 Feb 2015 11 Feb 2015 Tdk mau diambil
26 Mar 2015 27 Mar 2015 28 Mar 2015
Umur 9bln 21 Apr 2015 21 Apr 2015 22 Apr 2015
umur 9bln 29 Apr 2015 29 Apr 2015 29april 2015
Belum 4 May 2015 8 May 2015 9 May 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Y H
Negatif Negatif
Y H
Negatif Positif T H
Y H
Y H
Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
CL Klinik RS Baznas
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data :Puskesmas GAMPING 2Tahun 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120500215XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1 120500215001
2 120500215002
MARET 3 120500215003
4
5
6
7
8
9
10
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11
12
13
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1
2
3
4
5
6
7
8
9
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
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28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
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46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
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64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
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82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
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100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
RINDI NATASYA
AGUS SWARNO
NURYONO SAPUTRO
ALAMAT (Desa/RT/RW) DAN TELP
DAVID DWI BANYUMENENG RT 12 RW 04 BANYURADEN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
GAMPING 2
GAMPING 2
GAMPING 2
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1529 P 1
44 TH L 1
7.00 L 0
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 Jan 18, 1900 20 21
1/14/2015 1/14/2015 1/14/2015
1/12/2015 1/15/2015 1/15/2015
BLM WKTNYA 8 Mar 2015 9 Mar 2015 9 Mar 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif
Negatif Negatif
Negatif Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
KINDARNA
KINDARNA
CLGP 2
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data :Puskesmas GODEAN 1Tahun 2015Periode KLB* (Tanggal Mulai-Akhir)* diisi jika terjadi KLBPENOMORAN EPID : 120500315XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JAN 1 120500315001
FEBRUARI 2 120500315002
MARET 3
APRIL 4 120500715001
5
6
7
8
9
10
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
Muh Fadhil Gatama* (diambil RSKA 45) Dukuh IV RT 02/08 Sidomoyo
IQBAL HABIBI NURMAN TAUFIK SENTUL SIDOAGUNG
NIHIL
ARTA ARENDRA ENDRO
ALAMAT (Desa/RT/RW) DAN TELP
NGENTAK MARGOLUWIH SEYEGAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
GODEAN 1 GODEAN
GODEAN 1 GODEAN
SEYEGAN SEYEGAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 151 L Tidak Tahu
1.00 9.00 L 2
2.00 9.00 L 2
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
LUPA 1/15/2015 1/16/2015 1/19/2015
18 BLN 28 Feb 2015 27 Feb 2015 28 Feb 2015
LUPA 4/2/2015 4/4/2015 4/4/2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif
Negatif Negatif Y
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA KET
28 29 30 31
GODEAN 1 PRATIWI
GODEAN 1 PRATIWI
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI : DIYTanggal rekam/edit data :Puskesmas : GODEAN IITahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120500415XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1
FEBRUARI 2
MARET 3
APRIL 4
MEI 5 120500415001
6
7
8
9
10
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA ALAMAT (Desa/RT/RW) DAN TELP
5 6 7
NIHIL
NIHIL
NIHIL
NIHIL
ADISENO ADYANATA FA.MUYAR KLEBEN VII, SIDOREJO, GODEAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
GODEAN II GODEAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
7.00 L
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
8/1/2014 5/1/2015 5/5/2015 5/7/2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
MOYUDAN
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data :Puskesmas :SEYEGANTahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120500615XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
FEBRUARI 1 120500615001
2 120500615002
3 120500615003
4 120500615004
5 120500615005
6 120500615006
MARET 7
8 120500615007
9
10
APRIL
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
TAKIA ROMI PELANI
KHUZAIFA ALI SAPUTRA ROMI PELANI
AMIRATUN SOLICHA ROMI PELANI
MARWANTI ROMI PELANI
AINI IRVIANISA ANGGRAINI DULJANI
HUSEN dr.FADLI
NIHIL
ALAMAT (Desa/RT/RW) DAN TELP
PANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJOPANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJOPANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJOPANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJO
JARAKAN SENDANG REJO MINGGIR
PANTI ASUHAN DARUL TAQWA JARAKAN SENDANGREJO
SEPTIA NUR KWARASAN SD MULYO MINGGIR
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
MINGGIR MINGGIR
MINGGIR MINGGIR
MINGGIR MINGGIR
MINGGIR MINGGIR
MINGGIR MINGGIR
MINGGIR MINGGIR
MINGGIR MINGGIR
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1511 P 0
8 L 0
15 P 2
15 P Tidak Tahu
5 6 L 1
5 6 L 1
12 P 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI
SAKIT Rash
16 17 18 19 20
BLM 20 January 2015 21 January 2015
BLM 23 January 2015 24 January 2015
BIAS SD 27 January 2015 28 January 2015
28 January 2015 29 January 2015
10 February 2015 16 February 2015
12 February 2015 15 February 2015
BIAS 18 April 2014 19 APRIL2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
SERUM URIN IgM Rubella Isolasi Virus
21 22 23 24 25 26
tidak diambil
###Negatif Negatif Y
###Negatif Negatif Y
###Negatif Negatif Y
###Negatif Negatif Y
###Negatif Negatif Y
20 April 2015
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
PENGIRIM NAMA TANDA TANGAN
27 28 29 30 31H CL
Pusk Minggir
H NPusk Minggir Dwi Wahyuningsih
H NPusk Minggir Dwi Wahyuningsih
H NPusk Minggir Dwi Wahyuningsih
HPusk Minggir Dwi Wahyuningsih
HPusk Minggir Dwi Wahyuningsih
KEADAAN AKHIR
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI DIYTanggal rekam/edit data 8 May 2015Puskesmas :SeyeganTahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120500715XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
Januari 0 Nihil
FEB 1 120500715001
Maret 2 120500715002
April
1
2
3
4
5
6
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7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
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25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
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43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
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61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
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79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
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97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
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115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
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133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
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151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
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169
170
171
172
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181
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185
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
GENTA SUKARNO JAGALAN RT04 MARGODADI
Faiz Nur Hasanah SIGIT SURYANTO
nihil
ALAMAT (Desa/RT/RW) DAN TELP
RISKA MARETA
GONDANGAN RT 06 RW 14, MARGOMULYO
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
SEYEGAN SEYEGAN
SEYEGAN SEYEGAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
14.00 P 1
10.00 P 2
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
15 Feb 2015 15 Feb 2015 16/02/2015,TDK ADA HSL,TDK KIRIM LWT DINAS
SD 23 Mar 2015 26 Mar 2015 26 Mar 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
16/02/2015,TDK ADA HSL,TDK KIRIM LWT DINAS
Positif Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
ATTPUROT
CLTP II
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI DIYTanggal rekam/edit data :Puskesmas MoyudanTahun 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120500515XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JAN 1 120500515001
FEBRUARI 2 120500515002
FEBRUARI 3 120500515003
MARET 4 120500515004
April 5 120500515005
April 6 120500515006
April 7 120500515007
April 8 120500515008
9
10
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
SUHARYANTO Gono Rahrjo Paten Sumber Agung Moyudan
RISKY FARDAN SAPUTRA MARSIYONO GAMPLONG 3 SB RAHAYU
CEMPAKA AYU KRISTANTO KLEPU SUMBERAGUNG
FATIHAH N FATHAN BETAAN SUMBERRAHAYU
Lukman hakim Sutimin Gatak Sumberagung
Ibnu Pradia Mulyono Pingitan Sumberarum
Petrus Pargiono Petrus Pargiono Gesikan Sumbersari
Nurul Aini Junaedi Klisat Sumbersari
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
MOYUDAN
MOYUDAN MOYUDAN
MOYUDAN MOYUDAN
MOYUDAN MOYUDAN
MOYUDAN MOYUDAN
MOYUDAN MOYUDAN
MOYUDAN MOYUDAN
MOYUDAN MOYUDAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1518 TH L
8.00 L 0
P
18.00 P
7.00 L
10.00 L
36.00 L
33.00 P
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
TH 2002 21 Jan 2015 26 Jan 2015 26 Jan 2015
BLM WKT 7 Feb 2015 10 Feb 2015 23 Feb 2015
2/10/2015 2/11/2015 TDK MAU DIAMBIL
2003 24 Mar 2015 30 Mar 2015 30 Mar 2015
2014 5/24/2015 4/25/2015 4/25/2015
2011 4/23/2015 4/23/2015 4/25/2015
tdk Ingt 4/26/2015 4/28/2015 4/29/2015
Tdk Ingt 4/28/2015 4/28/2015 4/30/2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif
Negatif Negatif Y H
TDK MAU DIAMBILY H
Negatif Negatif Y H
Y H
Y H
Y H
Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31CL
MOYUDAN TITIK
CLMOYUDAN TITIK
CK
CLMOYUDAN TITIK
MOYUDAN TITIK
MOYUDAN TITIK
MOYUDAN TITIK
MOYUDAN TITIK
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI : DIYTanggal rekam/edit data :Puskesmas mlati1Tahun 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120500815XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 120500815001
1
2
3
4
5
6
7
8
9
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154
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172
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
FAIZAL MIFTANUDIN
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
MLATI 1
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1514 TH L
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 Jan 16, 1900 Jan 17, 1900 Jan 18, 1900 Jan 19, 1900 Jan 20, 1900
TT 16 Jan 2015 16 Jan 2015 19 Jan 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Positif
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI DIYTanggal rekam/edit data :Puskesmas :MLATI2Tahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120500915XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1
2
3
4
5
6
7
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 Jan 16, 1900 Jan 17, 1900 Jan 18, 1900 Jan 19, 1900 Jan 20, 1900
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data :Puskesmas :DEPOK 1Tahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120501015XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1 120501015001
2 120501415002
FEBRUARI 3 120501415003
MARET 4 120501415004
5
6
7
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
178
179
180
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LAPORAN KASUS CAMPAK INDIVIDUDIISI TGL LAPORAN
NAMA KASUS NAMA ORANG TUA
5 6 7
SRI WIDATI PARMATO WIYONO
ALIV ZIDAN SLAMET ARYADI
Kristina Suminarsih (diambil Pleret)** Maguwoharjo
Andi Maguwoharjo
ALAMAT (Desa/RT/RW) DAN TELP
Modinan sambilegi, Maguwoharjo,Depok
Bokoharjo Bajeng Maguwoharjo Depok
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
Depok 1 Depok
Depok 1 Depok
Depok 1 Depok
Depok 1 Depok
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1534 P 1
3 TH 5 L
26 L
23 L Tidak Tahu
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 16 Jan 1900 17 Jan 1900 18 Jan 1900 19 Jan 1900 20 Jan 1900
8 Jan 2014 9 Jan 2014 9 Jan 2014 10 Jan 2014 10 Jan 2014
1 kali 13 Jan 2015 14 Jan 2015 16 Jan 2015
1 Feb 2015 1 Feb 2015 4 Feb 2015
15 Mar 2015 17 Mar 2015 17 Mar 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif Y H
Negatif Negatif Y H
Negatif Positif Y H
Negatif Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31CK
DEPOK 1 EDI PURWANTO
CLwalidi kalasan
CLpleret
CLGondokusuman 2
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data : Puskesmas :Depok IITahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120501115XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1 120501115001
2 120501115002
3 120501115003
4 120501115004
5 120501115005
6 120501115006
7 120501115007
FEB 8 120501115008
9 120501115009
10 120501115010
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11 120501115011
12 120501115012
MARET 13 120501115013
14 120501115014
15 120501115015
16 120501115016
17
18
19
20
21
22
23
24
25
26
27
28
![Page 871: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/871.jpg)
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
![Page 872: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/872.jpg)
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
AISYAH QORRY NAILA JL WAHID HASYIM IV/28, CC
MUH ZEIN ALMA PURWANTO
ALAELATUL IZZA NY BAROTUTAQIYA
ERNA EKAWATI BAMBANG HARYANTO JL MLATI II PERUMNAS CC
BASARUDIN MARUAT GORONGAN NO 181 CC
LEVI YANTHO PURWANTO
AHMAD SYAROFIK UMI SALAMA
FATIN AQILA EKAWATI
Aulia Hasna Khalilah Sendowo no 40 Sleman
Emanuel CC
ALAMAT (Desa/RT/RW) DAN TELP
PANTI ASUHAN SINAR MELATI 2 CC
JL PERUMNAS NO 99 CONDONG SARI NGROPOH CC
PANTI ASUHAN SINAR MELATI 2 CC
KENTUNGAN BABADAN BARU7/50 CC
PANDEAN 2 GG KANTIL NO 16 CC
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Noviana
Parikesit ANTON KRISTANTO
Larasati Sekar A SRI WANTI DABAG RT 01/26 CONCAT
Erian Junanda HERI KUNARTO SENGKAN RT 05/09 CONCAT
KHIRAN SUWARNO
RAENAD AQILA SUGIYANTO KAYEN RT 04/44 CONCAT
KARANGASEM, 16/22 CONDONGCATUR, DEPOK
WIDORO RT 05/25 NGROPOH, CONCAT
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
DEPOK 2
Depok 2
Depok 2
Depok 2
Depok 2
DEPOK 2
DEPOK 2
DEPOK 2
SLEMAN
DEPOK 2
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DEPOK 2
DEPOK 2 DEPOK
DEPOK 2 DEPOK
DEPOK 2 DEPOK
DEPOK 2 DEPOK
DEPOK 2 DEPOK
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 154 BL P 0
6 L 1
5.00 5.00 P 1
35 TH P 1
24 TH L 1
6 L Tidak Tahu
43 L Tidak Tahu
1 9.00 P 2
8.00 P 0
21 L 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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13 P 2
13 L 2
1 6.00 P 1
21 L 2
2 P 1
10.00 L 1
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
BELUM 1/2/2015 1/6/2015 13/01/2015 20/01/2015 1/6/2015
BAYI 1/12/2015 1/14/2015 20/01/2015 13/02/2015 1/19/2015
11 Jan 2015 14 Jan 2015 16/01/2015 20/01/2015 16 Jan 2015
TT 14 Jan 2015 18 Jan 2015 23/01/2015 25/01/2015 1/20/2015
BAYI 1/18/2015 1/20/2015 23/01/2015 23/01/2015 1/21/2015
TT 23 Jan 2015 27 Jan 2015 28/01/2015 30/01/2015 28 Jan 2015
TT ### ### ### ### ###
11/1/2014 ### ### ### ### ###
BELUM ### ### ###
SD ### ### ###
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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SD ### ### ### ### ###
SD ### ### ### ###
BAYI ### ### ### 9 March 2015
SD ### ### ### 7 March 2015
BAYI 13 Mar 2015 3/16/2015 3/19/2015 4/7/2015 3/16/2015
3/1/2015 21/03/2015 3/25/2015 3/30/2015 3/25/2015
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif Y H
Positive ND Y H
Negatif Negatif Y H
Negatif Negatif T H
Negatif Negatif Y H
Positive ND Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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Negatif Positif Y H
Negatif Negatif Y H
Negatif Negatif Negatif Y H
Negatif Negatif Y H
Equivocal Negatif Y H
Negatif Negatif Y H
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PENGIRIM NAMA
28 29 30 31N
DEPOK II HESTI PANGASTUTI
CLRSCC RSCC
NDEPOK II HESTI PANGASTUTI 1/12/2014
NDEPOK II HESTI PANGASTUTI
NDEPOK II HESTI PANGASTUTI
CLRCC RSCC
NDEPOK II HESTI PANGASTUTI
NDEPOK II HESTI PANGASTUTI
N
(diambil Gondokusuman 2)BUKAN DEPOK 2
(diambil Gondokusuman 2)
KLASIFIKASI FINAL
KETERANGAN (TANGGAL
PENGIRIMAN, JUMLAH KASUS LUAR WILAYAH)
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CLGondokusuman 2 ALAMAT TIDAK JELAS UNTUK DILAKUKAN PE
NDEPOK 2 HESTI PANGASTUTI
NDEPOK 2 HESTI PANGASTUTI
NDEPOK 2 HESTI PANGASTUTI
CLDEPOK 2 HESTI PANGASTUTI
CLDEPOK 2 HESTI PANGASTUTI
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ALAMAT TIDAK JELAS UNTUK DILAKUKAN PE
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RTInstruksi Pengisian Laporan Bulanan
Petunjuk Umum● Format STANDAR ini digunakan sebagai pelaporan oleh Provinsi ke Subdit KLB dan telah dimodifikasi untuk memudahkan proses pengolahan database● Laporan merupakan DATA BULANAN kasus tersangka campak yang dilaporkan dari kabupaten/kota● Laporan dikirimkan SETIAP BULAN ke Dinkes Sleman bersama dengan laporan Integrasi PD3I lainnya sebelum tanggal 8● No. EPID Kasus CBMS dan NO. EPID Kasus KLB ditentukan berdasarkan tahun mulai ruam tersangka kasus campak
Kolom Keterangan
NO. EPID KASUS RUTIN/CBMS ▪ - Digit 1 dan 2 kode provinsi
- Digit 3 dan 4 kode kabupaten / kota
- Digit 5,6 dan 7 kode puskesmas di kabupaten/kota tersebut
- Digit 8 dan 9 kode tahun
- Digit 10,11, dan 12 kode kasus yang dimulai dengan 001Contoh:DIY, SLEMAN, Puskesmas GODEAN 1 dilaporkan kasus pertama campaktahun 2014 maka penomoran Epidnya adalah sbb : 120500314001
NO. EPID KASUS KLB ▪ Contoh: Provinsi Aceh, Kota Banda Aceh, Puskesmas X dilaporkan sebagai kasus pada KLB campak pertama
di tahun 2012 maka penomoran Epidnya adalah sbb:
- Kasus 1
- Kasus 2
- Kasus 3- Kasus 4- Kasus 5
NO. KLB (Kejadian) ▪ Contoh: Provinsi Aceh, Kota Banda Aceh, Puskesmas X dilaporkan terjadi KLB campak pertama
di tahun 2012 maka penomoran Epidnya adalah sbb:
- Kasus 1
- Kasus 2
- Kasus 3- Kasus 4- Kasus 5
NAMA KASUS ▪ Nama lengkap penderita tersangka kasus campak
NAMA ORANG TUA ▪ Nama lengkap orang tua penderita tersangka kasus campak
ALAMAT LENGKAP (DESA/KEL./R ▪ Menunjukan alamat lengkap tempat tinggal tersangka kasus campak
PUSKESMAS ▪ Menunjukan wilayah kerja puskesmas tempat tinggal tersangka kasus campak
KECAMATAN ▪ Menunjukan kecamatan tempat tinggal tersangka kasus campak
KABUPATEN/KOTA ▪ Menunjukan kabupaten/kota tempat tinggal tersangka kasus campak
PROVINSI ▪ Menunjukan provinsi tempat tinggal tersangka kasus campak
UMUR ▪ Menunjukan usia tersangka kasus campak, diisi dalan satuan tahun dan bulan
JENIS KELAMIN ▪ Pilih salah satu dan diisi, jika:- L: Laki-laki- P: Perempuan
VAKSINASI CAMPAK SEBELUM S ▪ Berapa kali: Frekwensi vaksinasi campak yang pernah didapat oleh tersangka kasus campak sampai sebelum sakit
Pilih salah satu dan diisi, jika:- T: Tidak pernah
TANGGAL VAKSINASI CAMPAK S ▪ Tanggal tersangka kasus campak diberikan vaksin campak sebelum sakit
TANGGAL MULAI ▪ - Demam: Tanggal mulai tersangka kasus campak menderita demam >= 380 Celcius
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- Ruam: Tanggal mulai munculnya ruam di tubuh tersangka kasus campak
TANGGAL LAPORAN DITERIMA ▪ Tanggal laporan diterima oleh Petugas Puskesmas
TANGGAL PELACAKAN ▪ Tanggal pelacakan tersangka kasus campak oleh Petugas Puskesmas
TANGGAL AMBIL SAMPEL ▪ - Serum: Tanggal diambilnya sampel darah tersangka kasus campak oleh petugas di lapangan
- Urin: Tanggal diambilnya sampel urin tersangka kasus campak oleh petugas di lapangan
HASIL LABORATORIUM ▪ - IgM Campak:
▪ - IgM Rubella:
- Isolasi Virus:
DIBERI VIT A (SAAT SAKIT CAMP ▪ Pilih salah satu dan diisi, jika:- Y: Ya- T: Tidak
KEADAAN AKHIR ▪ Pilih salah satu dan diisi, jika:- H: Hidup- M: Mati
KLASIFIKASI FINAL ▪ - CL:- RL:- CRL:- N:- CK:- E:
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● Format STANDAR ini digunakan sebagai pelaporan oleh Provinsi ke Subdit KLB dan telah dimodifikasi untuk memudahkan proses pengolahan database● Laporan merupakan DATA BULANAN kasus tersangka campak yang dilaporkan dari kabupaten/kota● Laporan dikirimkan SETIAP BULAN ke Dinkes Sleman bersama dengan laporan Integrasi PD3I lainnya sebelum tanggal 8● No. EPID Kasus CBMS dan NO. EPID Kasus KLB ditentukan berdasarkan tahun mulai ruam tersangka kasus campak
Digit 3 dan 4 kode kabupaten / kota
Digit 5,6 dan 7 kode puskesmas di kabupaten/kota tersebut
Digit 10,11, dan 12 kode kasus yang dimulai dengan 001
DIY, SLEMAN, Puskesmas GODEAN 1 dilaporkan kasus pertama campaktahun 2014 maka penomoran Epidnya adalah sbb : 120500314001
Contoh: Provinsi Aceh, Kota Banda Aceh, Puskesmas X dilaporkan sebagai kasus pada KLB campak pertama
di tahun 2012 maka penomoran Epidnya adalah sbb:
: 010200112001/K1
: 010200112002/K1
: 010200112003/K1: 010200112004/K1: 010200112005/K1 dan seterusnya.
Contoh: Provinsi Aceh, Kota Banda Aceh, Puskesmas X dilaporkan terjadi KLB campak pertama
di tahun 2012 maka penomoran Epidnya adalah sbb:
: 010200112/K1
: 010200112/K1
: 010200112/K1: 010200112/K1: 010200112/K1 dan seterusnya.
Nama lengkap penderita tersangka kasus campak
Nama lengkap orang tua penderita tersangka kasus campak
Menunjukan alamat lengkap tempat tinggal tersangka kasus campak
Menunjukan wilayah kerja puskesmas tempat tinggal tersangka kasus campak
Menunjukan kecamatan tempat tinggal tersangka kasus campak
Menunjukan kabupaten/kota tempat tinggal tersangka kasus campak
Menunjukan provinsi tempat tinggal tersangka kasus campak
Menunjukan usia tersangka kasus campak, diisi dalan satuan tahun dan bulan
Berapa kali: Frekwensi vaksinasi campak yang pernah didapat oleh tersangka kasus campak sampai sebelum sakit
Tanggal tersangka kasus campak diberikan vaksin campak sebelum sakit
Demam: Tanggal mulai tersangka kasus campak menderita demam >= 380 Celcius
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Ruam: Tanggal mulai munculnya ruam di tubuh tersangka kasus campak
Tanggal laporan diterima oleh Petugas Puskesmas
Tanggal pelacakan tersangka kasus campak oleh Petugas Puskesmas
Serum: Tanggal diambilnya sampel darah tersangka kasus campak oleh petugas di lapangan
Urin: Tanggal diambilnya sampel urin tersangka kasus campak oleh petugas di lapangan
PositifNegatifEquivocalPending
PositifNegatifEquivocalPendingPositifNegatifPending
Campak konfirmasi laboratoriumRubella konfirmasi laboratoriumMix (Campak & Rubela) konfirmasi laboratoriumNegatif campak & rubela konfirmasi laboratoriumCampak klinis (tanpa pemeriksaan laboratorium)Kasus klinis yang mempunyai hubungan epidemiologi dengan kasus yang pasti secara laboratorium
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● No. EPID Kasus CBMS dan NO. EPID Kasus KLB ditentukan berdasarkan tahun mulai ruam tersangka kasus campak
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● No. EPID Kasus CBMS dan NO. EPID Kasus KLB ditentukan berdasarkan tahun mulai ruam tersangka kasus campak
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data :Puskesmas depok3Tahun 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120502515XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JAN 1 120502515001
2 120502515002
3 120502515003
FEB 4
maret 5 120502515004
6 120502515005
April 7
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
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62
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64
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65
66
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83
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101
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119
120
121
122
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137
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155
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173
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178
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
EVIS NUR CHASANAH TARMAN SETURAN 05/03 CT
MOH. FACHRY AL MAHDALY FAKHRUL ZAIN
YULI HERIANI BERT ARINANDO (SUAMI)
NIHIL
Monica Eva Sari WALPEN SIPAYUNG
Sukemi Purwaningsih
ALAMAT (Desa/RT/RW) DAN TELP
KOMP. POLRI GOWOK BLOK E1 211 DEPOK SLEMAN
JALAN PANDEGA SATYA NO 26 D-1 KALIURANG
BABARSARI TAMBAK BAYAN CT
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
DEPOK 3 DEPOK
DEPOK
DEPOK
DEPOK 3
DEPOK 3
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1518 P Tidak Tahu
4 L
30 P
20.00 P
51.00 P Tidak Tahu
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
27 Jan 2015 29 Jan 2015 29 Jan 2015
18/01/2015 21/01/2015 21/01/2015 22/01/2015
30/01/2015 31/01/2015 31/01/2015 TIDAK KIRIM SAMPLE/ RJALAN
### 5 March 2015 7 March 2015
15maret ### April ###
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif
Positif T H
TIDAK KIRIM SAMPLE/ RJALANT H
Y H
Negatif Positif Y H
Negatif Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA Keterangan
28 29 30 31
DP 2
ASTRI RS JIH sudah di PE 26/03/15
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
(diambil Depok 2)
umbulharjo infomasi dari hasil lab
Luar wilayah
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI : DIYTanggal rekam/edit data : 06/5/2015Puskesmas : BERBAHTahun : 2015Periode KLB* (Tanggal Mulai-Akhir) : 06/5/2015* diisi jika terjadi KLBPENOMORAN EPID : 120501215XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
jan
Februari 1 120501215001
Maret 2
3
4
5
6
7
8
9
April
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
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28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
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46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
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63
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64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
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82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
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100
101
102
103
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118
119
120
121
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125
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136
137
138
139
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
Fallah Aulia Ruzan
NIHIL
NIHIL
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
berbah berbah
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
4.00 10.00 L Tidak Tahu
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
7 Feb 2015 10 Feb 2015 11 Feb 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
Negatif Negatif
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
(diambil Mantrijeron)
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data :Puskesmas :KalasanTahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120501415XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JAN 1 120501415001
FEBRUARI 2 120501415002
MARET 3 120501415003
MARET 4 120501415004
5 120501415005
6 120501415006
7 120501415007
8 120501415008
9
10
APRIL
april
april
april
![Page 1087: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1087.jpg)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
![Page 1088: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1088.jpg)
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
HIROMI HENDRO PURWOKO PERM PURWO RT01/03 KLS
NY. KHALIFAH NUR B (IBU HAMNY. SITI WAHIDAH
WIJIONO BENDAN,TIRTOMARTANI
NIA KARENINA NN
RCHANISA BAMBANG SUTOYO
alfa fenisa wasto perum purwo blok kh purwo
Rafa Dimas Setyo Widodo Kalimati 03/34,Tortomartani
Muh Aji Surya Saputra Spriyono Pakem01/01Tamanmartani
ALAMAT (Desa/RT/RW) DAN TELP
DUKUHSARI PURWOMARTANI
FITRIANA HARINI
JL RAYA BOGEM 175 TAMANMARTANI KALASAN SLEMAN
PUNDUNG 05/032,TIRTOMARTANI
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
KALASAN
KALASAN KALASAN
KALASAN KALASAN
KALASAN KALASAN
KALASAN KALASAN
KALASAN KALASAN
KALASAN KALASAN
KALASAN KALASAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 154 P 1
22 P Tidak Tahu
35 P Tidak Tahu
18 P Tidak Tahu
12 P 1
5 P 1
1 4 L 1
19 L 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
1/9/2015 1/12/2015 1/13/2015
TDK INGAT 28 Jan 2015 2 Feb 2015 3 Feb 2015 2 Feb 2015
13 Mart 201513 Mart 15 18 Mart 15 18 Mart 15
17 TAHUN YLL 27 Maret 20128 mart 2015 3/31/2015 3/31/2015
11 TH YG LALU 6/4 2015 4/8/2015 4/8/2015
5 th yg lalu 8 aprl 2015 7 april 2015 9/4/15
septemb 2014 11/4/15 15/4/15
19 th yg lalu 20/4/15 24/4/15
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
5 april 2015
8 april 2015
21/4/15 21/4/15
25/4/15 25/4/15
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif
Negatif Negatif T H
Negatif Negatif Y H
Negatif Negatif T H
Pending Negatif Y H
Pending Negatif Y H
Pending Negatif T H
Pending Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
KINDARNA
CLTARTI PDHI
CLKLS
CLRS PANTI RINI RURI
PUSK.KALASAN
PUSK.KALASAN
PUSK.KALASAN
pusk.kalasan
KLASIFIKASI FINAL
WALIDI
WALIDI
walidi
walidi
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data :Puskesmas :Tahun :Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120501315XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JAN
FEB 1 120501315001
MARET
1
2
3
4
5
6
7
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8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
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44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
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62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
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80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
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98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
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116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
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134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
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152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
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170
171
172
173
174
175
176
177
178
179
180
181
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
NIHIL
AN. IVANKA DEWA
NIHIL
ALAMAT (Desa/RT/RW) DAN TELP
SUNGGINGAN PERENG PRAMBANAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
PRAMBANAN PRAMBANAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
11 P
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
22 Dec 2014 9 Feb 2015 12 Feb 2015 14 Feb 2014 13 Feb 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
Negatif Negatif T H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
CLSUTARTI PDHI
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data :Puskesmas NGEMPLAK ITahun 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120501515XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1
2
3
4
5
6
7
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
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175
176
177
178
179
180
181
182
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA
28 29 30 31
KLASIFIKASI FINAL
KETERANGAN
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data :Puskesmas :Ngemplak IITahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120501615XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JAN 1 120501615001
FEB 2 120501615002
3 120501615003
JANUARI 4 120501615005
JANUARI 5 120501615006
JANUARI 6 120501615007
8 120501615004
9 120501615008
April 10 120501615009
11
MARET
MARET
![Page 1311: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1311.jpg)
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
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30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
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48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
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66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
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84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
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102
103
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138
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156
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
BINTANG ARKA HARI NUGROHO PUPUCANGAN WEDODO
YOPI AGUSTIAN FEBRINAYATI
RENA SUPARDI
AURORA KYLA KUSPRIYONO TRI HARYATI
AGHNAZA KELANDRA PRASETYA PUGUH PRASETYO
ARFAIZ AKBAR PRAMADANA BANU ARIF W
TALENTA RAHMA M. JUNI POKOH WEDOMARTANI
GALIH RANGGA ALBARIKO WIDIYANTO
Aska Arik Saren, Wedo
ALAMAT (Desa/RT/RW) DAN TELP
PRM CANDI GEBANG EE14 WEDO
MALANGREJO WEDOMARTANI
JAMBUSARI INDAH JL. JAMBU AIR X10 MIDOMARTANI NGEMPLAK SLEMAN DIY
PERUM ATMAJAYA BLOK B1 / 4A NGEMPLAK SLEMAN
NGLINGGAN RT 05/53 WEDOMARTANI NGEMPLAK SLEMAN DIY
PRM CANDI GEBANG BARU NO 10 WEDO
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
NGEMPLAK 2 NGEMPLAK
NGEMPLAK 2 NGEMPLAK
NGEMPLAK 2 NGEMPLAK
NGEMPLAK 1 NGEMPLAK
NGEMPLAK 0 NGEMPLAK
NGEMPLAK 1 NGEMPLAK
NGEMPLAK 2 NGEMPLAK
NGEMPLAK 3 NGEMPLAK
Ngemnplak 2 Ngemplak
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 151 1 L 1
5.00 L 1
11.00 P 2
7 P Tidak Tahu
2 L
5 L 1
6.00 P 1
28.00 L 0
L 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
14 October 2014 23 Jan 2015 26 Jan 2015 29 Jan 2015
### ### 9 February 2015
2004 25 Feb 2015 26 Feb 2015 27/02/2015,SAMPEL TDK DIKIRIM
03/01/2015 04/01/2015 04/01/2015 TIDAK KIRIM SAMPLE/ R INAP
19/07/2014 02/01/2015 04/01/2015 04/01/2015 TIDAK KIRIM SAMPLE/ R INAP
22/01/2015 26/01/2015 26/01/2015 TIDAK KIRIM SAMPLE/ R INAP
5/12/2009 6 Mar 2015 6 Mar 2015 9 Mar 2015 10 Mar 2015
LUPA 3/14/2015 3/17/2015 3/17/2015 3/17/2015
3/10/2015 4/16/2015 4
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negative Negative
Negatif Negatif
27/02/2015,SAMPEL TDK DIKIRIM
TIDAK KIRIM SAMPLE/ R INAPT H
TIDAK KIRIM SAMPLE/ R INAPT H
TIDAK KIRIM SAMPLE/ R INAPY H
Negatif Negatif Y H
Negatif Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6
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PENGIRIM NAMA Keterangan
28 29 30 31
panti nugroho
DARAH TDK DIKIRIMKRN SERUM TDK MENCUKUPI
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
CLNgempla 2 kamto
CLDP II
KLASIFIKASI FINAL
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PROVINSI :DIYTanggal rekam/edit data :Puskesmas Ngaglik ITahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120501715XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1 120501715001
2 120501715002
3 120501715003
4 120501715004
5 120501715005
6 120501715006
7 120501715007
8 120501715008
9
10
11
12
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13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
![Page 1389: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1389.jpg)
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
![Page 1390: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1390.jpg)
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
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67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
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85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
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103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
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121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
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139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
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157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
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175
176
177
178
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NAMA KASUS NAMA ORANG TUA
5 6 7
AIRWAN HARYADI
ANDRE MIKO
SUPRIHADI
UMAR MTS BABADAN BARU
ANAS MTS BABADAN BARU
YOGI MTS BABADAN BARU
AYUDYA MTS BABADAN BARU
LIA ALVIANA MTSN BABADAN BARU
ALAMAT (Desa/RT/RW) DAN TELP
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PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
NGAGLIK 1
NGAGLIK 1
NGAGLIK 1
NGAGLIK 1
NGAGLIK 1
NGAGLIK 1
NGAGLIK 1
NGAGLIK 1
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PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1519 TH L 1
16 TH L Tidak Tahu
65 TH L 1
14.00 L 1
14.00 L Tidak Tahu
15.00 L 1
12.00 L 2
15.00 P 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 16 Jan 1900 17 Jan 1900 18 Jan 1900 19 Jan 1900 20 Jan 1900
6 Jan 2014 7 Jan 2014 8 Jan 2014
LUPA 24 Jan 2015 25 Jan 2015 26 Jan 2015
TT 25 Jan 2015 26 Jan 2015 28 Jan 2015
BIAS 25 Jan 2015 26 Jan 2015 30 Jan 2015
22 Jan 2015 27 Jan 2015 30 Jan 2015
BIAS 19 Jan 2015 23 Jan 2015 30 Jan 2015
BIAS 22 Jan 2015 26 Jan 2015 30 Jan 2015
BIAS 29 Jan 2015 30 Jan 2015 30 Jan 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
21 Jan 1900 23 24 25 26 27Negatif Positif
Negative Equivocal
Negative Negative
Negatif Negatif
Negatif Negatif
Negatif Negatif
Negatif Negatif
Negatif Negatif
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
p. nugroho
NGK 1 SITI R
NGK 1 SITI R
NGK 1 SITI R
NGK 1 SITI R
NGK 1 SITI R
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI : DIYTanggal rekam/edit data :Puskesmas : NGAGLIK 2Tahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120501815XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
FEBRUARI 1 120501815001
JAN 2 120501815002
JAN 3 120501815003
MARET 4 120501815004
5
6
7
8
9
10
![Page 1465: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1465.jpg)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
Erto Ari Wibowo
ACHILLES TRISNA NASAID EVAND YOHANSA
MUH HANIF ABBAD PUTUT SUPRIYADI
Rohadi JETIS SURUH DONOHAQRJO
ALAMAT (Desa/RT/RW) DAN TELP
BENDOSARI RT 04/16 SARIHARJO NGAGLIK SLEMAN YK
PERUM SUKOHARJO INDAH BLOK C-26 SUKOHARJO NGAGLIK SLEMAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
NGAGLIK 2 NGAGLIK
NGAGLIK 2 NGAGLIK
NGAGLIK 2 NGAGLIK
NGAGLIK 2 NGAGLIK
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
10 L
5 L
48 L
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 16 Jan 1900 17 Jan 1900 18 Jan 1900 19 Jan 1900 20 Jan 1900
22 Feb 2015 22 Feb 2015 23 Feb 2015
17/02/2015 07/01/2015 12/01/2015 12/01/2015 TIDAK KIRIM SAMPLE/ R INAP
27/12/2014 01/01/2015 01/01/2015 TIDAK KIRIM SAMPLE/ RJALAN
4 Mar 2015 4 Mar 2015 7 Mar 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
21 Jan 1900 23 24 25 26 27Negatif Negatif Y H
TIDAK KIRIM SAMPLE/ R INAPY H
TIDAK KIRIM SAMPLE/ RJALANT H
Negatif Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31CL
NGK2
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
CLngk 2
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI DIYTanggal rekam/edit dataPuskesmas SLEMANTahun 2015Periode KLB* (Tanggal Mulai-Akh:* diisi jika terjadi KLBPENOMORAN EPID : 120501915XXX
BULAN No NO EPID KASUS NO KLB* NAMA KASUS
1 2 3 4 5
1/1/2015 1 120501915001 HANI FARIDA
2 120501915002 ANISA MAULIDIA
3 120501915003 IBNU HIBAN
4 120501915004 TAUFIK DWI NUGRAHA
5 120501915005 DANANG DWI KUSHARYANTO
6 120501915006 TRI ASTUTI
7 120501915007 ANANDA
8 120501915008 TUKINAH
9 120501915009 ANDRI NUGROHO
FEBUARI 1 120501915010 MAHATMA JENAR W
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2 120501915011 EKA NURHAYATI
3 120501915012 FIRDA ANAZIYAH
4 120501915013 RINGGA INDRA KUSUMA
5 120501915014 ABIAN SHAHZADA EGA.S
MARET 1 120501915015 NOVILA NEYSA CHOIRURIFA
2 120501915016 YASMIN JIHAN KIRANA
3 120501915017 AMINAH
APRIL 1 120501915018 SAKURA KAYLA SALSABILA
2 120501915019 ENANG PURNAMA
3 120501915020 ABITAMA WILDAN
4 120501915021 SUBAGYO
5 120501915022 MAYA PUSPITA HANDAYANI
6
7
8
9
10
11
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12
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30
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48
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66
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84
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102
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120
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA ORANG TUA PUSKESMAS KECAMATAN
6 7 8 9
NURWAHID / SHOHIRAH SLEMAN SLEMAN
NURWAHID / SHOHIRAH SLEMAN SLEMAN
SLEMAN SLEMAN
SARDI / YAMINAH SLEMAN SLEMAN
DANANG DWI KUSHARYANTO KALAKIJO 7/3 TRIHARJO SLEMAN SLEMAN
PAIBAN / PAINAH SLEMAN SLEMAN
SUPAID / SRI WAHYUNI SLEMAN SLEMAN
SUHARJO SLEMAN SLEMAN
BUDIONO / TUKINAH SLEMAN SLEMAN
SLEMAN SLEMAN
ALAMAT (Desa/RT/RW) DAN TELP
KLEPU BENER 01/01 KARANGSARI, KEBUMEN / BERAN LOR RT05 RW 22 TRIDADI SLEMANDUKUH RT05 RW 29 TRIDADI SLEMAN
MARGONO/ BARIYATUL MUFIDAH
JOGOKERTEN DOMISILI DI : TEMULAWAK TRIHARJO
SIDOREJO 02/20 CATURHARJO SLEMAN
GABUGAN 05/15 PANDOWOHARJO
KLEBEN 01/24 PANDOWOHARJO
KEPITU DOMISILI DI : SIDOREJO CATURHARJO
KARANGTANJUNG PANDOWOHARJO
WIBISONO HERU S / MAHMUDAH
PANGUKAN RT04 RW 10 TRIDADI SLEMAN
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SAMUN / JUMINI SLEMAN SLEMAN
EDY SUHANI / WARSIATI DENGGUNG 01 / 01 TRIDADI SLEMAN SLEMAN
SARWOKO / DWI ASTUTI SLEMAN SLEMAN
JUMIRAN / RIYANTI SLEMAN SLEMAN
MARJONO / SUPRIYATUN SLEMAN SLEMAN
SLEMAN SLEMAN
SUGIYONO SLEMAN SLEMAN
ZULKARNAIN / YENI SUCEN, TRIHARJO SLEMAN SLEMAN SLEMAN
NGEMPLAK CATURHARJO SLEMAN
JOKO LISTYANTO SLEMAN SLEMAN
SUBAGYO SLEMAN SLEMAN
WINARSO / WALMUJIYATI SLEMAN SLEMAN
SANGGRAHAN 01/22 CATURHARJO
KLONCOMAN PANDOWOHARJO
MURANGAN VIII, RT 04 RW 27 TRIHARJO
SANGGRAHAN 03/23 CATURHARJO
EKO MARYANTO/' RINI WAHYUNINGSIH
MURANGAN VII 02/24, TRIHARJO
TEMULAWAK, 05/37, TRIHARJO
NGELO/NYAEN RT 04 RW 35 PANDOWOHARJO SLEMAN
KOKAP SIDOMULYO, TRIMULYO SLEMAN
MURANGAN VIII, RT 07 RW 28 TRIHARJO
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LAPORAN KASUS CAMPAK INDIVIDU
KABUPATEN/KOTA PROVINSI
UMUR
TAHUN BULAN
10 11 12 13 14 1523 1 P 1
9 8 P 2
3 8 L 0
1 6 L 1
36 1 L 2
21 3 P 1
8 10 L 1
52 1 P 1
14 11 L 1
9 7 L 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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11 2 P 2
3 10 P 1
5 2 L 1
0 5 L 0
2 P 1
2 3 L 1
67 3 P Tidak Tahu
5 3 P 1
46.00 L Tidak Tahu
9 6 L Tidak Tahu
49 1 L 1
11 5 L 2
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
SAAT USIA 9 BL 04 JAN 15 05 JAN 15 05 JAN 15 05 JAN 15 05 JAN 15
BIAS 2014 05 JAN 15 06 JAN 15 06 JAN 15 06 JAN 15 06 JAN 15
11 JAN 15 13 JAN 15 13 JAN 15 13 JAN 15 15 JAN 15
19 JAN 15 20 JAN 15 21 JAN 15 21 JAN 15 21 JAN 15
22 JAN 15 23 JAN 15 26 JAN 15 26 JAN 15 26 JAN 15
08 JAN 15 25 JAN 15 26 JAN 15 26 JAN 15 26 JAN 15
25 JAN 15 26 JAN 15 26 JAN 15 26 JAN 15 26 JAN 15
24 JAN 15 26 JAN 15 30 JAN 15 30 JAN 15 30 JAN 15
29 JAN 15 30 JAN 15 31 JAN 15 31 JAN 15 31 JAN 15
01 FEB 15 02 FEB 15 4'02 FEB 15 04 FEB 15 04 FEB 15
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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SAAT BIAS 2014 05 JAN 15 06 JAN 15 06 JAN 15 06 JAN 15 06 JAN 15
08 FEB 15 09 FEB 15 10 FEB 15 10 FEB 15 10 FEB 15
09 FEB 15 11 FEB 15 13 FEB 15 13 FEB 15 13 FEB 15
24 FEB 15 26 FEB 15 26 FEB 15 27 FEB 15 26 FEB 15
SAAT UMUR 9 BL 2 MARET 15 4 MARET15 4 MARET 15 5 MARET 15 4 MARET 15
SAAT UMUR 9 BL 15 MARET 15 17 MARET15 18MARET 15 19 MARET 15 18 MARET 15
25 MARET 15 27 MARET15 27MARET 15 28 MARET 15 27 MARET 15
SAAT USIA 9 BL 30 MAET 15 31 MARET15 02 APRIL 15 04 APRIL 15 02 APRIL 15
11 Mar 2015 10 Mar 2015 14 Mar 2015
ORTU LUPA 2 Apr 2015 7 Apr 2015 13 Apr 2015 11 Apr 2015 11 Apr 2015
SAAT USIA 9 BL 11 APRIL 201513 APRIL 201513 APRIL 201514 APRIL 2015 13 APRIL 2015
BIAS 2014 4 MEI 15 5 MEI 15 6 MEI 15 5/6/2015 6 MEI 15
BELUM CUKUP UMUR
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Equivocal Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Positif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6
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Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif T H
Negatif Negatif Y H
Negatif Negatif Y H
Y H
TDK DIPERIKSA
-T H
Y H
Y H
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PENGIRIM NAMA KETERANGAN
28 29 30 31CL
KINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
KLASIFIKASI FINAL
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CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
CLKINDARNA
Aturots
RS PURI HUSADA RINI
CLKINDARNA
CLKINDARNA
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data :Puskesmas :Tempel 1Tahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120502015XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JAN 1
FEB 2
MARET 3 120502015001
4 120502015002
5
6
7
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
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38
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40
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46
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65
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
NIHIL
NIHIL
TRI NUR BAETI SUKRI
NIRMALA PARAMITA YADI NGEPOS LUMBUNG REJO
ALAMAT (Desa/RT/RW) DAN TELP
KROMODANGSAN, LUMBUNGREJO
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
TEMPEL I TEMPEL
TEMPEL I TEMPEL
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
26.00 L Tidak Tahu
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
LUPA 14 Mar 2015 14 Mar 2015 16 Mar 2015
19 Mar 2015 18 Mar 2015 18 Mar 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
ND
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
Negatif Negatif Y H
PositifND
Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA
28 29 30 31
CL
CL
KLASIFIKASI FINAL
KETERANGAN
TP I
TP I
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI : DIYTanggal rekam/edit data : Puskesmas : TEMPEL IITahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120502115XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1 120502115001
2 120502115002
FEB 3 120502115003
MARET 4 120502115004
5
6
7
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
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119
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128
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136
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137
138
139
140
141
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143
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145
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149
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154
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155
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158
159
160
161
162
163
164
165
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167
168
169
170
171
172
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173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
SIDIQ AGUNG SUNARDI
KEVIN RADITYA UTAMA Bp. UTAMI, NY. SRI LESTARI JENENGAN SUMBERREJO
SUNARDI
ANITA SARYANTO PISANGAN, SUBEREJO
ALAMAT (Desa/RT/RW) DAN TELP
KARANG METHIKAN RT 2 BANYUREJO
BANJAR PONDOKREJO TEMPEL
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
TEMPEL II TEMPEL
TEMPEL II TEMPEL
TEMPEL II TEMPEL
TEMPEL II TEMPEL
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1520.00 3.00 L Lengkap
5.00 6.00 L Lengkap
2.00 P
7.00 P 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
LUPA 6 Jan 2015 9 Jan 2015 10 Jan 2015 10 Jan 2015 10 Jan 2015
LUPA 24 Jan 2015 27 Jan 2015 28 Jan 2015 28 Jan 2015 TIDAK MAU DIAMBIL
21 Feb 2015 26 Feb 2015 27 Feb 2015
SD 24 Mar 2015 24 Mar 2015 26 Mar 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif Y H
TIDAK MAU DIAMBIL Y H
Negatif Positif Y H
Positif Negatif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA KET/TGL KIRIM
28 29 30 31CL
TEMPEL II RETNO I 1/12/2014
CK
CLTEMPEL II
CLTEMPEL II
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data : 4 April 2015Puskesmas :TURITahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120502215XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
Januari 1 120502215001
2 120502215002
Februari 3
Maret 4 120502215003
April 5
6
7
8
9
10
![Page 1743: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1743.jpg)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
Ragil Saputra Bp. Marjiyono Ngandong Girikerto Turi
NAJWA BAHIRA
NIHIL
Isduwi Ida Haryani Bp. Muhadiyanto Becici Wonokerto Turi
NIHIL
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
Sleman (Turi) Turi
TURI
TURI TURI
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 157.00 L 2
6 BL P
7.00 P 2
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
16 Sept 2013 3 Jan 2015 5 Jan 2015 ### ### 1/8/2015
1/13/2015 1/16/2015 1/19/2015
15 SEPT 2013 ### 3/30/2015 Mar 30, 2015 Mar 31, 2015 Mar 30, 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif Y H
Negatif Negatif
Negatif Positif Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31N
Turi Sari
KINDARNA
Turi Sari
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data :Puskesmas : PakemTahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120502315XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
BL JANUARI 2015 1
FEB 2 120502315001
MARET 3 120502315002
4 120502315003
5 120502315004
6 120502315005
7 120502315006
8 120502315007
9 120502315008
10 120502315009
![Page 1820: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1820.jpg)
11 120502315010
12 120502315011
13 120502315012
14 120502315012
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
Yehezkiel Dimas
Simdhy YAYASAN AULIA KATEN HARJO BINANGUN
MUH. AZKA ANJAR TURGO GEDE HARJO
APRIYANI WANMEN DEMEN,PAKEMBINANGUN
Azka Aurellio
Lukman Nurwanto
Nauli Muslina Budiman Randujayan Harjobinangun
Akhila mairen Suko Puspono
Emilia Nining Ibnu Haryanto Kaliurang sel
ALAMAT (Desa/RT/RW) DAN TELP
Turgogedhe Harjobinangun
Sempu Pakembinangun Pakem
Sempu Pakembinangun Pakem
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Rafasya Kurnia Dian Pakem tegal
Anita Nuryanto Ngampel
Muh Arif Lestari Widodo Tegalsari
Muh Ridwan Lestari Widodo Tegalsari
Muhamad fadli Sumadi Banjarsari,Pakembinangun
Amanda Sugeng Tegalsari
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
PAKEM PAKEM
PAKEM PAKEM
PAKEM PAKEM
PAKEM PAKEM
Pakem Pakem
Pakem Pakem
Pakem Pakem
Pakem Pakem
Pakem Pakem
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Pakem Pakem
Pakem Pakem
Pakem Pakem
Pakem Pakem
Pakem Pakem
Pakem Pakem
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
6.00 L 1
7.00 P 0
1.00 7.00 L 1
14.00 P 2
8.00 L
3.00 L
22.00 P
9.00 P
24.00 P
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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3.00 P
4.00 P Tidak Tahu
5.00 L
3.00 L
15.00 L Tidak Tahu
8.00 P
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
22 Feb 2015 23 Feb 2015 24 Feb 2015 24 Feb 2015
12 Mar 2015 15 Mar 2015 16 Mar 2015 16 Mar 2015
9 BLN 24 Mar 2015 24 Mar 2015 26 Mar 2015 26 Mar 2015
SD 24 Mar 2015 27 Mar 2015 28 Mar 2015 28 Mar 2015
3/17/2015 3/18/2015
Tidak Imun 6 Apr 2015 8 Apr 2015 13 Apr 2015
SD 3 Apr 2015 8 Apr 2015 13 Apr 2015
9 Apr 2015 12APR15 14 Apr 2015
SD 9 Apr 2015 13 Apr 2015 14 Apr 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Belum Tidak Cek
Belum
Lampiran 6Lampiran 6 Lampiran 6
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2014 25 Apr 2015 26 Apr 2015 27 Apr 2015
2011 27 Apr 2015 30 Apr 2015 30 Apr 2015
9bul 26 Apr 2015 29 Apr 2015 30 Apr 2015
Umur 9bln 26 Apr 2015 29 Apr 2015 30 Apr 2015
4mei2015 9 mei2015 tidak di ambil
belum 5 May 2015 7 May 2015 tidak di ambil
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
Negatif Negatif Y H
T H
Y
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
CLPAKEM
CLPAKEM
CLNGK I
CLPAKEM
CKP. NUGROHO
Pakem
Pakem
Pakem
KLASIFIKASI FINAL
pakem
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Pakem
Pakem
Pakem
Pakem
Pakem
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data 5/18/2015Puskesmas : CANGKRINGANTahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 120502415XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
februari 1 120502415001
maret 2 120502415002
3 120502415003
4 120502415004
april 5 120502415005
mei 6 120502415006
7 120502415007
8
9
10
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
Nathan arsavin Mujiman/Ana dwi astuti
Zaqi putra praditya Sofian
Davina R Gandung
Anita Putri Sokiman-Hartini
Anisa Kirana Rudiyanto- Ayu Lestari
Ilma Ulima Barayah
Dewi Maulida Sukapto
ALAMAT (Desa/RT/RW) DAN TELP
Plagrak, Wukirsari, cangkringan
Watuadeg, Wukirsari, Cangkringan
Ngepringan, Wukirsari, Cangkringan
Plagrak, Wukirsari, cangkringan
Plosokerep, Umbulharjo, Cangkringan
Gatak, Wukirsari, Cangkringan
Sintokan, Wukirsari, Cangkringan
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
Cangkringan cangkringan
Cangkringan cangkringan
Cangkringan cangkringan
Cangkringan cangkringan
Cangkringan cangkringan
Cangkringan cangkringan
Cangkringan cangkringan
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 154 L 1
3 L 2
1.5 P 1
3 P 2
6 P 1
2 8 P 1
5 P 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
lupa 14/02/2015 16/02/2015 16/02/2015
LUPA 22/03/2015 24/03/2015 25/03/2015 3/25/2015
25/04/2014 23/03/2015 26/03/2015 27/03/2015 26/03/2015
LUPA 25/03/2015 28/03/2015 28/03/2015 28/03/2015
LUPA 08/04/2015 11/04/2015 11/04/2015 11/04/2015
12/05/2015 13/05/2015 13/05/2015 13/05/2015
LUPA 11/05/2015 14/05/2015 15/05/2015 15/05/2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif Y H
Negatif Pending Y H
Negatif Pending T H
Negatif Pending T H
Y H
Y H
Y H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
px menolak diambil darah
hesti hesti
hesti hesti
hesti hesti
hesti hesti
hesti hesti
hesti hesti
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data :Puskesmas :Tahun :Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLB
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1
2
3
4
5
6
7
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
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95
96
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98
99
100
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102
103
104
105
106
107
108
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115
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117
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137
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139
140
141
142
143
144
145
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147
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149
150
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153
154
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155
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157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
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191
192
193
194
195
196
197
198
199
200
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
![Page 1998: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/1998.jpg)
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
![Page 2010: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2010.jpg)
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![Page 2014: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2014.jpg)
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
![Page 2034: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2034.jpg)
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data :Puskesmas :Tahun :Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLB
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1
2
3
4
5
6
7
8
9
10
![Page 2058: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2058.jpg)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
![Page 2059: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2059.jpg)
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
![Page 2060: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2060.jpg)
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
![Page 2061: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2061.jpg)
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
![Page 2062: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2062.jpg)
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
![Page 2065: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2065.jpg)
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
![Page 2067: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2067.jpg)
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
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191
192
193
194
195
196
197
198
199
200
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
![Page 2082: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2082.jpg)
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
![Page 2094: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2094.jpg)
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Daerah Istimewa YogyakartaTanggal rekam/edit data :Rumah Sakit : RSU Panti BaktiningsihTahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
Januari 1
Februari 2
Maret 3
April 1
2
MEI 3
4
5
6
7
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8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
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44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
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62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
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80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
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98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
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116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
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134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
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152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
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170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
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LAPORAN KASUS CAMPAK INDIVIDU:Daerah Istimewa Yogyakarta
NAMA KASUS NAMA ORANG TUA
5 6 7
NIHIL
NIHIL
NIHIL
Suwarto Hadi
Adrick Ananda Allonso Paulus Bindi Kurniawan
ALAMAT (Desa/RT/RW) DAN TELP
Beatrix Phebe AbiGail Sejati deso, sumberarum, Moyudan, Sleman
Jlegongan, Margodadi, Seyegan, Sleman
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
Moyudan Moyudan
Seyegan Seyegan
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
2.00 P 2
7.00 L 1
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
4/3/2015 4/6/2015 tidak diperiksa
4/13/2015 4/17/2015 tidak diperisa
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
tidak diperiksaY H
tidak diperisaT H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
RSU P Baktiningsih
RSU P Baktiningsih
KLASIFIKASI FINAL
Ch. Ana Dwi S
Ch. Ana Dwi S
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI DIYTanggal rekam/edit dataRumah Sakit RSU QUEEN LATIFATahun 2015Periode KLB* (Tanggal Mulai-Akhir)* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1
2
MARET 3
4
5
6
7
8
9
10
FEBRUARI
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
NIHIL
NIHIL
NIHIL
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI : DIYTanggal rekam/edit data : Rumah Sakit : RSU At Turots Al IslamyTahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1 NIHIL
FEBRUARI 2 120500715001
MARET 3
APRIL 4 NIHIL
MEI 5 120500615XXX
6 120501915XXX
7 120500315XXX
8
9
10
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
GENTA SUKARNO JAGALAN RT04 MARGODADI
ENANG PURNAMA NGEMPLAK CATURHARJO
ERNA PARTIANINGSIH
ENI RETNO HANDAYANI SUNGKONO
ANGGARINI DWI PUTRI
ALAMAT (Desa/RT/RW) DAN TELP
RISKA MARETA
BERO SENDANGMULYO MINGGIR
PANGGERAN XII TRIHARJO SLEMAN
GENENG SIDOAGUNG GODEAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
SEYEGAN
SLEMAN
MINGGIR MINGGIR
SLEMAN SLEMAN
GODEAN I GODEAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
14.00 P 1
46.00 L Tidak Tahu
29.00 P Tidak Tahu
23.00 P Tidak Tahu
24.00 P Tidak Tahu
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
15 Feb 2015 15 Feb 2015 16/02/2015,TDK ADA HSL,TDK KIRIM LWT DINAS
11 Mar 2015 10 Mar 2015 14 Mar 2015
8 May 2015 10 May 2015 11 May 2015
9 May 2015 13 May 2015 16 May 2015
15 May 2015 16 May 2015 16 May 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
16/02/2015,TDK ADA HSL,TDK KIRIM LWT DINAS
TDK DIPERIKSA
T H
T H
T H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
Aturots
Aturots
Aturots dr. Ratna
Aturots dr. Johny
Aturots dr. Bidha
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI : DIYTanggal rekam/edit data :Puskesmas RS PURI HUSADATahun 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1
FEBRUARI 2
MARET 3
APRIL 4
APRIL 5
APRIL 6
MEI 7
8
9
10
![Page 2373: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2373.jpg)
11
12
13
14
15
16
1
2
3
4
5
6
7
8
9
10
11
12
![Page 2374: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2374.jpg)
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
![Page 2375: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2375.jpg)
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
![Page 2376: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2376.jpg)
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
![Page 2377: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2377.jpg)
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
![Page 2378: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2378.jpg)
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
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103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
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121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
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139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
NIHIL
NIHIL
NIHIL
ABITAMA WILDAN JOKO LISTYANTO
SLAMET IKSAN JUSHANI
RAHMAD YUSUF SETIAWAN HERI
SRI LESTARI YUWANTO
ALAMAT (Desa/RT/RW) DAN TELP
NGELO/NYAEN RT 04 RW 35 PANDOWOHARJO SLEMAN
TEMPUR SARI RT 02 RW 27 SARDONOHARJO
JONGKE LOR RT 1 RW 26 SENDANG ADI MLATI SLEMAN
KARANG RT 04 RW 20 TRIMULYO SLEMAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
SLEMAN SLEMAN
NGAGLIK I NGAGLIK
SLEMAN SLEMAN
SLEMAN SLEMAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
9 6 L Tidak Tahu
9 7 L Lengkap
14 6 L Lengkap
31 11 P Tidak Tahu
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
ORTU LUPA 2 Apr 2015 7 Apr 2015 13 Apr 2015 11 Apr 2015 11 Apr 2015
ORTU LUPA 16 Apr 2015 4/20/2015 4/24/2015 27 Apr 2015 22 Apr 2015
ORTU LUPA 9 Apr 2015 13 Apr 2015
LUPA 4/27/2015 2 May 2015 7 May 2015 7 M EI 2015 2 May 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
-T H
T H
T H
T H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
RS PURI HUSADA RINI
RS PURI HUSADA RINI
RS PURI HUSADA RINI
RS PURI HUSADA RINI
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI DIYTanggal rekam/edit data 5/8/2015Rumah Sakit RS Panti RiniTahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI
FEBRUARI
MARET 1 120501415004
APRIL
MEI 1 120501415009
2
3
4
5
6
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7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
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25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
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43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
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61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
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79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
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97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
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115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
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133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
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151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
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169
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
NIHIL
NIHIL
NIA KARENINA NN
NIHIL
ABDI SURYO SDR
ALAMAT (Desa/RT/RW) DAN TELP
JL RAYA BOGEM 175 TAMANMARTANI KALASAN SLEMAN
TEGALBOJAN PURWOMARTANI KALASAN SELMAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
KALASAN KALASAN
KALASAN KALASAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
18.00 P Tidak Tahu
30.00 L Tidak Tahu
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
17 TAHUN YLL 3/27/2015 3/28/2015 3/31/2015 3/31/2015
- 4/30/2015 5/6/2015 5/6/2015 5/7/2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
Negatif Negatif T H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
CLRS PANTI RINI RURI
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI DIY
Tanggal rekam/edit data :
Puskesmas : RS "JIH"
Tahun 2015
Periode KLB* (Tanggal Mulai-Akhir) :
* diisi jika terjadi KLB
PENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1
2
3
4
5
6
7
FEBRUARI 8
9
10
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11
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29
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47
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65
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83
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101
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119
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137
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155
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173
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
AURORA KYLA KUSPRIYONO TRI HARYATI
AGHNAZA KELANDRA PRASETYA PUGUH PRASETYO
ARFAIZ AKBAR PRAMADANA BANU ARIF W
ACHILLES TRISNA NASAID EVAND YOHANSA
MUH HANIF ABBAD PUTUT SUPRIYADI
MOH. FACHRY AL MAHDALY FAKHRUL ZAIN
YULI HERIANI BERT ARINANDO (SUAMI)
MOHAMMAD QOHHAAR FATHONI SULARDI
FREVITA ANGGRIANTI
MUHAMMAD YUSUF ASHARI ARIF AMIRUDDIN
ALAMAT (Desa/RT/RW) DAN TELP
JAMBUSARI INDAH JL. JAMBU AIR X10 MIDOMARTANI NGEMPLAK SLEMAN DIY
PERUM ATMAJAYA BLOK B1 / 4A NGEMPLAK SLEMAN
NGLINGGAN RT 05/53 WEDOMARTANI NGEMPLAK SLEMAN DIY
BENDOSARI RT 04/16 SARIHARJO NGAGLIK SLEMAN YK
PERUM SUKOHARJO INDAH BLOK C-26 SUKOHARJO NGAGLIK SLEMAN
KOMP. POLRI GOWOK BLOK E1 211 DEPOK SLEMAN
JALAN PANDEGA SATYA NO 26 D-1 KALIURANG
MECES UMBULMARTANI NGEMPLAK SLEMAN YOGYAKARTA
KARANG ASEM JL.SAJADANA II/195 CONCAT DEPOK SLEMAN YK
GRIYA TAMAN SEJAHTERA D-11 KLURAK TAMAN MARTANI KALASAN SLEMAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
NGEMPLAK
NGEMPLAK
NGEMPLAK
NGAGLIK
NGAGLIK
DEPOK
DEPOK
NGEMPLAK
DEPOK
KALASAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
JENIS KELAMIN
TAHUN BULAN
11 12 13 14 157 P Tidak Tahu
2 L
5 L
10 L
5 L
4 L
30 P
15 L
26 P
17 L
DOSIS VAKSINASI CAMPAK YANG
DITERIMA SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
03/01/2015 04/01/2015 04/01/2015
19/07/2014 02/01/2015 04/01/2015 04/01/2015
22/01/2015 26/01/2015 26/01/2015
17/02/2015 07/01/2015 12/01/2015 12/01/2015
27/12/2014 01/01/2015 01/01/2015
18/01/2015 21/01/2015 21/01/2015 22/01/2015
30/01/2015 31/01/2015 31/01/2015
02/02/2015 05/02/2015 05/02/2015
02/02/2015 02/02/2015
2/27/2015 28/02/2015 2/28/2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A KEADAAN AKHIR
URIN IgM CAMPAK IgM Rubella Isolasi Virus
22 23 24 25 26 27T H
T H
T H
Y H
T H
Positif T H
T H
T H
T H
T H
Lampiran 6 Lampiran 6Lampiran 6
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KLASIFIKASI FINAL PENGIRIM NAMA TANDA TANGAN
28 29 30 31
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
ASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
TIDAK KIRIM SAMPLE/ RASTRI RS JIH
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1
LAPORAN KASUS CAMPAK INDIVIDUPROVINSI DIYTanggal rekam/edit data :Puskesmas Rumah Sakit Condong CaturTahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1
2
3
4
5
6
7
8
9
10
![Page 2604: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2604.jpg)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
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173
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data : 11 MARET 2015Puskesmas :RUMAH SAKIT PANTINUGROHOTahun :2015Periode KLB* (Tanggal Mulai-Akhir) 1/12/2015* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1/1/2015 1
1/27/2015 2
2/1/2015 3
3/9/2015 4
3/9/2015 5 120502315005
5/7/2015 6
5/9/2015 7
5/11/2015 8
5/15/2015 9
5/15/2015 10
![Page 2688: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2688.jpg)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
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108
109
110
111
112
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119
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127
128
129
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136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
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191
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LAPORAN KASUS CAMPAK INDIVIDU
:RUMAH SAKIT PANTINUGROHO
NAMA KASUS NAMA ORANG TUA
5 6 7
Airwan Haryadi Darmadi Nglanjaran
Bentang Arka Daksa Hari Nugroho Pucanganom Rt.08 Rw.27
NIHIL
Asyifa Fahira Yusup Hidayah Palupi Kemiren Srumbung
Azka Aurellio Anjar Kristanto
Rita Dwi Mulati Ngadirah Kayunan Donoharjo Ngaglik
Fitri Nur Sukardiyono Nglingi Harjobinangun
Heppy Wulandari Heri Suprapto Kemiri Purwobinangun
Jelita Gaida Johan Kustalen Pentingsari Umbulharjo
Muhammad Zahfran ArkharegPutri Dewi Brengosan Donoharjo
ALAMAT (Desa/RT/RW) DAN TELP
Turgogedhe Harjobinangun
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
Ngaglik Ngaglik
Ngemplak Ngemplak
Srumbung Salam
Pakem Pakem
Ngaglik Ngaglik
Pakem Pakem
Pakem Pakem
Cangkringan Cangkringan
Ngaglik Ngaglik
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1519.00 L 0
1.00 L
9.00 P
8.00 L
34.00 P
23.00 P
25.00 P
8.50 P
7.00 L
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
1/6/2015 1/6/2015 1/8/2015 1/8/2015 1/8/2015
1/23/2015 1/27/2015 1/27/2015 1/27/2015
3/24/2015 3/27/2015
3/17/2015 3/18/2015
Waktu Bayi 4/30/2015 5/7/2015 5/4/2015 5/5/2015 5/5/2015
SD 5/3/2015 5/8/2015 5/9/2015 5/10/2015 5/9/2015
SD 5/5/2015 5/5/2015 5/8/2015 5/11/2015 5/11/2015
5/13/2015 5/15/2015 5/15/2015 5/15/2015 5/15/2015
5/12/2015 5/13/2015 5/14/2015 5/15/2015 5/15/2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Belum Imunisasi Tidak Cek
Belum Tidak Cek
Belum Vaksin
Belum Vaksin
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Positif
Negatif Negatif
T H
T H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
CKP. NUGROHO
CKP. NUGROHO
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :DIYTanggal rekam/edit data : 8 April 2015Rumah Sakit : RS PDHITahun : 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
JANUARI 1
FEBRUARI 2 120501414002
3 120501415001
MARET 4
APRIL 5
MEI 6 120501414XXX
7
8
9
10
![Page 2772: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2772.jpg)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
![Page 2773: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2773.jpg)
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
![Page 2774: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2774.jpg)
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
178
179
180
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
NIHIL
NY. KHALIFAH NUR B (IBU HAMIL) NY. SITI WAHIDAH
AN. IVANKA DEWA
NIHIL
NIHIL
SDR. HENDRI SURJONO TN. SUKAMTO
ALAMAT (Desa/RT/RW) DAN TELP
DUKUHSARI PURWOMARTANI
SUNGGINGAN PERENG PRAMBANAN
KALIAJIR LOR KALITIRTO RT 2/11 BERBAH SLEMAN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
KALASAN KALASAN
PRAMBANAN PRAMBANAN
BERBAH SLEMAN
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
22 P Tidak Tahu
11 P
26 L Tidak Tahu
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
TDK INGAT 28 Jan 2015 2 Feb 2015 3 Feb 2015 2 Feb 2015
22 Dec 2014 9 Feb 2015 12 Feb 2015 14 Feb 2014 13 Feb 2015
TDK INGAT 29 Apr 2015 5 May 2015 4 May 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6 Lampiran 6Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
T H
T H
T H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6 Lampiran 6Lampiran 6
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PENGIRIM NAMA KETERANGAN
28 29 30 31
CLPDHI SUTARTI
CLPDHI SUTARTI
CLPDHI SUTARTI
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI :Tanggal rekam/edit data :RS : PRAMBANANTahun :2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLBPENOMORAN EPID : 12050XX15XXX
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
1
2
3
4
5
6
7
8
9
10
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
![Page 2851: Format C-1 Google Drive](https://reader030.vdocuments.site/reader030/viewer/2022033016/55cf8566550346484b8d989f/html5/thumbnails/2851.jpg)
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
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65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
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83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
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119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
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137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
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155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
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173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
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191
192
193
194
195
196
197
198
199
200
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
klo tidak ada kasus tolong pada bulan ditulis bulan pada nama kasus di tulis nihil
ALAMAT (Desa/RT/RW) DAN TELP
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 15
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
KLASIFIKASI FINAL
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NO PUSKESMAS NO DESA NO EPID1 Moyudan 1 Sumberrahayu
120500514XXX2 Sumbersari3 Sumberagung4 Sumberarum
2 Minggir 5 Sendangmulyo
120500614XXX6 Sendangarum7 Sendangrejo8 Sendangsari9 Sendangagung
3 Seyegan 10 Margoluwih
120500714XXX11 Margodadi12 Margomulyo13 Margoagung14 Margokaton
4 Godean 1 15 Sidoluhur
120500314XXX16 Sidomulyo17 Sidoagung18 Sidomoyo
5 Godean 2 19 Sidorejo120500414XXX20 Sidokarto
21 Sidoarum6 Gamping 1 22 Balecatur
120500114XXX23 Ambarketawang
7 Gamping 2 24 Banyuraden120500214XXX25 Nogotirto
26 Trihanggo8 Mlati 1 27 Sendangadi
120500814XXX28 Sinduadi
9 Mlati 2 29 Tirtoadi120500914XXX30 Sumberadi
31 Tlogoadi10 Depok 1 32 Maguwoharjo 120501014XXX
11 Depok 2 33 Condongcatur 120501114XXX
12 Depok 3 34 Catur Tunggal 120502514XXX13 Berbah 35 Sendangtirto
120501214XXX36 Tegaltirto37 Jogotirto38 Kalitirto
14 Prambanan 39 Sumberharjo
120501314XXX
40 Wukirharjo41 Gayamharjo42 Sambirejo
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43 Madurejo
120501314XXX
44 Bokoharjo15 Kalasan 45 Purwomartani
120501414XXX46 Tirtomartani47 Tamanmartani48 Selomartani
16 Ngemplak 1 49 Umbulmartani120501514XXX50 Bimomartani
51 Sindumartani17 Ngemplak 2 52 Wedomartani
120501614XXX53 Widodomartani
18 Ngaglik 1 54 Sinduharjo120501714XXX55 Minomartani
56 Sardonoharjo19 Ngaglik 2 57 Sariharjo
120501814XXX58 Sukoharjo59 Donoharjo
20 Sleman 60 Caturharjo
120501914XXX61 Triharjo62 Tridadi63 Pandowoharjo64 Trimulyo
21 Tempel 1 65 Mororejo
120502014XXX66 Margorejo67 Lumbungrejo68 Merdikorejo
22 Tempel 2 69 Banyurejo
120502114XXX70 Tambakrejo71 Sumberrejo72 Pondokrejo
23 Turi 73 Bangunkerto
120502214XXX74 Donokerto75 Girikerto76 Wonokerto
24 Pakem 77 Purwobinangun
120502314XXX78 Candibinangun79 Harjobinangun 80 Pakembinangun81 Hargobinangun
25 Cangkringan 82 Wukirsari
120502414XXX83 Argomulyo84 Glagahharjo85 Kepuhharjo86 Umbulharjo
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSITanggal rekam/edit data :Puskesmas SlemanTahun 2015Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLB
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
April 1 1205xxxxxxxxx
Mei 2 1205xxxxxxxx
3
4
5
6
7
8
9
10
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11
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29
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47
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65
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83
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101
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119
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137
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155
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173
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LAPORAN KASUS CAMPAK INDIVIDU
FW
NAMA KASUS NAMA ORANG TUA
5 6 7
Aurelia Bp. Anang Heri
Fiona Yovela Ari Dwi Admoko Soprayan Girikerto Turi
ALAMAT (Desa/RT/RW) DAN TELP
Panggung Sari Rt 8/ Rw 23 No. 16 C Ngaglik Sleman
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
Ngaglik ngaglik
Turi Turi
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1510.00 P 2
3.00
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
lupa 12 Apr 2015 12 Apr 2015 13 Apr 2015
Lengkap 5 May 2015 6 May 2015 8 May 2015 8 May 2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Y H
Negatif Negatif Negatif Y
KEADAAN AKHIR
IgM CAMPAK
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31
depok 3
KLASIFIKASI FINAL
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LAPORAN KASUS CAMPAK INDIVIDUPROVINSI : LUAR SLEMANTanggal rekam/edit data :Puskesmas :Tahun :Periode KLB* (Tanggal Mulai-Akhir) :* diisi jika terjadi KLB
BULAN No NO EPID KASUS NO KLB*
1 2 3 4
MARET 3 120501315002
3/9/2015 4
5
6
7
8
9
10
11
12
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85
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170
171
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LAPORAN KASUS CAMPAK INDIVIDU
NAMA KASUS NAMA ORANG TUA
5 6 7
BANGKIT DIMAS TUNGGUL B.
Asyifa Fahira Yusup Kemiren Srumbung
ALAMAT (Desa/RT/RW) DAN TELP
BANJARSARI PRAMBANAN KLATEN
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LAPORAN KASUS CAMPAK INDIVIDU
PUSKESMAS KECAMATAN KABUPATEN/KOTA
8 9 10
PRAMBANAN PRAMBANAN
Srumbung Salam
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LAPORAN KASUS CAMPAK INDIVIDU
PROVINSI
UMUR
TAHUN BULAN
11 12 13 14 1516 L
9.00 P
JENIS KELAMIN
DOSIS VAKSINASI
CAMPAK YANG DITERIMA
SEBELUM SAKIT
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LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL MULAI TANGGAL AMIBIL SAMPEL
SAKIT Rash SERUM
16 17 18 19 20 21
18 Mar 2015 18 Mar 2015 18 Mar 2015 18 Mar 2015
3/24/2015 3/27/2015
TANGGAL VAKSINASI CAMPAK
TERAKHIR
TANGGAL LAPORAN DITERIMA
TANGGAL PELACAKAN
Belum Imunisasi Tidak Cek
Lampiran 6Lampiran 6 Lampiran 6
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FORMAT: C-1 (Routine & Outbreak) - Modifikasi
LAPORAN KASUS CAMPAK INDIVIDU
TANGGAL AMIBIL SAMPEL HASIL LAB
Vitamin A
URIN IgM Rubella Isolasi Virus
22 23 24 25 26 27Negatif Negatif Y H
T H
KEADAAN AKHIR
IgM CAMPAK
Lampiran 6Lampiran 6 Lampiran 6
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PENGIRIM NAMA TANDA TANGAN
28 29 30 31CL
RATI PKM PRAMBANAN
CKP. NUGROHO
KLASIFIKASI FINAL
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