Mulai Tanggal

: ........................................................

Sampai Tanggal

: ........................................................

LAPORAN PENINJAUAN YANG SAYA LAKUKAN

Bulan : .......................................
1. Hari/Tanggal

: ..............................................................................................

2. Pukul

: ..................................... s/d .................................................

3. Satuan Yang Ditinjau

: S/G/T/D ( .. ) Gudep : .....................................................

4. Alamat

: ..............................................................................................

5. Hasil Peninjauan

a. Personil

1) Jumlah Pembina

: ..............................................................................................

2) Nama Pembina Satuan : ..............................................................................................

3) Jumlah Peserta Didik

: ..............................................................................................

4) Nama Pembina Gudep

: ..............................................................................................

b. Tingkat Kecakapan Umum :

1) Siaga

: Mula

= .......... , Bantu

= ............ , Tata

= ............

2) Penggalang

: Ramu

= .......... , Rakit

= ............. , Terap = ............

3) Penegak

: Bantara

= .......... , Laksana = ...........................................

4) Pandega

: ..............................................................................................
2

c. TKK yang dicapai :

1) Siaga
2) Penggalang
3) Penegak
4) Pandega

= ....................................
= ....................................
= ....................................
= ....................................

d. Keadaan Satuan
1) Tempat Latihan
2) Acara Latihan
3) Pelaksanaan
4) Alat Perlengkapan
5) Metode
6) Sikap Peserta Didik
7) Sikap Pembina
8) Administrasi Satuan

:
:
:
:
:
:
:
:

orang .................................
orang .................................
orang .................................
orang .................................

macam
macam
macam
macam

..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................

e. Kesimpulan/pendapat saya :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................... , .........................
Peserta Kursus

LAPORAN HASIL DISKUSI

Hari/Tanggal

Waktu

Tempat

Anggota Diskusi

....................... , .........................
Peserta Kursus

CERAMAH/RAPAT YANG SAYA IKUTI BULAN INI

NO

Tanggal

Judul

Nama dan tanda tangan yang

memimpin

KONSULTASI-KONSULTASI YANG SAYA LAKUKAN BULAN INI

NO

Tanggal

Tentang

Nama dan tanda tangan Konsultan

DAFTAR BUKU ( LETERATUR ) PENDIDIKAN YANG TELAH

SAYA BACA DALAM BULAN SEBAGAI BERIKUT
NO

Judul

Pengarang/Penerbit

Kesan-Kesan

LAPORAN KEGIATAN KELUAR SATUAN KAMI BULAN INI

NO

Tanggal

Tempat

Jumlah Peserta

Kegiatan-kegiatan

Mengetahui
Pembina Gugus Depan
..
8

BAKTI KEPADA MASYARAKAT

1. Waktu

: Hari .......................... Tanggal ............................... Jam ........................

2. Tempat Bakti

: ...................................................................................................................

3. Masa Bakti

: ...................................................................................................................

4. Kesan-kesan

: ...................................................................................................................

.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................

Sasaran

Hasil

Beaya

Keterangan

Mengetahui
Pembina Gugus Depan

,.
Peserta Kursus

.......................
10