NAMA GURU
: ..............................................................
MATA PELAJARAN : ..............................................................
SEMESTER
: ..............................................................
TAHUN PELAJARAN
: ..............................................................
NO
NAMA
CATATAN HAMBATAN
SISWA
PENYEBAB
TINDAK LANJUT
PENCEGAHAN
K3 .
Miri, ..
Guru Mapel
..
NIP. :
..
NIP. :