Nama guru
: ....................................................................
NIP
: ....................................................................
Pangkat/Golongan
: ...............................................................
.....
Jenis Kelamin
: ....................................................................
Tempat, tanggal lahir
: ....................................................................
Pendidikan terakhir
: ....................................................................
Program keahlian
No.
1.
2.
3.
4.
5.
6.
7.
8.
: ....................................................................
Skor
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
.......
Keterangan :
1 = sangat tidak baik
2 = tidak baik
3 = kurang baik
4 = baik
5 = sangat baik
........................, .................
Penilai,
(....................................)
NIP/NIK