Anda di halaman 1dari 3

LEMBAR BUKU INDUK SISWA SMK

Nama Peserta Didik


NIS / NISN
Nama Sekolah
Alamat Sekolah
Kompetensi Keahlian

:
:
:
:
:

.........................................................
................/........................................
.........................................................
.........................................................
.........................................................

:
:
:
:
:
:
:
:
:
:
:
:
:
:

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

A. KETERANGAN PRIBADI
1. Nama Peserta Didik
- Nama Lengkap
- Nama Panggilan
2. Jenis Kelamin
3. Tempat Lahir
4. Tanggal Lahir
5. A g a m a
6. Kewarganegaraan
7. Anak ke berapa
8. Jumlah Saudara Kandung
9. Jumlah Saudara Tiri
10. Jumlah Saudara Angkat
11. Anak yatim/piatu/yatim piatu
12. Bahasa sehari-hari di rumah

Pas Foto

Cap tiga jari tengah tangan kiri


diatas pas foto bagian bawah
waktu meninggalkan sekolah.

B. KETERANGAN
13. Alamat
14. Nomor Telepon
15. Tempat Tinggal tersebut adalah

: ....................................................................................................................................
: ....................................................................................................................................
:
pada orang tua kandung
pada seseorang dengan hubungan keluarga
menumpang pada orang lain
asrama........................................................................................................
bagi.............................................................................................................
16. Jarak dari tempat tinggal ke sekolah : .....................................................
17. Ke sekolah dengan kendaraan
berjalan kaki
: .....................................................

C. KETERANGAN KESEHATAN

18. Berat Badan


19. Tinggi badan

Pas Foto

Pada waktu terima

Pada waktu
Meninggalkan sekolah

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

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

Cap tiga jari tengah tangan kiri


diatas pas foto bagian bawah
waktu meninggalkan sekolah.

20. Golongan darah


: .....................................................
21. Penyakit yang pernah diderita (contoh TBC, cacar dan lain-lain...............)
Nomor
Urut

Jenis Penyakit

Kelas

Tahun

Lama Sakit

Keterangan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

22. Kelamin Jasmaniah / lainnya

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

D. KETERANGAN PENDIDIKAN SEBELUMNYA


23. Asal Sekolah
a. Tanggal dan Nomor STTB
- Tanggal dan Nomor STTB
- Lama Belajar
b. SLTP lainnya
- Tanggal dan Nomor STTB
- Lama Belajar
24. a. Pindah dari sekolah
- Diterima disekolah ini
b. Alasan Pindah

:
:
:
:
:
:
:
:
:
:

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................20.............di kelas...................................................
....................................................................................................................................

E. KETERANGAN TENTANG ORANG TUA KANDUNG


No.
25.
26.
27.
28.
29.
30.
31.

Orang Tua Kandung


Nama
Tempat Tanggal Lahir
Kewarganegaraan
Ijazah Terakhir
Pekerjaan
Penghasilan / bulan
Alamat

Ayah

Ibu

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

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

F. KETERANGAN TENTANG WALI


No.
32.
33.
34.
35.
36.

Wali
Nama
Ijazah Terakhir
Pekerjaan
Penghasilan / bulan
Alamat

Laki - Laki

Perempuan

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

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

G. KETERANGAN TENTANG WALI


37. Intelegensi (IQ)

38. Aspek Kepribadian


No.

Aspek yang dinilai

: ....................................................................................................................................
(berdasarkan tes pada tanggal................................bulan............................................
tahun...........................................................................................................................
: ....................................................................................................................................
Semester Semester Semester Semester Semester Semester Semester Semester Semester
B C K B C K B C K B C K B C K B C K B C K B C K B C K

1.
2.
3.
4.
5.
6.

Disiplin / Ketertiban
Prakarsa / Kreativitas
Tanggung Jawab
Penyesuaian
Kemantapan Emosi
Kerjasama

39. Bakat khusus dan prestasi yang menonjol dalam


No.
1.
2.
3.
4.
5.
6.
7.
8.

SMTH / TH

Kesenian

Olahraga

Kemasyarakatan
Organisasi

Hasta Karya

Karya Tulis

H. KETERANGAN KEHADIRAN
40. Jumlah hari kehadiran tiap semester :
Tidak Hadir Karena
Ijin

Alpa

Jumlah Hari Belajar


Efektif

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

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

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

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

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

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

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

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

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

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

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

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

Semester......./ Kls......

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

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

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

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

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

Semester......./ Kls......

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

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

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

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

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

Semester......./ Kls......

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

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

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

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

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

Semester / Kls

Hadir

Semester......./ Kls......

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

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

Semester......./ Kls......

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

Semester......./ Kls......

Sakit

I. KETERANGAN SEKITAR PERKEMBANGAN PESERTA DIDIK


41. Tahun Masuk / terdaftar
42. Prestasi peserta didik
Tahun
Pelajaran

Kelas

Smt.

: ....................................................................................................................................
: ....................................................................................................................................
Program
Umum

Jumlah
Mat Pel

Nilai
Rata 2

Peringkat
Kelas/
Rangking

Khusus

Nilai
Rata 2

Nilai
Tinggal
Kelas

20...../20......

20...../20......

20...../20......

43. Tahun meninggalkan sekolah


dengan alasan
44. Pindah sekolah ke
45. Melanjutkan pendidikan ke

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

J. PENERIMAAN SISWA
Tahun : ................................................................ dari : ..........................................................................................
Tahun : ................................................................ dari : ..........................................................................................
Tahun : ................................................................ dari : ..........................................................................................