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7.16 Format Alih Tangan Kasus

7.16 Format Alih Tangan Kasus

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Dipublikasikan oleh Ria Wastiani

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Published by: Ria Wastiani on Apr 18, 2012
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10/26/2014

SMP ISLAM AL-AZHAR KELAPA GADING JAKARTA

FORMAT
ALIH TANGAN KASUS
No. Dok
No. Revisi
No. Terbit
Tgl Berlaku
Halaman
: F/BK/16
: 00
:
:
: 1 dari 1

ALIH TANGAN KASUS

Nama Siswa : ...................................................................................
Kelas : ...................................................................................
Jenis Kelamin* : L / P
Waktu : ...................................................................................
Pemberi Rujukan : ...................................................................................
Pihak Rujukan* : Dokter/ Polisi/ Biro Psikologi/ Lain-lain ......................
Bidang : ...................................................................................
Nama Petugas Pihak Dirujukan : ...................................................................................
Masalah Siswa : ...................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
Data yang Dilampirkan : ...................................................................................
.....................................................................................
.....................................................................................
Hasil Rujukan : ...................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
Evaluasi dan Tindak Lanjut : ...................................................................................
.....................................................................................
.....................................................................................

Catatan: * Pilih salah satu


Mengetahui, Jakarta, ........................................
Kepala Sekolah Koord. Guru Bimbingan Konseling
SMPI Al-Azhar Kelapa Gading SMPI Al-Azhar Kelapa Gading




Drs. H. Asmawi, M.Pd Dra. Kholilah
NIP. 343974 264720 0 002 NIP. 363574 664830 0 062



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