: _____________________________________________________________________
TARIKH
: ____________________ HARI
______________________________________________________
: ___________________
SKALA
1,2,3
ULASAN / CATATAN
/33
/18
/42
15
Lampiran A
BII
L
E.
1.
2.
3.
4.
5.
6.
ADA /
TIDAK
SKALA
1,2,3
ULASAN / CATATAN
/18
JUMLAH KESELURUHAN
F.
1.
2.
3.
4.
6.
5.
6.
7.
6.
5.
6.
8.
G.
H.
ULASAN PEMANTAU
: _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
TANDATANGAN
: ____________________________________________
: ______________________________
TARIKH : ___________________________
: ______________________________
__________________________________
__________________
COP