Nama Kelompok
Kelurahan
Kecamatan
Kabupaten
Provinsi
No
1
2
3
4
5
6
: .............................................................
: .............................................................
: .............................................................
: .............................................................
: .............................................................
Indikator
Nilai *)
7
8
9
*) 1 jika terpenuhi
No.
1
2
3
dan
Kriteria Kelompok
Tunas
Tumbuh
Kembang
Skor
04
58
9 10
Lampiran 4
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Parameter
Sumber data
Daftar Hadir
Daftar Hadir
(...............................)
UPK