Nama : .........................................................................................
Kelas : ............................................................................................
Mata Pelajaran : ............................................................................................
Alokasi Waktu : ........................................................................................
Tanggal : ...........................................................................................
Keterangan :
1. 1 = Sangat kurang berperan
2. 2 = Kurang berperan
3. 3 = Berperan
4. 4 = Sangat berperan
(...............................................................)