Anda di halaman 1dari 1

BORANG PENOLAKAN PEMBERIAN TABLET

BAHAGIAN 1: MAKLUMAT GURU

Nama Guru : ............................................................................................................


No. Kad Pengenalan : ....................................................
Kod Sekolah : ....................................................
Sekolah : ............................................................................................................

BAHAGIAN 2: SEBAB-SEBAB PENOLAKAN

Sila nyatakan:
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

BAHAGIAN 3: PERAKUAN GURU

Saya ....................................................................................... (Nama seperti dalam Kad


Pengenalan) mengaku bahawa semua maklumat di atas adalah benar.

………………………...................
(Tandatangan)
Tarikh: