Hari/tanggal ………………………………………………………………………………………….
Nama ………………………………………………………………………………………….
Status Orang Tua/Wali Siswa *)
Nama Siswa : ………………………………………………………………………………………….
Nama Sekolah : ………………………………………………………………………………………….
Kelas : ………………………………………………………………………………………….
Kab/Kota/Prov ………………………………………………………………………………………….
1. Pekerjaan anda?
PNS/TNI/Polri Pedagang
Lainnya …………………………………………………………
2. Pendidikan terakhir?
SD/Sederajat D3/S1
SMP/Sederajat S2/S3
Ada
Cerai
Meninggal
10. Jumlah anak dalam keluarga anda yang menerima dana PIP?
……………………………………………………………………………………………………..
Ya
Tidak
16.Untuk apa anda menggunakan dana PIP? (dipersilahkan memilih lebih dari 1 jawaban)
Lainnya …………………………………………………………………………………………...
……………………………………………………………………………………………………...
18. Menurut kebutuhan Anda, kapan waktu yang tepat penyaluran dana PIP?
Lainnya….…………………………………………………………………………………...
19. Apa yang anda lakukan jika bantuan dana PIP terlambat diterima?
Lainnya….………………………………………………………………………………….........
karena…………………….………………………………………………………………………
21. Saran atau perbaikan yang anda harapkan atas dana PIP
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Catatan Pemeriksa :
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