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Telepon : ……………………………………………………….
No. Fax:………………………………………………………..
E-mail :…………………………………………………………
Lab IPA :
Lab Bahasa :
Lab Komputer :
Lab Keterampilan :
Bengkel kerja :
Perpustakaan :
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Lingkari yang sesuai dengan kondisi sekolah kemudian tuliskan ke dalam skor
2. Karyawan
a. 1:≤9 c. 1 : 13 – 15
b. 1 : 9 – 12 d. 1 : > 16
a. 1:≤9 c. 1 : 13 – 15
b. 1 : 9 – 12 d. 1 : > 16
a. 1 : ≤ 120 c. 1 : 200
b. 1 : 150 d. 1 : ≥ 250
3. Kepala Sekolah
a. ≥ S2 c. D3/Sarjana muda
b. S1 d. ≤ D2
a. ≥ 4 Tahun c. 2 Tahun
a. Ya
b. Tidak
1. Kondisi Siswa
a. 1 : ≤ 35 c. 1 : 41 – 45
b. 1 : 36 – 40 d. 1 : > 45
C. Aspek Sarana
1. Ruang Kelas
a. 1:1 c. 1 : 1,5
a. ≥ 63 m2 (7 x 9 m2) c. 49 – 55 m2
b. 56 – 62 m2 d. < 49 m2
4. Pencahayaan ruangan
b. Baik d. Kurang
b. Baik d. Kurang
b. Tidak sesuai
2. Laboratorium
b. (96-119) m2 d. (64-79) m2
3. Perpustakaan
a. ≥ 84 m2 (7x12) m2 c. 56 - 69 m2
b. 70 - 83 m2 d. < 56 m2
a. 1:1 c. 1:3
b. 1:2 d. 1:>3
a. ≥ 21 m2 c. 12 m2 (4x3) m2
b. 16 – 20 m2 d. 9 m2 (3x3) m2
a. Layak
b. Tidak layak
5. Ruang Guru
a. Standar
b. Tidak standar
a. Layak
b. Tidak layak
b. Lengkap d. Kurang
b. Baik d. Kurang
a. 42 m2 (6x7) m2 c. 30 – 35 m2
b. 36 – 41 m2 d. 24 – 29 m2
a. Layak
b. Tidak layak
8. Kamar kecil
a. 1:1 c. 1:2
b. 1 : 1,5 d. 1:>2
a. 7 c. 3
b. 5 d. <3
a. Layak
b. Tidak layak
a. Mencapai 5 – 6 K c. Mencapai 1 – 2 K
b. Mencapai 3 – 4 K
1. Sumber Dana
b. 4 – 5 sumber d. 2 sumber
(sebutkan.................................................................................................)
2. Penggunaan Dana
a. >9% c. 3% - 5%
b. 6% - 8% d. < 3%
a. > 10% c. 3% - 5%
b. 6% - 9% d. < 3%
b. Kurikulum nasional
2. Bahan Ajar
1. Jumlah referensi tiap mata pelajaran yang dimiliki oleh guru, selain
buku paket untuk siswa (minimal wawancara dengan 5 guru)
a. ≥ 3 buku c. 1 buku
a. Selalu c. Kadang-kadang
3. Buku Siswa
a. ≥ 3 buku c. 1 buku
a. Selalu c. Kadang-kadang
a. ≥ 3 buku c. 1 buku
B. Aspek PBM
1. Kesiapan Guru
a. > 50%
b. < 50%
2. Pengelolaan Kelas
1. Kehadiran siswa
3. Metodologi Pengajaran
a. Selalu c. Kadang-kadang
C. Aspek Penilaian
1. Kesiapan guru
a. > 50%
b. < 50%
b. Tinggi d. Rendah
a. Ya
b. Tidak
a. Ya
b. Tidak
a. Selalu c. Kadang-kadang
2. Implementasi program
b. Tinggi d. Rendah
3. Pengawasan
a. Selalu c. Kadang-kadang
a. Selalu c. Kadang-kadang
4. Kepemimpinan
a. Peringkat 1 c. Peringkat 3
b. Naik d. Turun
a. Peringkat 1 c. Peringkat 3
2. Non Akademik
a. ≥ 5 kejuaraan c. 1 – 2 kejuaraan
3. Kepribadian
a. ≥ 20 % c. (10 – 14) %
2. Non Akademik
a. Juara 1 c. Juara 3
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