Logbook

Log Book Skripsi Fakultas Kedokteran Universitas Andalas
DAFTAR ISI
PROPOSAL
- Formulir Usulan Penelitian
- Blangko Pengambilan Data
- Kartu Mengikuti Seminar Proposal
- Log Book Bimbingan Proposal
- Formulir Kesedian Penguji
- Jadwal Ujian Proposal
- Surat Pernyataan
- Revisi Proposal
SKRIPSI
- Blangko Penelitian
- Log Book Bimbingan Skripsi
- Formulir Kesedian Penguji
- Jadwal Ujian Skripsi
- Surat Pernyataan
- Revisi Skripsi
- Time Schedule Proposal / Skripsi
Log Book Skripsi Fakultas Kedokteran Universitas Andalas 1

LOG BOOK PROPOSAL

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
FORMULIR USULAN PENELITIAN
NAMA : _________________________________________________
NO.BP : _________________________________________________
RENCANA TIPIK PENELITIAN : (Diisi ketiga alternatif)
ALTERNATIF I: _________________________________________________
ALTERNATIF II : _________________________________________________
ALTERNATIF III : _________________________________________________
TANDA TANGAN
PEMBIMBING I : ____________________________ (___________________)
PEMBIMBING II : ____________________________ (___________________)
DISETUJUI
TOPIK PENELITIAN : ALTERNATIF __________
PADANG, 20…
Ketua Tim Skripsi MAHASISWA YBS,
......................................... ( )
Nip.

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
SURAT PERMOHONAN PENGAMBILAN DATA / PENELITIAN
Nama :________________________________________________________
No. BP :________________________________________________________
Alamat :________________________________________________________
No. HP / e-Mail :________________________________________________________
Pembimbing 1 :________________________________________________________
Pembimbing 2 :________________________________________________________
Melaksanakan Kegiatan : Pengambilan Data / Penelitian______________________________
Ditujukan kepada :________________________________________________________
Dalam rangka : Pembuatan Proposal / Hasil Skripsi_________________________
Judul :________________________________________________________
________________________________________________________
________________________________________________________
Saya yang memohon,
(_________________________)

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
KARTU MENGIKUTI SEMINAR Proposal
NAMA :__________________________
NO.BP :__________________________
NO HARI/TANGGAL PEMAKALAH JUDUL PARAF

KETUA
PENGUJI
1.
2.
3.
4.
5.
6.
Padang,
Ketua Tim Skripsi
.............................................
Nip.

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
Log Book Bimbingan Proposal
Pembimbing I :
Judul Proposal :...........................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
MASALAH YANG DIBICARAKAN DAN HASIL

NO HARI/TANGGAL PARAF
KONSULTASI
7.
Padang,
Ketua Tim Skripsi
.....................................................
Nip.
Log Book Bimbingan Proposal

Pembimbing II :
Judul Proposal :...........................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

KONSULTASI
1.

2.
3.
4.
5.
6.
7.
Padang,
Ketua Tim Skripsi
.....................................................
Nip.

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
FORMULIR KESEDIAAN PENGUJI
NAMA : __________________________________________________
NO.BP : __________________________________________________
JUDUL : _________________________________________________
_________________________________________________
_________________________________________________
PENGUJI : TANDA TANGAN
1. NAMA : ___________________________________ (___________________)
NIP : ___________________________________
2. NAMA : ___________________________________ (___________________)
NIP : ___________________________________
3. NAMA : ___________________________________ (___________________)
NIP : ___________________________________
PADANG, 20…
TIM SKRIPSI
( )

BLANKO KESEDIAAN HADIR DALAM

SEMINAR PROPOSAL / UJIAN SKRIPSI
NAMA MAHASISWA / NO. BP : ______________________________________
No Nama Dosen Jam Kesediaan Hadir Keterangan

. Senin Salasa Rabu Kamis Jumat Sabtu
1.
2.
3.
4.
5.
Padang,
Ketua Tim Skripsi
............................................................
Nip.
9

SURAT PERNYATAAN
Yang bertandatangan dibawah ini :
Nama :..........................................................................................................................
No.BP : .........................................................................................................................
Ujian : Proposal / Skripsi
Judul Proposal / Skripsi : .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
..........................................................................................................................
..........................................................................................................................
Pembimbing 1 : .........................................................................................................................
Pembimbing 2 : .........................................................................................................................
Penguji : .........................................................................................................................
Penguji : .........................................................................................................................
Penguji : .........................................................................................................................
Dengan ini menyatakan bahwa log book proposal / skripsi (terlampir) telah saya isi dengan sebenar-
benarnya dan tandatangan yang terlampir di dalam log book proposal / skripsi tersebut adalah asli
dari pembimbing dan penguji.
Jika dikemudian hari ditemukan hal yang mencurigakan dalam pengisian log book proposal / skripsi
ataupun terjadi pemalsuan tandatangan dari pembimbing dan penguji maka saya bersedia menerima
sanksi akademik atas hal tersebut.
Demikian surat pernyataan ini saya buat, terimakasih.
Padang, ..................................................
.....................................................................
10
LEMBAR PENGESAHAN PERBAIKAN PROPOSAL
NAMA :...............................................................................................................
NO.BP :................................................................................................................
JUDUL PROPOSAL :................................................................................................................

................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
NO NAMA PENGUJI PERNYATAAN DAN SARAN TANDATANGAN

1 1............................................................
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2............................................................
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LOG BOOK SKRIPSI

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
SURAT PERMOHONAN PENGAMBILAN DATA / PENELITIAN
Nama :________________________________________________________
No. BP :________________________________________________________
Alamat :________________________________________________________
No. HP / e-Mail :________________________________________________________
Pembimbing 1 :________________________________________________________
Pembimbing 2 :________________________________________________________
Melaksanakan Kegiatan : Pengambilan Data / Penelitian______________________________
Ditujukan kepada :________________________________________________________
Dalam rangka : Pembuatan Proposal / Hasil Skripsi_________________________
Judul :________________________________________________________
________________________________________________________
________________________________________________________
Saya yang memohon,
(_________________________)

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
Log Book Bimbingan Penelitian dan Skripsi
Pembimbing I :
Judul Proposal :...........................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

KONSULTASI
1.
2.
3.
4.
5.
6.
Padang,
Ketua Tim Skripsi
.............................................................
Nip.
Log Book Bimbingan Penelitian dan Skripsi

Pembimbing II :
Judul Proposal :...........................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
MASALAH YANG DIBICARAKAN DAN

HASIL KONSULTASI
1.
2.

3.
4.
5.
6.
7.
Padang,
Ketua Tim Skripsi
.............................................................
Nip.
FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
FORMULIR KESEDIAAN PENGUJI
NAMA : __________________________________________________
NO.BP : __________________________________________________
JUDUL : _________________________________________________
_________________________________________________
_________________________________________________
PENGUJI : TANDA TANGAN
1. NAMA : ___________________________________ (___________________)
NIP : ___________________________________
2. NAMA : ___________________________________ (___________________)

NIP : ___________________________________
3. NAMA : ___________________________________ (___________________)
NIP : ___________________________________
PADANG, 20…
TIM SKRIPSI
( )

BLANKO KESEDIAAN HADIR DALAM

SEMINAR PROPOSAL / UJIAN SKRIPSI
NAMA MAHASISWA / NO. BP : ______________________________________
No Nama Dosen Jam Kesediaan Hadir Keterangan

. Senin Salasa Rabu Kamis Jumat Sabtu
1.
2.
3.
4.
5.
Padang,
Ketua Tim Skripsi
..................................................................
Nip.
21

SURAT PERNYATAAN
Yang bertandatangan dibawah ini :
Nama :..........................................................................................................................
No.BP : .........................................................................................................................
Ujian : Proposal / Skripsi
Judul Proposal / Skripsi : .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
..........................................................................................................................
..........................................................................................................................
Pembimbing 1 : .........................................................................................................................
Pembimbing 2 : .........................................................................................................................
Penguji : .........................................................................................................................
Penguji : .........................................................................................................................
Penguji : .........................................................................................................................
Dengan ini menyatakan bahwa log book proposal / skripsi (terlampir) telah saya isi dengan sebenar-
benarnya dan tandatangan yang terlampir di dalam log book proposal / skripsi tersebut adalah asli
dari pembimbing dan penguji.
Jika dikemudian hari ditemukan hal yang mencurigakan dalam pengisian log book proposal / skripsi
ataupun terjadi pemalsuan tandatangan dari pembimbing dan penguji maka saya bersedia menerima
sanksi akademik atas hal tersebut.
Demikian surat pernyataan ini saya buat, terimakasih.
Padang, ..................................................
.....................................................................
22
LEMBAR PENGESAHAN PERBAIKAN SKRIPSI
NAMA :...............................................................................................................
NO.BP :................................................................................................................
JUDUL PROPOSAL :................................................................................................................

................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
NO NAMA PENGUJI PERNYATAAN DAN SARAN TANDATANGAN

1 1............................................................
.
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2............................................................
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3. ...........................................................
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4. ...........................................................
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5. ...........................................................
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2 1............................................................
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2............................................................
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3 1............................................................
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2............................................................
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2............................................................
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5. ...........................................................
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TIME SCHEDULE PROPOSAL/SKRIPSI

PENDIDIKAN DOKTER
FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
TIME SCHEDULE PROPOSAL/SKRIPSI

BULAN
NO KEGIATAN
1 2 3 4 5 6
1 PENGESAHAN JUDUL
2 PEMBUATAN PROPOSAL
3 UJIAN PROPOSAL
4 REVISI PROPOSAL & MELAKUKAN PENELITIAN
5 UJIAN SKRIPSI
6 REVISI SKRIPSI & MEMPERBANYAK SKRIPSI
ANGGARAN BIAYA
BIAYA
NO KEGIATAN
(Rp)
1 OBSERVASI
2 TRANSPOSTASI
3 PENGAMBILAN DATA
4 BAHAN HABIS PAKAI
5 PENELITIAN
TOTAL BIAYA
Padang,
………………………………………

Logbook

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 1

LOG BOOK PROPOSAL

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 2

FORMULIR USULAN PENELITIAN

RENCANA TIPIK PENELITIAN : (Diisi ketiga alternatif)

ALTERNATIF III : _________________________________________________

PEMBIMBING I : ____________________________ (___________________)

PEMBIMBING II : ____________________________ (___________________)

TOPIK PENELITIAN : ALTERNATIF __________

Ketua Tim Skripsi MAHASISWA YBS,

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 3

SURAT PERMOHONAN PENGAMBILAN DATA / PENELITIAN

No. HP / e-Mail :________________________________________________________

Melaksanakan Kegiatan : Pengambilan Data / Penelitian______________________________

Ditujukan kepada :________________________________________________________

Dalam rangka : Pembuatan Proposal / Hasil Skripsi_________________________

Saya yang memohon,

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 4

KARTU MENGIKUTI SEMINAR Proposal

NO HARI/TANGGAL PEMAKALAH JUDUL PARAF

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 5

MASALAH YANG DIBICARAKAN DAN HASIL

Log Book Bimbingan Proposal

MASALAH YANG DIBICARAKAN DAN HASIL

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 6

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 7

FORMULIR KESEDIAAN PENGUJI

PENGUJI : TANDA TANGAN

1. NAMA : ___________________________________ (___________________)

2. NAMA : ___________________________________ (___________________)

3. NAMA : ___________________________________ (___________________)

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 8

BLANKO KESEDIAAN HADIR DALAM

NAMA MAHASISWA / NO. BP : ______________________________________

No Nama Dosen Jam Kesediaan Hadir Keterangan

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 10

Yang bertandatangan dibawah ini :

Demikian surat pernyataan ini saya buat, terimakasih.

LEMBAR PENGESAHAN PERBAIKAN PROPOSAL

JUDUL PROPOSAL :................................................................................................................

NO NAMA PENGUJI PERNYATAAN DAN SARAN TANDATANGAN

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 11

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 12

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 15

LOG BOOK SKRIPSI

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 16

SURAT PERMOHONAN PENGAMBILAN DATA / PENELITIAN

No. HP / e-Mail :________________________________________________________

Melaksanakan Kegiatan : Pengambilan Data / Penelitian______________________________

Ditujukan kepada :________________________________________________________

Dalam rangka : Pembuatan Proposal / Hasil Skripsi_________________________

Saya yang memohon,

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 17

MASALAH YANG DIBICARAKAN DAN HASIL

Log Book Bimbingan Penelitian dan Skripsi

MASALAH YANG DIBICARAKAN DAN

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 18

FORMULIR KESEDIAAN PENGUJI

PENGUJI : TANDA TANGAN

1. NAMA : ___________________________________ (___________________)

2. NAMA : ___________________________________ (___________________)

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 19

PEMBIMBING I : __________ (_)

PEMBIMBING II : __________ (_)

1. NAMA : _________________ (_)

2. NAMA : _________________ (_)

3. NAMA : _________________ (_)

1. NAMA : _________________ (_)

2. NAMA : _________________ (_)

3. NAMA : _________________ (_)