DATA MONITORING DAN EVALUASI PESERTA PASCA PELATIHAN BAGI

PELAKU UKM KABUPATEN DONGGALA

KECAMATAN :...........................................................

TANGGAL MONEV :...........................................................

I. IDENTITAS PESERTA
Nama :..................................................... Jenis Kelamin : L/P
Alamat :..................................................... Pendidikan Terakhir : SD/SMP/SLTA/SI

II. IDENTITAS UKM/UMKM

Nama usaha UKM :..........................................
No. Izin Usaha :..........................................
Tgl. Izin Usaha :..........................................
Alamat Usaha UKM :..........................................

III. JENIS USAHA YANG DIJALANKAN

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IV. JENIS PELATIHAN YANG PERNAH DIIKUTI

a. Pelatihan.................................................................... Tahun...........................
b. Pelatihan.................................................................... Tahun...........................
c. Pelatihan.................................................................... Tahun...........................

V. DATA PERKEMBANGAN USAHA :

a. Sudah berapa lama usaha ini dijalankan.....................................................
b. Berapa jumlah modal awal dalam mendirikan usaha : Rp.........................
c. Apakah ada tambahan modal usaha selama ini, bila ada berapa jumlahnya : Rp.........................
dan berasal dari modal sendiri/bank/...........................................................................................
d. Berapa pendapatan rata-rata: Rp. ....................................../hari/minggu/bulan
e. Penghasilan bersih rata-rata : Rp. ....................................../hari/minggu/bulan
f. Apakah tempat usaha ini: milik sendiri/sewa/pinjam/, dan jika miik sendiri kira-kira berapa nilai
tempat usaha terebut : Rp. .....................................................
VI. PASCA PELATIHAN
a. Apakah ada perubahan dalam menjalankan usaha sebelum dam sesudah mengikuti pelatihan?
jelaskan ............................................................................................................................................
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 b. Apakah materi yang diperoleh setelah megikuti pelatihan sudah/belum dilaksanakan dalam
menjalankan usaha ini?
Jelaskan: . ...................................................................................................................................
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c. Pelatihan apa yang dibutuhkan dalam mengemangkan usaha ini?
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VII. PERMASALAHAN YANG DIHADAPI DALAM PENEGMBANGAN USAHA
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........................,.........,............................2019
Peserta Pasca Pelatihan

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