LEMBAR BUKU INDUK SISWA SMK

Nama Peserta Didik : ......................................................... Pas Foto

NIS / NISN : ................/........................................
Nama Sekolah : .........................................................
Alamat Sekolah : ......................................................... Cap tiga jari tengah tangan kiri
diatas pas foto bagian bawah
Kompetensi Keahlian : ......................................................... waktu meninggalkan sekolah.

A. KETERANGAN PRIBADI
: ....................................................................................................................................
1. Nama Peserta Didik
- Nama Lengkap : ....................................................................................................................................
- Nama Panggilan : ....................................................................................................................................
2. Jenis Kelamin : ....................................................................................................................................
3. Tempat Lahir : ....................................................................................................................................
4. Tanggal Lahir : ....................................................................................................................................
5. A g a m a : ....................................................................................................................................
6. Kewarganegaraan : ....................................................................................................................................
7. Anak ke berapa : ....................................................................................................................................
8. Jumlah Saudara Kandung : ....................................................................................................................................
9. Jumlah Saudara Tiri : ....................................................................................................................................
10. Jumlah Saudara Angkat : ....................................................................................................................................
11. Anak yatim/piatu/yatim piatu : ....................................................................................................................................
12. Bahasa sehari-hari di rumah : ....................................................................................................................................
B. KETERANGAN
13. Alamat : ....................................................................................................................................
14. Nomor Telepon : ....................................................................................................................................
15. Tempat Tinggal tersebut adalah : pada orang tua kandung
pada seseorang dengan hubungan keluarga
menumpang pada orang lain
asrama........................................................................................................
bagi.............................................................................................................
16. Jarak dari tempat tinggal ke sekolah : .....................................................
17. Ke sekolah dengan kendaraan
berjalan kaki : .....................................................

C. KETERANGAN KESEHATAN
Pas Foto
Pada waktu
Pada waktu terima
Meninggalkan sekolah
18. Berat Badan ...................................... ...................................... Cap tiga jari tengah tangan kiri
diatas pas foto bagian bawah
19. Tinggi badan ...................................... ...................................... waktu meninggalkan sekolah.

20. Golongan darah : .....................................................

21. Penyakit yang pernah diderita (contoh TBC, cacar dan lain-lain...............)
Nomor
Jenis Penyakit Kelas Tahun Lama Sakit Keterangan
Urut

............. .................................................. ............. ............. ............. ..........................................

............. .................................................. ............. ............. ............. ..........................................
............. .................................................. ............. ............. ............. ..........................................
............. .................................................. ............. ............. ............. ..........................................

22. Kelamin Jasmaniah / lainnya : ....................................................................................................................................

....................................................................................................................................
D. KETERANGAN PENDIDIKAN SEBELUMNYA
23. Asal Sekolah : ....................................................................................................................................
a. Tanggal dan Nomor STTB : ....................................................................................................................................
- Tanggal dan Nomor STTB : ....................................................................................................................................
- Lama Belajar : ....................................................................................................................................
b. SLTP lainnya : ....................................................................................................................................
- Tanggal dan Nomor STTB : ....................................................................................................................................
- Lama Belajar : ....................................................................................................................................
24. a. Pindah dari sekolah : ....................................................................................................................................
- Diterima disekolah ini : ....................................................20.............di kelas...................................................
b. Alasan Pindah : ....................................................................................................................................
E. KETERANGAN TENTANG ORANG TUA KANDUNG
No. Orang Tua Kandung Ayah Ibu
25. Nama ............................................................. .............................................................
26. Tempat Tanggal Lahir ............................................................. .............................................................
27. Kewarganegaraan ............................................................. .............................................................
28. Ijazah Terakhir ............................................................. .............................................................
29. Pekerjaan ............................................................. .............................................................
30. Penghasilan / bulan ............................................................. .............................................................
31. Alamat ............................................................. .............................................................

F. KETERANGAN TENTANG WALI

No. Wali Laki - Laki Perempuan
32. Nama ............................................................. .............................................................
33. Ijazah Terakhir ............................................................. .............................................................
34. Pekerjaan ............................................................. .............................................................
35. Penghasilan / bulan ............................................................. .............................................................
36. Alamat ............................................................. .............................................................

G. KETERANGAN TENTANG WALI

37. Intelegensi (IQ) : ....................................................................................................................................
(berdasarkan tes pada tanggal................................bulan............................................
tahun...........................................................................................................................
38. Aspek Kepribadian : ....................................................................................................................................
No. Aspek yang dinilai Semester Semester Semester Semester Semester Semester Semester Semester Semester
B C K B C K B C K B C K B C K B C K B C K B C K B C K
1. Disiplin / Ketertiban
2. Prakarsa / Kreativitas
3. Tanggung Jawab
4. Penyesuaian
5. Kemantapan Emosi
6. Kerjasama
39. Bakat khusus dan prestasi yang menonjol dalam
Kemasyarakatan
No. SMTH / TH Kesenian Olahraga Hasta Karya Karya Tulis
Organisasi
1.
2.
3.
4.
5.
6.
7.
8.
H. KETERANGAN KEHADIRAN
40. Jumlah hari kehadiran tiap semester :
Tidak Hadir Karena Jumlah Hari Belajar
Semester / Kls Hadir
Sakit Ijin Alpa Efektif

Semester......./ Kls...... ...................... ...................... ...................... ...................... .......................................

Semester......./ Kls...... ...................... ...................... ...................... ...................... .......................................

Semester......./ Kls...... ...................... ...................... ...................... ...................... .......................................

Semester......./ Kls...... ...................... ...................... ...................... ...................... .......................................

Semester......./ Kls...... ...................... ...................... ...................... ...................... .......................................

Semester......./ Kls...... ...................... ...................... ...................... ...................... .......................................

I. KETERANGAN SEKITAR PERKEMBANGAN PESERTA DIDIK

41. Tahun Masuk / terdaftar : ....................................................................................................................................
42. Prestasi peserta didik : ....................................................................................................................................

Peringkat Nilai
Tahun Program Jumlah Nilai Nilai
Kelas Smt. Kelas/ Khusus Tinggal
Pelajaran Umum Mat Pel Rata 2 Rata 2
Rangking Kelas

20...../20......

20...../20......

20...../20......

43. Tahun meninggalkan sekolah : ....................................................................................................................................

dengan alasan
44. Pindah sekolah ke : ....................................................................................................................................
45. Melanjutkan pendidikan ke : ....................................................................................................................................

J. PENERIMAAN SISWA

Tahun : ................................................................ dari : ..........................................................................................

Tahun : ................................................................ dari : ..........................................................................................

Tahun : ................................................................ dari : ..........................................................................................