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SEKOLAH LUAR BIASA AL – HASYEMI

KECAMATAN CILAWU KABUPATEN GARUT


Kp. Cipager RT.02/04 Ds. Karya Mekar Cilawu- Kab.Garut 44181
No.ijin oprasional Nomor. 4219/SLB.BPMPT/XII/2015
Tlp.081221419054. email:alhasyemi@yahoo.com

HASIL KUNJUNGAN RUMAH ( HOME VISITE)

I. IDENTITAS
a. Nama :
b. Kelas :
c. Nama Orang Tua :
d. Alamat :

II. HASIL WAWANCARA

III. HASIL OBSERVASI

IV. PESAN/ SARAN ORANG TUA/ WALI


SEKOLAH LUAR BIASA AL – HASYEMI
KECAMATAN CILAWU KABUPATEN GARUT
Kp. Cipager RT.02/04 Ds. Karya Mekar Cilawu- Kab.Garut 44181
No.ijin oprasional Nomor. 4219/SLB.BPMPT/XII/2015
Tlp.081221419054. email:alhasyemi@yahoo.com

LAPORAN HOME VISIT


I. IDENTITAS
1. Nama Siswa (Lengkap) : .............................................................................
2. Nama Orang Tuar/ Wali : .............................................................................
3. Pekerjaan : .............................................................................
4. Alamat : .............................................................................
...............................................................................
...............................................................................
II. Tujuan Home Visit : .............................................................................
...............................................................................
...............................................................................
III. Hasil Wawancara : Kondisi Rumah :
Layak Huni Tidak Layak Huni

Golongan Keluarga :

Mampu Tidak Mampu

IV. Kesimpulan : ...............................................................................


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

Mengetahui, Garut, .............................................. 2019


Kepala Sekolah Petugas Home Visit

Tamudin, S.Pd ( )
NIP.