KOP SURAT

SURAT PERNYATAAN KEASLIAN

Yang bertanda tangan di bawah ini,

Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
dengan ini menyatakan "KEASLIAN" bahwa laporan hasil Penelitian Tindakan
Kelas/Sekolah*) dengan judul ………………………………………………………………..
….………………………………………………………………………………………………..
yang dibuat oleh:
Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
Demikian surat pernyataan kami buat untuk memenuhi persyaratan Administrasi dalam
Pengembangan Profesi dan Jabatan Fungsional Guru.

…..……………………, ………………… 20…

Kepala

………………………………………………….
NIP. ………………………
 KOP SURAT

SURAT KETERANGAN
PENYIMPANAN HASIL PENELITIAN TINDAKAN KELAS
Nomor ………………………..

Yang bertanda tangan di bawah ini,

Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
menerangkan bahwa:
Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
telah menyimpan arsip hasil PTK dan telah dibukukan dengan rincian sebagai berikut:
1. Judul Laporan PTK : .......................................................................................................
2. Nomor induk Buku : .......................................................................................................
3. Tanggal dibukukan : .......................................................................................................
4. Tahun terbit : .......................................................................................................
5. Jumlah halaman : .......................................................................................................
6. Penulis/penyusun : .......................................................................................................
Demikian surat keterangan ini dibuat dengan sebenar-benarnya.

Mengetahui ………………, ……………….. 201..

Kepala Sekolah, Pengelola Perpustakaan,

…………………………………………… ………………………………..
NIP. …………………………… NIP. ...............................
Lampiran : 1 (satu) lembar
Perihal : Permohonan ijin

Kepada
Yth. …………………………………………
……………………………………………....
di
……………….

Dengan hormat,
Melalui surat ini saya
Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
mengajukan permohonan izin untuk melaksanakan PTK di …………………….. mulai
tanggal …………….. sampai dengan ……………….. dengan judul
…………………………………..
…………………………………………………………………………………………………...
Demikian permohonan izin penelitian ini disampaikan.
Terima kasih.

…………………., ……………………. 20 ..
Hormat saya,

………………………………………………
NIP. …………………………
 KOP SURAT

Nomor : ...............................
Lampiran : -
Perihal : Pemberian Izin Penelitian

Yang bertanda tangan di bawah ini,

Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
telah memberikan izin penelitian kepada:
Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
untuk melaksanakan Penelitian Tindakan Kelas (PTK) di …………………….. mulai tanggal
…………….. sampai dengan ……………….. dengan judul …………………………………..
…………………………………………………………………………………………………...
Demikian surat izin penelitian diberikan, untuk dilaksanakan sebagaimana mestinya dan
menyampaikan laporan setelah PTK selesai.

…………………., ………………. 20..

Kepala

……………………………………………..
NIP. ……………………………………..
 KOP SURAT

Nomor : ...............................
Lampiran : -
Perihal : Keterangan Telah Melaksanakan Penelitian

Yang bertanda tangan di bawah ini,

Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
menerangkan bahwa:
Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
telah melaksanakan PTK mulai tanggal ………………….. sampai dengan …….……………..
di …………………………….. dengan judul
……………………………………………….......
…………………………………………………………………………………………………...
Demikian surat keterangan ini diberikan, untuk digunakan sebagaimana mestinya

…………………, ……………… 20..

Kepala

………………………………………………..
NIP. ………………………….
 KOP SURAT

BERITA ACARA
PELAKSANAAN SEMINAR LAPORAN HASIL PENELITIAN

Pada hari ini Sabtu tanggal dua bulan desember tahun dua ribu dua belas, telah dilaksanakan
Seminar Laporan Hasil Penelitian atas nama:
Nama : .........................................................................................................................
NIP : ..........................................................................................................................
Pangkat/Gol. : ..........................................................................................................................
Jabatan : .........................................................................................................................
Instansi : ..........................................................................................................................
Judul Laporan Hasil Penelitian
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
………………………………………….
Demikian Berita Acara ini dibuat sebagai bahan pertimbangan selanjutnya.

……………………., …………….. 20…

Moderator, Ketua Panitia,

…………………………………. H…………………….………………M.M.
NIP. ………………………. NIP. ……………………….

Mengetahui,
Kepala

………………………………………………………..
NIP. …………………………………..
 KOP SURAT

NOTULEN

Seminar (Judul) :
..................................................................................................................
Tujuan :
..................................................................................................................
Waktu :
...................................................................................................................
Tanggal :
...................................................................................................................
Tempat :
...................................................................................................................
Moderator :
...................................................................................................................
Peserta :
15 (lima belas) orang
Susunan Acara :
1. Sambutan dari moderator
2. Penyaji menyampaikan seminar
3. Sesi tanya jawab
4. Kesimpulan
5. Penutup
Pelaksanaan :
1. Pelaksanaan dibuka oleh moderator dengan ucapan salam, latar belakang diadakannya
seminar dan narasumber ……………………………………. di
……………………………
2. Penyaji menyampaikan pada audiens bahwa ………………………………………………..
……………………………………………………………………………………………….
Sesi Tanya Jawab :
1. Tanya : ............................................................................................................................
Jawab : ...........................................................................................................................
2. Tanya : ............................................................................................................................
Jawab : ............................................................................................................................
3. Tanya : ............................................................................................................................
Jawab : ...........................................................................................................................

Kesimpulan
...................................................................................................................................................

Penutup
 …………………., …………………. 20….
Moderator, Ketua Panitia,

………………………………….. H…...................................................M.M.
NIP. …………………………. NIP. ………………………

Mengetahui,
Kepala

………………………………………………………
NIP. ……………………………….
 KOP SURAT

DAFTAR HADIR
PELAKSANAAN SEMINAR LAPORAN HASIL PENELITIAN

Hari : ....................................................................................................................................
Tanggal : ....................................................................................................................................
Tempat : ....................................................................................................................................
No. Nama / NIP Instansi Tanda Tangan
1.
NIP.
2.
NIP.
3.
NIP.
4.
NIP.
5.
NIP.
6.
NIP.
7.
NIP.
8.
NIP.
9.
NIP.
10.
NIP.
11.
NIP.
12.
NIP.
13.
NIP.
14.
NIP.
15.
NIP.

Mengetahui ………………….., …………… 20…

Kepala Ketua Panitia Seminar,

……………………………………… …………………………………..
NIP. …………………… NIP. ………………………