KEPOLISIAN NEGARA REPUBLIK INDONESIA

DAERAH JAWA TIMUR

RESOR BANGKALAN

NO. UJIAN :............

TANGGAL TES : . . . . . . . . . . . .OKT 2020
JAM : . . . . . . . . . . . .WIB
GOLONGAN :............

HASIL TEST KESAMAPTAAN JASMANI

1. N A M A :...................................................................................................................
2. PANGKAT / NRP :...................................................................................................................
3. TEMPAT / TGL. LAHIR :...................................................................................................................
4. BAG / SAT / SEK / SI :...................................................................................................................
5. TINGGI BADAN :...................................................................................................................
6. BERAT BADAN :...................................................................................................................
7. LINGKARAN PERUT :...................................................................................................................
8. JENIS KELAMIN :...................................................................................................................
9. HOBBY OLAH RAGA :...................................................................................................................
I. TEST KESAMAPTAAN ” A ”

- LARI 12 MENIT :...............................Meter ( T.Score = . . . . . . . . . . )

II. TEST KESAMAPTAAN JASMANI ” B ”

NO ITEM TEST HASIL T. SCORE PARAF PENGUJI

1 PULL UP / CHINNING
2 SIT UP
3 PUSH UP
4 SHUTLE RUN

JUMLAH : ............................
RATA – RATA : ............................

III. NILAI AKHIR ( T. SCORE ”A” + RATA – RATA ”B” ) : ............................

IV. KATEGORI : ............................

Bangkalan, Oktober 2020

KETUA PENGUJI
KEPALA BAGIAN SUMBER DAYA

SUTRISNO, S.H.
KOMISARIS POLISI NRP 64070591