1. Nama Sekolah/Madrasah..............................................................:
2. Status Sekolah/Madrasah.............................................................:
3. Alamat Sekolah/Madrasah............................................................:
5. Mata Pelajaran..............................................................................:
Pukul : ..................................................................................................
7. Jumlah Peserta Ulangan Umum....................................................:
JUMLAH
KELAS HADIR TIDAK HADIR KETERANGAN
PESERTA
I
II
III
IV
V
VI
JUMLAH
..................................................................................................
14. Kesan-kesan..................................................................................:
..................................................................................................
Cilacap, .........................................................