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KEMENTERIAN AGAMA

KELOMPOK KERJA PENGAWAS PAI (POKJAWAS PAI)


KANTOR KABUPATEN CILACAP
Alamat : Jalan DI. Panjaitan No.44 Telp. (0282)531155 Cilacap

PEMANTAUAN PELAKSANAAN ULANGAN TENGAH SEMESTER I/II


TAHUN PELAJARAN ........... / ...........

1. Nama Sekolah/Madrasah..............................................................:

2. Status Sekolah/Madrasah.............................................................:

3. Alamat Sekolah/Madrasah............................................................:

4. Hari, Tanggal ................................................................................:

5. Mata Pelajaran..............................................................................:

6. Pelaksanaan Jam Ke..........................................................................................:

Pukul : ..................................................................................................
7. Jumlah Peserta Ulangan Umum....................................................:
JUMLAH
KELAS HADIR TIDAK HADIR KETERANGAN
PESERTA
I
II
III
IV
V
VI
JUMLAH

8. Jumlah Naskah UTS I/II.................................................................: Cukup


/ Lebih / Kurang
9. Naskah UTS I/II.............................................................................:
Dicetak / Distensil / Diketik / Ditulis Tangan
10. Naskah UTS I/II.............................................................................: Jelas /
Kurang Jelas / Tidak Jelas
11. Besar Anggaran UTS I/II...............................................................:
Rp ........................... / Siswa
12. Sumber Dana UTS I/II...................................................................:
a. Dari APBD II : Rp ........................... / Siswa
b. Dari Dana BOS : Rp ........................... / Siswa
c. Dari Komite Sekolah : Rp ........................... / Siswa
13. Kejadian-kejadian Penting.............................................................:

..................................................................................................
14. Kesan-kesan..................................................................................:

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

Cilacap, .........................................................

Kepala Madrasah Pengawas


______________________________ ________________________________
NIP: ............................................. NIP: .............................................................

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