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

: ..................................................................................................
Jumlah Peserta Ulangan Umum....................................................:

7.
KELAS

JUMLAH
PESERTA

HADIR

TIDAK HADIR

KETERANGAN

I
II
III
IV
V
VI
JUMLAH
8.
/ Lebih / Kurang
9.
10.
Kurang Jelas / Tidak Jelas
11.

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

Cukup

Naskah UTS I/II.............................................................................:
Dicetak / Distensil / Diketik / Ditulis Tangan
Naskah UTS I/II.............................................................................:

Jelas /

12.
a. Dari APBD II
b. Dari Dana BOS
c. Dari Komite Sekolah
13.

Besar Anggaran UTS I/II...............................................................:
Rp ........................... / Siswa
Sumber Dana UTS I/II...................................................................:
: Rp ........................... / Siswa
: Rp ........................... / Siswa
: Rp ........................... / Siswa
Kejadian-kejadian Penting.............................................................:

14.

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

Cilacap, .........................................................
Kepala Madrasah

Pengawas

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

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

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