Nama SD : ...........................................................
Nama Guru : ...........................................................
Pangkat Golongan : ...........................................................
Jam Tatap Muka : ...... jam
Jumlah Skor
Keterangan : Skor Perolehan X 100%
Nilai Akhir = Skor maximal
TINDAK LANJUT :
Kepala SD ................................
(Supervisor) Guru Kelas
(………………..…………) (………………….………)
NIP ......................................... NIP .........................................