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04

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

DAFTAR ISI
PROPOSAL
- Formulir Usulan Penelitian
- Blangko Pengambilan Data
- Kartu Mengikuti Seminar Proposal
- Log Book Bimbingan Proposal
- Formulir Kesedian Penguji
- Jadwal Ujian Proposal
- Surat Pernyataan
- Revisi Proposal
SKRIPSI
- Blangko Penelitian
- Log Book Bimbingan Skripsi
- Formulir Kesedian Penguji
- Jadwal Ujian Skripsi
- Surat Pernyataan
- Revisi Skripsi
- Time Schedule Proposal / Skripsi

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 1

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

LOG BOOK PROPOSAL

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 2

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

FORMULIR USULAN PENELITIAN

NAMA : _________________________________________________

NO.BP : _________________________________________________

RENCANA TIPIK PENELITIAN : (Diisi ketiga alternatif)

ALTERNATIF I: _________________________________________________

ALTERNATIF II : _________________________________________________

ALTERNATIF III : _________________________________________________

TANDA TANGAN

PEMBIMBING I : ____________________________ (___________________)

PEMBIMBING II : ____________________________ (___________________)

DISETUJUI

TOPIK PENELITIAN : ALTERNATIF __________

PADANG, 20…

Ketua Tim Skripsi MAHASISWA YBS,

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 3

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

......................................... (
)
Nip.
FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

SURAT PERMOHONAN PENGAMBILAN DATA / PENELITIAN

Nama :________________________________________________________

No. BP :________________________________________________________

Alamat :________________________________________________________

No. HP / e-Mail :________________________________________________________

Pembimbing 1 :________________________________________________________

Pembimbing 2 :________________________________________________________

Melaksanakan Kegiatan : P
​ engambilan Data / Penelitian______________________________

Ditujukan kepada :________________________________________________________

Dalam rangka : ​Pembuatan Proposal / Hasil Skripsi_________________________

Judul :________________________________________________________

________________________________________________________

________________________________________________________

Saya yang memohon,

(_________________________)

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 4

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

KARTU MENGIKUTI SEMINAR Proposal

NAMA :__________________________
NO.BP :__________________________

PARAF
NO HARI/TANGGAL PEMAKALAH JUDUL KETUA
PENGUJI

1.

2.

3.

4.

5.

6.

Padang,
Ketua Tim Skripsi

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 5

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

.............................................
Nip.

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 6

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
Log Book Bimbingan Proposal
Pembimbing I :
Judul Proposal
:...........................................................................................................................

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

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

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

HARI/TANGGA MASALAH YANG DIBICARAKAN DAN HASIL

NO PARAF
L KONSULTASI

7.

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 7

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

Padang,
Ketua Tim Skripsi

.....................................................
Nip.

Log Book Bimbingan Proposal

Pembimbing II :
Judul Proposal
:...........................................................................................................................

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

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

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

HARI/TANGGA MASALAH YANG DIBICARAKAN DAN HASIL

NO PARAF
L KONSULTASI

1.

2.

3.

4.

5.

6.

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 8

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

7.

Padang,
Ketua Tim Skripsi

.....................................................
Nip.

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 9

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

FORMULIR KESEDIAAN PENGUJI

NAMA : __________________________________________________

NO.BP : __________________________________________________

JUDUL : _________________________________________________

_________________________________________________

_________________________________________________

PENGUJI : TANDA TANGAN

1. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

2. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

3. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

PADANG, 20…

KETUA TIM SKRIPSI

( )

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 10

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

BLANKO KESEDIAAN HADIR DALAM

SEMINAR PROPOSAL / UJIAN SKRIPSI

NAMA MAHASISWA / NO. BP :

______________________________________

Jam Kesediaan Hadir

Nama Dosen Paraf
Senin Selasa Rabu Kamis Jumat Sabtu

P
ada
ng,
K
etu
a
Ti
m
Skr
ipsi

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

Nip.

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

SURAT PERNYATAAN

Yang bertandatangan dibawah ini :

Nama
:..........................................................................................................................
No.BP :
.........................................................................................................................
Ujian : Proposal / Skripsi
Judul Proposal / Skripsi :
.........................................................................................................................

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

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

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

........................................................................................................................
..
Pembimbing 1 :
.........................................................................................................................
Pembimbing 2 :
.........................................................................................................................
Penguji :
.........................................................................................................................
Penguji :
.........................................................................................................................
Penguji :
.........................................................................................................................

10

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

Dengan ini menyatakan bahwa log book proposal / skripsi (terlampir) telah saya isi dengan
sebenar-benarnya dan tandatangan yang terlampir di dalam log book proposal / skripsi tersebut
adalah asli dari pembimbing dan penguji.

Jika dikemudian hari ditemukan hal yang mencurigakan dalam pengisian log book proposal /
skripsi ataupun terjadi pemalsuan tandatangan dari pembimbing dan penguji maka saya bersedia
menerima sanksi akademik atas hal tersebut.

Demikian surat pernyataan ini saya buat, terimakasih.

Padang, ..................................................

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

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 11

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Log Book Skripsi Fakultas Kedokteran Universitas Andalas

LEMBAR PENGESAHAN PERBAIKAN PROPOSAL

NAMA :...............................................................................................................

NO.BP :................................................................................................................

JUDUL PROPOSAL :................................................................................................................

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

NO NAMA PENGUJI PERNYATAAN DAN SARAN TANDATANGAN

1 1.............................................................
..............................................................
..............................................................
..............................................................

2.............................................................
..............................................................
..............................................................
..............................................................

3. ...........................................................
..............................................................
..............................................................
..............................................................

4. ...........................................................
..............................................................
..............................................................
..............................................................

5. ...........................................................

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 12

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

2 1.............................................................
..............................................................
..............................................................
..............................................................

2.............................................................
..............................................................
..............................................................
..............................................................

3. ...........................................................
..............................................................
..............................................................
..............................................................

4. ...........................................................
..............................................................
..............................................................
..............................................................

5. ...........................................................
..............................................................
..............................................................
3 1.............................................................
..............................................................
..............................................................
..............................................................

​Log Book Skripsi Fakultas Kedokteran Universitas Andalas 13

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