INSTRUMEN KELEMBAGAAN

PENDIDIKAN USIA DINI AL-QUR’AN (PADQU)

TAHUNPELAJARAN2021/2022

Nama Lembaga :

_____________________________________________________________________

BIDANG PENDIDIKAN DINIYAH DAN PONDOK PESANTREN

KANTOR WILAYAH KEMENTERIAN AGAMA PROVINSI JAWA BARAT
TAHUN 2022
 INSTRUMEN KELEMBAGAAN
PENDIDIKANUSIADINIAL-QUR’AN(PAUDQ)
BIDANGPENDIDIKAN DINIYAH DAN PONDOK PESANTREN KANTOR WILAYAH KEMENTERIAN
AGAMA PROVINSI JAWA BARAT TAHUN 2022

1. Nama Lembaga : ..........................................................................................................................

2. Nomor Statistik PAUDQ : ..........................................................................................................................
3. NPSN : ..........................................................................................................................
4. Ijin Operasional : .........................................................................................................................
a. Nomor SK : .........................................................................................................................
b. Tanggal SK : .........................................................................................................................
c. Instansi Penerbit : .........................................................................................................................
5. Alamat PAUDQ : ..........................................................................................................................
RT/RW : ..........................................................................................................................
Desa/Kelurahan : ..........................................................................................................................
Kecamatan : ..........................................................................................................................
Kabupaten/Kota : ..........................................................................................................................
Kode Pos : ..........................................................................................................................
6. Telp dan Faksimil : ..........................................................................................................................
7. E-mail : ..........................................................................................................................
8. NPWP : ..........................................................................................................................
a. Nomor : ..........................................................................................................................
b. Nama : ..........................................................................................................................
9. Nama Yayasan : ..........................................................................................................................
No. Akte Yayasan : ..........................................................................................................................
Tanggal Akte Yayasan : ..........................................................................................................................

10. Sumber Dana* : 1. Yayasan

2. APBN
3. Swadana Masyarakat
4. Sponsor
5. APBD Kabupaten/Kota/Provinsi
6. Lainnya………………………………………………………....
11. Rekening :
a. Nama Bendahara : ......................................................................................................................
b. Nomor Rekening : .......................................................................................................................
c. Nama Rekening : .......................................................................................................................
d. Cabang Bank : .......................................................................................................................
12. Kepemilikan Bangunan* : 1. Milik Sendiri
2. Milik Pemerintah
3. Fasilitas Umum
4. Sewa
5. Lainnya............................................................................... ]*
13. Nama Pimpinan : .........................................................................................................................
14. Tahun Berdiri : .........................................................................................................................
15. Luas Tanah : .........................................................................................................................
16. Kepemilikan Tanah : Yayasan/Wakaf/Sewa/Pribadi/Lainnya................................]*
17. Status Tanah : Sertifikat/Akta/Girik/HGB/Lainnya.......................................]*
18. Luas Bangunan : .........................................................................................................................
19. Jumlah Ruang Bangunan :
1. Ruang Kelas : ..........................................................................................................................
2. Ruang Tenaga Pendidik : ..........................................................................................................................
3. Ruang Tenaga Kependidikan : ..........................................................................................................................
4. RuangTunggu : ..........................................................................................................................
5. RuangKesehatan : ..........................................................................................................................
6. RuangSerbaGuna : ..........................................................................................................................
7. RuangPerpustakaan : ..........................................................................................................................
8. Gudang : ..........................................................................................................................
9. Dapur : ..........................................................................................................................
10 Toilet : ..........................................................................................................................
20 Titik Koordinat :
1. Lintang : ..........................................................................................................................
2. Bujur : ..........................................................................................................................
21. Kondisi Bangunan : Baik/RusakRingan/RusakBerat**

22. Waktu Penyelenggaraan : Pagi/Siang/Sore/Kombinasi**

23. Metode Pembelajaran : Klasikal/Tahsin/Tilawati/Lainnya (......................................)*

24. Waktu Belajar : Klasikal/Tahsin/Tilawati/Lainnya (......................................)*
25. Lokasi Belajar : Dalam Masjid/Ruang Kelas/Lainnya)*
26. JumlahSantri/Santriwati*** : Pria :……………Orang Wanita :……………Orang
27. JumlahUstadz/Ustadzah*** : Pria :……………Orang Wanita :……………Orang
28. Ormas : NU/Muhammadiyah/Persis/PUI/SI/MA/Al-Irsyad/DDII
Lainnya...........................................................(Tulis Nama
Ormas)
29. Prestasi yang pernah diraih
30. Visi PAUDQ****
31. Misi PAUDQ****
: ..........................................................................................................................
..........................................................................................................................
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: ...........................................................................................................................
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Petugas, Kepala,

…………………………………………………… ……………………………………………………

Catatan:
1. Tanda* Bubuhi tanda centang pada salah satu pilihan dan atau tuliskan;
2. Tanda** Coret salah satu pilihan;
3. Tanda***Lampirkan Daftar Nama Santri/Santriwati dan Ustadz/Ustadzah format terlampir;
4. Tanda****Visi dan Misi PAUDQ Wajib di tik serta dilampirkan.
 Lampiran Nomor 14
DAFTAR NAMA SANTRI/SANTRIWATI PENDIDIKAN USIA DINI AL-QUR'AN (PAUDQ)
DI LINGKUNGAN KANTOR WILAYAH KEMENTERIAN AGAMA PROVINSI JAWA
BARAT TAHUN PELAJARAN 2022

Identitas Lembaga Santri Alamat Tempat Tinggal Santri Orangtua Santri

Nama Tanggal Lahir Jenis Ayah/Wali Ibu/Wali

NO No. Nama Desa Tempat Desa No. Kartu
NPSN Alamat Kecamatan Kab./Kota Provinsi NISN Lengkap (dd/mm/yyyy Kelamin Alamat Kecamatan Kab./Kota Provinsi Nama Pendidikan Nama Pendidikan
Statistik Lembaga /Kel Lahir /Kel Keluarga Pekerjaan Pekerjaan
Santri ) (L/P) Lengkap Formal Lengkap Formal
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

………………………………, …………………………………………

Mengetahui, Kepala PAUDQ

Kepala Seksi PD. Pontren/PAKIS/PENDIS/TOS ………………………………………………………………………….

…………………………………………………………………………. ………………………………………………………………………….
NIP. …………………………………………………………………
 Lampiran Nomor 15
DAFTAR NAMA USTADZ/USTADZAH PENDIDIKAN USIA DINI AL-QUR'AN (PAUDQ)
DI LINGKUNGAN KANTOR WILAYAH KEMENTERIAN AGAMA PROVINSI JAWA
BARAT TAHUN PELAJARAN 2022

Identitas Lembaga Ustadz/Ustadzah Alamat Tempat Tinggal Ustadz/Ustadzah

NO Jenis
Nama Tempat Tanggal Lahir Pendidikan
No. Statistik NPSN Alamat Desa/Kel Kecamatan Kab./Kota Provinsi No. KTP Nama Lengkap Kelamin Alamat Desa/Kel Kecamatan Kab./Kota Provinsi
Lembaga Lahir (dd/mm/yyyy) Terakhir
(L/P)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

………………………………, …………………………………………

Mengetahui, Kepala PAUDQ

Kepala Seksi PD. Pontren/PAKIS/PENDIS/TOS ………………………………………………………………………….

…………………………………………………………………………. ………………………………………………………………………….
NIP. …………………………………………………………………