INSTRUMEN KELEMBAGAAN

LEMBAGA PENDIDIKAN AL-QUR’AN (LPQ)

TAHUNPELAJARAN2021/2022

Nama Lembaga :

BIDANG PENDIDIKAN DINIYAH DAN PONDOK PESANTREN

KANTOR WILAYAH KEMENTERIAN AGAMA
PROVINSI JAWA BARAT
TAHUN 2022
 INSTRUMEN KELEMBAGAAN LEMBAGA
PENDIDIKAN AL-QUR’AN (LPQ)
BIDANGPENDIDIKAN DINIYAH DAN PONDOK PESANTREN KANTOR WILAYAH
KEMENTERIAN AGAMA PROVINSI JAWA BARAT TAHUN 2022

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

2. Nomor Statistik LPQ : .....................................................................................................
3. NPSN : .....................................................................................................
4. Ijin Operasional : .....................................................................................................
a. Nomor SK : .....................................................................................................
b. Tanggal SK : .....................................................................................................
c. Instansi Penerbit : .....................................................................................................
5. Alamat LPQ : .....................................................................................................

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. :……………Oran
JumlahSantri/Santriwati*** : Pria :……………Orang Wanita
g
27. :……………Oran
JumlahUstadz/Ustadzah*** : Pria :……………Orang Wanita
g
28. NU/Muhammadiyah/Persis/PUI/SI/MA/Al-Irsyad/DDII
Ormas :
Lainnya ................................................. (Tulis Nama Ormas)
29. Prestasi yang pernah diraih : ......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
30. Visi LPQ**** : ......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................

31. Misi LPQ**** : ......................................................................................................

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

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 LPQ Wajib di tik serta dilampirkan.
 Lampiran Nomor 14
DAFTAR NAMA SANTRI/SANTRIWATI LEMBAGA PENDIDIKAN AL-QUR'AN
(LPQ) DI LINGKUNGAN KANTOR WILAYAH KEMENTERIAN AGAMA
PROVINSI JAWA BARAT TAHUN PELAJARAN 2022

Identitas Lembaga Santri Alamat Tempat Tinggal Santri Orangtua Santri

NO Nama Tanggal Lahir Jenis Ayah/Wali Ibu/Wali

No. Nama Desa Tempat Desa No. Kartu
NPSN Alamat Kecamatan Kab./Kota Provinsi NISN Lengkap (dd/mm/yyyy Kelamin Alamat Kecamatan Kab./Kota Provinsi
Statistik Lembaga /Kel Lahir /Kel Keluarga Nama Pendidikan Nama Pendidikan
Santri ) (L/P) Pekerjaan Pekerjaan
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 LPQ

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

…………………………………………………………………………. ………………………………………………………………………….
NIP. …………………………………………………………………
 Lampiran Nomor 15
DAFTAR NAMA USTADZ/USTADZAH LEMBAGA PENDIDIKAN AL-QUR'AN
(LPQ) 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 LPQ

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

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