YAYASANPEMBINA LEMBAGA PENDIDIKAN DASAR DAN MENENGAH

PERSATUAN GURU REPUBLIK INDONESIA JAWA TIMUR

CABANG KABUPATEN GRESIK
SMK PGRI 1 GRESIK ( TERAKREDITASI ”A” )
Bidang Studi Keahlian : Teknologidan Rekayasa
Alamat : Jalan Dr. Sutomo No. 46 Telp. (031) 3981487 Fax. (031) 3981487 Gresik

NSS : 324050105004 NPSN : 20500411

LAPORAN KUNJUNGAN RUMAH ( HOME VISIT )

1. IDENTITAS SISWA :
a. Nama Siswa : ___________________________________________
b. Kelas : ___________________________________________
c. Nama Orang Tua : ___________________________________________
d. Pekerjaan : ___________________________________________
c. Alamat/No. Telp. : ______________________________________________________________________

2. TANGGAL PELAKSANAAN KUNJUNGAN : ________________________________________________

3. TUJUAN KUNJUNGAN RUMAH :

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4. HASIL KUNJUNGAN RUMAH :
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5. TINDAK LANJUT / KESIMPULAN :

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Orang Tua / Wali Siswa Guru BK

____________________ Saiful Hadi,S.Pd

 DATA SISWA
Nomor Induk Siswa :
Nama Lengkap : …………………………………......................................…………………….
NISN :.……………….…….…
Nama Panggilan : …………………………………......................................……………………..

Tempat, Tanggal Lahir : …………………………………......................................…………………….

Jenis Kelamin : L / P ( lingkari salah satu ) Foto

3 x 4 cm
Alamat : …………………………………......................................……………………..

…………………………………......................................……………………..

Agama : …………………………………......................................……………………..

Nomer HP siswa : …………………………………......................................……………………..

Asal Sekolah : …………………………………......................................……………………...

Nama Ayah : …………………………………......................................……………………..

Pekerjaan / Agama / Umur : ........................................................../......................................./…….......…thn

Nama Ibu : …………………………………......................................……………………...

Pekerjaan / Agama / Umur : ........................................................./......................................../…….......…thn

Alamat Orang Tua / No HP : …………………………………......................................…………………......

………………………………….................../................................................…..

Data Saudara Kandung : Jumlah Saudara Kandung : .....….. Orang.

No Nama L/P Bekerja / Sekolah di ……….

CATATAN SISWA :
TTD TTD
No Jenis Kegiatan Tgl Keterangan Ortu Siswa

Ket : Jenis kegiatan bisa diisi seperti : Panggilan siswa, panggilan orang tua, home visit, surat pernyataan,
Pemberitahuan keadaan siswa ke orang tua, surat skorsing
Mengetahui,
Kepala Sekolah Wakasek Kesiswaan Guru Wali

Drs. ARIEF SUSANTO, M.Pd INDRAYANA, SPd _______________________