LEMBAR BUKU INDUK SISWA SMK

Pas Foto

Nama Peserta Didik : .........................................................

NIS / NISN : ................/........................................
Nama Sekolah Alamat Sekolah : .........................................................
Kompetensi Keahlian : .........................................................
A. KETERANGAN PRIBADI : .........................................................

1. Nama Peserta Didik : ............................................................................................................

- Nama Lengkap : ............................................................................................................
- Nama Panggilan : ............................................................................................................
2. Jenis Kelamin
: ............................................................................................................
3. Tempat Lahir
: ............................................................................................................
4. Tanggal Lahir
5. A g a m a : ............................................................................................................

6. Kewarganegaraan : ............................................................................................................
7. Anak ke berapa : ............................................................................................................
8. Jumlah Saudara Kandung : ............................................................................................................
9. Jumlah Saudara Tiri : ............................................................................................................

: ............................................................................................................

10. Jumlah Saudara Angkat : ....................................................................................................................................

11. Anak yatim/piatu/yatim piatu : ....................................................................................................................................
12. Bahasa sehari-hari di rumah : ...........................................................................................................
B. KETERANGAN : .......................................................................................................................
13. Alamat : .......................................................................................................................
14. Nomor Telepon

15. Tempat Tinggal tersebut adalah : p

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 16. Jarak dari tempat tinggal ke sekolah : .....................................................
17. Ke sekolah dengan kendaraan

Pas Foto

berjalan kaki : .....................................................

C. KETERANGAN KESEHATAN
Pada waktu Meninggalkan
Pada waktu terima sekolah

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18. Berat Badan Cap tiga jari tengah tangan kiri d
meningga
19. Tinggi badan
20. Golongan darah

: .....................................................
21. Penyakit yang pernah diderita (contoh TBC, cacar dan lain-lain. )
Nomor Jenis Penyakit Kelas Tahun Lama Sakit Keterangan
Urut

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

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

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

22. Kelamin Jasmaniah / lainnya : ..............................................................................................................................

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D. KETERANGAN PENDIDIKAN SEBELUMNYA

MK

Cap tiga jari tengah tangan kiri diatas pas foto bagian bawah
waktu meninggalkan sekolah.

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 Cap tiga jari tengah tangan kiri diatas pas foto bagian bawah waktu
meninggalkan sekolah.

Keterangan

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 23. Asal Sekolah .......................................................................................................
:

a. Tanggal dan Nomor STTB ...

- Tanggal dan Nomor STTB :
.......................................................................................................
- Lama Belajar
b. SLTP lainnya
...
- Tanggal dan Nomor STTB
:
.......................................................................................................
- Lama Belajar ...
24. a. Pindah dari sekolah :
.......................................................................................................
- Diterima disekolah ini ...
b. Alasan Pindah :
.......................................................................................................
...
:
.......................................................................................................
...
:
.......................................................................................................
E. KETERANGAN TENTANG ORANG ... TUA KANDUNG
No. Orang Tua Kandung : Ayah Ibu
.......................................................................................................
25 Nama ...
............................................................. ...............................................
:
....................................................20.............di
26 Tempat Tanggal Lahir .............................................................
kelas................................................... ...............................................
27 Kewarganegaraan .............................................................
: ...............................................
.......................................................................................................
28 Ijazah Terakhir ...
............................................................. ...............................................
29 Pekerjaan ............................................................. ...............................................
30 Penghasilan / bulan ............................................................. ...............................................
31 Alamat ............................................................. ...............................................
F. KETERANGAN TENTANG WALI
No. Wali Laki - Laki Perempuan
32 Nama ............................................................. ...............................................
33 Ijazah Terakhir ............................................................. ...............................................
34 Pekerjaan ............................................................. ...............................................
35 Penghasilan / bulan ............................................................. ...............................................
36 Alamat ............................................................. ...............................................
G. KETERANGAN TENTANG WALI
37. Intelegensi (IQ) ........................................................................................................
:

38. Aspek Kepribadian ..

(berdasarkan tes pada
tanggal................................bulan............................................
tahun.................................................................................................
No. Aspek yang dinilai Semester: ........................................................................................................
Semester Semester Semester Semester Semester Semester
B C K.. B C K B C K B C K B C K B C K B
1 Disiplin / Ketertiban
2 Prakarsa / Kreativitas
3 Tanggung Jawab
4 Penyesuaian
5 Kemantapan Emosi
6 Kerjasama
 39. Bakat khusus dan prestasi yang menonjol dalam
Kemasyarakatan
No. SMTH / TH Kesenian Olahraga Organisasi Hasta Karya

1
2
3
4
5
6
7
8
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Ibu
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.....di
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Perempuan
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Semester Semester Semester
C K B C K B C K
Hasta Karya Karya Tulis
H. KETERANGAN KEHADIRAN
40. Jumlah hari kehadiran tiap semester :
Tidak Hadir Karena Jumlah Har
Semester / Kls Hadir Sakit Ijin Alpa

Semester......./ Kls...... ...................... ...................... ...................... ......................

Semester......./ Kls...... ...................... ...................... ...................... ......................

Semester......./ Kls...... ...................... ...................... ...................... ......................

Semester......./ Kls...... ...................... ...................... ...................... ......................

Semester......./ Kls...... ...................... ...................... ...................... ......................

Semester......./ Kls...... ...................... ...................... ...................... ......................

I. KETERANGAN SEKITAR PERKEMBANGAN PESERTA DIDIK
41. Tahun Masuk / terdaftar :
............................................................................................................
42. Prestasi peserta didik :
............................................................................................................
Tahun Program Jumlah Nilai Peringkat
Pelajaran Kelas Smt. Umum Mat Pel Rata2 Kelas/ Khusus
Rangking
20...../20......
20...../20......
20...../20......
43. Tahun meninggalkan sekolah :
...........................................................................................................
dengan alasan :
...........................................................................................................
44. Pindah sekolah ke :
...........................................................................................................
45. Melanjutkan pendidikan ke

J. PENERIMAAN SISWA
Tahun : ................................................................ dari : ...................................................................................
Tahun : ................................................................ dari : ...................................................................................

Tahun : ................................................................ dari : ...................................................................................

 Jumlah Hari Belajar
Efektif

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DIK
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Nilai Nilai
Khusus Rata2 Tinggal
Kelas

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