Nama Madrasah : ........................... Kelas : .............................

Alamat : ........................... Semester Ke : .............................

Nama Siswa : ........................... Tahun Pelajaran : .............................

NISN : ...........................

No Mata Pelajaran KKM* Nilai

Angka Huruf
1 Pendidikan Agama Islam

a. Qur’an Hadist
b. Aqidah Akhlak
c. Fiqih
d. SKI
2 Pendidikan Kewarganegaraan
3 Bahasa Indonesia
4 Bahasa Arab
5 Matematika
6 Ilmu Pengetahuan Alam
7 Ilmu Pengetahuan Sosial
8 Seni Budaya
9 Pendidikan Jasmani, Olahrga dan Kesehatan
10 Muatan Lokal
a. Bahasa Lampung
b. Bahasa Inggris
c. Keterampilan / Teknologi Informasi dan Komunikasi

d. ...................................................
Jumlah Nilai
Rata - rata
Peringkat Kelas ke : .......... dari ......... Siswa
*Kriteria Ketuntasan Minimal

PENGEMBANGAN DIRI

Nilai
No BENTUK KEGIATAN
A B C
1
2
3
Nama Madrasah : ........................... Kelas : .............................

Alamat : ........................... Semester Ke : .............................

Nama Siswa : ........................... Tahun Pelajaran : .............................

NISN : ...........................

PERILAKU
.....................................................................................................................................................................

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

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

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

PERILAKU / KEPERIBADIAN KETIDAK HADIRAN / ABSENSI

No Aspek Keterangan No Alasan Jumlah Hari
1 1
2 2
3 3

CATATAN GURU / WALI KELAS

1. a ........................................................................................................................................................................
b ........................................................................................................................................................................
c ........................................................................................................................................................................
d ........................................................................................................................................................................
2. ...........................................................................................................................................................................
3. ...........................................................................................................................................................................
4. ...........................................................................................................................................................................
5. ...........................................................................................................................................................................
6. ...........................................................................................................................................................................
7. ...........................................................................................................................................................................
8. ...........................................................................................................................................................................
9. ...........................................................................................................................................................................
10. ...........................................................................................................................................................................
11. ...........................................................................................................................................................................
12. a ........................................................................................................................................................................
b ........................................................................................................................................................................
c ........................................................................................................................................................................

Keputusan :
Dengan memperhatikan hasil yang dicapai,
Maka siswa ini ditetapkan :
Naik Ke Kelas : .................. (...................)
Tinggal Di Kelas : .................. (...................)

..................................................................
Mengetahui Wali Kelas Kepala Madrasah
Orang Tua / Wali
( ............................................) ( ............................................) ( ............................................)