BERITA ACARA

TRY OUT UJIAN SEKOLAH BERSTANDAR NASIONAL (USBN) SD / MI

TAHUN PELAJARAN 2017/2018

Pada hari ini ...................... tanggal ......................... bulan ....................... tahun dua ribu delapan belas.

a. Telah dilaksanakan kegiatan Try Out USBN SD/MI dari pukul ............ sampai dengan pukul ............
Pada Sekolah : .....................................................................................................
Kode Sekolah : .....................................................................................................
Ruang : .....................................................................................................
Jumlah peserta seharusnya : .....................................................................................................
Jumlah peserta yang tidak hadir :..................... orang, yakni nomor ................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
Jumlah peserta yang hadir :..................... orang, yakni nomor ................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
b. Telah dibuka sampul Try Out USBN SD/MI Mata Pelajaran ...............................................................
di ruang Try Out USBN SD/MI dengan disaksikan oleh para peserta, berisi lembaran soal
sebanyak ..................eksemplar, berita acara sebanyak . ...................lembar, dan daftar hadir/
nilai sebanyak .................. lembar. Sebelum dibuka sampul Try Out USBN SD/MI dalam keadaan
baik.

c. Catatan selama penyelenggaraan Try Out USBN

SD/MI : .................................................................................................................................................
...........
............................................................................................................................................................
............................................................................................................................................................

Berita Acara ini dibuat dengan sesungguhnya.

Pengawas I Pengawas II
Tanda Tangan : ............................. Tanda Tangan : .............................
Nama : ............................. Nama :.............................
NIP : ............................. NIP :.............................
PEMERINTAH KOTA BEKASI
DINAS PENDIDIKAN
UNIT PELAKSANA TEKNIS DINAS PEMBINAAN SD
KECAMATAN BANTARGEBANG
Jl. Narogong KM. 10 Telp. ( 021 ) 826001

DAFTAR HADIR
Nama Sekolah : .................................. Tanggal : ..................................
Ruang : .................................. Pukul : ..................................
No
Nomor Peserta Nama Peserta Tanda Tangan
Urut
1.
1 .................. 2 ..................
2.
3.
3 .................. 4 ..................
4.
5.
5 .................. 6 ..................
6.
7.
7 .................. 8 ..................
8.
9.
9 .................. 10 ..................
10.
11.
11 .................. 12 ..................
12.
13.
13 .................. 14 ..................
14.
15.
15 .................. 16 ..................
16.
17.
17 .................. 18 ..................
18.
19.
19 .................. 20 ..................
20.

Bekasi, ................................. 2017

Pengawas I Pengawas II
........................................ .......................................
NIP. NIP.