KEMENTERIAN PENDIDIKAN, KEBUDAYAAN,

RISET, DAN TEKNOLOGI

UNIVERSITAS NEGERI SURABAYA
LEMBAGA PENDIDIKAN DAN SERTIFIKASI PROFESI (LPSP)
Kampus Lidah Wetan, Jalan Kampus Lidah Wetan Unesa, Surabaya 60213
Telepon : 031-51169396, Faksimil : 031-51169397
Laman : http://lp3m.unesa.ac.id, email : lp3m@unesa.ac.id

BERITA ACARA PELAKSANAAN MAHASISWA PRAKTIK PENGALAMAN LAPANGAN

PPG PRAJABATAN GELOMBANG 1 & 2 TAHUN 2022

Pada hari ini,…………. tanggal……Bulan……………….. tahun ….........Pukul ........... s.d. ...........WIB,

saya yang bertanda tangan di bawah ini :
Nama : ................................................................
NIP : ................................................................
Jabatan : Dosen (DPL)

Berdasarkan Surat Tugas Ketua Lembaga Pengembangan Pembelajaran dan Profesi Nomor :
....................................................................... telah melaksanakan Tugas Penyerahan dan mendampingi
mahasiswa PRAKTIK PENGALAMAN LAPANGAN (PPL) PPG Prajabatan Gelombang 1 / 2*
tahun 2022 di sekolah mitra.
Mata Pelajaran : .........................................................................................................................
Satuan Pendidikan : ….....................................................................................................................
Alamat : .........................................................................................................................
.........................................................................................................................
Nama Mahasiswa Bimbingan :
1. .............................................................................................................................................
2. .............................................................................................................................................
3. .............................................................................................................................................
4. .............................................................................................................................................
5. .............................................................................................................................................
6. .............................................................................................................................................
7. .............................................................................................................................................

Catatan Hasil Tugas (dapat ditulis dibalik kertas ini jika tidak cukup) :
1. ...............................................................................................................................................
2. ...............................................................................................................................................
3. ...............................................................................................................................................
4. ...............................................................................................................................................

www.unesa.ac.id“Growing with character”

 KEMENTERIAN PENDIDIKAN, KEBUDAYAAN,
RISET, DAN TEKNOLOGI
UNIVERSITAS NEGERI SURABAYA
LEMBAGA PENDIDIKAN DAN SERTIFIKASI PROFESI (LPSP)
Kampus Lidah Wetan, Jalan Kampus Lidah Wetan Unesa, Surabaya 60213
Telepon : 031-51169396, Faksimil : 031-51169397
5. Laman : http://lp3m.unesa.ac.id, email : lp3m@unesa.ac.id
...............................................................................................................................................

6. ...............................................................................................................................................
7. ...............................................................................................................................................
8. ...............................................................................................................................................
9. ...............................................................................................................................................
10. ...............................................................................................................................................

Demikian Berita Acara ini dibuat untuk dijadikan laporan bukti telah melaksanakan tugas.
Surabaya, 2023
Pembuat Berita Acara,

.....................................................
NIP. ..............................................

www.unesa.ac.id“Growing with character”