Responden:
Pengajar Praktik (PP)
Calon Guru Penggerak (CGP)
Nama : .....................................................................................................................
Instansi : ......................................................................................................................
Alamat Instansi : ......................................................................................................................
Kecamatan : ......................................................................................................................
Kota/Kab : ......................................................................................................................
Provinsi : ......................................................................................................................
No. Telepon/HP : ......................................................................................................................
E-mail : ......................................................................................................................
Tanggal : ......................................................................................................................
Pelaksanaan PI
Waktu : ......................................................................................................................
Pelaksanaan PI
Tempat : ......................................................................................................................
Pelaksanaan PI
Petugas
……………………………………..
NIP.
Petunjuk Pengisian :
Pengisian instrumen dilakukan dengan cara:
1. Petugas monev mengisi instrumen secara mandiri melalui observasi dan wawancara yang dilakukan.
Instrumen monev tidak diserahkan dan tidak diisi oleh responden (tidak oleh PP maupun CGP).
2. Petugas monev memberikan tanda check (√) pada kolom "Ya" atau " Tidak" sesuai dengan fakta yang
ditemui di lokasi kegiatan.
3. Petugas monev menulis catatan mengenai hasil penilaian pada kolom yang tersedia.
Jawaban Ket
No Pertanyaan/Pernyataan Jawaban/
Ya Tidak
Bukti Fisik
A Kegiatan Awal Pendampingan
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Saran/Rekomendasi
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
............................... .................................
NIP NIP
Nama : .....................................................................................................................
Instansi : ......................................................................................................................
Alamat Instansi : ......................................................................................................................
Kecamatan : .......................................................................................................................
Kota/Kabupaten : .......................................................................................................................
Propinsi : .......................................................................................................................
No. Telepon/HP : .......................................................................................................................
E-mail : .......................................................................................................................
Responden
……………………………………..
NIP.
Nama : .....................................................................................................................
Instansi : ......................................................................................................................
Alamat Instansi : ......................................................................................................................
Kecamatan : .......................................................................................................................
Kota/Kabupaten : .......................................................................................................................
Propinsi : .......................................................................................................................
No. Telepon/HP : .......................................................................................................................
E-mail : .......................................................................................................................
Responden
……………………………………..
NIP.