Nama Sekolah :
Nama Kepala Sekolah :
Nama Wakil Sarana Prasana :
Jumlah Skor
Padang, ...........................2023
Pengawas Sekolah Kepala Sekolah
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NIP. NIP.
NILAI AKHIR
skor perolehan X 100 %
Keterangan : Nilai Akhir =
skor maximal
TINDAK LANJUT :
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