Nama Sekolah :
Nama Guru : ...................................................................
Mata Pelajaran : ...................................................................
Kelas/Semester : ...................................................................
Hari/Tanggal/jam ke : ...................................................................
Materi : ...................................................................
Jumlah siswa : .... orang, Tidak hadir : .......orang
Pasuruan,.....................................
Catatan :
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Pasuruan,............................
Guru Matpel Supervisor