PEMERINTAH PROVINSI JAWA TIMUR

DINAS PENDIDIKAN
SEKOLAH MENENGAH KEJURUAN NEGERI 1 DUDUKSAMPEYAN
Jl. Sumari Kec. Duduksampeyan Kab. Gresik Telp. (031) 3904392
E-mail : smkn1duduksampeyan@yahoo.co.id Web.Site : www.smkn1duduksampeyan.sch.id
GRESIK
61162

Pada hari.....................................tanggal.....................bulan..................tahun..................kami telah

mengadakan kunjungan rumah (home visit) kepada siswa sebagai berikut :

I. Identitas siswa yang dikunjungi :

1. Nama :

2. Kelas/Absen/No. Induk :

3. Nama Orang Tua/Wali :

4. Pekerjaan Orang tua/Wali :

5. Alamat :

6. No. Telp/Hp :

II. Tujuan kunjungan rumah/catatan masalah :

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III. Hasil wawancara

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IV. Kesimpulan

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Gresik,
Mengetahui, Wali Kelas
Wali Murid

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