FORM LITMAS ASIMILASI COVID

NAMA : ...................................................................................................................................................................

NIK : ...................................................................................................................................................................

TEMPAT / TANGGAL LAHIR : ...................................................................................................................................................................

JENIS KELAMIN : .................................................. AGAMA : ...................................................................

SUKU : ................................................... PENDIDIKAN TERAKHIR : ...................................................................

PEKERJAAN : ................................................... STATUS PERKAWINAN : ...................................................................

ALAMAT TERAKHIR : ...................................................................................................................................................................

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NOMOR REGISTER : ...................................................................................................................................................................

PERKARA / PASAL : ...................................................................................................................................................................

NOMOR PUTUSAN : ...................................................................................................................................................................

TANGGAL PUTUSAN : ...................................................................................................................................................................

LAMA PIDANA : ...................................................................................................................................................................

1/3 MP : ............................................. ½ MP : . ............................................ 2/3 MP : ...........................................

EKSPIRASI : ..................................................................................................................................................................

PENJAMIN

NAMA : ...................................................................................... NIK : ................................................................

TEMPAT TANGGAL LAHIR : ...................................................................................................................................................................

AGAMA : ................................... SUKU : ................................................. PENDIDIKAN TERAKHIR : ....................

PEKERJAAN : ................................................................. NOMOR HP : .........................................................................

ALAMAT : ...................................................................................................................................................................

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HUBUNGAN KELUARGA : ...................................................................................................................................................................

Kegiatan pembinaan krpibadian atau kemandirian yang di ikuti :

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Klien menempati kamar dan blok berapa dan isi kamar berapa

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Hubungan dengan sesama WBP bagaimana, pernah tidak ribut didalam kamar atau blok, gara-gara apa

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Hubungan dengan petugas Lapas Bagaimana, pernah tidak ketangkap hp atau berkelahi selama didalam Lapas

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Hubungan dengan keluarga bagaimana, berapa kali menghubungi keluarga, atau dapat kiriman berapa kali sebulan

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Asesmen RRI dan Kriminogenik
 FORM LITMAS REINTEGRASI PB

Nama : ....................................................................................................................................................
Tempat / Tanggal Lahir : ....................................................................................................................................................
Nomor Registerasi : ....................................................................................................................................................
Jenis Kelamin : ................................................. Agama : Islam / Non Islam = ................................................
Suku/ Bangsa/ Warga Negara : ...................................................................................................................................................
Pendidikan Terakhir : SD (TT)/ SD/ SMP/ SMA/ Diploma/ Sarjana ..... Pekerjaan : ................................................
Status Perkawinan : ..................................................................................................................................................
Nomor dan Tanggal Putusan : ..................................................................................................................................................
Lama Pidana : ..................................................................................................................................................
Alamat Tempat Tinggal : ..................................................................................................................................................
Ciri-Ciri Khusus : ..................................................................................................................................................

Ayah Kandung Ibu Kandung

a. Nama : .................................................... Nama : .............................................

b. Tempat/ Tanggal Lahir : .................................................... Tempat/ Tanggal Lahir : . ...........................................

c. Agama : .................................................... Agama : .............................................

d. Suku/ Bangsa/ Warga Negara : .................................................... Suku/ Bangsa/ Warga Negara : .............................................

e. Pendidikan Terakhir : .................................................... Pendidikan Terakhir : .............................................

f. Pekerjaan : .................................................... Pekerjaan : . ...........................................

g. Status Perkawinan : .................................................... Status Perkawinan : ............................................

h. Alamat : .................................................... Alamat : .............................................

Penjamin Istri / Suami

a. Nama : .................................................... Nama : .............................................

b. Tempat/ Tanggal Lahir : .................................................... Tempat/ Tanggal Lahir : . ...........................................

c. Jenis Kelamin : .................................................... Agama : .............................................

d. Agama : .................................................... Suku/ Bangsa/ Warga Negara : .............................................

d. Suku/ Bangsa/ Warga Negara : .................................................... Pendidikan Terakhir : .............................................

e. Pendidikan Terakhir : .................................................... Pekerjaan : . ...........................................

f. Pekerjaan : .................................................... Status Perkawinan : ............................................

g. Status Perkawinan : .................................................... Alamat : .............................................

h. Alamat : ....................................................

i. Hubungan dengan Klien : ....................................................

j. Nomor Telepon / HP : ....................................................

k. NIK : ....................................................
Susunan Keluarga Klien Susunan Keluarga Penjamin Klien

1. .................................................... 1. ....................................................

2. .................................................... 2. ....................................................

3. .................................................... 3. ....................................................

4. .................................................... 4. ....................................................

5. .................................................... 5. ....................................................

Riwayat kelahiran Klien

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Riwayat pertumbuhan (fisik) Klien

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Riwayat perkembangan (psikososial) Klien

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Pendidikan dalam keluarga

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Pendidikan Formal

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Pendidikan Non Formal

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Bakat dan potensi yang dimiliki Klien

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Relasi sosial dengan orang tua dan keluarga

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Riwayat pelanggaran hukum

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Riwayat penggunaan rokok, napza, dan alkohol

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Riwayat Perkawinan Klien

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Riwayat Perkawinan Orangtua

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Keadaan Ekonomi Orang Tua Klien

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Kondisi alam tempat Klien

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Penggolongan Profesi dan Mata Pencaharian

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Tingkat Pendidikan (rata-rata) Warga Masyarakat

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Riwayat perkawinan penjamin

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Pekerjaan dan keadaan ekonomi

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Program Pembinaan Kepribadian

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Program Pembinaan Kemandirian

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Tanggapan dan Harapan Keluarga

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Latar Belakang pidana

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Keadaan Korban

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Kronologis
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Asesmen RRI dan Kriminogenik

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