CATATAN PRIBADI SISWA

(CUMMULATIVE RECORDS)

BK - SMA Negeri 1 Mertoyudan 1


PETUNJUK : Isilah daftar keterangan pribadi ini dengan sebaik-baiknya dan sejujur-jujurnya.
A. IDENTITAS SISWA
1. Nama lengkap
2. Nama panggilan
3. Tempat dan tgl. lahir
4. Jenis kelamin
5. Suku / Agama
6. No. Telepon / HP
7. Alamat
8. E-Mail
9. Asal SMP
10. Masuk sekolah ini tanggal
11. Masuk sekolah ini
B. LATAR BELAKANG IDENTITAS RUMAH
1. Siswa tinggal dengan : (lingkari yang paling sesuai)
a. Ayah dan Ibu kandung
b. Ayah tiri, Ibu kandung
c. Ayah kandung, Ibu titi
d. Ayah kandung
e. Ibu kandung
f. Saudara/Keluarga/Wali
g. Menumpang / Kost
2. Ayah siswa
a. Nama
b. Umur
c. Suku / Agama
d. Pekerjaan dan Pangkat
e. Pendidikan terakhir
f. Alamat / No. Telp/HP
3. Ibu siswa
a. Nama
b. Umur
c. Suku / Agama
d. Pekerjaan dan Pangkat
e. Pendidikan terakhir
f. Alamat / No. Telp/HP
BK - SMA Negeri 1 Mertoyudan
CATATAN PRIBADI SISWA
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: Siswa baru / Pindahan
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
: ....................................................................................................
2
 4. Nama Saudara

Kakak Sekolah / Kelas /

Nama L/P Umur Pekerjaan
/Adik Kuliah Tingkat

5. Tempat tinggal (lingkari yang paling sesuai)

a. Rumah : 1) Milik orang tua sendiri

2) Warisan
3) Rumah dinas/Instansi dalam satu komplek/sendiri
4) Menyewa / kontrak

b. Dinding rumah : 1) Tembok

2) Papan
3) Bilik

c. Lantai rumah : 1) Teraso / Keramik

2) Tegel biasa (Abu-abu)
3) Tanah

d. Nomor telepon / HP : .......................................................................................................

e. Ruang belajar : 1) Tersendiri
2) Bersama-sama
3) Tidak ada

f. Kamar tidur : 1) Tersendiri

2) Bersama-sama
3) Tidak ada

g. Halaman bermain : 1) Ada

2) Tidak ada

h. Lingkungan rumah : 1) Di Gang

2) Di daerah perkotaan/ dekat pasar/ perumahan/ dekat tempat
keramaian, dll
3) Di Jalan daerah tidak terlalu ramai
4) Di Jalan Provinsi / Kabupaten (ramai)

6. Transportasi : 1) Diantar
2) Jalan Kaki
3) Angkutan Umum
4) Sepeda
5) Sepeda Motor
6) Mobil

BK - SMA Negeri 1 Mertoyudan 3

 7. Alat-alat musik : _________________________________________________
(sebutkan jika memiliki) _________________________________________________
_________________________________________________

8. Alat-alat olahraga : _________________________________________________

(sebutkan jika memiliki) _________________________________________________
_________________________________________________

9. Perpustakaan : 1) Ada
(sebutkan jika memiliki) 2) Tidak ada

C. LATAR BELAKANG PENDIDIKAN

1. Riwayat Pendidikan
a. TK : tamat th. ...................... di ................................................. berijazah/tidak
b. SD : tamat th. ...................... di ................................................. berijazah/tidak
c. MI : tamat th. ...................... di ................................................. berijazah/tidak
d. SMP : tamat th. ...................... di ................................................. berijazah/tidak
e. MTs : tamat th. ...................... di ................................................. berijazah/tidak
f. Kursus : ........................................ th.............................................. berijazah/tidak
........................................ th.............................................. berijazah/tidak

g. Pernah tinggal kelas di :

SD/MI Kls ............................... tahun .......................... di ..............................
SD/MI Kls ............................... tahun .......................... di ..............................
SMP/MTs Kls ............................... tahun .......................... di ..............................
SMP/MTs Kls ............................... tahun .......................... di ..............................

h. Mutasi / Pindah Sekolah :

Thn ................ dari SD/MI ..................................... ke SD/MI ............................ Kls ......
Thn ................ dari SD/MI .................................... ke SD/MI ............................ Kls ......
Thn ................ dari SMP/MTs ............................... ke SMP/MTs ....................... Kls ......
Thn ................ dari SMP/MTs ................................ ke SMP/MTs ....................... Kls ......
Thn ................ dari SMA ....................................... ke SMA ............................... Kls ......
Thn ................ dari SMA ....................................... ke SMA ............................... Kls ......

2. Pelajaran : (SMP / MTs)

a. Pelajaran yang diminati :
1) .............................................................................................................................................
.............................................................................................................................................
Alasan .................................................................................................................................
.............................................................................................................................................

2) .............................................................................................................................................
Alasan ................................................................................................................................
.............................................................................................................................................

b. Pelajaran yang kurang diminati :

1) .............................................................................................................................................
.............................................................................................................................................
Alasan .................................................................................................................................
.............................................................................................................................................

2) .............................................................................................................................................
Alasan ................................................................................................................................
.............................................................................................................................................

BK - SMA Negeri 1 Mertoyudan 4

 3. Pelajaran : (SMA)
a. Pelajaran yang diminati :
1) .............................................................................................................................................
.............................................................................................................................................
Alasan .................................................................................................................................
.............................................................................................................................................

2) .............................................................................................................................................
Alasan ................................................................................................................................
.............................................................................................................................................

b. Pelajaran yang kurang diminati :

1) .............................................................................................................................................
Alasan .................................................................................................................................
.............................................................................................................................................

2) .............................................................................................................................................
Alasan .................................................................................................................................
.............................................................................................................................................

c. Kesulitan-kesulitan yang dihadapi saat belajar :

(Lingkarilah yang paling sesuai, dan boleh memilih lebih dari satu)
1) Kurang bisa memusatkan perhatian pada pelajaran sekolah
2) Lekas lupa pada bahan pelajaran yang telah dipelajari
3) Sering melamun pada waktu pelajaran
4) Kurang dapat memahami penjelasan guru
5) Binging dan gelisah memahami pelajaran tertentu
6) Lainnya ...............................................................................................................................
.............................................................................................................................................
d. Langkah-langkah pemecahan masalah mengenai kesulitan belajar :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

e. Cita-cita
1) Untuk pribadi (yang anda inginkan)
a) Ingin bekerja sebagai :
......................................................................................................................................
......................................................................................................................................
Alasan ..........................................................................................................................
......................................................................................................................................
......................................................................................................................................

b) Ingin melanjutkan ke :
......................................................................................................................................
......................................................................................................................................
Alasan ..........................................................................................................................
......................................................................................................................................
......................................................................................................................................

c) Wirausaha :
......................................................................................................................................
......................................................................................................................................
Alasan ..........................................................................................................................

BK - SMA Negeri 1 Mertoyudan 5

 2) Untuk orang-tua (yang diingkan oleh orang-tua)
a) Ingin bekerja sebagai :
......................................................................................................................................
......................................................................................................................................
Alasan ..........................................................................................................................
......................................................................................................................................
......................................................................................................................................

b) Ingin melanjutkan ke :
......................................................................................................................................
......................................................................................................................................
Alasan ..........................................................................................................................
......................................................................................................................................
......................................................................................................................................

c) Perubahan-perubahan yang saya harapkan terjadi di sekolah :

......................................................................................................................................
......................................................................................................................................
Alasan ..........................................................................................................................
......................................................................................................................................
......................................................................................................................................

BK - SMA Negeri 1 Mertoyudan 6

D. PERGAULAN
1. Nama teman yang dekat, hubungannya dengan saya di kelas :
a. ....................................... Alamat : ...............................................................................
b. ....................................... Alamat : ...............................................................................
c. ....................................... Alamat : ...............................................................................
d. ....................................... Alamat : ...............................................................................
e. ....................................... Alamat : ...............................................................................
f. ....................................... Alamat : ...............................................................................

2. Nama yang dekat, hubungannya dengan saya di luar sekolah :

a. ....................................... Sekolah di ............................................ Kelas ......................
b. ....................................... Sekolah di ............................................ Kelas ......................
c. ....................................... Sekolah di ............................................ Kelas ......................

3. Nama Guru yang dekat, hubungannya dengan saya di sekolah :

a. .................................................... Mata pelajaran .........................................................
b. .................................................... Mata pelajaran .........................................................
c. .................................................... Mata pelajaran .........................................................

4. Kenalan / teman / orang yang berusian di atas 20 tahun di luar sekolah :

a. .................................................... pekerjaan .................................................................
hubungan .....................................................................................................................
b. .................................................... pekerjaan .................................................................
hubungan .....................................................................................................................
c. .................................................... pekerjaan .................................................................
hubungan .....................................................................................................................

5. Teman sekolah yang tempat tinggalnya dekat dengan saya :

No NAMA KELAS ALAMAT

BK - SMA Negeri 1 Mertoyudan 7

 6. Guru / Karyawan di sekolah ini yang tempat tinggalnya dekat dengan anda :

GURU /
No NAMA ALAMAT
KARYAWAN

7. Teman sekolah yang tempat tinggalnya dekat dengan saya :

a. Saya kurang cocok dengan orang yang bersifat / bersikap :
................................................................................................................................................
................................................................................................................................................
b. Sikap / sifat kaum tua yang kurang saya sukai adalah :
................................................................................................................................................
................................................................................................................................................
c. Perubahan yang saya harapkan terjadi pada diri sendiri :
................................................................................................................................................
................................................................................................................................................

8. Pengalaman / aktivitas yang mengesankan selama di sekolah :

No Pengalaman/Aktivitas SD SMP SMA

1. Di Lingkungan
sekolah

2. Di Luar sekolah

BK - SMA Negeri 1 Mertoyudan 8

E. KONDISI KESEHATAN
Penyakit yang pernah diderita (tuliskan jika ada)

1. Alergi : ........................................................................... Tahun .......................

2. TBC : ........................................................................... Tahun .......................
3. Typus : ........................................................................... Tahun .......................
4. Kecelakaan : ........................................................................... Tahun .......................
5. Jantung : ........................................................................... Tahun .......................
6. Ginjal : ........................................................................... Tahun .......................
7. Mata : ........................................................................... Tahun .......................
8. Operasi : ........................................................................... Tahun .......................
9. ................ : ........................................................................... Tahun .......................
10. ................ : ........................................................................... Tahun .......................

F. AKTIFITAS
1. Di SD aktif sebagai : ........................................................................................
2. Di SMP/SMA aktif sebagai : ........................................................................................
3. Di rumah mendapat tugas : ........................................................................................
4. Di RT aktif sebagai : ........................................................................................
5. Di RW aktif sebagai : ........................................................................................
6. Di Organisasi sosial aktif : ........................................................................................
7. Di Organisasi massa aktif : ........................................................................................
8. .................................... : ........................................................................................
9. .................................... : ........................................................................................
10. .................................... : ........................................................................................

G. PIAGAM & SERTIFIKAT (SMP & SMA)

1. Piagam / Penghargaan yang pernah diperoleh :
No Nama / Jenis Penghargaan Dikeluarkan Oleh Tahun

1.

2.

3.

4.

2. Sertifikat yang pernah diperoleh (akademik/non akademik)

No Nama Sertifikat Dikeluarkan Oleh Tahun

1.

2.

3.

4.

BK - SMA Negeri 1 Mertoyudan 9

 3. Beasiswa yang pernah diperoleh
No Nama Beasiswa Sumber Tahun

1.

2.

3.

4.

H. PILIHAN ARAH KARIR

Pelatihan / Kursus : Alasan :

.......................................................... ...................................................................
.......................................................... ...................................................................

Pekerjaan : Alasan :

.......................................................... ...................................................................
.......................................................... ...................................................................

Sumber yang saya butuhkan dalam perkembangan :

Sumber informasi/materi yang saya butuhkan dalam bidang pendidikan :
.................................................................................................................................................
.................................................................................................................................................

Sumber informasi/materi yang saya butuhkan dalam bidang pelatihan / kursus :

.................................................................................................................................................
.................................................................................................................................................

Sumber informasi yang saya butuhkan dalam pencarian pekerjaan :

.................................................................................................................................................
.................................................................................................................................................

Sumber informasi yang saya butuhkan dalam berwirausaha :

.................................................................................................................................................
.................................................................................................................................................

BK - SMA Negeri 1 Mertoyudan 10

I. KESENANGAN-KESENANGAN (HOBBY)

No HOBY RUTIN/KADANG-KADANG

J. KEADAAN JASMANI

Tahun 20 .... 20 .... 20 .... 20 .... 20 ....

1. Berat badan ............... ............... ............... ............... ...............
2. Tinggi badan ............... ............... ............... ............... ...............
3. Golongan darah ............................................................................................................

K. EKSTRAKURUKULER/ORGANISASI YANG DIIKUTI

No EKSTRAKURIKULER/ORGANISASI JABATAN TAHUN

..............................................
Yang bersangkutan,

..............................................

BK - SMA Negeri 1 Mertoyudan 11

 DIISI OLEH KONSELOR/GURU BIMBINGAN & KONSELING
(Berdasarkan hasil Psykotest)

Petunjuk :
1. Beri tanda cek ( √ ) pada kolom yang tersedia
2. Penentuan lima kategori didasarkan pada kriteria sebagai berikut :
A = Amat Baik
B = Baik
C = Cukup
D = Kurang
E = Kurang Sekali

KECERDASAN IQ
Aspek yang diselidiki SKOR SKOR SKOR SKOR SKOR
1. Kemampuan non verbal
2. Kemampuan Bahasa
3. Kemampuan Ilmu Pasti
4. Kemampuan IPS
5. Kemampuan dalam hal-hal yang praktis
6. Ketelitian
7. Kecerdasan Umum
8. Kemampuan lain jelaskan

Kesimpulan/Rekomendasi :

HASIL TES BAKAT

SMP SMA
TES BAKAT
HASIL TES KETERANGAN HASIL TES KETERANGAN
Tes
Kemampuan
Berfikir Verbal
Tes
Kemampuan
Berfikir
Numerikal
Tes Skolastik

Tes Berfikir
Abstrak

Tes Berfikir
Mekanik

BK - SMA Negeri 1 Mertoyudan 12

PERKIRAAN MINAT PADA MATA PELAJARAN (SMA)

SEMESTER Mata Pelajaran

I ............................................................................................................................
............................................................................................................................
............................................................................................................................
II
............................................................................................................................
............................................................................................................................
III
............................................................................................................................
............................................................................................................................
IV
............................................................................................................................
............................................................................................................................
V
............................................................................................................................

SIKAP (SMA)

Disesiuaikan dengan Standar Th. Th. Th.

Penilaian dalam raport Kls. Kls. Kls.
A B C D E A B C D E A B C D E

SIKAP ORANG TUA TERHADAP SEKOLAH (SMA)

KELAS ............................ ............................ ............................

TAHUN ............................ ............................ ............................

A B C D E A B C D E A B C D E

Dukungan

Perhatian

BK - SMA Negeri 1 Mertoyudan 13

SIKAP ORANG TUA TERHADAP SISWA (SMA)

KELAS ............................ ............................ ............................

TAHUN ............................ ............................ ............................

A B C D E A B C D E A B C D E

Dukungan

Perhatian

HUBUNGAN SOSIAL SISWA

KELAS ............................ ............................ ............................

TAHUN ............................ ............................ ............................

A B C D E A B C D E A B C D E
Hub. Keluarga
Hub. Masyarakat
Kondisi Keluarga
Kondisi Masyarakat

BK - SMA Negeri 1 Mertoyudan 14

INSTRUMEN NON TES YANG DIKEMBANGKAN :

Instrumen Non Tes  DCM  ..........................

yang dikembangkan :  AUM  ..........................
(lingkari Instrumen  ITP  ..........................
yang telah anda  IKMS
gunakan)  Wawancara
 Angket
 Observasi
Tujuan : .....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
Hasil Skor .....................................................................................................

Hasil Interpretasi Data

(kesimpulan)

BK - SMA Negeri 1 Mertoyudan 15

DAFTAR NILAI UJIAN NASIONAL SMP

NO MATA PELAJARAN NILAI

01.
02.
03.
04.
05.
06.

DAFTAR NILAI UJIAN PRAKTIK SMP

NO MATA PELAJARAN NILAI

01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
13.

BK - SMA Negeri 1 Mertoyudan 16

 DAFTAR NILAI RAPORT/UAS SMP/MTs

Nilai Semester
No Komponen/ Mata Pelajaran Keterangan
1 2 3 4 5 6

BK - SMA Negeri 1 Mertoyudan 17

 PENETAPAN PEMINATAN
(Diisi Ketika Siswa Sedang Masuk Ke SMA)
A. Prestasi Akademik
Kelas Mata Pelajaran Dengan Niali Terbaik Nilai
VII 1.
2.
3.
VIII 1.
2.
3.
IX 1.
2.
3.

B. Prestasi Non-Akademik
Bidang Kategori Prestasi/Jenis Kualiafikasi
Keolahragaan
Kesenian
Keorganisasian
Kesehatan
Keilmuan
Keagamaan
Kewirausahaan

C. Bakat
No. Arah Kecenderungan Bakat Kualiafikasi
1.
2.
3.
4.

D. Bidang yang Diminati Peserta Didik

KUALIFIKASI
No. Bidang Peminatan %
Tinggi Sedang Rendah
1.
2.
3.
4.

E. Nilai Ujian Nasional / UN SMP :

F. Harapan Orang Tua :
G. Harapan Peserta Didik :
H. Rekomendasi Pihak Sekolah :

BK - SMA Negeri 1 Mertoyudan 18

CATATAN PRIBADI SISWA UNTUK BIMBINGAN KARIR

Nama : .........................................................................................................
Tempat/Tgl. Lahir : .........................................................................................................
Jurusan/Program Studi : .........................................................................................................

Apa tujuan siswa memasuki sekolah ini ?

Bekerja setelah lulus sekolah Menikah setelah lulus

Berwirausaha setelah lulus sekolah Melanjutkan ke PT

Karir pilihan :

Utama Alternatif

Tahun 1 : ....................................................... ..................................................

Tahun 2 : ....................................................... ..................................................
Tahun 3 : ....................................................... ..................................................

Hobby : .........................................................................................................
.........................................................................................................
Olah raga : .........................................................................................................
.........................................................................................................
Club / Organisasi : .........................................................................................................
.........................................................................................................

Kedudukan dalam organisasi /aktifitas di atas :

...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Apa yang dapat saya perbuat ?
Kemampuan dan keterampilan yang dapat saya lakukan :
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

Prestasi yang dapat saya lakukan :

...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

BK - SMA Negeri 1 Mertoyudan 19

 Prestasi yang saya peroleh dalam pelajaran:
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

Minat yang saya senangi / sukai :

...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

Kemampuan yang ingin saya kembangkan :

...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

Apa yang saya butuhkan untuk memperbaiki diri saya ?

Bidang yang perlu saya kembangkan :
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

Cara-cara pengembangannya :
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

Pilihan-pilihan untuk hari depan saya :

Pendidikan
...................................................................... ......................................................................
...................................................................... ......................................................................
...................................................................... ......................................................................

BK - SMA Negeri 1 Mertoyudan 20

 DAFTAR NILAI RAPORT/UAS SMA

Nilai Semester
No Komponen/ Mata Pelajaran Keterangan
1 2 3 4 5 6

BK - SMA Negeri 1 Mertoyudan 21

DAFTAR NILAI RAPORT/UAS SMA YANG KURANG DARI STANDAR NILAI MINIMUM
SEBELUM (REMEDIAL TEACHING/PEMBENAHAN)

Nilai Raport Semester Tgl Tgl Paraf

No Mata Pelajaran Nilai Nilai Guru
1 2 3 4 5 6 Masuk Keluar Mapel

PERKEMBANGAN NILAI RAPORT/UAS SMA SETELAH DIADAKAN (REMEDIAL

TEACHING/PEMBENAHAN)

Nilai Raport Semester Tgl Tgl Paraf

No Mata Pelajaran Nilai Nilai Guru
1 2 3 4 5 6 Masuk Keluar Mapel

BK - SMA Negeri 1 Mertoyudan 22

 CATATAN KEJADIAN SISWA
(ANECDOTAL RECORDS)

BK - SMA Negeri 1 Mertoyudan 23

 CATATAN PELANGGARAN SISWA (Kls. X)

Tindak Lanjut / Ttd Ttd

No Tgl Jenis Pelanggaran Skor
Follow Up Konselor Wali

BK - SMA Negeri 1 Mertoyudan 24

 CATATAN PELANGGARAN SISWA (Kls. XI)

Tindak Lanjut / Ttd Ttd

No Tgl Jenis Pelanggaran Skor
Follow Up Konselor Wali

BK - SMA Negeri 1 Mertoyudan 25

 CATATAN PELANGGARAN SISWA (Kls. XII)

Tindak Lanjut / Ttd Ttd

No Tgl Jenis Pelanggaran Skor
Follow Up Konselor Wali

BK - SMA Negeri 1 Mertoyudan 26

 CATATAN PRESTASI (Kls. X)

Akademik / Tanda Tangan

No Hari/Tgl PRESTASI
Non Akademik Ybs. Konselor

BK - SMA Negeri 1 Mertoyudan 27

 CATATAN PRESTASI (Kls. XI)

Akademik / Tanda Tangan

No Hari/Tgl PRESTASI
Non Akademik Ybs. Konselor

BK - SMA Negeri 1 Mertoyudan 28

 CATATAN PRESTASI (Kls. XII)

Akademik / Tanda Tangan

No Hari/Tgl PRESTASI
Non Akademik Ybs. Konselor

BK - SMA Negeri 1 Mertoyudan 29

 PRESENSI SISWA
KELAS X

JULI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

AGUSTUS S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

SEPTEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

OKTOBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

NOVEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

DESEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

JANUARI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

FEBRUARI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

MARET S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

APRIL S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

MEI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

JUNI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

BK - SMA Negeri 1 Mertoyudan 30

 PRESENSI SISWA
KELAS XI

JULI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

AGUSTUS S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

SEPTEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

OKTOBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

NOVEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

DESEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

JANUARI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

FEBRUARI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

MARET S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

APRIL S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

MEI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

JUNI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

BK - SMA Negeri 1 Mertoyudan 31

 PRESENSI SISWA
KELAS XII

JULI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

AGUSTUS S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

SEPTEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

OKTOBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

NOVEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

DESEMBER S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

JANUARI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

FEBRUARI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

MARET S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

APRIL S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

MEI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

JUNI S I A Jml
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

BK - SMA Negeri 1 Mertoyudan 32

 MENINGGALKAN PELAJARAN (Kls. X)

Tanda Tangan
No Hari/Tgl Waktu Alasan / Sebab
Ybs. Konselor

BK - SMA Negeri 1 Mertoyudan 33

 MENINGGALKAN PELAJARAN (Kls. XI)

Tanda Tangan
No Hari/Tgl Waktu Alasan / Sebab
Ybs. Konselor

BK - SMA Negeri 1 Mertoyudan 34

 MENINGGALKAN PELAJARAN (Kls. XII)

Tanda Tangan
No Hari/Tgl Waktu Alasan / Sebab
Ybs. Konselor

BK - SMA Negeri 1 Mertoyudan 35

 CATATAN KONSELING SISWA (Kls. X)
(Mengenai permasalahan Akademik/Non Akademik di Sekolah maupun di luar sekolah)

Ttd
No Tanggal Permasalahan Solusi
Konselor

BK - SMA Negeri 1 Mertoyudan 36

 CATATAN KONSELING SISWA (Kls. XI)
(Mengenai permasalahan Akademik/Non Akademik di Sekolah maupun di luar sekolah)

Ttd
No Tanggal Permasalahan Solusi
Konselor

BK - SMA Negeri 1 Mertoyudan 37

 CATATAN KONSELING SISWA (Kls. XII)
(Mengenai permasalahan Akademik/Non Akademik di Sekolah maupun di luar sekolah)

Ttd
No Tanggal Permasalahan Solusi
Konselor

BK - SMA Negeri 1 Mertoyudan 38

 CATATAN HOME VISIT (KUNJUNGAN RUMAH)

Ttd Wali Ttd

Tgl Tujuan Home Visit Tanggapan Wali Siswa
Kelas Konselor
KELAS X

KELAS XI

KELAS XII

BK - SMA Negeri 1 Mertoyudan 39

 PERKEMBANGAN ILMU/BAKAT/SOFT SKILLS YANG DIPEROLEH SISWA
SELAMA MENEMPUH PENDIDIKAN DI SMA

KELAS PRIBADI SOSIAL BELAJAR KARIR

KELAS X

KELAS XI

KELAS XII

BK - SMA Negeri 1 Mertoyudan 40

 TANGGAPAN GURU MATA PELAJARAN & WALI KELAS TERHADAP
PERKEMBANGAN SISWA SELAMA MENEMPUH PENDIDIKAN DI SMA

NAMA GURU MAPEL TANGGAPAN PESAN/MASUKAN

TANGGAPAN KONSELOR TERHADAP PERKEMBANGAN SISWA SELAMA DI SMA

NAMA TANGGAPAN
PESAN/MASUKAN
KONSELOR Perkemb. Akademik Perkemb. Non Akademik

BK - SMA Negeri 1 Mertoyudan 41

 CATATAN AKHIR SISWA :

1. Siswa tersebut meninggalkan sekolah ini tanggal :

.....................................................................................................................................................
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2. Siswa meninggalkan sekolah ini karena :
.....................................................................................................................................................
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3. Meninggalkan sekolah ini dengan diberi :
IJAZAH No. ______________________ Tanggal ______________________
Surat Keterangan Lain : .............................................................................................................
.....................................................................................................................................................

Magelang, ..............................
Mengetahui,
Kepala Sekolah SMA N 1 Mertoyudan Konselor

(...........................................................) (...........................................................)

BK - SMA Negeri 1 Mertoyudan 42

 CATATAN KONSELOR :
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BK - SMA Negeri 1 Mertoyudan 43

 DENAH RUMAH SISWA

BK - SMA Negeri 1 Mertoyudan 44