Log Book Skripsi Fakultas Kedokteran Universitas Andalas

DAFTAR ISI
PROPOSAL
- Formulir Usulan Penelitian
- Blangko Pengambilan Data
- Kartu Mengikuti Seminar Proposal
- Log Book Bimbingan Proposal
- Formulir Kesedian Penguji
- Jadwal Ujian Proposal
- Surat Pernyataan
- Revisi Proposal
SKRIPSI
- Blangko Penelitian
- Log Book Bimbingan Skripsi
- Formulir Kesedian Penguji
- Jadwal Ujian Skripsi
- Surat Pernyataan
- Revisi Skripsi
- Time Schedule Proposal / Skripsi

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 1

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

LOG BOOK PROPOSAL

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 2

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

FORMULIR USULAN PENELITIAN

NAMA : _________________________________________________

NO.BP : _________________________________________________

RENCANA TIPIK PENELITIAN : (Diisi ketiga alternatif)

ALTERNATIF I : _________________________________________________

ALTERNATIF II : _________________________________________________

ALTERNATIF III : _________________________________________________

TANDA TANGAN

PEMBIMBING I : ____________________________ (___________________)

PEMBIMBING II : ____________________________ (___________________)

DISETUJUI

TOPIK PENELITIAN : ALTERNATIF __________

PADANG, 20…

Ketua Tim Skripsi MAHASISWA YBS,

......................................... ( )
Nip.
Log Book Skripsi Fakultas Kedokteran Universitas Andalas 3
Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

SURAT PERMOHONAN PENGAMBILAN DATA / PENELITIAN

Nama :________________________________________________________

No. BP :________________________________________________________

Alamat :________________________________________________________

No. HP / e-Mail :________________________________________________________

Pembimbing 1 :________________________________________________________

Pembimbing 2 :________________________________________________________

Melaksanakan Kegiatan : Pengambilan Data / Penelitian______________________________

Ditujukan kepada :________________________________________________________

Dalam rangka : Pembuatan Proposal / Hasil Skripsi_________________________

Judul :________________________________________________________

________________________________________________________

________________________________________________________

Saya yang memohon,

(_________________________)

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 4

 Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

KARTU MENGIKUTI SEMINAR Proposal

NAMA :__________________________
NO.BP :__________________________

NO HARI/TANGGAL PEMAKALAH JUDUL PARAF

KETUA
PENGUJI

1.

2.

3.

4.

5.

6.

Padang,
Ketua Tim Skripsi

.............................................
Nip.

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 5

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
Log Book Bimbingan Proposal
Pembimbing I :
Judul Proposal :...........................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

MASALAH YANG DIBICARAKAN DAN HASIL

NO HARI/TANGGAL PARAF
KONSULTASI

7.

Padang,
Ketua Tim Skripsi

.....................................................
Nip.

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 6

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

Log Book Bimbingan Proposal

Pembimbing II :
Judul Proposal :...........................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

MASALAH YANG DIBICARAKAN DAN HASIL

NO HARI/TANGGAL PARAF
KONSULTASI

1.

2.

3.

4.

5.

6.

7.

Padang,
Ketua Tim Skripsi

.....................................................
Nip.

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 7

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

FORMULIR KESEDIAAN PENGUJI

NAMA : __________________________________________________

NO.BP : __________________________________________________

JUDUL : _________________________________________________

_________________________________________________

_________________________________________________

PENGUJI : TANDA TANGAN

1. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

2. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

3. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

PADANG, 20…

TIM SKRIPSI

( )

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 8

 Log Book Skripsi Fakultas Kedokteran Universitas Andalas

BLANKO KESEDIAAN HADIR DALAM

SEMINAR PROPOSAL / UJIAN SKRIPSI

NAMA MAHASISWA / NO. BP: ______________________________________

No. Nama Dosen Jam Kesediaan Hadir Keterangan

Senin Salasa Rabu Kamis Jumat Sabtu
1.
2.
3.
4.
5.

Padang,
Ketua Tim Skripsi

............................................................
Nip.

9
 Log Book Skripsi Fakultas Kedokteran Universitas Andalas

SURAT PERNYATAAN

Yang bertandatangan dibawah ini :

Nama :..........................................................................................................................
No.BP : .........................................................................................................................
Ujian : Proposal / Skripsi
Judul Proposal / Skripsi : .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
..........................................................................................................................
..........................................................................................................................
Pembimbing 1 : .........................................................................................................................
Pembimbing 2 : .........................................................................................................................
Penguji : .........................................................................................................................
Penguji : .........................................................................................................................
Penguji : .........................................................................................................................

Dengan ini menyatakan bahwa log book proposal / skripsi (terlampir) telah saya isi dengan sebenar-
benarnya dan tandatangan yang terlampir di dalam log book proposal / skripsi tersebut adalah asli
dari pembimbing dan penguji.

Jika dikemudian hari ditemukan hal yang mencurigakan dalam pengisian log book proposal / skripsi
ataupun terjadi pemalsuan tandatangan dari pembimbing dan penguji maka saya bersedia
menerima sanksi akademik atas hal tersebut.

Demikian surat pernyataan ini saya buat, terimakasih.

Padang, ..................................................

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

10
Log Book Skripsi Fakultas Kedokteran Universitas Andalas

LEMBAR PENGESAHAN PERBAIKAN PROPOSAL

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

NO.BP :................................................................................................................

JUDUL PROPOSAL :................................................................................................................

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

NO NAMA PENGUJI PERNYATAAN DAN SARAN TANDATANGAN

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

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

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

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

5. ...........................................................
Log Book Skripsi Fakultas Kedokteran Universitas Andalas 11
Log Book Skripsi Fakultas Kedokteran Universitas Andalas

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

2 1.............................................................
..............................................................
..............................................................
..............................................................

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

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

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

5. ...........................................................
..............................................................
..............................................................
3 1.............................................................
..............................................................
..............................................................
..............................................................

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 12

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

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

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

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

5. ...........................................................
..............................................................
..............................................................
4 1.............................................................
..............................................................
..............................................................
..............................................................

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

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

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 13

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

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

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

5. ...........................................................
..............................................................
..............................................................
5 1.............................................................
..............................................................
..............................................................
..............................................................

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

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

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

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

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 14

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

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

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 15

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

LOG BOOK SKRIPSI

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 16

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

SURAT PERMOHONAN PENGAMBILAN DATA / PENELITIAN

Nama :________________________________________________________

No. BP :________________________________________________________

Alamat :________________________________________________________

No. HP / e-Mail :________________________________________________________

Pembimbing 1 :________________________________________________________

Pembimbing 2 :________________________________________________________

Melaksanakan Kegiatan : Pengambilan Data / Penelitian______________________________

Ditujukan kepada :________________________________________________________

Dalam rangka : Pembuatan Proposal / Hasil Skripsi_________________________

Judul :________________________________________________________

________________________________________________________

________________________________________________________

Saya yang memohon,

(_________________________)

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 17

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS
Log Book Bimbingan Penelitian dan Skripsi
Pembimbing I :
Judul Proposal :...........................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

MASALAH YANG DIBICARAKAN DAN HASIL

NO HARI/TANGGAL PARAF
KONSULTASI

1.

2.

3.

4.

5.

6.

Padang,
Ketua Tim Skripsi

.............................................................
Nip.
Log Book Skripsi Fakultas Kedokteran Universitas Andalas 18
Log Book Skripsi Fakultas Kedokteran Universitas Andalas

Log Book Bimbingan Penelitian dan Skripsi

Pembimbing II :
Judul Proposal :...........................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

MASALAH YANG DIBICARAKAN DAN

NO HARI/TANGGAL PARAF
HASIL KONSULTASI

1.

2.

3.

4.

5.

6.

7.

Padang,
Ketua Tim Skripsi

.............................................................
Nip.

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 19

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

FORMULIR KESEDIAAN PENGUJI

NAMA : __________________________________________________

NO.BP : __________________________________________________

JUDUL : _________________________________________________

_________________________________________________

_________________________________________________

PENGUJI : TANDA TANGAN

1. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

2. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

3. NAMA : ___________________________________ (___________________)

NIP : ___________________________________

PADANG, 20…

TIM SKRIPSI

( )

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 20

 Log Book Skripsi Fakultas Kedokteran Universitas Andalas

BLANKO KESEDIAAN HADIR DALAM

SEMINAR PROPOSAL / UJIAN SKRIPSI

NAMA MAHASISWA / NO. BP: ______________________________________

No. Nama Dosen Jam Kesediaan Hadir Keterangan

Senin Salasa Rabu Kamis Jumat Sabtu
1.
2.
3.
4.
5.

Padang,
Ketua Tim Skripsi

..................................................................
Nip.

21
 Log Book Skripsi Fakultas Kedokteran Universitas Andalas

SURAT PERNYATAAN

Yang bertandatangan dibawah ini :

Nama :..........................................................................................................................
No.BP : .........................................................................................................................
Ujian : Proposal / Skripsi
Judul Proposal / Skripsi : .........................................................................................................................
.........................................................................................................................
.........................................................................................................................
..........................................................................................................................
..........................................................................................................................
Pembimbing 1 : .........................................................................................................................
Pembimbing 2 : .........................................................................................................................
Penguji : .........................................................................................................................
Penguji : .........................................................................................................................
Penguji : .........................................................................................................................

Dengan ini menyatakan bahwa log book proposal / skripsi (terlampir) telah saya isi dengan sebenar-
benarnya dan tandatangan yang terlampir di dalam log book proposal / skripsi tersebut adalah asli
dari pembimbing dan penguji.

Jika dikemudian hari ditemukan hal yang mencurigakan dalam pengisian log book proposal / skripsi
ataupun terjadi pemalsuan tandatangan dari pembimbing dan penguji maka saya bersedia
menerima sanksi akademik atas hal tersebut.

Demikian surat pernyataan ini saya buat, terimakasih.

Padang, ..................................................

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

22
Log Book Skripsi Fakultas Kedokteran Universitas Andalas

LEMBAR PENGESAHAN PERBAIKAN SKRIPSI

NAMA : Nadira Edrian

NO.BP : 1610311044

JUDUL SKRIPSI : Hubungan Kadar Anti-Double Stranded DNA dengan Aktivitas

Penyakit pada Penderita Lupus Eritematosus Sistemik

NO NAMA PENGUJI PERNYATAAN DAN SARAN TANDATANGAN

1 Dr. dr. Arina Widya 1 Apa penyebab perbedaan aktivitas
Murni, SpPD-KPsi
penyakit pada penelitian ini dengan
penelitian sebelumnya?

2 Apa yang dapat memengaruhi nilai

r sehingga kekuatan korelasi hanya
dalam derajat sedang

3. Saran: kenapa penting dilakukan

pemeriksaan kadar anti-dsDNA
untuk menunjang penilaian aktivitas
penyakit? Mengapa tidak cukup
MEX-SLEDAI saja?

4. Tambahkan keterbatasan
penelitian.

2 Dr. Hasmiwati, M.Kes 1. Tambahkan keterbatasan

penelitian

2. Tambahkan penjelasan grafik

scatter plot dari korelasi

3. Perbaikan penulisan
Log Book Skripsi Fakultas Kedokteran Universitas Andalas 23
Log Book Skripsi Fakultas Kedokteran Universitas Andalas

4.Perbaikan daftar pustaka

5.Perbaikan lampiran
3 Dr. dr. Najirman, SpPD- 1. Sesuai saran penguji
KR
4 dr. Nice Rachmawati 1. Tambahkan penjelasan grafik
Masnadi, SpA(K)
scatter plot dari korelasi

2. Perbaikan penutup
5 dr. Tuti Handayani, 1. Sesuai saran penguji
SpRad

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 24

Log Book Skripsi Fakultas Kedokteran Universitas Andalas

TIME SCHEDULE PROPOSAL/SKRIPSI

PENDIDIKAN DOKTER
FAKULTAS KEDOKTERAN
UNIVERSITAS ANDALAS

TIME SCHEDULE PROPOSAL/SKRIPSI

BULAN
NO KEGIATAN
1 2 3 4 5 6
1 PENGESAHAN JUDUL
2 PEMBUATAN PROPOSAL
3 UJIAN PROPOSAL
4 REVISI PROPOSAL & MELAKUKAN PENELITIAN
5 UJIAN SKRIPSI
6 REVISI SKRIPSI & MEMPERBANYAK SKRIPSI

ANGGARAN BIAYA
BIAYA
NO KEGIATAN
(Rp)
1 OBSERVASI
2 TRANSPOSTASI
3 PENGAMBILAN DATA
4 BAHAN HABIS PAKAI
5 PENELITIAN
TOTAL BIAYA

Padang,

………………………………………

Log Book Skripsi Fakultas Kedokteran Universitas Andalas 25