KEPOLISIAN NEGARA REPUBLIK INDONESIA NO DADA: ……………………………….

DAERAH JAWA BARAT

SATKER : ……………………………….
FORMULIR DATA PESERTA
UJI KESAMAPTAAN JASMANI BERKALA PERIODIK I T.A. 2024

1. NAMA : ..............................................................................................................
2. PANGKAT/NRP : ..............................................................................................................
3. JABATAN : ..............................................................................................................
4. TINGGI/BERAT BADAN : ..............................................................................................................
5. TEMPAT/TANGGAL LAHIR : ..............................................................................................................
6. USIA : ..............................................................................................................
7. JENIS KELAMIN : ..............................................................................................................

8. TGL PELAKSANAAN TES : ..............................................................................................................

9. TENSI DARAH : ..............................................................................................................

I. UJIAN KESAMAPTAAN “A”

JUMLAH PUTARAN KELEBIHAN HASIL PARAF

1 2 3 4 5 6 7 8 9 JARAK GERAKAN PESERTA PETUGAS
.

II. UJIAN KESAMAPTAAN “B”

HASIL PARAF
HASIL GERAKAN
NO ITEM TES “B” GERAKAN
(HGB) PESERTA PETUGAS
(NGB)
1 PULL UP (B1)

2 SIT UP (B2)

3 PUSH UP (B3)

4 SHUTTLE RUN (B4)

NILAI GERAKAN “B” NGB : + + + = ...........................

4

NILAI GERAKAN (NKJ) “A”+”B” : NGA + NGB = ...........................

2

Dilaksanakan di : Bandung
Hari/Tanggal : ......................./......................
Waktu/Pukul :...............................................
PESERTA