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LEMBAR BUKU INDUK SISWA SMK Nama Peserta Didik NIS / NISN Nama Sekolah Alamat Sekolah Kompetensi Keahlian



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A. KETERANGAN PRIBADI 1. Nama Peserta Didik - Nama Lengkap - Nama Panggilan 2. Jenis Kelamin 3. Tempat Lahir 4. Tanggal Lahir 5. A g a m a 6. Kewarganegaraan 7. Anak ke berapa 8. Jumlah Saudara Kandung 9. Jumlah Saudara Tiri 10. Jumlah Saudara Angkat 11. Anak yatim/piatu/yatim piatu 12. Bahasa sehari-hari di rumah



Pas Foto



Cap tiga jari tengah tangan kiri diatas pas foto bagian bawah waktu meninggalkan sekolah.



B. KETERANGAN 13. Alamat 14. Nomor Telepon 15. Tempat Tinggal tersebut adalah



: .................................................................................................................................... : .................................................................................................................................... : pada orang tua kandung pada seseorang dengan hubungan keluarga menumpang pada orang lain asrama........................................................................................................ bagi............................................................................................................. 16. Jarak dari tempat tinggal ke sekolah : ..................................................... 17. Ke sekolah dengan kendaraan berjalan kaki : .....................................................



C. KETERANGAN KESEHATAN



18. Berat Badan 19. Tinggi badan



Pas Foto



Pada waktu terima



Pada waktu Meninggalkan sekolah



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Cap tiga jari tengah tangan kiri diatas pas foto bagian bawah waktu meninggalkan sekolah.



20. Golongan darah : ..................................................... 21. Penyakit yang pernah diderita (contoh TBC, cacar dan lain-lain...............) Nomor Urut



Jenis Penyakit



Kelas



Tahun



Lama Sakit



Keterangan



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22. Kelamin Jasmaniah / lainnya



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D. KETERANGAN PENDIDIKAN SEBELUMNYA 23. Asal Sekolah a. Tanggal dan Nomor STTB - Tanggal dan Nomor STTB - Lama Belajar b. SLTP lainnya - Tanggal dan Nomor STTB - Lama Belajar 24. a. Pindah dari sekolah - Diterima disekolah ini b. Alasan Pindah



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E. KETERANGAN TENTANG ORANG TUA KANDUNG No. 25. 26. 27. 28. 29. 30. 31.



Orang Tua Kandung Nama Tempat Tanggal Lahir Kewarganegaraan Ijazah Terakhir Pekerjaan Penghasilan / bulan Alamat



Ayah



Ibu



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F. KETERANGAN TENTANG WALI No. 32. 33. 34. 35. 36.



Wali Nama Ijazah Terakhir Pekerjaan Penghasilan / bulan Alamat



Laki - Laki



Perempuan



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G. KETERANGAN TENTANG WALI 37. Intelegensi (IQ)



38. Aspek Kepribadian No.



Aspek yang dinilai



: .................................................................................................................................... (berdasarkan tes pada tanggal................................bulan............................................ tahun........................................................................................................................... : .................................................................................................................................... Semester Semester Semester Semester Semester Semester Semester Semester Semester B C K B C K B C K B C K B C K B C K B C K B C K B C K



1. 2. 3. 4. 5. 6.



Disiplin / Ketertiban Prakarsa / Kreativitas Tanggung Jawab Penyesuaian Kemantapan Emosi Kerjasama



39. Bakat khusus dan prestasi yang menonjol dalam No. 1. 2. 3. 4. 5. 6. 7. 8.



SMTH / TH



Kesenian



Olahraga



Kemasyarakatan Organisasi



Hasta Karya



Karya Tulis



H. KETERANGAN KEHADIRAN 40. Jumlah hari kehadiran tiap semester : Tidak Hadir Karena Ijin



Alpa



Jumlah Hari Belajar Efektif



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Semester / Kls



Hadir



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Semester......./ Kls......



Sakit



I. KETERANGAN SEKITAR PERKEMBANGAN PESERTA DIDIK 41. Tahun Masuk / terdaftar 42. Prestasi peserta didik Tahun Pelajaran



Kelas



Smt.



: .................................................................................................................................... : .................................................................................................................................... Program Umum



Jumlah Mat Pel



Nilai Rata 2



Peringkat Kelas/ Rangking



Khusus



Nilai Rata 2



Nilai Tinggal Kelas



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43. Tahun meninggalkan sekolah dengan alasan 44. Pindah sekolah ke 45. Melanjutkan pendidikan ke



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J. PENERIMAAN SISWA Tahun : ................................................................ dari : .......................................................................................... Tahun : ................................................................ dari : .......................................................................................... Tahun : ................................................................ dari : ..........................................................................................