7.14 Format Hasil Kunjungan Rumah

SMP ISLAM AL-AZHAR KELAPA GADING JAKARTA J AKARTA FORMAT HASIL KUNJUNGAN RUMAH

No. Dok No. Revisi No. Terbit Tgl Berlaku Halaman

: F/BK/14 : 00 : : : 1 dari 1

LAPORAN HASIL KUNJUNGAN RUMAH (home visit) I.

IDENTITAS SISWA 1. N a m a 2. Kelas/No Absen 3. N I S

: .................................................. ............................................................................ ............................................ .................. : .................................................. ............................................................................ ............................................ .................. : .................................................. ............................................................................ ............................................ ..................

II. IDENTITAS ORANGTUA 1. Nama Ayah : .................................................. ............................................................................ ............................................ .................. 2. Pekerjaan Ayah : .................................................. ............................................................................ ............................................ .................. 3. Nama Ibu : .................................................. ............................................................................ ............................................ .................. 4. Pekerjaan Ibu : .................................................. ............................................................................ ............................................ .................. 5. Alamat Rumah : .................................................. ............................................................................ ............................................ .................. ............................................... ......................................................................... ................................................. ....................... 6. Telp/ HP : .................................................. ............................................................................ ............................................ .................. III. TUJUAN KUNJUNGAN RUMAH ................................................ .......................................................................... .................................................... ................................................... ............................... ...... ................................................ .......................................................................... .................................................... ................................................... ............................... ...... IV. HASIL WAWANCARA & OBSERVASI ................................................ .......................................................................... .................................................... ................................................... ............................... ...... ................................................ .......................................................................... .................................................... ................................................... ............................... ...... ................................................ .......................................................................... .................................................... ................................................... ............................... ...... ................................................ .......................................................................... .................................................... ................................................... ............................... ...... V. KESIMPULAN/TINDAK LANJUT ................................................ .......................................................................... .................................................... ................................................... ............................... ...... ................................................ .......................................................................... .................................................... ................................................... ............................... ...... ................................................ .......................................................................... .................................................... ................................................... ............................... ......

Mengetahui, Kepala Sekolah SMPI Al-Azhar Kelapa Gading

Jakarta, ........................................ ........................................ Koord. Guru Bimbingan Konseling SMPI Al-Azhar Kelapa Gading

Drs. H. Asmawi, M.Pd NIP. 343974 264720 0 002

Dra. Kholilah NIP. 363574 664830 0 062