7.16 Format Alih Tangan Kasus

SMP ISLAM AL-AZHAR KELAPA GADING JAKARTA

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

FORMAT ALIH TANGAN KASUS

: F/BK/16 : 00 : : : 1 dari 1

ALIH TANGAN KASUS

Nama Siswa Kelas Jenis Kelamin* Waktu Pemberi Rujukan Pihak Rujukan* Bidang Nama Petugas Pihak Dirujukan Masalah Siswa

Data yang Dilampirkan

Hasil Rujukan

Evaluasi dan Tindak Lanjut

: ................................................... ............................................................................. ................................ ...... : ................................................... ............................................................................. ................................ ...... :L/P : ................................................... ............................................................................. ................................ ...... : ................................................... ............................................................................. ................................ ...... : Dokter/ Polisi/ Biro Psikologi/ Lain-lain ....... ............... ............... ....... : ................................................... ............................................................................. ................................ ...... : ................................................... ............................................................................. ................................ ...... : ................................................... ............................................................................. ................................ ...... ................................................. ........................................................................... .................................... .......... ................................................. ........................................................................... .................................... .......... ................................................. ........................................................................... .................................... .......... : ................................................... ............................................................................. ................................ ...... ................................................. ........................................................................... .................................... .......... ................................................. ........................................................................... .................................... .......... : ................................................... ............................................................................. ................................ ...... ................................................. ........................................................................... .................................... .......... ................................................. ........................................................................... .................................... .......... ................................................. ........................................................................... .................................... .......... : ................................................... ............................................................................. ................................ ...... ................................................. ........................................................................... .................................... .......... ................................................. ........................................................................... .................................... ..........

Catatan: * Pilih salah satu

Mengetahui, 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