PELAKSANA URUSAN ADMINISTRASI SARANA DAN PRASARANA
Lampiran 47 Contoh Buku Kegiatan Harian Pelaksana Urusan
Administrasi Sarana dan Prasarana
Lampiran 48 Contoh Daftar Pengeluaran Barang Inventaris
Lampiran 49 Contoh Daftar Pengeluaran Barang Non Inventaris Lampiran 50 Contoh
Daftar Peminjaman Barang Inventaris Lampiran 51 Contoh Buku Induk Barang
Inventaris Lampiran 52 Contoh Kartu Inventaris Barang (KIB) A Tanah
Lampiran 53 Contoh Kartu Inventaris Barang (KIB) B
Peralatan dan Mesin Lampiran 54 Contoh Kartu Inventaris Barang (KIB) C Gedung
dan Bangunan Lampiran 55 Contoh Kartu Inventaris Barang (KIB) D Jalan, Irigasi
dan Bangunan Lampiran 56 Contoh Kartu Inventaris Ruangan
Lampiran 57 Contoh Daftar Penerimaan Barang Inventaris
Lampiran 58 Contoh Daftar Penerimaan Barang Noninventaris Lampiran 59 Contoh
Buku Pemeliharaan dan Perbaikan
Lampiran 60 Contoh Format Barang ATK yang Harus
Ditambah/Dibeli Lampiran 61 Contoh Kartu Stok Barang Lampiran 62 Contoh Stok
Barang ATK yang Ada
Lampiran 63 Contoh Program Kerja Pelaksana Urusan Sarana
Prasarana Lampiran 64 Contoh Daftar Kebutuhan Barang Inventaris dan Non
inventaris Lampiran 65 Contoh Laporan Bulanan Penggunaan Laboratorium/Bengkel
Lampiran 66 Contoh Laporan Semesteran Penggunaan Laboratorium/Bengkel Lampiran
67 Contoh Laporan Tahunan Penggunaan Laboratorium/Bengkel Lampiran 68 Contoh
Daftar Laboratorium/Bengkel Sekolah
Lampiran 69 Contoh Formulir Denah Ruang dan Bangunan
Laboratorium/Bengkel Lampiran 70 Contoh Daftar Peralatan Pendukung
Laboratorium/Bengkel Lampiran 71 Contoh Penjadwalan Kegiatan Praktik Siswa
Lampiran 72 Contoh Prosedur Operasi Standar
Lampiran 73 Contoh Lembar Kerja Perawatan Alat dan Mesin
Lampiran 74 Contoh Kegiatan Perawatan Alat dan Mesin
Lampiran 75 Contoh Kartu Peminjaman Alat
Lampiran 76 Contoh Bon Peminjaman Peralatan
Laboratorium/Bengkel
Lampiran 77 Contoh
Daftar Pengeluaran Bahan Praktik Laboratorium/Bengkel Lampiran 78 Contoh Daftar
LKS (Job-sheet)
Lampiran 79 Contoh Daftar Penyerahan Hasil Praktik
Laboratorium/Bengkel
Lampiran 80 Contoh Daftar Nilai Praktik
Laboratorium/Bengkel
vii
Lampiran 47
Contoh Buku Kegiatan Harian Pelaksana Urusan
Administrasi Sarana dan Prasarana
PELAKSANA URUSAN ADMINISTRASI SARANA DAN PRASARANA
BUKU KEGIATAN HARIAN
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No. |
Hari/ Tanggal |
Jenis Kegiatan |
Keterangan |
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77
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78 |
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Lampiran 48 |
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Contoh Daftar Pengeluaran Barang Inventaris |
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KOP SEKOLAH |
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DAFTAR PENGELUARAN
BARANG INVENTARIS |
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NAMA DAN |
TANDA BUKTI |
NAMA DAN URAIAN |
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NO. |
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PENERIMAAN |
BANYAKNYA |
HARGA SATUAN |
JUMLAH |
KET. |
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TGL. KELUAR |
ALAMAT |
BARANG
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BARANG |
PENGIRIM |
TANGGAL |
NOMOR |
UKURAN, DSB) |
VOLUMESATUAN |
Rp. |
Rp |
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9 |
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Kepala …………………. Pengurus Barang Inventaris
NIP NIP
Lampiran
49 Contoh Daftar Pengeluaran Barang Non Inventaris
KOP SEKOLAH
DAFTAR PENGELUARAN BARANG NON INVENTARIS
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TGL |
NAMA DAN |
TANDA BUKTI |
NAMA DAN URAIAN |
BANYAKNYA |
HARGA SATUAN |
JUMLAH |
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NO. |
PENGELUARAN |
ALAMAT
YANG |
PENGELUARAN |
BARANG
(MEREK, |
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KET. |
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BARANG |
MENGELUARKAN |
TANGGAL |
NOMOR |
UKURAN, DSB.) |
VOLUMESATUAN |
Rp. |
Rp |
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3 |
4 |
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6 |
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Kepala …………………. Pengurus Barang Noninventaris
NIP NIP
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80 |
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Lampiran 50 Contoh Daftar Peminjaman Barang
Inventaris |
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KOP SEKOLAH |
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DAFTAR PEMINJAMAN
BARANG INVENTARIS |
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NO. |
TANGGAL |
NAMA BARANG |
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MEREK |
JUMLAH |
UNTUK |
TANGGAL |
TANDA TANGAN |
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PEMINJAMAN |
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KEPERLUAN |
PENGEMBALIAN |
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VOLUME |
SATUAN |
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5 |
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6 |
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7 |
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8 |
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9 |
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Kepala …………………. Pengurus Barang Inventaris
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NIP ……………………
NIP ………………………
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Lampiran 51 |
Contoh Buku Induk Barang Inventaris |
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BUKU INDUK BARANG INVENTARIS |
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PROVINSI |
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:…………………………. |
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MODEL INVENTARIS |
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KABUPATEN/KOTAMADYA |
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:…………………………. |
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UNIT |
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:…………………………. |
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KODE UNIT/SK |
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:……………….. |
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NAMA KANTOR SATUAN KERJA |
:…………………………. |
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TAHUN LAPOR |
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:……………….. |
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ALAMAT |
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:……………….. |
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NOMOR |
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SPESIFIKASI BARANG |
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KODE |
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ASAL |
BULAN |
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KETERANGAN |
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KOMPONEN |
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ANGGARAN |
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REGISTER |
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NO.SERTIFIKAT |
KONTR/SPK |
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RUANGAN |
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AN |
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MEREK |
PEROLEHAN |
TAHUN |
JUMLAH |
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SA |
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PERUBAH |
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JENIS |
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BARANG |
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JUMLAH |
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NO. POLISI/BPKB |
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KODE BARANG |
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TYPE |
BELI |
UKURAN |
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TU |
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BARANG |
PABRIK, NO |
TGL. NO. BA |
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HARGA |
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PEMAKAI KODE |
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ALAMAT |
PEROLEH |
BARNG |
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MUTASI |
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CHASIS/MESIN |
TGL/NO. |
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KELURAHAN |
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18 |
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Kepala …………………. |
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Pengurus Barang Inventaris |
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NIP |
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NIP |
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81 |
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82 |
Lampiran 52 Contoh Kartu Inventaris Barang
(KIB) A Tanah
KARTU INVENTARIS BARANG (KIB) A
TANAH
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Provinsi |
: |
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Kab./Kota |
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Kecamatan |
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Bidang |
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Unit Organisasi |
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Subunit Organisasi |
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U P B / SEKOLAH |
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NO. KODE LOKASI |
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JENIS |
NOMOR |
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TAHUN |
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STATUS TANAH |
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KODE |
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LETAK/ |
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SERTIFIKAT |
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NO. |
BARANG/NAM |
REGISTE |
LUAS |
PENGA |
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PENGGUNAAN |
ASAL
USUL |
HARGA |
KET. |
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A BARANG |
BARAN |
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DAAN |
ALAMAT |
HAK |
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TANGG |
NOMOR |
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R |
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AL |
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1 |
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12 |
13 |
14 |
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Mengetahui
………….,………………..
KEPALA SEKOLAH
PENGURUS BARANG
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………………………….
NIP ……………………
NIP ……………………
Lampiran 53 Contoh Kartu Inventaris Barang
(KIB) B Peralatan dan Mesin
KARTU INVENTARIS BARANG (KIB) B
PERALATAN DAN MESIN
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Bidang |
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U P B / SEKOLAH |
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NO. KODE LOKASI |
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JENIS |
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NOMOR |
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KET. |
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SUM |
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KONDISI |
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BARANG/ |
REGISTER |
MEREK/ |
UKURAN/C |
BAHAN |
THN PEMBELIAN |
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ASAL |
HARG |
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NAMA |
TIPE |
C |
PABRI |
RAN |
MESIN |
POLISI |
BPK |
USUL |
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BER |
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BARANG |
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K |
GKA |
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RB) |
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A |
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83 |
Mengetahui
KEPALA SEKOLAH
...............................................
NIP
.......................................
………….,………………..
PENGURUS BARANG
..............................................
NIP
.....................................
|
84 |
Lampiran 54 Contoh Kartu Inventaris Barang
(KIB) C Gedung dan Bangunan
KARTU INVENTARIS BARANG (KIB) C
GEDUNG DAN BANGUNAN
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Kecamatan |
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Unit Organisasi |
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Sub Unit Organisasi |
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U P B / SEKOLAH |
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NO. KODE LOKASI |
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JENIS |
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KONDISI |
KONSTRUKSI BANGUNAN |
Luas |
Letak/ |
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Dokumen |
Luas |
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Nomor |
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Keterangan |
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NOMOR |
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NO. |
BARANG/ |
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BANGUNAN |
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NAMA |
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Bertingkat/ |
Beton/ |
Lantai |
Lokasi |
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Tanah |
Status |
Kode |
Asal |
Harga |
Sumber |
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BARANG |
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KODE |
REG |
(B,KB,RB) |
tidak |
tidak |
(M2) |
Alamat |
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Tang |
Nomor |
(M2) |
Tanah |
Tanah |
Usul |
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Dana |
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gal |
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Mengetahui,
KEPALA SEKOLAH
………….,………….
PENGURUS BARANG
...................................................
..................................................
NIP ...........................................
NIP
...........................................
Lampiran 55 Contoh Kartu Inventaris Barang (KIB) D Jalan, Irigasi dan
Bangunan
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KARTU INVENTARIS BARANG (KIB) D |
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Provinsi |
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JALAN, IRIGASI DAN JARINGAN |
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Kab./Kota |
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Kecamatan |
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Bidang |
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Unit Organisasi |
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Sub Unit Organisasi |
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U P B / SEKOLAH |
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NO. KODE LOKASI |
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Letak/ |
Dokumen Gedung |
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Nomor |
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Jenis |
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Nomor |
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Luas |
Lokasi |
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Status |
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Harga |
Kondisi |
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Konstruksi |
Panjang |
Lebar |
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Kode |
Asal |
Keterangan |
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No. |
Barang/ |
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Nama |
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Kode |
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(m) |
(m) |
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(M2) |
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Tanggal |
Nomor |
Tanah |
Tanah |
Usul |
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(B,
KB, RB) |
Sumber |
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Barang |
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Dana |
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Mengetahui, ………….,………………..
KEPALA SEKOLAH PENGURUS BARANG
................................................... ..................................................
NIP ........................................... NIP
...........................................
|
85 |
|
86 |
Lampiran 56
Contoh Kartu Inventaris Ruangan
KARTU INVENTARIS RUANGAN
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Sub Unit Organisasi |
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: |
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Sub Sekolah |
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Ruangan |
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Keadaan Barang *) |
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Keterangan |
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Tahun Pembuatan / |
No. Kode Barang |
Jumlah Barang |
Harga Beli/ |
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Kurang Baik |
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Pembelian |
(Satuan) |
Perolehan |
Baik (B) |
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Rusak Berat (RB) |
Sumber Dana |
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(KB) |
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Mengetahui,
............................................,
........................, 20 .................
Kepala Sekolah
Pengurus barang
..........................................................
NIP .............................................
..............................................
Lampiran 57 Contoh Daftar Penerimaan Barang Inventaris
KOP SEKOLAH
DAFTAR PENERIMAAN BARANG INVENTARIS
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NAMA DAN |
TANDA BUKTI |
NAMA DAN URAIAN |
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NO. |
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PENGIRIM |
BANYAKNYA |
HARGA SATUAN |
JUMLAH |
KET. |
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TGL.
TERIMA |
ALAMAT |
BARANG (MEREK, |
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BARANG |
PENGIRIM |
TANGGAL |
NOMOR |
UKURAN, DSB.) |
VOLUME
SATUAN |
Rp. |
Rp |
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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Kepala …………………. Pengurus Barang Inventaris
NIP NIP
|
87 |
|
88 |
Lampiran 58 Contoh Daftar Penerimaan Barang Non Inventaris
KOP SEKOLAH
DAFTAR PENERIMAAN BARANG NONINVENTARIS
|
|
TGL. TERIMA |
NAMA DAN |
TANDA BUKTI |
NAMA DAN URAIAN |
BANYAKNYA |
HARGA SATUAN |
JUMLAH |
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NO |
ALAMAT YANG |
PENGELUARAN |
BARANG
(MEREK, |
KET. |
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BARANG |
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MENGELUARKAN |
TANGGAL |
NOMOR |
UKURAN, DSB.) |
VOLUMESATUAN |
Rp. |
Rp |
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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Kepala …………………. Pengurus Barang Non Inventaris
NIP NIP
Lampiran 59 Contoh Buku Pemeliharaan dan Perbaikan
KOP SEKOLAH
BUKU PEMELIHARAAN DAN PERBAIKAN
KELOMPOK
ALAT-ALAT KANTOR
|
Jenis |
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:………………………. |
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No. Kode Inventaris |
:………………………. |
|
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Merek |
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:………………………. |
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Tahun Pengadaan |
:………………………. |
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Ukuran |
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:………………………. |
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Harga/Sewa |
:………………………. |
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Nomor Seri |
:………………………. |
|
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Satuan Pemakai |
:………………………. |
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Tahun Pembuatan |
:………………………. |
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Alamat |
:………………………. |
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JUMLAH BIAYA |
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NO. |
TANGGAL |
URAIAN PEMELIHARAAN/MACAM PERBAIKAN |
DIKERJAKAN OLEH |
BIAYA DARI |
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KETERANGAN |
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UPAH KERJA |
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JUMLAH |
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HARGA BAHAN/PER |
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Mengetahui,
Kepala ………………….
Pengurus Barang
Inventaris
.........................................................
NIP
.....................................................
.........................................................
NIP
.....................................................
|
89 |
|
90 |
Lampiran 60
Contoh Format Barang ATK Yang Harus Ditambah/Dibeli
BARANG ATK YANG HARUS DITAMBAH/DIBELI
TAHUN …………
|
NO. |
NAMA BARANG |
JUMLAH BARANG |
KETERANGAN |
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Mengetahui,
………………, ……………………
Kepala ……………
Pengurus Barang
………………………….
………………………….
NIP ……………………
NIP ……………………
Lampiran
61 Contoh Kartu Stok Barang
KARTU STOK BARANG
NAMA BARANG :
KODE BARANG :
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Tanggal |
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Tanda Bukti |
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No. |
Terima |
Nama dan Alamat |
Pengirim |
Nama dan Uraian Barang |
Penerimaan |
Pengeluaran |
Jumlah Saldo Barang |
Keterangan |
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Urut |
Barang |
Pengirim |
Tanggal |
Nomor |
( Merek, Ukuran, dsb.) |
Volume |
Satuan |
Volume |
Satuan |
Volume |
Satuan |
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1 |
2 |
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10 |
11 |
12 |
13 |
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Kepala …………………. Pengurus Barang Inventaris
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NIP ……………………. NIP ……………………………
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91 |
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92 |
Lampiran 62
Contoh Stok Barang ATK Yang Ada
STOK BARANG ATK YANG ADA
PADA
………………… AKHIR TAHUN ……..
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NO. |
NAMA BARANG |
JUMLAH BARANG |
KETERANGAN |
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Mengetahui,
………………, ……………………
Kepala ……………
Pengurus Barang
………………………….
………………………….
NIP ……………………
NIP ……………………
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Lampiran 63 |
Contoh Program Kerja Pelaksana Urusan Administrasi Sarana Prasarana |
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KOP SEKOLAH |
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PROGRAM KERJA PELAKSANA
URUSAN ADMINISTRASI SARANA PRASARANA |
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TAHUN PELAJARAN
…………………………….. |
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NO |
KEGIATAN |
TUJUAN |
SASARAN |
TARGET |
WAKTU |
PELAKSANA |
SUMBER |
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DANA |
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1
2
3
4
5
6
dst.
Mengetahui, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,.
.......................20..................
Kepala TAS
Pelaksana Urusan
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NIP
................................................ ............................................
NIP ............................................
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Lampiran
64
Contoh
Daftar Kebutuhan Barang Inventaris dan Non Inventaris
DAFTAR KEBUTUHAN BARANG INVENTARIS DAN NON
INVENTARIS
TAHUN ANGGARAN …………..
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NO. |
NAMA BARANG |
MEREK VALUME SATUAN |
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BULAN |
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KETERANGAN |
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7 |
8 |
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10 |
11 |
12 |
1 |
2 |
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5 |
6 |
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JUMLAH
Mengetahui,
Kepala ………………….
.........................................
Pengurus Barang
Inventaris
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NIP .............................
.........................................
NIP
.........................................
Lampiran 65
Contoh Laporan Bulanan Penggunaan
Laboratorium/Bengkel
KOP SEKOLAH
LAPORAN BULANAN PENGGUNAAN
LABORATORIUM/BENGKEL
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Unit Kerja |
: Laboratorium/Bengkel
*……………………… |
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Bulan |
: ................................. |
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No. |
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Item Laporan |
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Jumlah |
Satuan |
Keterangan |
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1. |
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Jumlah Kelas
Praktik |
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Kelas |
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2. |
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Jumlah Pekerjaan
Praktik |
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Pekerjaan |
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3. |
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Jumlah Siswa
(Praktikan) |
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Org |
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4. |
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Kegiatan
Penggunaan Bengkel Lainnya |
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Keg. |
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5. |
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Pemakaian Bahan
(Nama Bahan ) |
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a. |
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b. |
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c. |
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d. |
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e. |
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f. |
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g. |
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h. |
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i. |
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j.dst. |
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6. |
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Pemakaian Alat
(Nama Alat) |
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a. |
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b. |
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c. |
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d. |
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e. |
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f. |
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g. |
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h. |
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i. |
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j.dst. |
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7. |
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Jumlah Pemantauan
Bengkel |
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8. |
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Bahan Rusak |
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a. |
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b. |
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95
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No. |
Item Laporan |
Jumlah |
Satuan |
Keterangan |
c.
d.
e.
f.
g.
h.
i.
j.dst.
9.
Alat Rusak
a.
b.
c.
d.
e.
f.
g.
h.dst.
10.
Perbaikan
a.
Alat/ Mesin
b. Perbaikan Fisik
Bangunan
c.
Perbaikan Ruangan Bengkel
d. Perbaikan Instalasi
Listrik
e.
Perbaikan Jaringan Air/ Kotor
f.
dll.
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11. |
............................... dll. |
Ket: satuan untuk perbaikan bisa jumlah, buah, volume
atau rupiah
Mengetahui/Menyetujui: ................., ........................... 20…
Kepala Sekolah, WKS Bidang……../Ka Prog.*............. Ka Lab/Ka Bengkel*
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(................................................... |
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(
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( .................................... |
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NIP |
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NIP |
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96
Lampiran 66 Contoh Laporan
Semesteran Penggunaan Laboratorium/Bengkel
KOP SEKOLAH
LAPORAN SEMESTERAN PENGGUNAAN LABORATORIUM/BENGKEL*
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Unit Kerja |
: Laboratorium/Bengkel
*……………………… |
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Semester |
: Ganjil / Genap
Tahun Ajaran |
.......... / ........... |
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No. |
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Item Laporan |
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Jumlah |
Satuan |
Keterangan |
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1 |
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Jumlah Kelas
Praktik |
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Kelas |
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2 |
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Jumlah Pekerjaan
Praktik |
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Pekerjaan |
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3 |
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Jumlah Siswa
(Praktikan) |
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Org |
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4 |
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Kegiatan
Penggunaan Bengkel Lainnya |
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Keg. |
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5 |
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Pemakaian Bahan
(Nama Bahan ) |
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c. |
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d. |
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e. |
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f. |
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g. |
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h. dst. |
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6 |
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Pemakaian Alat
(Nama Alat) |
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a. |
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d. |
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e. |
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f. |
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g. |
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h. |
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i.dst. |
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7 |
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Jumlah Pemantauan
Bengkel |
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8 |
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Bahan Rusak |
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a. |
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d. |
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e. |
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f. |
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g. |
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97
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No. |
Item Laporan |
Jumlah |
Satuan |
Keterangan |
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i. |
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j. dst. |
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9
Alat Rusak a.
b.
c.
d.
e.
f.
g.
h.
i.
j.dst.
10
Perbaikan a.Alat/ Mesin
b.
Perbaikan Fisik Bangunan
c.
Perbaikan Ruangan Bengkel
d.
Perbaikan Instalasi Listrik
e.
Perbaikan Jaringan Air/ Kotor
f.
dll.
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11
............................... |
dll. |
Ket.: *Coret yang tidak perlu
................., ........................ 20…
Mengetahui/Menyetujui: WKS Bidang……../Ka Prog.*............. Ka Lab/Ka Bengkel*
Kepala Sekolah,
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(................................................... |
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( ........................................... |
( ................................ |
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NIP .................................... |
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NIP |
NIP ................................... |
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98
Lampiran 67. Contoh Laporan Tahunan Penggunaan Laboratorium/Bengkel
KOP SEKOLAH
LAPORAN TAHUNAN PENGGUNAAN LABORATORIUM/BENGKEL*
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Unit Kerja |
: Laboratorium/Bengkel
*……………………… |
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Tahun Ajaran:
.......... /........... |
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No. |
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Item Laporan |
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Jumlah |
Satuan |
Keterangan |
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1 |
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Jumlah Kelas
Praktik |
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Kelas |
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2 |
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Jumlah Pekerjaan
Praktik |
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Pekerjaan |
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3 |
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Jumlah Siswa
(Praktikan) |
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Org |
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4 |
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Kegiatan
Penggunaan Bengkel Lainnya |
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Keg. |
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5 |
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Pemakaian Bahan
(Nama Bahan ) |
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f. |
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g. |
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h. |
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i. |
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j.dst. |
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6 |
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Pemakaian Alat
(Nama Alat) |
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a. |
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b. |
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c. |
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d. |
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e. |
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f. |
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g. |
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h. |
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i. |
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j.dst. |
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7 |
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Jumlah Pemantauan
Bengkel |
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8 |
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Bahan Rusak |
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a. |
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b. |
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99
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No. |
Item Laporan |
Jumlah |
Satuan |
Keterangan |
c.
d.
e.
f.
g.
h.
i.
j. dst.
9
Alat Rusak a.
b.
c.
d.
e.
f.
g.
h.
i.
j.dst.
10
Perbaikan a.Alat/ Mesin
b.
Perbaikan Fisik Bangunan
c.
Perbaikan Ruangan Bengkel
d.
Perbaikan Instalasi Listrik
e.
Perbaikan Jaringan Air/ Kotor
f.
dll.
|
11. |
............................... dll. |
Ket.: * Coret yang tidak perlu
Mengetahui/Menyetujui: ................., ........................ 20…
Kepala Sekolah, WKS Bidang……../Ka Prog.*............. Ka Lab/Ka Bengkel*
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(................................................... |
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( ......................................... |
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(
...................................... |
) |
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NIP .................................... |
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NIP .................................... |
NIP ................................... |
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100
Lampiran 68 Contoh Daftar Laboratorium/Bengkel Sekolah
KOP SEKOLAH
DAFTAR LABORATORIUM/BENGKEL* SEKOLAH
Tahun Ajaran : …..… / ……
|
No. |
Nama Bengkel |
Daya |
Untuk PBM |
Kondisi |
Foto |
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Tampung |
Mata Pelajaran |
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2. |
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3. |
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4. |
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5. |
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Ket.: * Coret
yang tidak perlu
Mengetahui/Menyetujui: ................., .................................. 20…
Kepala Sekolah, Waka Bidang Sarpras,
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(................................................... |
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( |
.................................................
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NIP .................................... |
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NIP ................................... |
101
Lampiran 69 Contoh Daftar Peralatan Laboratorium/Bengkel
KOP SEKOLAH
PERALATAN UTAMA LABORATORIUM/BENGKEL*
Nama Laboratorium/Bengkel*: ………………………………………………………………………………….
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No. |
Nama Peralatan/ Mesin |
Spesifikasi |
Kondisi Alat |
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Ket.: * Coret yang tidak perlu
................., ....................... 20…
Mengetahui/Menyetujui: WKS Bidang……../Ka Prog.*............. Ka Lab/Ka Bengkel*,
Kepala Sekolah,
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(................................................... |
) |
( |
................................................
) |
( |
.................................................
) |
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NIP .................................... |
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NIP .................................... |
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NIP ................................... |
102
Lampiran 69 Contoh Formulir Denah Ruang dan Bangunan
Laboratorium/Bengkel
KOP SURAT
DENAH RUANG DAN
BANGUNAN LABORATORIUM/BENGKEL *
|
Nama Lab/Bengkel* |
: …………………………………………………………………………………… |
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Luas Bangunan |
: ……… m2. |
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Kepala Lab/Bengkel* |
: ……………………………………………………………………………………. |
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Teknisi |
: ……………………………………………………………………………………. |
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Denah Lab/Bengkel*: |
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.............. |
, ......................... 20… |
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Mengetahui/Menyetujui: |
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WKS Bidang……../Ka |
Ka Lab/Ka Bengkel*, |
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Kepala Sekolah, |
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Prog.*............. |
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(
............................................ |
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(........................................... |
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( |
.......................................
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NIP ................................... |
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NIP |
NIP .................................... |
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103
Lampiran 70 Contoh Daftar Peralatan Pendukung Laboratorium/Bengkel
KOP SEKOLAH
PERALATAN
PENDUKUNGLABORATORIUM/BENGKEL
Nama Laboratorium/Bengkel:
………………………………………………………………………….
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No. |
Nama Peralatan/ Mesin |
Spesifikasi |
Kondisi Alat |
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................., .......................... 20…
Mengetahui/Menyetujui:
Kepala Program
.........................
Kepala Bengkel,
Kepala Sekolah,
....................................
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(............................................ |
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(
...................................... |
) |
( ...................................... |
) |
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NIP |
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NIP .................................... |
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NIP
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104
Lampiran 71 Contoh Formulir Kegiatan Praktik
Siswa
KEGIATAN PRAKTIK SISWA
|
Mata Pelajaran |
: ………………………………………………………………………………. |
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Semester |
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: ………………………………………………………………………………. |
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Pengampu |
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: ………………………………………………………………………………. |
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No. |
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Nama Pekerjaan Praktik Siswa |
Waktu(Jam) |
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Keterangan |
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Mengetahui/Menyetujui: ................., ...................... 20…
Kepala Sekolah, WKS Bidang……../Ka Prog.*............. Ka Lab/Ka Bengkel*,
|
(................................................... |
) |
( ................................................ |
) |
( |
.................................................
) |
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NIP .................................... |
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NIP .................................... |
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NIP ................................... |
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105
Lampiran 72 Contoh Prosedur Operasi Standar
KOP SEKOLAH
PROSEDUR OPERASI STANDAR
Laboratorium/Bengkel* : ………………………………………………………………………
Prosedur operasi standar (standart
operating procedur) merupakan langkah-langkah untuk melakukan suatu
pekerjaan secara baik dan benar.
Keterangan
|
No. |
Nama Prosedur Operasi Standar |
Ada Tidak
Ket. : * Coret yang tidak perlu
Mengetahui/Menyetujui:
................., ......................... 20…
Kepala Sekolah,
WKS Bidang……../Ka Prog.*.............
Ka Lab/Ka Bengkel*,
....................................
....................................
|
(................................................... |
) |
(
................................................ |
) |
( |
.................................................
) |
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NIP |
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NIP |
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NIP ................................... |
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106
Lampiran 73 Contoh Lembar Kerja Perawatan Alat
dan Mesin
KOP SEKOLAH
LEMBAR KERJA PERAWATAN ALAT DAN MESIN
Laboratorium/Bengkel*:
…………………………………………………….
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Kondisi |
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No. |
Nama Peralatan / Mesin |
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Baik |
Rusak: |
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Ringan/ Sedang/
Berat |
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.........................................
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Ket.: * Coret yang tidak perlu |
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Mengetahui/Menyetujui: |
|
WKS Bidang……../Ka Prog.*............. |
.................,
......................... 20… |
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Kepala Sekolah, |
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Ka Lab/Ka Bengkel*, |
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(.......................................... |
) |
( |
) |
( |
............................................
) |
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NIP ................................... |
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NIP |
NIP .................................... |
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107
Lampiran 74 Contoh Formulir Kegiatan Perawatan Alat dan
Mesin
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KOP
SURAT |
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KEGIATAN
PERAWATAN ALAT / MESIN |
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Laboratorium/Bengkel* :………………………………………………………………………….. |
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No. |
Nama Peralatan / Mesin |
Tanda Kerusakan |
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Panas |
Short |
Terbakar |
Kendor
Putus |
Lainnya |
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Ket.: * Coret yang tidak perlu |
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Mengetahui/Menyetujui: |
|
WKS Bidang……../Ka |
|
................., ........................... 20… |
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Kepala
Sekolah, |
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Prog.*............ |
|
Ka Lab/Ka Bengkel*, |
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(.............................................. |
) |
( |
................................... ) |
( |
.................................................
) |
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NIP ................................... |
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NIP |
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NIP
.................................... |
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.................................... |
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108
Lampiran 74 Contoh Kegiatan
Perawatan Alat dan Mesin
KOP SEKOLAH
KEGIATAN PERAWATAN ALAT / MESIN
Laboratorium/Bengkel*
: …………………………………………………………………………..
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Tanda Kerusakan |
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No. |
Nama Peralatan/
Mesin |
Software |
Hang |
Tak |
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Lambat |
Not |
Lainnya |
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Normal |
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Respon |
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Ket.: * Coret yang tidak perlu |
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................................. 20… |
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Mengetahui/Menyetujui: |
WKS Bidang…….. /Ka |
Ka Lab/Ka Bengkel*, |
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|
Kepala Sekolah, |
Prog.*............. |
|
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....................................
....................................
...................................
|
(............................................... |
) |
( .................................. |
) |
(
........................................... |
) |
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NIP |
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NIP |
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| NIP |
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109
Lampiran 75 Contoh Lembar Kerja Perbaikan Alat dan Mesin
KOP SEKOLAH
LEMBAR KERJA PERBAIKAN ALAT/ MESIN
Laboratorium/Bengkel* : ………………………………………………………………………
Nama Alat/ Mesin : …………………………………………………………………………
|
No. Inventaris |
: ………………………………………………………………………… |
||
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NO. |
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JENIS PERBAIKAN |
CATATAN PERBAIKAN |
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Ket.: * Coret yang tidak perlu
|
Mengetahui/Menyetujui: |
WKS Bidang……../Ka |
................................. 20… |
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Kepala
Sekolah, |
Prog.*............. |
Ka Lab/Ka Bengkel*, |
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....................................
....................................
...................................
|
(............................................... |
) |
( .................................. |
) |
( ........................................... |
) |
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NIP |
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NIP |
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110
Lampiran 76 Contoh Kartu Peminjaman Alat
KOP SEKOLAH
KARTU PEMINJAMAN ALAT
Laboratorium/Bengkel*
: ……………………………………………………………………………
|
No. |
Nama Peminjam |
Keperluan |
Peralatan yang |
Tgl. Pinjam |
Tgl Kembali |
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dipinjam |
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Ket.: * Coret yang tidak perlu |
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.................................
20… |
|
|
Mengetahui/Menyetujui: |
WKS Bidang…….. /Ka |
Ka Lab/Ka Bengkel*, |
|
|
Kepala Sekolah, |
Prog.*............. |
|
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...................................
....................................
....................................
|
(............................................... |
) |
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( ........................................... |
) |
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( .................................. |
) |
NIP |
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NIP |
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NIP |
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111
Lampiran 77 Contoh Bon Peminjaman Peralatan Laboratorium/Bengkel
KOP SEKOLAH
BON PEMINJAMAN
PERALATAN LABORATORIUM/BENGKEL *
Hari/Tanggal:
…………………………………………………………………………………….
Nama Pekerjaan Praktik:
…………………………………………………………………………………….
|
No. |
NIS |
Nama Siswa |
Tanda Tangan |
Keterangan |
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Ket.: * Coret yang tidak perlu |
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................................. 20… |
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Mengetahui/Menyetujui: |
WKS Bidang…….. /Ka |
Ka Lab/Ka Bengkel*, |
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Kepala Sekolah, |
Prog.*............. |
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...................................
....................................
....................................
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(............................................... |
) |
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(
........................................... |
) |
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( ....................................... |
) |
NIP |
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NIP |
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NIP |
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112
|
Lampiran 78 Contoh Daftar Hadir Praktik
Laboratorium/Bengkel |
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KOP SEKOLAH |
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||
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DAFTAR HADIR PRAKTIK LABORATORIUM/BENGKEL* |
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Nama
Lab/Bengkel*: ………………………………………………………………………………. |
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|||||||
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Hari/Tanggal:
……………………………………………………………………………….. |
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|||||
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Nama Pekerjaan
Praktik: ……………………….……………………………………………………… |
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|||||||
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Semester:
……………………………………………………………………………….. |
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Guru/Instruktur:
……………………………………………………………………………….. |
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No. |
NIS |
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Nama Siswa |
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Tanda Tangan |
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Keterangan |
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Ket.: * Coret yang tidak perlu |
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.................................
20… |
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|
Mengetahui/Menyetujui: |
WKS Bidang…….. /Ka |
Ka Lab/Ka Bengkel*, |
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Kepala Sekolah, |
Prog.*............. |
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...................................
....................................
....................................
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(............................................... |
) |
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(
........................................... |
) |
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( ....................................... |
) |
NIP |
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NIP |
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NIP |
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113
Lampiran 79 Contoh Daftar Pengeluaran Bahan Praktik
Laboratorium/Bengkel
KOP SEKOLAH
DAFTAR PENGELURAN
BAHAN PRAKTIK LABORATORIUM/BENGKEL*
Laboratorium/Bengkel*:
………………………………………………………………………….
Nama Pekerjaan:
………………………………..………………………………………..
Kelas/ Semester:
………………………………………………………………..………..
|
No. |
Nama Bahan/ |
Jumlah |
Nama Siswa |
Tanda Tangan |
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Ukuran/
Spesifikasi |
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Ket.: * Coret yang tidak perlu
|
Mengetahui/Menyetujui: |
WKS Bidang……../Ka |
................................. 20… |
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|
Kepala
Sekolah, |
Prog.*............. |
Ka Lab/Ka Bengkel*, |
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....................................
....................................
...................................
|
(............................................... |
) |
(
....................................... |
) |
(
........................................... |
) |
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NIP |
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NIP |
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114
Lampiran 80 Contoh Daftar LKS (Job-sheet)
KOP SEKOLAH
DAFTAR LKS (JOB-SHEET)
Laboratorium/Bengkel*
: ……………………………………………………………………………….
|
No. |
Nama LKS/ Job Sheet |
Kelas/ Semester |
Kompetensi |
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Ket.: * Coret yang tidak perlu |
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.................................
20… |
|
|
Mengetahui/Menyetujui: |
WKS Bidang…….. /Ka |
Ka Lab/Ka Bengkel*, |
|
|
Kepala Sekolah, |
Prog.*............. |
|
|
|
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|
|
....................................
....................................
...................................
|
(............................................... |
) |
(
....................................... |
) |
(
........................................... |
) |
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NIP |
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NIP |
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| NIP |
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115
Lampiran 81 Contoh Daftar Penyerahan Hasil Praktik Laboratorium/Bengkel
KOP SEKOLAH
|
|
|
DAFTAR PENYERAHAN HASIL PRAKTIK
LABORATORIUM/BENGKEL* |
|
||
|
Nama
Lab/Bengkel* : …………………………………………………………………………………….. |
|
||||
|
Semester/ Kelas |
: …………………………………………………………………………………….. |
|
|||
|
Guru/Instruktur |
: ……………………………………………………………………………………. |
|
|||
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No. |
NIS |
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Nama Siswa |
Judul (Pekerjaan Praktik) |
Tanda Tangan |
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Ket.: * Coret yang tidak perlu |
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20… |
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Mengetahui/Menyetujui: |
WKS Bidang…….. /Ka |
Ka Lab/Ka Bengkel*, |
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Kepala Sekolah, |
Prog.*............. |
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NIP |
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116
Lampiran 81 Contoh Daftar Nilai Praktik
Laboratorium/Bengkel
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KOP SEKOLAH |
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DAFTAR NILAI PRAKTIK LABORATORIUM/BENGKEL* |
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Nama
Lab/Bengkel* : …………………………………………………………………………….. |
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Semester/ Kelas |
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Guru/
Instruktur |
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Nilai Praktik Pekerjaan Ke: |
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No. |
NIS |
Nama Siswa |
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Pekerjaan |
Pekerjaan |
Pekerjaan |
Pekerjaan |
…… |
Rerata |
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1 |
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4 |
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Ket.: *Coret yang
tidak perlu |
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.................................
20… |
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Mengetahui/Menyetujui: |
WKS Bidang…….. /Ka |
Ka Lab/Ka Bengkel*, |
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Kepala Sekolah, |
Prog.*............. |
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(...............................................) ( .......................................
) ( ........................................... )
NIP .................................... NIP .................................... NIP ...................................
117
