1.Nama Sekolah : SK Haji Kassim Jasin, Selengkoh, Yan, Kedah.
2.Unit Beruniform/ Kelab dan Persatuan/ Sukab & Permainan : ____________________________________________________________ 3. Nama Guru :_____________________________________________ 4. Jumlah ahli : L = ______ ; P = _________ Keseluruhan : __________ 5. Tarikh & Masa : _____________________________________________ 6. Tajuk aktiviti : _____________________________________________ 7. Objektif aktiviti : _____________________________________________ _____________________________________________ _____________________________________________ 8. Sisipan aktiviti PIKeBM : __________________________________________________________ 9. Laporan aktiviti mingguan : __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ 10. Refleksi dan impak : __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ 11. Ulasan Guru : __________________________________________________________ __________________________________________________________