YAYASAN GRIYA ANAK

SMP CENDEKIA HARAPAN

Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

FORM 1. TITLE
SUBMITTING TITLE OF
PROBLEM-BASED LEARNING (PBL)

Dear ……………………,
PBL Controller

Hereby, I:

Student Name: ________________________________

Student No.: __________________________________

Grade: _____________

Propose:
Title of Problem-Based Learning (PBL): _____________________________

This statement is made truthfully and is to be used accordingly.

___________________ _____________________

Signature of Supervisor Signature of the Student

Date: _________________ Date: _________________

 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

Problem Identification and Scope of the Study

Question to be asked Answer

What?

Who?

When?

Where?

Why?

How?

Scope of the Study

 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

Purpose

Benefit

Method

Jimbaran, …………………
Supervisor, Student,

(………………………………) (…………………………..)
 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

FORM 2. BACKGROUND

Name: Grade:

Number Symptom Problem Root(s) of Problem

Jimbaran, …………………
Supervisor, Student,

(………………………………) (…………………………..)
 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

Form 3. INTEGRATION TABLE

Name: Grade:

No. Subject Topic Summary Connection to Problem

Jimbaran, …………………
Supervisor, Student,

(………………………………) (…………………………..)
 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

Form 4. METHOD

Name: Grade:

No. Symptom Problem Root(s) of Problem Solution Action Plan

Jimbaran, …………………
Supervisor, Student,

(………………………………) ( )
 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

Form WR
Student’s Name: Grade:
WEEKLY REPORT/PROGRESS REPORT
A. Daily Activities in This Week

B. Achievement(s) During This Week

C. Difficulties That I Have Faced and How I Overcame Them

D. Lesson(s) Learned

E. Activities Planned for Next Week

 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

Report Date :

Signature :
Student, Supervisor, Controller,

(………………………..) (……………………….) (………………………)

 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

Form 6. EXAMINATION PROPOSAL

PBL SARASEHAN
PROPOSAL

Dear ……………………,
PBL Controller

Hereby, I:

Student Name: ________________________________

Student No.: __________________________________

Grade: _____________

Propose:
PBL Sarasehan with the Title of: _____________________________

This statement is made truthfully and is to be used accordingly.

___________________ _____________________

Signature of Supervisor Signature of the Student

 YAYASAN GRIYA ANAK
SMP CENDEKIA HARAPAN
Jln. Seruni i2 No. 8 Perumahan Puri Gading Jimbaran-Bali, Telp. 0361 702121
email: info@balichildrenshouse.com, web: www.balichildrenshouse.com

Date: _________________ Date: _________________

Form 7. OPEN EXAMINATION REGISTRATION

Student’s Name: Grade:

Note: Students who will present should submit Form 1, Form 2, Form 3, Form 4, Form 6, weekly
report, final PBL paper, and guidance card beforehand.

Tick the
boxes for
Requirements completed
requirements
(√)
Form 1, Form 2, Form 3, Form 4, Form 6

Weekly Report/Progress Report (Form WR)

Final PBL paper

Guidance Card

Jimbaran, …………………
Controller, Student,

(………………………………) (…………………………..