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| DINAS PENDIDIKAN |
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| PROVINSI SUMATERA UTARA |
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| FORMULIR ISIAN KEPALA SEKOLAH TAHUN 2022 |
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| A. TEMPAT BEKERJA |
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| 1 |
Unit Kerja |
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SMA NEGERI 1 SIBOLGA |
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| 2 |
Instansi Tempat Bekerja |
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a. Alamat |
: |
JL. Sutoyo Siswomiharjo No.1 Sibolga |
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b. Desa / Kelurahan *) |
: |
- |
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c. Kecamatan |
: |
Sibolga Kota |
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d. Kabupaten/Kota *) |
: |
Sibolga |
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| 3 |
Instansi Induk |
: |
DINAS PENDIDIKAN PROVINSI SUMATERA UTARA |
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| B. IDENTITAS PEGAWAI |
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| 1 |
N I P |
: |
19690424 199503 1 002 |
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| 2 |
NUKS |
: |
00-000-000-0000-0-0-0-000000 |
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| 3 |
NUPTK |
: |
6754747649200052 |
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| 4 |
Nama Lengkap |
: |
MUHAMMAD ALI |
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| 5 |
Gelar Kesarjanaan |
: |
- |
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(Di depan nama) |
S.Pd, MM |
(Di belakang nama) |
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| 6 |
Tempat / Tgl. Lahir |
: |
KLEGO |
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Tgl. |
2 |
4 |
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Bln |
0 |
4 |
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Thn |
1 |
9 |
6 |
9 |
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| 7 |
Jenis Kelamin |
: |
L |
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Laki-laki/Perempuan (Isikan L atau P) |
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| 8 |
Suku |
: |
JAWA |
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| 9 |
Agama |
: |
1 |
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1 |
Islam |
2 |
Katolik |
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3 |
Protestan |
4 |
Budha |
5 |
Hindu |
6 Konghucu |
(pilih angka 1 s.d. 6) |
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| 10 |
Status Perkawinan |
: |
2 |
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1 |
Belum kawin |
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2 |
Kawin |
3 |
Janda |
4 |
Duda |
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(pilih angka 1 s.d. 4) |
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| 11 |
Alamat Tempat Tinggal |
: |
JL. KH. DEWANTARA BLOK C.72 PANDAN |
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Telepon/Hp |
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: |
081361704100 |
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Kode Pos |
: |
22611 |
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Desa/Kelurahan |
: |
PANDAN |
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Kecamatan |
: |
PANDAN |
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Kab/Kota *) |
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: |
TAPANULI TENGAH |
|
Provinsi |
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: |
SUMATERA UTARA |
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| 12 |
Alamat email pribadi |
: |
[email protected] |
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| C. JABATAN SAAT INI |
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| 1 |
Nama Jabatan |
: |
KEPALA SEKOLAH |
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| 2 |
Surat Keputusan Jabatan |
: |
Nomor |
873/BKD/2014 |
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Tgl. |
1 |
9 |
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Bln |
0 |
9 |
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Thn |
2 |
0 |
1 |
4 |
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| 4 |
Pejabat yang Menetapkan |
: |
BUPATI TAPANULI TENGAH |
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| 5 |
TMT Jabatan |
: |
Tgl. |
2 |
2 |
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Bln |
0 |
9 |
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Thn |
2 |
0 |
1 |
4 |
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| 6 |
SK Pelantikan |
: |
Nomor |
240/SPP/2014 |
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Tgl. |
2 |
2 |
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Bln |
0 |
9 |
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Thn |
2 |
0 |
1 |
4 |
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| D. RIWAYAT KEPANGKATAN |
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| PANGKAT/GOL. RUANG |
TMT PANGKAT |
SURAT KEPUTUSAN |
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| (dd - mm - yyyy) |
PEJABAT YANG MENETAPKAN |
NOMOR |
TANGGAL (dd - mm - yyyy) |
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| PENGATUR MUDA, II/a |
0 |
0 |
- |
0 |
0 |
- |
0 |
0 |
0 |
0 |
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| PENGATUR MUDA Tk. I, II/b |
0 |
0 |
- |
0 |
0 |
- |
0 |
0 |
0 |
0 |
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| PENGATUR, II/c |
0 |
0 |
- |
0 |
0 |
- |
0 |
0 |
0 |
0 |
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| PENGATUR Tk. I, II/d |
0 |
0 |
- |
0 |
0 |
- |
0 |
0 |
0 |
0 |
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| PENATA MUDA, III/a |
0 |
1 |
- |
0 |
3 |
- |
1 |
9 |
9 |
5 |
MENDIKBUD |
11059/A2/C/1995 |
0 |
1 |
- |
0 |
3 |
- |
1 |
9 |
9 |
5 |
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| PENATA MUDA Tk. I, III/b |
0 |
1 |
- |
1 |
0 |
- |
1 |
9 |
9 |
8 |
KEPALA BKN |
VI.13.02/00092/KEP/X/1998/T |
2 |
8 |
- |
1 |
0 |
- |
1 |
9 |
9 |
8 |
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| PENATA, III/c |
0 |
1 |
- |
0 |
4 |
- |
2 |
0 |
0 |
1 |
KEPALA BKN |
VI.13.02/035/KEP/IV/2001 |
0 |
8 |
- |
0 |
6 |
- |
2 |
0 |
0 |
1 |
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| PENATA Tk. I, III/d |
0 |
1 |
- |
0 |
4 |
- |
2 |
0 |
0 |
4 |
BUPATI TAPTENG |
303/KEPEG/2004 |
2 |
6 |
- |
0 |
4 |
- |
2 |
0 |
0 |
4 |
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|
|
| PEMBINA, IV/a |
0 |
1 |
- |
0 |
4 |
- |
2 |
0 |
0 |
7 |
GUBERNUR SUMUT |
823.4/772/2007 |
1 |
8 |
- |
0 |
4 |
- |
2 |
0 |
0 |
7 |
|
|
|
|
|
| PEMBINA Tk. I, IV/b |
0 |
1 |
- |
0 |
4 |
- |
2 |
0 |
1 |
2 |
GUBERNUR SUMUT |
823.4/2033/2012 |
0 |
7 |
- |
0 |
5 |
- |
2 |
0 |
1 |
2 |
|
|
|
|
|
| PEMBINA UTAMA MUDA, IV/c |
0 |
1 |
- |
0 |
4 |
- |
2 |
0 |
1 |
5 |
PRESIDEN RI |
00063/KEP/AA/21204/15 |
2 |
9 |
- |
0 |
1 |
- |
2 |
0 |
1 |
5 |
|
|
|
|
|
| PEMBINA UTAMA MADYA, IV/d |
0 |
0 |
- |
0 |
0 |
- |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
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- |
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- |
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| |
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Halaman 2 dari 3 |
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|
| E. RIWAYAT JABATAN |
|
|
|
|
|
| UNIT KERJA |
JENIS JABATAN (Struktural / Fungsional/Pj. Negara/Non Struktural) |
NAMA JABATAN |
ESELON |
TMT |
|
SURAT KEPUTUSAN |
|
|
|
|
|
| |
PEJABAT YG MENETAPKAN |
NOMOR |
TANGGAL |
|
|
|
|
|
| |
|
|
|
|
|
| SMAN 1 MATAULI PANDAN |
FUNGSIONAL |
GURU |
- |
01-03-1995 |
MENDIKBUD |
11059/A2/C/1995 |
27-02-1995 |
|
|
|
|
|
| SMPN 2 PANDAN NAULI |
FUNGSIONAL |
KEPALA SEKOLAH |
- |
18-11-2008 |
BUPATI TAPTENG |
821.29/877/BKD/2008 |
18-11-2008 |
|
|
|
|
|
| SMAN 1 TUKKA |
FUNGSIONAL |
KEPALA SEKOLAH |
- |
|
27-01-2011 |
|
BUPATI TAPTENG |
65/BKD/2011 |
|
27-01-2011 |
|
|
|
|
|
|
|
| DINAS PENDIDIKAN |
FUNGSIONAL |
PENGAWAS SEKOLAH |
- |
|
14-12-2011 |
|
BUPATI TAPTENG |
855/BKD/2011 |
|
14-12-2014 |
|
|
|
|
|
|
|
| SMAN 1 PINANGSORI |
FUNGSIONAL |
KEPALA SEKOLAH |
- |
|
19-09-2014 |
|
BUPATI TAPTENG |
873/BKD/2014 |
|
19-09-2014 |
|
|
|
|
|
|
|
| SMAN 1 SIBOLGA |
FUNGSIONAL |
KEPALA SEKOLAH |
- |
|
|
|
|
|
|
|
|
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| |
|
|
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|
|
| F. TANDA JASA / PENGHARGAAN / KEHORMATAN |
|
|
|
|
|
| NAMA TANDA JASA / PENGHARGAAN |
SURAT KEPUTUSAN |
TAHUN |
ASAL PEROLEHAN |
|
|
|
|
|
| NOMOR |
TGL - BLN |
|
|
|
|
|
| SATYA LENCANA KARYA SATYA XX TAHUN |
124/TK/2015 |
25 |
|
- |
11 |
|
2015 |
PRESIDEN RI |
|
|
|
|
|
| GURU BERPRESTASI |
002/846/2008 |
2 |
|
- |
5 |
|
2008 |
BUPATI TAPTENG |
|
|
|
|
|
| KEPALA SMP BERPRESTASI |
002/1854/2010 |
17 |
|
- |
8 |
|
2010 |
BUPATI TAPTENG |
|
|
|
|
|
| KEPALA SMP BERPRESTASI |
|
14 |
|
- |
7 |
|
2010 |
GUBERNUR SUMUT |
|
|
|
|
|
| PENGAWAS SEKOLAH BERPRESTASI |
002/1124/2014 |
23 |
|
- |
5 |
|
2014 |
BUPATI TAPTENG |
|
|
|
|
|
| PENGAWAS SEKOLAH BERPRESTASI |
188.44/521/KPTS/2014 |
14 |
|
- |
7 |
|
2014 |
GUBERNUR SUMUT |
|
|
|
|
|
| PENGAWAS SEKOLAH BERPRESTASI |
5239/D/KP/2014 |
15 |
|
- |
8 |
|
2014 |
KEMDIBUD |
|
|
|
|
|
| KEPALA SMA BERPRESTASI |
002/1603.1/2016 |
9 |
|
- |
6 |
|
2016 |
BUPATI TAPTENG |
|
|
|
|
|
| G. PENGUASAAN BAHASA |
|
|
|
|
|
| NAMA BAHASA |
KEMAMPUAN BICARA (Aktif atau Tidak Aktif) |
|
|
|
|
|
| BAHASA INDONESIA |
AKTIF |
|
|
|
|
|
| BAHASA INGGRIS |
AKTIF |
|
|
|
|
|
| BAHASA DAERAH JAWA |
|
|
|
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|
|
AKTIF |
|
|
|
|
|
| BAHASA ASING LAINNYA …………… |
|
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|
|
| H. RIWAYAT PENDIDIKAN |
|
|
|
|
|
| TINGKAT PENDIDIKAN |
JURUSAN |
NAMA SEKOLAH/PTN/PTS |
TEMPAT |
TAHUN LULUS |
|
|
|
|
|
| SD |
|
|
|
|
|
|
- |
|
|
|
|
|
MI ISLAMIYAH KEDOKAN |
KLEGO, BOYOLALI |
1982 |
|
|
|
|
|
| SMP |
|
|
|
|
|
- |
|
|
|
|
|
SMPN KARANGGEDE |
KARANGGEDE, BOYOLALI |
1985 |
|
|
|
|
|
| SMA |
ILMU-ILMU FISIK |
SMAN TENGARAN |
TENGARAN, SEMARANG |
1988 |
|
|
|
|
|
| D-1/D-2/D-3/D-4 |
PENDIDIKAN FISIKA |
IKIP YOGYAKARTA / UNY |
YOGYAKARTA |
1990 |
|
|
|
|
|
| STRATA-1 |
PENDIDIKAN FISIKA |
IKIP YOGYAKARTA / UNY |
YOGYAKARTA |
1994 |
|
|
|
|
|
| STRATA-2 |
MAGISTER MANAJEMEN |
UNIVERSITAS TERBUKA |
MEDAN |
2012 |
|
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| |
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|
|
| I. RIWAYAT DIKLAT STRUKTURAL |
|
|
|
|
|
| NAMA DIKLAT |
TEMPAT DIKLAT |
PENYELENGGARA |
ANG. |
LAMA PENDIDIKAN |
STTPP |
PERINGKAT |
|
|
|
|
|
| TGL. MULAI |
TGL. SELESAI |
JAM |
NOMOR |
TGL. |
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| |
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|
Halaman 3 dari 3 |
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|
| J. RIWAYAT DIKLAT FUNGSIONAL |
|
|
|
|
|
| NAMA DIKLAT |
TEMPAT DIKLAT |
PENYELENGGARA |
ANG. |
LAMA PENDIDIKAN |
STTPP |
PERINGKAT |
|
|
|
|
|
| TGL. MULAI |
TGL. SELESAI |
JAM |
NOMOR |
TGL. |
|
|
|
|
|
| PENINGKATAN KOMPETENSI KEPALA SMA |
BERASTAGI |
DISDIK PROV.SUMUT |
|
17 -11-2009 |
20-11-2009 |
42 |
424/1705/PTK.4/22/2009 |
20-11-2009 |
|
|
|
|
|
|
| TIM PENGEMBANG KURIKULUM |
TAPTENG |
PUSKUR DEPDIKNAS |
|
|
16-11-2008 |
20-11-2008 |
40 |
2499.18/G3/LL/2008 |
22-11-2008 |
|
|
|
|
|
|
|
|
|
| IMPLEMENTASI K-13 |
JAKARTA |
KEMDIKBUD |
|
7/7/2013 |
14-7-2013 |
70 |
1636/J.3.1/LL/2013 |
15-7-2013 |
|
|
|
|
|
|
| CALON PELATIH KASEK |
JAKARTA |
KEMDIKBUD |
|
5/3/2009 |
14-3-2009 |
99 |
15706/F/KP/2009 |
11-12-2009 |
|
|
|
|
|
|
| PELATIHAN INSTRUKTUR NASIONAL |
MEDAN |
KEMDIKBUD |
|
4/28/2014 |
5/1/2014 |
42 |
1218/J16/DL/2014 |
9/19/2014 |
|
|
|
|
|
|
| DIKLAT PENULISAN KARYA TULIS |
TAPTENG |
DINAS PENDIDIKAN |
|
12/19/2015 |
12/23/2015 |
32 |
421.3/1320/DIKNAS/2015 |
12/23/2015 |
|
|
|
|
|
|
| PELATIHAN KURIKULUM |
TAPTENG |
DINAS PENDIDIKAN |
|
12/20/2016 |
12/23/2015 |
32 |
800/1028/DISDIK/2016 |
12/23/2016 |
|
|
|
|
|
|
| BIMTEK DAN SELEKSI TIM PENILAI JAB. FUNG. GURU |
JAKARTA |
KEMDIKBUD |
|
5/06/2017 |
9/06/2017 |
50 |
|
|
|
|
|
|
|
|
| DIKLAT CAKEP |
SIBOLGA |
KLP2KS KEMDIKBUD |
|
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| Bimtek dan selek |
|
|
|
|
|
| NAMA DIKLAT |
TEMPAT DIKLAT |
PENYELENGGARA |
ANG. |
LAMA PENDIDIKAN |
STTPP |
|
|
|
|
|
| TGL. MULAI |
TGL. SELESAI |
JAM |
NOMOR |
TGL |
|
|
|
|
|
| ASESOR AKREDITASI SEKOLAH |
MEDAN |
BAP SM PROVSU |
|
19-6-2012 |
23-6-2012 |
|
247/BAPSM/SUMUT/LL/VI/2012 |
23-6-2012 |
|
|
|
|
|
| PELATIH Dan PENILAI PKG |
PEMATANG SIANTAR |
LPMP |
|
11/12/2011 |
15-12-2011 |
43 |
03618/J19/KP/2011 |
15-12-2011 |
|
|
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| |
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|
| K. RIWAYAT SEMINAR / LOKAKARYA / SIMPOSIUM |
|
|
|
|
|
| NAMA SEMINAR / LOKAKARYA / SIMPOSIUM |
TEMPAT SEMINAR / LOKAKARYA / SIMPOSIUM |
PENYELENGGARA |
ANG. |
LAMA SEMINAR / LOKAKARYA / SIMPOSIUM |
PIAGAM/SERTIFIKAT |
|
|
|
|
|
| TGL. MULAI |
TGL. SELESAI |
JAM |
NOMOR |
TGL |
|
|
|
|
|
| WORKSHOP KTSP |
MEDAN |
DIDIK PROV. SUMUT |
I |
16-8-2006 |
20-8-2006 |
45 |
421.3/3014. DISDKSU/2006 |
20-8-2006 |
|
|
|
|
|
| |
WORKSHOP SEKOLAH SSN |
TAPTENG |
DEPDIKNAS |
|
3/10/2010 |
8/10/2010 |
50 |
2287/C3/KP/2008 |
8/10/2010 |
|
|
|
|
|
| REVIUW MODUL PKB |
JAKARTA |
KEMDIKBUD |
|
19-3-2012 |
22-3-2012 |
|
827/J3.2/LL/2012 |
22-3-2012 |
|
|
|
|
|
| SEMINAR NASIONAL |
JAKARTA |
APSI |
|
13-7-2013 |
- |
|
017/SM/VII/PP. APSI/2013 |
13-7-2013 |
|
|
|
|
|
| WORKSHOP TPK |
MEDAN |
DISDIK PROVSU |
|
9/12/2013 |
13-12-2013 |
46 |
421.2/260/DIKDAS/XII/2013 |
13-12-2013 |
|
|
|
|
|
| DESIMINASI BEST PRACTICE |
JAKARTA |
KEMDIKBUD |
|
25-10-2013 |
27-10-2014 |
|
9230/D5.1/KP/2014 |
27-10-2014 |
|
|
|
|
|
| WORSHOP PENYUSUNAN KURIKULUM |
TAPTENG |
DISDIK TAPTENG |
|
6/7/2016 |
6/10/2016 |
32 |
800/1027/DISDIK/2016 |
6/10/2016 |
|
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| |
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| L. RIWAYAT KURSUS DI DALAM / LUAR NEGERI |
|
|
|
|
|
| NAMA DIKLAT |
TEMPAT DIKLAT |
PENYELENGGARA |
ANG. |
LAMA PENDIDIKAN |
STTPP |
|
|
|
|
|
| TGL. MULAI |
TGL. SELESAI |
JAM |
NOMOR |
TGL |
|
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| |
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| Dengan ini saya menyatakan bahwa data yang telah diisi atau tercatat dalam formulir ini adalah benar, jelas dan lengkap menurut keadaan yang sebenarnya. |
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Sibolga, |
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Diisi oleh: |
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-MUHAMMAD ALI, S.Pd.,M.M |