Format Identifikasi

FORMAT IDENTIFIKASI PESERTA DIDIK BERKEBUTUHAN KHUSUS

PETUNJUK PENGISIAN

Gunakan Alat Indetifikasi Anak Berkebutuhan Khusus untuk anak yang dicurigai memiliki masalah

Catatan :

1. Usahakan untuk melihat gejala-gejala yang tampak pada setiap anak dengan seksama, mungkin memerlukan waktu beberapa hari, jangan tergesa-gesa;
2. Agar gejala mudah dikenali, pada beberapa pernyataan, anak dapat terlebih dahulu diberi tugas tertentu baru kemudian diamati pada saat mereka mereka mengerjakan tugas tersebut;
3. Terdapat kemungkinan bahwa seorang anak mengalami lebih dari satu jenis kelainan (kelainan ganda)

Isian Form 1

INFORMASI PERKEMBANGAN PESERTA DIDIK

Petunjuk :

Isilah daftar berikut pada kolom yang tersedia sesuai dengan kondisi anak yang sebenarnya. Jika ada yang kurang jelas, konsultasikan kepada orang tua / guru kelas tempat anak tersebut bersekolah.

A. Identitas Peserta Didik :

1. Nama                                                      : .................................................................................................
2. Tempat dan tanggal lahir/umur         : .................................................................................................
3. Jenis kelamin                                        : .................................................................................................
4. Agama                                                    : .................................................................................................
5. Status anak                                            : .................................................................................................
6. Anak ke dari jumlah saudara              : .................................................................................................
7. Nama sekolah                                       : .................................................................................................
8. Kelas                                                       : .................................................................................................
9. Alamat                                                    : .................................................................................................

  Desa/Kelurahan ...............................................................

  Kecamatan  ......................................................................

  Kabupaten .......................................................................

B.    Riwayat Kelahiran :

1. Perkembangan masa kehamilan        : .................................................................................................
2. Penyakit pada masa kehamilan          : ..................................................................................................
3. Usia kandungan                                    : ..................................................................................................
4. Riwayat proses kelahiran                    : ..................................................................................................
5. Tempat kelahiran                                 : .................................................................................................
6. Penolong proses kelahiran                : ..................................................................................................
7. Gangguan pada saat bayi lahir           : .................................................................................................
8. Berat bayi                                              : .................................................................................................
9. Panjang bayi                                          : .................................................................................................
10. Tanda-tanda kelainan pada bayi        : .................................................................................................

C. Perkebangan Masa Balita :

1. Menetek ibunya hingga umur           : .................................................................................................
2. Minum susu kaleng hingga umur      : .................................................................................................
3. Imunisasi (lengkap/tidak)                    : ...............................................................................................
4. Pemeriksaan/penimbangan rutin/tdk : ...........................................................................................
5. Kualitas makanan                                 : ...............................................................................................
6. Kuantitas makan                                   : ...............................................................................................
7. Kesulitan makan (ya/tidak)                 : ...............................................................................................

D. Perkembangan Fisik :

1. Dapat berdiri pada umur                    : ...............................................................................................
2. Dapat berjalan pada umur : ...............................................................................................
3. Naik sepeda roda tiga pada umur     : ...............................................................................................
4. Naik sepeda roda dua pada umur     : ...............................................................................................
5. Bicara dengan kalimat lengkap          : ...............................................................................................
6. Kesulitan gerakan yang dialami         : ..............................................................................................
7. Status Gizi Balita (baik/kurang)          : ..............................................................................................
8. Riwayat kesehatan (baik/kurang)      : ..............................................................................................
9. Penggunaan tangan dominan            : …………………………………………....................................................

E. Perkembangan Bahasa :

1. Meraba/berceloteh pada umur        : ................................................. .............................................
2. Mengucapkan satu suku kata yang bermakna kalimat (mis. Pa berarti bapak) pada umur : ....................................
3. Berbicara dengan satu kata bermakna pada umur : ..........................
4. Berbicara dengan kalimat lengkap sederhana pada umur : ……………..............................................

F. Perkembangan Sosial :

5. Hubungan dengan saudara                : ................................................................................................
6. Hubungan dengan teman                   : ................................................................................................
7. Hubungan dengan orangtua              : ................................................................................................
8. Hobi                                                        : ................................................................................................
9. Minat khusus                                        : ................................................................................................

F. Perkembangan Pendidikan :

1. Masuk TK umur                                    : ................................................................................................
2. Lama Pendidikan di TK                        : ................................................................................................
3. Kesulitan selama di TK                         : ................................................................................................
4. Masuk SD/MI umur                              : ................................................................................................
5. Kesulitan selama di SD/MI                  : ..................................................................................................
6. Masuk SMP/MTs umur                        : ..................................................................................................
7. Kesulitan selama di SMP/Mts             : ..................................................................................................
8. Pernak tidak naik kelas                       : ..................................................................................................
9. Pelayanan khusus yang pernah diterima anak: ..................................................................................
10. Prestasi belajar yang dicapai              : ..................................................................................................
11. Mata Pelajaran yang dirasa paling sulit : ...........................................................................................
12. Mata Pelajaran yang dirasa paling disenangi : ..................................................................................
13. Keterangan lain yang dianggap perlu : ...............................................................................................

Diisi Tanggal,…………………................

Yang mengamati,

                                                                                        .............................................................

                                                                                                                NIM :

Isian Form 2

DATA ORANG TUA/WALI PESERTA DIDIK

1. Nama  Anak                                                      : ..........................................................................................

2. Nama Sekolah                                                   : ..........................................................................................

3. Kelas                                                                  :...........................................................................................

A.  Identitas Orang tua/wali

Ayah :

1. Nama Ayah                                            : .........................................................................................
2. Umur                                                      : .........................................................................................
3. Agama                                                    : .........................................................................................
4. Status ayah                                            : .........................................................................................
5. Pendidikan Tertinggi                           : ........................................................................................
6. Pekerjaan Pokok                                  : ........................................................................................
7. Alamat tinggal                                       : ........................................................................................

  .................................................................................

  ..................................................................................

Ibu :

1. Nama Ibu                                               : .........................................................................................
2. Umur                                                      : .........................................................................................
3. Agama                                                    : .........................................................................................
4. Status Ibu                                               : .........................................................................................
5. Pendidikan Tertinggi                           : .........................................................................................
6. Pekerjaan Pokok                                  : .........................................................................................
7. Alamat tinggal                                       : .........................................................................................

   .................................................................................

   ..................................................................................

Wali :

1. Nama                                                      : ……………………………………………………………………....................
2. Umur                                                      : ……………………………………………………………………....................
3. Agama                                                    : ……………………………………………………………………...................
4. Status perkawinan                               : ……………………………………………………………………...................
5. Pend. Tertinggi                                     : ……………………………………………………………………...................
6. Pekerjaan                                              : ……………………………………………………………………...................
7. Alamat                                                   : ……………………………………………………………………...................

                                                                                  ..................................................................................

8. Hubungan Keluarga                             : ……………………………………………………………………...................

B. Hubungan Orang tua – anak

1. Kedua orang tua satu rumah                              : ..............................................................................
2. Anak satu rumah dengan kedua orang tua      : ..............................................................................
3. Anak diasuh oleh salah satu orang tua             : ..............................................................................
4. Anak diasuh wali/saudara                                   : ...............................................................................

C. Sosial Ekonomi Orangtua

1.       Jabatan formal ayah di kantor (jika ada)                                 : ............................................................

2. Jabatan formal ibu di kantor (jika ada)                             : .................................................................
3. Jabatan informal ayah di luar kantor (jika ada)               : .................................................................
4. Jabatan informal ibu di luar kantor (jika ada) : .................................................................
5. Rata-rata penghasilan (kedua orangtua) perbulan         : .................................................................

D.Tanggungan dan Tanggapan Keluarga

1. Jumlah anak                                                          : .................................................................................
2. Ysb. Anak yang ke                                                : .................................................................................
3. Persepsi orang tua terhadap anak ysb.            : .................................................................................
4. Kesulitan orang tua terhadap anak ysb.           : .................................................................................
5. Harapan orang tua terhadap pendidikan anak ysb. : .......................................................................
6. Bantuan yang diharapkan orang tua untuk anak ysb.: .....................................................................

Diisi tanggal :……….............................……….

Yang mengamati,

.....................................................................

                                                                                                                NIM :