LOG BOOK

DEPARTEMENT OF EDUCATIONUDAYANA UNIVERSITYFACULTY OF MEDICINE

ELECTIVE STUDY PROGRAM

Head of Program : Dr. dr. I W. P. Sutirta Yasa, M.SiSecretary : dr. P. A. Asri Damayanti, M. Kes

Student’s Name : P.P.G. Krisna Bayu P.R.Supervisor : dr. Nyoman Ratep, Sp. KJ (K)

Elective Study Program for 1 week

NO DAY/DATE ACTIVITYSUPERVISOR’S

SIGNATURE

Denpasar, Verified by

Head of Program Secretary

Dr. dr. I W. P. Sutirta Yasa, M.Si dr. P. A. Asri Damayanti, M. Kes NIP. NIP.

Elective Study Final Assessment by Supervisor

Elective Study Process Final AssessmentBy Supervisor

Title : Prevalensi dan Korelasi Insomnia terhadap Kemampuan Kognitif pada

Remaja Usia 15-18 Tahun di Panti Asuhan Widhya Asih 1 Denpasar

Exam Date/Time :

Student’s Name : P.P.G. Krisna Bayu P.R.

Student ID Number : 1002005071

Supervisor : dr. Nyoman Ratep, Sp. KJ (K)

Assessment :

The processes are approximately as follows

NO ITEM ASSESSMENT RANGE SCORE SCORE

1 Log book 0 - 30

2

Observation:

- Communication

- Attendance

- Gesture and posture

0 - 40

3 Ability to find the literature 0 - 30

TOTAL 0 - 100

Final result (Score):Criteria : A B C D E (please circling the criteria)Result Range :

A : 80 - 100B : 70 - 79C : 55 - 69D : 45 - 54E : 0 - 44

Supervisor,

dr. Nyoman Ratep, Sp. KJ (K) NIP.

Elective Study Final Assessment by Evaluator

Elective Study Process Final AssessmentBy Evaluator

Title : Prevalensi dan Korelasi Insomnia terhadap Kemampuan Kognitif pada

Remaja Usia 15-18 Tahun di Panti Asuhan Widhya Asih 1 Denpasar

Exam Date/Time :

Student’s Name : P.P.G. Krisna Bayu P.R.

Student ID Number : 1002005071

Supervisor : dr. Nyoman Ratep, Sp. KJ (K)

Assessment :

The final exam are approximately as follows

NO ITEM ASSESSMENT RANGE SCORE SCORE

1 Quality of material 0 - 60

2 Student’s interest and motivation 0 - 10

3 Critical thinking 0 - 10

4 Capability of information searching 0 - 10

5 Reliability 0 - 10

TOTAL 0 - 100

Final result (Score):Criteria : A B C D E (please circling the criteria)Result Range :

A : 80 - 100B : 70 - 79C : 55 - 69D : 45 - 54E : 0 - 44

Evaluator,

NIP.

Official Report of Elective Study Program Result

DEPARTEMENT OF EDUCATIONUDAYANA UNIVERSITYFACULTY OF MEDICINE

OFFICIAL REROT OF ELECTIVE STUDY ASSESSMENT

Today date time

Reffering to elective study assessment team assignment letter number

had been done an assessment to a student:

Name : P.P.G. Krisna Bayu P.R.

Student ID Number : 1002005071

Semester : VII

Elective Study Title : Prevalensi dan Korelasi Insomnia terhadap Kemampuan Kognitif

pada Remaja Usia 15-18 Tahun di Panti Asuhan Widhya Asih 1

Denpasar

By the Faculty of Medicine Udayana University Assessment Team consisting of the following:

1. Name of Supervisor :

2. Name of Evaluator :

Final Result

Supervisor’s score : (0 - 100)

Evaluator’s score : (0 - 100)

Thank you for your kind attention

Denpasar,

Supervisor signature :

Evaluator signature :

Student signature :