ࡱ> CEBy bjbj 48{{V4\\8&d$5$fnnn#######$%M(#nnnn##"""n#"n#""@"٬^h "#$05$") )")"nn"nnnnn##"nnn5$nnnn)nnnnnnnnn\ |: Formulario de muestra del Estado de Washington para denunciar incidentes de Acoso, Intimidacin u Hostigamiento (HIB, por sus siglas en ingls) Denunciante (opcional): _______________________________________________________________________ Estudiante acosado: __________________________________________________________________________ Su correo electrnico (opcional): ________________________________________________________________ Su nmero de telfono (opcional): ____________________Fecha de hoy: ______________________________ Nombre del adulto en la escuela al que ha contactado (en su caso): ___________________________________ Nombre/s del/los acosador/es (si se conocen): ___________________________________________________________________________________________ En qu fecha ocurri el/los incidente/s? (si se conoce): ___________________________________________________________________________________________ Dnde ocurri el incidente? Marque con un crculo todos lo que correspondan. Clase Pasillo Bao Patio de recreo Vestuario Cafetera Campo de deportes Estacionamiento Bus escolar Internet Telfono celular Durante una actividad escolar Fuera de las instalaciones de la escuela En camino a/de la escuela Otro (descrbalo): _______________________________________________________ Marque el casillero que mejor describa lo que el hostigador hizo. Marque todos lo que correspondan.  Le peg, pate, empuj, escupi, jal del pelo o tir algo al estudiante  Hizo que otra persona le pegue o le haga dao al estudiante  Se burl, injuri, critic o amenaz a la persona (por telfono, correo electrnico, etc.)  Menospreci al estudiante y lo hizo el objeto de bromas  Hizo gestos groseros y/o amenazantes  Excluy o rechaz al estudiante  Hizo que el estudiante se sienta temeroso, le exiga dinero o lo explotaba  Difundi rumores o chismes dainos Hubo acoso ciberntico (lo intimid con llamadas, mensajes de textos, correos electrnicos, publicaciones en la web, etc.)  Otro Si selecciona otro, descrbalo: _____________________________________________________________ Por qu cree que ocurri el acoso, la intimidacin o el hostigamiento? ___________________________________________________________________________________________ Hubo testigos? S No En caso afirmativo, dganos sus nombres: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Hubo alguna lesin fsica a causa de este incidente? En caso afirmativo, descrbala. ___________________________________________________________________________________________ El estudiante hostigado se ausent de la escuela a causa de este incidente? S No En caso afirmativo, describa. ___________________________________________________________________________________________ Tiene informacin adicional? ___________________________________________________________________________________________ ___________________________________________________________________________________________ Gracias por denunciar! ---------------------------------------Solo para uso de la oficina de la escuela (For Office Use)----------------------------------- Recibido por (Received by): ____________________________________________________________________ Fecha de recepcin (Date received): _____________________________________________________________ Accin tomada (Action taken): __________________________________________________________________ Padre/tutor contactado (Parent/guardian contacted): ______________________________________________ Haga un crculo alrededor de uno (Circle one): Resuelto (Resolved) Sin resolver (Unresolved) Derivado a (Referred to): _____________________________________     HIB Incident Reporting Form (Spanish) ./34=>?GHKLQR]_`pt  P Q f h p q øؑυzظrhUmH LsH Lh*h mH LsH Lh*h 5mH LsH LhR45mH LsH Lh6mH LsH Lh*h)RRmH LsH Lh*h*mH LsH Lh*h0[:mH LsH Lh*h0[:5mH LsH LhZG{5mH LsH LhU5mH LsH Lh*h*5mH LsH Lh{nr5mH LsH Lh*5mH LsH L,4Q  6 F 4a  d^gdcfdgd+U $da$gd+Uq s y    ! 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