邢唷��>� CE��B��欹�y� ��bjbj�� 48遻遻V4��\\��8&d�$�5$f��nnn�#�#�#�#�#�#�#$�%�M(��#�n��nnn�#��#�"�"�"n��#�"n�#�"�"@��"��佻誢��h ��"�#$05$�"�)� ��)�"�)��"�nn�"nnnnn�#�#�"nnn5$nnnn��)nnnnnnnnn\ |: Formulario de muestra del Estado de Washington para denunciar incidentes de Acoso, Intimidaci髇 u Hostigamiento (HIB, por sus siglas en ingl閟) Denunciante (opcional): _______________________________________________________________________ Estudiante acosado: __________________________________________________________________________ Su correo electr髇ico (opcional): ________________________________________________________________ Su n鷐ero de tel閒ono (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): ___________________________________________________________________________________________ 縀n qu� fecha ocurri� el/los incidente/s? (si se conoce): ___________________________________________________________________________________________ 緿髇de ocurri� el incidente? Marque con un c韗culo todos lo que correspondan. Clase Pasillo Ba駉 Patio de recreo Vestuario Cafeter韆 Campo de deportes Estacionamiento Bus escolar Internet Tel閒ono celular Durante una actividad escolar Fuera de las instalaciones de la escuela En camino a/de la escuela Otro (descr韇alo): _______________________________________________________ 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 da駉 al estudiante Se burl�, injuri�, critic� o amenaz� a la persona (por tel閒ono, correo electr髇ico, 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 exig韆 dinero o lo explotaba Difundi� rumores o chismes da駃nos Hubo acoso cibern閠ico (lo intimid� con llamadas, mensajes de textos, correos electr髇icos, publicaciones en la web, etc.) Otro Si selecciona otro, descr韇alo: _____________________________________________________________ 縋or qu� cree que ocurri� el acoso, la intimidaci髇 o el hostigamiento? ___________________________________________________________________________________________ 縃ubo testigos? S� No En caso afirmativo, d韌anos sus nombres: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 縃ubo alguna lesi髇 f韘ica a causa de este incidente? En caso afirmativo, descr韇ala. ___________________________________________________________________________________________ 縀l estudiante hostigado se ausent� de la escuela a causa de este incidente? S� No En caso afirmativo, describa. ___________________________________________________________________________________________ 縏iene informaci髇 adicional? ___________________________________________________________________________________________ ___________________________________________________________________________________________ racias por denunciar! ---------------------------------------Solo para uso de la oficina de la escuela (For Office Use)----------------------------------- Recibido por (Received by): ____________________________________________________________________ Fecha de recepci髇 (Date received): _____________________________________________________________ Acci髇 tomada (Action taken): __________________________________________________________________ Padre/tutor contactado (Parent/guardian contacted): ______________________________________________ Haga un c韗culo 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 鲰鲰嶝县碡碡县秘磲雒砻砻砀酶⒏貞蠀z⒇竢�h踀�mH LsH Lh�*�h� mH LsH Lh�*�h� 5乵H LsH Lh腞45乵H LsH Lh�6�mH LsH Lh�*�h)RRmH LsH Lh�*�h�*�mH LsH Lh�*�h0[:mH LsH Lh�*�h0[:5乵H LsH LhZG{5乵H LsH Lh踀�5乵H LsH Lh�*�h�*�5乵H LsH Lh{nr5乵H LsH Lh�*�5乵H LsH L,4��Q � € ��6��F � � 4��a��勁d�^勁gd攃fd�gd+U� $d�a$gd+U�q s y � � � � � � � � � � � � � � � � ! 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