DEPARTAMENTO DE EDUCACIN ESPECIAL

SUPERVISIN DE ZONA No. 2

USAER No._____

DERIVACIN AL MAESTRO DE USAER.

NOMBRE DEL ALUMNO: _____________________________________________________________________________

ESCUELA: ________________________________________________ GRADO Y GRUPO: __________________________

MOTIVO DE LA DERIVACIN:
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QUE ACCIONES HA IMPLEMENTADO PARA TRATAR DE SOLUCIONAR ESTA PROBLEMTICA:

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ACUERDO SOBRE ACCIONES A SEGUIR:

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FECHA DE DERIVACION ________________________________________________

FECHA DE INICIO DE ATENCION: __________________________________________

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NOMBRE Y FIRMA DE MTRO. DE GRUPO NOMBRE Y FIRMA DEL TUTOR QUE AUTORIZA
LA REALIZACION DE PRUEBAS FORMALES DE
LAS REAS QUE SE REQUIERA.

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FIRMA DEL DIRECTOR DE LA ESCUELA NOMBRE, FIRMA Y CEDULA PROFESIONAL
DE MTRO. USAER.