Here is the text we could read:
Favor de mandar este formulario de regreso en el sobre proveído o a:
450 So. State; P.O. Box 140241; Salt Lake City, Utah 84114-0241 ó al FAX (801) 578-3843
FORMULARIO DE INFORMACIÓN PARA
LA CO-CRIANZA
I. INFORMACIÓN DE IDENTIFICACIÓN C (información personal se mantendrá
confidencial)
NOMBRE COMPLETO: _______________________________________________________________
PRIMER NOMBRE
SEGUNDO NOMBRE
APELLIDO
IRECCIÓN DE DOMICILIO: ___________________________________________________________
CALLE Ó P.O BOX
NÚMERO DE APARTAMENTO
____________________________________________________________________________
Ciudad
Estado
Código Postal
ECHA DE NACIMIENTO: _____________________
eléfono de Domicilio: ______________ Teléfono de Trabajo: ______________ Teléfono Móvil: _____________
IRECCIÓN DE EMAIL: ______________________________________________________________________
ombre de su abogado: ________________________________________________________________________
ERSONA DE CONTACTO: ___________________________________________________________________
Nombre
Teléfono
___________________________________________________________________________________________________________________
Ciudad
Estado
Código Postal
Dirección
II. HIJOS O HIJAS (Involucrados en este caso)
Nombre
_________________________________
Fecha de Nacimiento
___________________________
_________________________________
___________________________
_________________________________
___________________________
INFORMACIÓN DEMOGRÁFICA
III.
Raza/Etnia (Marque sólo uno)
Ingreso Annual Aproximado
Indio Americano o Nativo de Alaska
(cid:0) Asíatico Americano
(cid:0) Negro/Africano Americano
(cid:0) Hispano o Latino
(cid:0) Nativo Hawaiano u Otro Isleño del Pacífico (cid:0) $40,000 y más
(cid:0) Blanco
(cid:0) Dos o más razas
(cid:0) Menos de $10,000
(cid:0) $10,000 - $19,000
(cid:0) $20,000 - $29,000
(cid:0) $30,000 - $39,000
D
_
F
T
D
N
P
_
Por favor complete el formulario entero (vea el reverso)
(cid:0)
TIEMPO PATERNAL/MATERNAL DE CUSTODIA (VISITACIÓN)
EXISTE ACTUALMENTE UNA ORDER REFERENTE AL TIEMPO
PATERNAL/MATERNAL?
(SI EXISTE):
1) ¿SON CLAROS LOS TÉRMINOS DE SU ORDEN DE CUSTODIA –
TIEMPO PATERNAL/MATERNAL?
2) ¿SE ESTÁN CUMPLIENDO LOS TÉRMINOS DE SU ORDEN DE CUSTODIA –
TIEMPO PATERNAL/MATERNAL?
SÍ
NO
SÍ
NO
SÍ
NO
SI NO, ¿CUÁL ES SU QUEJA?__________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
PARA PADRES SIN CUSTORIA SOLAMENTE:
EN LOS ÚLTIMOS TREINTA DÍAS:
1.
¿CUÁNTOS DÍAS SE SUPONÍA QUE VERÍA A SU(S) HIJO(S)? _________________________________
¿CUÁNTOS DÍAS REALMENTE VIÓ A SU(S) HIJO(S)? _______________________________________
EN SU OPINIÓN, ¿QUÉ SE NECESITA HACER PARA RESOLVER ESTE PROBLEMA? ______________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
¿HA HABIDO VIOLENCIA DOMÉSTICA CON EL OTRO PADRE/MADRE (CO-CRIADOR)?
SI LA HA HABIDO, POR FAVOR EXPLIQUE: __________________________________________________________
NO
SÍ
_______________________________________________________
_______________________________________________________
¿EXISTE ACTUALMENTE UNA ACCIÓN REFERENTE AL SOPORTE ECONÓMICO DE LOS HIJOS(AS)?
(ENCIERRE UNA OPCIÓN)
SÍ
NO
SI EXISTE, ¿CUÁNDO SE PRESENTÓ ESTA ACCIÓN? __________________________________
¿EXISTE ACTUALMENTE UNA ORDER DE PROTECCIÓN? (ENCIERRE UNA OPCIÓN)
SÍ
NO
¿
2.
.
V
Formulario de Informacion para la Co-Crianza (Co-Parenting Screening Intake Form - Spanish)
This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts.
To learn more about the project, check out our about page.
Downloads: You can download both the original form (last checked 2023-03)
and the machine-processed form with normalized data fields.
About This Form:
- Sourced from legacy.utcourts.gov (2023-03)
- Page(s): 2
- Fields(s): 43
- Average fields per page: 21
- Reading Level: Grade 12
- LIST Grouping(s):
GO-00-00-00-00.
Use our Rate My PDF tool to learn more.
Go beyond the above insights and learn more about this or any pdf form at
RateMyPDF.com, includes: counts of difficult words used,
passive voice decetion, and suggestions for how to make the form more usable.
Identified Data Fields:
We have done our best to automaticly identify and name form fields according to our naming conventions.
When possible, we've used names tied to our question library. See e.g., user1_name.
If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.
Here are the fields we could identify.
state_box_lake_city_utah_al was 450_so__state__p_o__box_140241_salt_lake_city__utah_84114_0241_ó_al_fax__801__578_3843 (0.55 conf)primer_nombre was primer_nombre (0.47 conf)calle_p_box was calle_ó_p_o_box (0.39 conf)direcci_n_de_domicilio was dirección_de_domicilio (0.49 conf)estado was estado (0.48 conf)tel_fono_vil was teléfono_móvil (0.52 conf)page_field__1 was page_0_field_6 (0.31 conf)direcci_n_de_email was dirección_de_email (0.46 conf)tel_fono_de_trabajo was teléfono_de_trabajo (0.48 conf)nombre_de_su_abogado was nombre_de_su_abogado (0.59 conf)nombre was nombre (0.46 conf)c_digo_postal was código_postal (0.41 conf)fecha_de_nacimiento was fecha_de_nacimiento (0.54 conf)page_field__2 was page_0_field_13 (0.31 conf)page_field__3 was page_0_field_14 (0.31 conf)page_field__4 was page_0_field_15 (0.31 conf)page_field__5 was page_0_field_16 (0.31 conf)informaci_n_demogr_fica was información_demográfica (0.48 conf)indio_americano_nativo_de_alaska was cid_0__indio_americano_o_nativo_de_alaska (0.44 conf)cid_menos_de was cid_0__menos_de__10_000 (0.48 conf)cid_atico_americano was cid_0__asíatico_americano (0.36 conf)cid__1 was cid_0_10_000_19_000 (0.30 conf)cid_negro_africano_americano was cid_0__negro_africano_americano (0.39 conf)cid__2 was cid_0_20_000_29_000 (0.30 conf)cid_hispano_latino was cid_0__hispano_o_latino (0.37 conf)cid__3 was cid_0_30_000_39_000 (0.34 conf)u_otro_isle_del_pac_fico was cid_0__nativo_hawaiano_u_otro_isleño_del_pacífico_cid_0_40_000_y_más (0.39 conf)page_check was page_0_check_9 (0.33 conf)cid_blanco was cid_0__blanco (0.34 conf)cid_dos_razas was cid_0__dos_o_más_razas (0.45 conf)sí was sí (0.46 conf)si_cu_l_es_su_queja was si_no_cuál_es_su_queja (0.45 conf)cu_ntos_se_supon_que_ver_su_hijo was cuántos_días_se_suponía_que_vería_a_su_s__hijo_s (0.49 conf)page_field__6 was page_1_field_3 (0.36 conf)en_su_se_este_problema was en_su_opinión_qué_se_necesita_hacer_para_resolver_este_problema (0.53 conf)page_field__7 was page_1_field_5 (0.36 conf)page_field__8 was page_1_field_6 (0.36 conf)page_field__9 was page_1_field_7 (0.36 conf)page_field__10 was page_1_field_8 (0.36 conf)con_el_otro_padre_madre was ha_habido_violencia_doméstica_con_el_otro_padre_madre__co_criador (0.49 conf)no was no (0.45 conf)si_la_ha_habido_por_favor_explique was si_la_ha_habido__por_favor_explique (0.58 conf)page_field__11 was page_1_field_12 (0.36 conf)
We've done our best to group similar variables togther to avoid overwhelming the user.
Suggested Screen 0:
state_box_lake_city_utah_alprimer_nombrecalle_p_boxdirecci_n_de_domicilioestadotel_fono_vilpage_field__1direcci_n_de_emailtel_fono_de_trabajonombre_de_su_abogadonombrec_digo_postalfecha_de_nacimientopage_field__2page_field__3page_field__4page_field__5informaci_n_demogr_ficaindio_americano_nativo_de_alaskacid_menos_decid_atico_americanocid__1cid_negro_africano_americanocid__2cid_hispano_latinocid__3u_otro_isle_del_pac_ficopage_checkcid_blancocid_dos_razassísi_cu_l_es_su_quejacu_ntos_se_supon_que_ver_su_hijopage_field__6en_su_se_este_problemapage_field__7page_field__8page_field__9page_field__10con_el_otro_padre_madrenosi_la_ha_habido_por_favor_expliquepage_field__11
Create an Interactive Version of this Form:
The Weaver creates a draft guided interview from a template form, like the one provided here. You can use the link below to open this form in the Weaver.
To learn more, read "Weaving" your form into a draft interview.
Launch Form in Weaver
