ExCEL After School Injury Report 2018-2019
*NOTE: this form is not able to be edited after you submit. Therefore, please make sure you:

1. Have all information relevant to situation (staff referring, date/time, resolution, date when administrator is notified, solution focused plan or resolution)
2. Email a copy (will be emailed to you) to your administrator and keep for your own records
3. Email any additional documentation/reports to excelasp@sfusd.edu


Email Address is for SITE COORDINATOR's email address.

Email address *
Site Coordinator Name *
Your answer
Staff Completing Form *
Your answer
Student Name (Last Name) *
Your answer
Student Name (First Name) *
Your answer
Any additional students involved
Your answer
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
School Site *
Location of Incident *
Type of Injury *
Required
Description of Circumstances of Injury (include care given and email any additional documentation to ExcelASP@sfusd.edu) *
Your answer
Hospital Required? *
If Yes, by whom and which hospital?
Your answer
Police Called?
By Whom (name/title)
Your answer
Names of Persons present during police interview of student(s):
Your answer
SFUSD Administrator/Principal Notified (e.g. in person, email, phone call, text) *
Required
Parent/Guardian Notified (e.g. in person, email, phone call, text) *
Required
As a result, were any students suspended/expelled from the Program? *
Was an Afterschool Referral Form Completed? *
Who will be conducting follow up? *
A copy of your responses will be emailed to the address you provided.
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