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 *
Time of Incident *
School Site *
Location of Incident *
Type of Injury *
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) *
Parent/Guardian Notified (e.g. in person, email, phone call, text) *
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.
Never submit passwords through Google Forms.
This form was created inside of San Francisco Unified School District. Report Abuse - Terms of Service - Additional Terms