Injury, Referral, and Crisis Forms Moving to Digital Submission

Pluses and Deltas of the Switch to Google Pros Cons Gathers standardized information Google form version can entered via laptop or cellphone Paperless Allows staff to make data based decisions Supports equity by providing consistency and predictability of system to staff and students Promotes high standards by identifying potential supports needed for students and staff Response emailed to whoever completed the form Must be emailed to PM and Administrator Does not convert to PDF for easy printing Form corrections require filling out a new form

Review of Steps for Injury Form Submission Investigate Injury Context (Who, what, where, when and how) If injury was beyond first aid, how was it addressed? Did student have to go to hospital? Contact parent and administrator if needed Use Injury Google Form to submit to ExCEL Complete the Google Form within 24-48 hours of incident Share the copy of the form with PM and Administrators

Be on the lookout for these frequent injury form mistakes... Avoid Common Areas of Concern Instead Try “Helen needed ice pack for head injury. Told parent.” Context of Situation “Helen was on the yard with group and tribe leader. She was running and fell and hit her head. Leader has a student help her to get an ice pack. She sat out for recess. Parent was called and Mom came to pick up early.” “Parent picked up.” Family Follow-Up “Helen’s mother came to pick up early and said she wanted to take Helen to the doctor. I informed her that assistance with medical bills is available through our insurance.

Review of Steps for Referral Form Submission Investigate Referral Context of incident (Who, what, where, when and how) Avoid interviewing students together Contact parent and administrator if needed Use Referral Google Form to submit to ExCEL If follow up is needed, please make sure to include the plan in the Google form Complete Referral Form via Google Form within 24-48 hours of incident Share the copy of the form with PM and Administrators Conduct follow up Contact school day teacher and/or Social Worker Find out if student has existing supports for similar behavior during the school day If it is a repeated referral, see next steps on the ExCEL Behavior Matrix

Section 1: Logistics of the Incident Referral Details Staff Referring Student Name Additional Student Names (if involved) Date Time School Site Location of Incident Categories of Behavior Description of Incident Section 1: Logistics of the Incident

Section 2: Hypothesis of the Behavior Why adult believes student engaged in the behavior Adult supports provided Description of Support Student Hypothesis for Own Behavior (if discussed with student) Referral Details Section 2: Hypothesis of the Behavior

Section 2: Solution Focused Plan Repeat Referral Skill Building Restorative Punitive Description of Plan/Resolution Estimated Time Out of Program for Incident Notification Follow Up Referral Details Section 2: Solution Focused Plan

Review of Steps for Crisis Form Submission Investigate Crisis Context of incident (Who, what, where, when and how) Avoid interviewing students together Avoid interviewing student and staff together for adult/student related issues Contact parent and administrator Witness statements are required for: Physical Assault Sexual Harassment Inappropriate touch/contact Inappropriate adult/student boundaries Develop follow up plan that will be included in the Google Form Complete the Crisis Form Google Form within 24 hours or COB next day If form cannot be fully completed, send an email to excelasp@sfusd.edu to immediately inform us that incident has happened and report is pending. If related to a referral, see next steps on the ExCEL Behavior Matrix

Common Areas of Concern Be on the lookout for these frequent referral and crisis form mistakes... Avoid Common Areas of Concern Instead Try “Jake was disrespectful and it will not be tolerated by our program” Objective descriptions focus on what was observable in terms of behavior. “Jake was in the cafeteria in line for snack. He pushed past students in front of him. He grabbed snack and ran to his table. When Karina asked him to come back, he yelled ‘no’” “Will talk to George again (this is the 3rd time) about how we shouldn’t grab friends’ private parts in the bathroom.” Description of Plan should describe the people you will check in and how you will prevent the behavior from happening again “We checked in with teacher and social worker and this does not happen during school day because they don’t go in partners. We will meet with parents about bathroom policy. Next steps are to have George still go with a partner, per policy, but partner waits outside for him. May have adult supervise the few times.”

Your Role as a Leader in this Process Clearly communicate importance of having site-based internal protocol Determine a clear procedure for investigating thoroughly and conducting post incident follow up Develop a clear method for monitoring referrals to determine need for intervention for program participants Communicate clear expectations for upholding documentations systems

To complete this professional development module, please click the quiz link to the right Injury, Referral and Crisis Module Quiz

What to Do After My Quiz? Passing Criteria Click link to view your score Use this link to try again!

After receiving the email with a passing score, Site Coordinators will forward this email to Program Manager for confirmation. Click “View Score” to see score

Thank you for taking time to complete this module!