1. Injury, Referral, and Crisis Forms
Moving to Digital Submission

2. 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 ed to whoever completed the form
Must be ed to PM and Administrator
Does not convert to PDF for easy printing
Form corrections require filling out a new form

3. 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 hours of incident
Share the copy of the form with PM and Administrators

4. 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.

5. 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 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

6. 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

7. 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

8. 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

9. 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 to 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

10. 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.”

11. 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

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

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

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

15. Thank you for taking time to complete this module!