School-Based Outreach Visit Log

Documents school visits, classrooms reached, materials distributed, and contacts with school staff for youth-serving programs and prevention specialists.

Visit Details

• Date of Visit *
  Select the date the school visit took place.
• Visit Start Time *
• Visit End Time *
• School Name *
• School District *
• School Level *
• Type of Visit *
  Select the primary purpose of this visit.
• Describe Visit Type
• Outreach Worker / Prevention Specialist Name *
• Program or Organization Name *

Classrooms and Participants Reached

• Number of Classrooms Visited *
  Enter 0 if no classroom presentations were conducted.
• Grade Levels Reached
  Select all grade levels that participated in outreach activities.
• Estimated Number of Students Reached
  Provide your best estimate of total unduplicated student participants.
• Number of School Staff Who Participated
  Include teachers, counselors, administrators, and support staff who actively participated (not just observed).
• Number of Parents / Guardians Who Participated
• Curriculum, Program, or Topic Delivered
  Include the evidence-based curriculum name and lesson number if applicable.
• Session Format

Materials Distributed

• Were Any Materials Distributed? *
• Materials Distributed — Detail
  List each material type, quantity distributed, and intended audience. Add a row for each distinct item.
• Additional Notes on Materials

School Staff Contacts

• Primary School Contact Name *
  The school staff member who coordinated or hosted this visit.
• Primary Contact Title / Role *
• Primary Contact Email
  Optional — only collect if needed for follow-up communication.
• Primary Contact Phone
  Optional — only collect if needed for follow-up communication.
• Were Additional Staff Contacts Made?
• Additional Staff Contacts — Names and Roles
• Overall School Receptiveness to Outreach
  Rate the school's overall engagement and openness to your outreach activities (1 = Not receptive, 5 = Very receptive).

Visit Summary and Observations

• Were the Planned Visit Objectives Met? *
• Explain Partial or Unmet Objectives
• Barriers or Challenges Encountered
  Select all that apply.
• Notable Observations or Student / Staff Feedback
  Do not include student names or other identifying information about minors.
• Were Photos or Documentation Collected?
  Only photograph participants if written consent has been obtained per your organization's media release policy.
• Upload Visit Photos or Supporting Documentation
  Attach photos, sign-in sheets, or other supporting documents. Do not upload images of minors without verified written consent.

Follow-Up Actions

• Is Follow-Up Action Required? *
• Follow-Up Actions Needed
  Select all that apply.
• Follow-Up Due Date
• Follow-Up Notes
  Do not record student names or other PII about minors in this field.
• Is a Return Visit Already Planned?
• Anticipated Next Visit Date

Submission and Acknowledgment

• Outreach Worker Signature *
  Sign to certify the accuracy of this visit log.
• Date of Submission
  Confirm the date you are submitting this log. Best practice: submit within 48 hours of the visit.
• Supervisor Review Notes
  For supervisor use during approval review. Leave blank at time of submission.