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Run: School-Based Outreach Visit Log

A structured log for youth-serving outreach staff to document every school visit — classrooms reached, materials distributed, staff contacts, and follow-up a...

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Visit Details

Date of Visit * (required)

Select the date the school visit took place.

Visit Start Time * (required)

Visit End Time * (required)

School Name * (required)

School District * (required)

School Level * (required)

Type of Visit * (required)

Select the primary purpose of this visit.

Describe Visit Type

Outreach Worker / Prevention Specialist Name * (required)

Program or Organization Name * (required)

Classrooms and Participants Reached

Number of Classrooms Visited * (required)

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? * (required)

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 * (required)

The school staff member who coordinated or hosted this visit.

Primary Contact Title / Role * (required)

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? * (required)

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? * (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 * (required)

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.

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