To be completed by University of Minnesota staff. Registering a program means the program leader has read and understands the Safety of Minors Policy, including the Health and Safety Appendix. Please indicate which type of program you would like to submit: Step-Up Employment Program K-12 Youth Event/Program/Camp/Intern/Conference (In-Person and/or On line) Step-Up Youth Employment Will you be hiring a Step-Up Youth Employment Intern? Yes No Number of Youth Interns Dates Site Location Host Contact Info Name Email Phone Is this your first time hosting a youth intern? Yes No Have you completed all required paperwork per the Step-Up program via the City of Minneapolis? Yes No Have all adults working directly with the youth intern/s completed the on-line Safety of Minors training found in the training hub? Yes No Not yet Have all adults working directly with the youth intern/s passed a background check within the last three years? Yes No Not yet Per the Safety of Minors: Health and Safety Requirements, I understand that the youth intern/s will maintain appropriate ratios, including no one-on-one interaction with an adult. Interactions must be observable and interruptible at all times. Yes, I understand this requirement Basic Information Program Title Unit Link to Program Registration Description A short 2-3 sentence description. Phone Email (point of contact for participants) Program Director/Leader I verify that all program staff (faculty, staff, students- including student employees- or volunteers) who are required to complete the U of M training on safety of minors and pass a background check have or will have done so within three years prior to the event. I also verify that this program has established practices for program activities that adequately address health and safety considerations for minors. Program Leader Email Program Information Start Date Start Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Start Date: Day Day12345678910111213141516171819202122232425262728293031 Start Date: Year Year2018201920202021202220232024 End Date End Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec End Date: Day Day12345678910111213141516171819202122232425262728293031 End Date: Year Year2018201920202021202220232024 Months Offered According to the start and end date, please select all the month(s) your program resides in. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Age Select all that apply. 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Estimated number of participants Subject Select one or more. Food, Agriculture, and Natural Resource Sciences Art, Design, Music, and Theater Health, Nutrition, and Human Development Leadership and Citizenship Science, Technology, Engineering, and Math Communication, Diversity, History, Languages, and Social Studies Recreation Business Program Location Select campus/region as well as if your program will be delivered in-person or virtually (check both boxes if your program plans to deliver both in-person and virtually). Crookston/Northwest MN- In-person Duluth/Northeast MN- In-person Morris/West Central MN- In-person Rochester/Southeast MN- In-person Southwest MN- In-person Twin Cities/Central MN- In-person Crookston/Northwest MN- Virtual Duluth/Northeast MN- Virtual Morris/West Central MN- Virtual Rochester/Southeast MN- Virtual Southwest MN- Virtual Twin Cities/Central MN- Virtual Publish on Youth Central website? Yes No Staffing Information Have all covered staff/volunteers passed a background check within the last three years? Yes Not yet Not applicable Have all covered staff/volunteers completed the Safety of Minors mandatory training via the Training Hub? Yes Not yet Not applicable Will there be a minimum of two program staff on duty at all times who are 18 or older and two years older than the oldest participant? Yes Not yet Not applicable Will all program staff/volunteers/student workers receive an orientation? The orientation should include expectations for program staff behavior when interacting with youth (both in-person and virtually), supervising, chaperoning or otherwise overseeing minors in program activities, recreational activities, and/or residential facilities. Yes Not yet Not applicable Safety of Minors Information Have you planned appropriate physical environments to ensure quality learning environments and help prevent illnesses and accidents? Yes Not yet Not applicable Is there a plan to change facilities or modify activities for participants with special needs? Yes Not yet Not applicable Is there a plan to change facilities or modify activities in case of extreme weather? Yes Not yet Not applicable Have you assessed the environment to determine if minors need to be accompanied to the bathrooms? Yes Not yet Not applicable Environmental assessment may include considering the relative age of participants, the presence of minors or adults not from the same program, sight lines, and distance. Is there a plan for the safe movement of minors? Yes Not yet Not applicable Do minors attend without a parent or other caretaker? Please review the health and safety requirements on this page: https://policy.umn.edu/operations/minorsafety-appa Yes No Does the program collect and keep within easy access information on each participant including current medications administered during program time frame and contact information for parents/guardians? Yes No Do program staff know how to find and use this information? Yes No Has the program established and communicated practices to prevent accidents and illnesses, including adequate first aid and proper handling of medications? Yes No Does the program have emergency plans for fire, weather (e.g., tornado), toxic gas evacuations, unfamiliar packages, intruders, lost or missing children, and other emergencies? Yes No Has the program established and communicated to program staff appropriate procedures for addressing emergencies, accidents and illnesses? Yes No Will the program obtain a signed release of liability from all parents/guardians of minors prior to participation? Yes No Does the program lodge people overnight? More information on health and safety requirements can be found here: https://policy.umn.edu/operations/minorsafety-appa Yes No Will the program follow lodging requirements? More information on lodging requirements can be found here: https://policy.umn.edu/operations/minorsafety-appa Yes No Will there be a minimum of two program staff on duty overnight who are 21 or older? Yes No Has the program operated previously? Yes No Were any incidents of suspected abuse known to have been reported to or by staff in the last year? Yes No Was the incident reported to police, sheriff or local social service agency? Yes No Did the incident allegedly occur during the program or involve program staff or volunteers? If yes, contact the policy owner to review actions, including preventing future incidents. Yes No Notification Date Will a minor be present in lab environment? Yes No In addition to the general release and waiver form, has each participants' adult caregiver signed off on the Labs Use Agreement Form (Paid Lab activity) or the Volunteers/Guests in Labs Form? Yes No Are you prepared to give a safety overview of the lab space? Yes No Not Yet Has your unit/department head received written communication informing them that minors will be in the lab on certain days and times? Yes No Not Yet Do you require any enrolled college students using the lab to complete a specific training safety module related to the lab activity? Yes No Have you required the minors to also take the training module (this is a requirement). Yes No Not Yet Do you need an additional HSRM risk assessment because chemicals, dust, fumes, vapors, gases, biological materials, radioactive materials or other substances may be present? Yes No Virtual Program Information Is this a virtual program? Yes No Is the platform supported by the University of MN? Supported platforms include Zoom, Flipgrid, Microsoft Teams, and Canvas. Yes No Have safety guidelines been addressed related to your platform? Yes No Not yet Will you be live streaming your program? Yes No Have safety precautions been put in place related to risks of live streaming? Yes No Not yet Have all staff/volunteers completed virtual safety guidelines training? Yes No Not yet Has oversight been established to include a minimum of two adults during all virtual engagement activities? Yes No Not yet Is recording taking place? Yes No Have all participants been informed that the recording will take place? Yes No Not yet Has the purpose for the recording been communicated to all participants? Yes No Not yet Will you delete the recording within 30 days? Yes No Will the recording be kept on a University accessible device? Yes No I agree to the terms of service. I verify that I have read and understand the Safety of Minors Policy, including the Health and Safety Appendix. I verify that all program staff (faculty, staff, students- including student employees- or volunteers) who are required to complete the U of M training on safety of minors and pass a background check have or will have done so within three years prior to the event. I also verify that this program has established practices for program activities that adequately address health and safety considerations for minors. Leave this field blank