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Sample Self-Audit Form for YSOs
(Adapt as Needed)
| 1. Does the YSO have a safe environment policy in place that includes key strategies addressing increased visibility, adequate supervision and controlled access – and are the policies and procedures for child and youth safetypublicized to all personnel?fsd mm● If Yes, describe the types and frequency of publication. (Examples might include publication in agency bulletins, information provided at staff meetings, brochures and/or posters in the vestibules of agency buildings.) mm● If No, provide explanation. | YES | NO |
| 2. a)Do all YSO leaders, employees, and volunteers know when, how, and to whom to report suspicions or allegations of abuse of a minor? mm● If No, provide explanation. | YES | NO |
| 2. b) Reporting procedures also exist for cases in which the alleged abuser is not, or is no longer affiliated with the school. mm● If No, provide explanation. | YES | NO |
| 3. a) Does the YSO have a Code of Conduct in place that outlines clear expectations for interactions between adults and students? mm● If No, provide explanation. | YES | NO |
| 3. b) Are copies of the code of conduct made available to YSO staff, volunteers and any other paid or non-paid personnel in positions of trust who have regular contact with children and youth? mm● If No, provide explanation. | YES | NO |
| 3. c) Are copies of the Code of Conduct made available to parents and other members of the YSO community? mm● If No, provide explanation. | YES | NO |
| 3. d) Have all staff, employees and volunteers signed a Statement of Receipt and Agreement indicating that they have read the Code of Conduct and agree to comply with the policies? mm● If No, provide explanation. | YES | NO |
| 4. Is safe environment training provided to all YSO staff and volunteers to help them recognize, respond to, and report child abuse and neglect? mm● If No, provide explanation. | YES | NO |
| 5. a) Does the YSO have a screening and hiring process in place that includes a written application, personal interview, reference check, criminal background check, and sex offender registry check? mm● If No, provide explanation. | YES | NO |
| 5. b) Does the YSO repeat the criminal background and sex offender registry checks at least (insert “annually” or another agreed upon/required timeframe in accordance with MA state law)? mm● If No, provide explanation. | YES | NO |
| 5. c) Does YSO leadership verify that background and criminal history checks are conducted by organizations for contractors, vendors, consultants and others who provide goods and services to the YSO (in the presence of minors) or who bring minors onto YSO property? mm● If No, provide explanation. | YES | NO |
| 6. Families are provided with materials on a regular basis to let them know about child abuse and neglect, and the YSO’s abuse prevention plan that is designed to protect their children. mm● If No, provide explanation. | YES | NO |
| 7. Partnerships with local child protection agencies are developed and active. mm● If No, provide explanation. | YES | NO |
| 8. The YSO’s child protection plan is audited on a regular basis (at least annually), results are communicated to all stakeholders, and each audit’s results inform plans for continuous improvement. mm● If No, provide explanation. | YES | NO |
Name of the person completing this agency self-assessment: ________________
Title: ______________________
Date: ______________________
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