Policy on Minimum Standards for Programs for Minors and Children

1. Definition of “Programs for Minors” Covered by this Policy

All programs involving transfer of responsibility for supervision and control of Minors (individuals under the age of 18) from parents or guardians to the University of Rochester and University of Rochester Medical Center (collectively “University”) or to a third party permitted by contract to use University facilities for such programs and meeting the further definitions in this section (hereinafter referred to as “Covered Programs”), must comply with the minimum standards for such programs as defined by the University in this Policy.

a) Covered Programs under this Policy are University programs, activities, workshops, and events, whether for academic, athletic, recreational, volunteering, training or other purposes whether on or off University premises, that involve the transfer of supervision responsibilities of Minors to the University. (“University premises” are properties owned, leased or controlled by the University). By way of example, Covered Programs include, but are not limited to, day and overnight camps of any nature for Minors, including camps conducted by University athletic coaches, schools operated by the University, early childhood centers, and instructional activities involving Minors. Covered Programs also include those that are held at locations that the University does not own, lease or control, if the University is a sponsor or a participant in the Covered Program and/or the University’s name is used to promote the Covered Program with the knowledge and approval of the University. Covered Programs also include those that are conducted or operated by University’s Authorized Persons [1] using their University title to promote the program with the knowledge and approval of the University, and/or using University premises or facilities. Covered Programs at the medical center and affiliates may include similar types of programs as the University, but may also include programs including, but not limited to, volunteer services, certain healthcare programs, events with local schools and certain social programs.

[1] As used in this Policy, the term “Authorized Persons” applies to all staff, faculty, students, employees, vendors and volunteers who are responsible for supervising Minors on behalf of the University.

b) Programs or services that serve Minors conducted or provided by an outside entity or contractor while on University premises or that are conducted or provided on behalf of or for the University are also Covered Programs. Such entities/contractors must be required by contract to comply with this Policy.

c) Covered Programs do not include:

• University undergraduate or graduate academic programs in which students enrolled at the University or another institution of higher education are the only Minors participating in the programs.
• University events such as fairs, festivals, or other events that are open to people of all age groups, but at or in which Minors may be present or participate, or University events at which Minors will be accompanied at all times by their parent, legal guardian or adult representative.
• Patient care provided to Minors in a clinical setting.

d) Activities involving Minors may be subject to other University or Hospital policies, which require additional safeguards and requirements, such as:

• Protection and Supervision of Minor Inpatient Policy
• Unattended Minors in Imaging Sciences
• Athletic Training Outreach Minors Policy
• Short-Term Observational Experiences Policy
• Shadowing/Observational Experience Guidelines for Students
• Research Involving Children
• Employment of Minors
• Visitors to Laboratories or Shops

This policy does not limit any additional standards set forth in these policies.

2. Responsibility for Approving Programs for Minors

a) The Program Sponsor is an individual responsible for approving the establishment of, and funding for, the Covered Program, and is ultimately accountable for ensuring compliance with all Policy requirements as defined herein.

b) The Program Administrator is an individual responsible for Policy compliance, including ensuring that all Minors who will be participating in a Covered Program are registered and any necessary information required by this Policy or by the Program Administrator is received before the Covered Program commences.

c) All Covered Programs must be approved by the Program Sponsor, Program Administrator and the department executive of the University department hosting the

3. Central Registration of Programs for Minors

a) All Covered Programs must be registered by the Program Administrator by filing a Registration Form with the Risk Management Department within the Office of

b) The registration documentation shall include a description of the program and the approval of the Program Sponsor all required elements on the Registration Form and the contact information for the Program

c) Covered Programs must be registered within 90 days of the start of the program.

d) Covered Programs must be re-registered each calendar year.

4. Registration of Participants in Programs for Minors and Permission for Participation

a) The Program Administrator will maintain a list of all registered participants, including the participant’s name; local room assignment (if applicable); gender, age, and phone number(s) of parent or legal guardian, as well as emergency contact information for the parent or legal

b) The Program Administrator will provide the parent or legal guardian with information detailing the manner in which the participant, the Program Sponsor and Security can be contacted during the

c) The Program Administrator will provide the parent or legal guardian with a written description of the procedure that will be used to contact them in case of Each Covered Program must have a procedure approved by the Program Sponsor for notifying the designated parent or legal guardian of participants in the program, in case of emergencies, including medical or behavioral problems, disasters, or significant program disruptions.

d) The Program Administrator must keep documentation to support the start and end of the Covered Program, such as a sign-in and sign-out sheet or drop-off and pick-up log.

e) All records of the Covered Program must be retained for time periods consistent with the University’s Retention of University Records Policy.

5. Background Checks of Employees Involved with Programs for Minors

a) All Authorized Persons who will have direct, regular and frequent contact with minors as a part of performing their University job or assigned role in connection with a Program for Minors are required to have a background check that has been completed within the last three years on record with the University prior to beginning work with minors. The Program Administrator will coordinate the completion of the checks consistent with University of Rochester Human Resources Department approved

b) Background checks applicable to persons who will be working with minors should include at a minimum: i) checking the relevant sexual offense registry; ii) checking for felony conviction records; and iii) requiring the employee or prospective employee to complete a self-disclosure

c) The self-disclosure form for Authorized Persons should require that the person completing the form disclose any criminal convictions in the past and agree to disclose any arrest and/or conviction in the future within 72 hours of

d) Any background check that is “positive” for conviction of a crime, and/or allegations of sexual misconduct or sexual offense, whether for a new potential employee or a current employee, must be reviewed by the Program Administrator and the Program Sponsor with Human Resources before any hiring or employment decision is made and prior to beginning the Covered Program. Human Resources will consult with the Office of Counsel as needed.

e) The results of background checks and the corresponding hiring and employment decisions should be documented in the appropriate employment or vendor

f) Outside vendors hired by the University to provide staff who will have direct, regular and frequent contact with minors at a Program for Minors as defined in Section 1 of this policy, shall be required by contract to have performed background checks on their Authorized Persons that are substantially similar to the background checks being performed on University employees. Vendors who are unable or unwilling to agree to the contract terms regarding background checks should not be

g) All background check requests should be submitted to the HR Service Center.

6. Supervision of Minors

a) The Program Administrator will ensure there is a written supervision plan, approved by the Program Sponsor, to ensure adequate supervision of minors while they are under University supervision and

b) Factors to consider in structuring a Covered Program in order to provide adequate supervision include, but are not limited to, the number, age and gender of participants, the activities involved, the risk of physical injury, the location of the activity, the type of housing (if applicable), the age and experience of the participants and the age and experience of the

c) Whenever possible, staffing should be maintained at a level that minimizes the deliberate frequency of private one-on-one contact. (See also Section 8 (a)).

d) Covered Programs allowing minors to reside in housing on University premises (property owned, leased or controlled by the University) must include supervision plans approved by the Program Sponsor and Residential Life that are age appropriate for the program participants.

e) Supervision plans for minors residing in University housing should include the following components:

1. Written permission signed by the parent/guardian for the minor to reside in university
2. Age-appropriate community rules concerning in-room visitation by other participants.
3. The program must comply with all security measures and procedures specified by Residence Life and Security.

7. Rules for Program Participants

a) Each Covered Program should have a clear set of rules of conduct for participants, including an explanation of potential discipline in the event of non-compliance, which has been approved by the Program

b) Covered Program participants and parents will be provided with a written copy of the rules prior to participation in the

c) Each set of rules must include at a minimum the following elements:

1. The possession or use of alcohol and other drugs, fireworks, guns and other weapons is
2. Participants may not leave the property or the program without permission of the Program
3. No violence by anyone involved, including sexual abuse or harassment, will be tolerated. Hazing is Bullying, including verbal, physical, and cyber bullying, are prohibited.
4. No use of tobacco products are allowed.
5. Misuse, damage or theft of property is Charges will be assessed against those participants who are responsible for damage, theft or misuse of university property.
6. Participants must follow all safety rules in accordance with university standards and/or as defined by the Program
7. Use of cameras, imaging, and digital devices are prohibited where privacy is expected, such as showers, locker rooms and

8. Behavioral Boundaries for Interacting with Minors in Programs for Minors

Authorized Persons involved with Covered Programs must observe appropriate behavioral boundaries with minors at all times, with the following activities limited or prohibited:

a) Private personal interactions with minors should be “One on one” interaction between a supervising adult and a minor should generally be avoided when it is not a standard and necessary part of the activity. When it is known that one on one contact between an adult supervisor and a minor is a necessary part of the activity, express written permission must be obtained from the parent or guardian of the minor.

b) Authorized Persons shall not enter a bathroom facility, or similar area where privacy is expected without another adult and/or counselor in attendance, other than in emergency

c) Authorized Persons shall not hit, physically assault, abuse or inappropriately touch minors; use language, make suggestions or offer advice that is sexually inappropriate, offensive or abusive; behave in a manner that is sexually provocative; act in ways intended to shame, humiliate, belittle or degrade minors; or otherwise perpetrate any form of emotional or physical

d) Direct and personal electronic communications (including but not limited to email and social media) between an adult supervisor and a minor participant should be limited and should generally not occur without another adult being included in the communication. Electronic communications that are being broadly distributed to a group of program participants do not require another adult being included in the

e) Authorized Persons shall not have personal and private (one on one) contact with minor participants in Covered Programs when outside of the program. This restriction does not apply to incidental contact in public or to situations where the adult supervisor is invited by the parents or guardian of the minor to participate in an event that includes other adults outside of the

f) Authorized Persons shall not drive minors in the employee’s personal vehicle unless specifically authorized in writing by the Program Administrator and the minor’s parent or legal guardian, or in emergency

g) Authorized Persons shall not provide alcohol or illegal drugs to any minor and shall take active steps to address the situation if a minor is discovered with alcohol or illegal

h) Authorized Persons shall not provide prescription drugs or any medication to a minor unless specifically authorized in writing by the minor’s parent or legal guardian, or in emergency circumstances. Authorized Persons shall take active steps to address the situation if a minor is discovered with prescription drugs or medications that the minor’s parent or guardian has not informed the program about and

i) Authorized Persons shall not make sexual materials in any form available to minors or assist them in any way in gaining access to such Authorized Persons shall take active steps to address the situation if a minor is discovered in possession of any such materials.

j) Authorized Persons shall not take photos of Covered Program participants that are unrelated to the program on personal cell phones or cameras belonging to the adult supervisor, without the permission of the minor’s parent or legal

9. Training of Adult Supervisors involved in Programs for Minors

a) All Authorized Persons who will have direct, regular and frequent contact with minors as a part of performing their University job or assigned role in connection with a Covered Program must receive the University’s approved MyPath training with respect to these policy requirements and any other expectations of the Program Administrator and Program Sponsor hosting the Covered Program.

b) Training must address the obligations of Authorized Persons to report suspected sexual abuse/ molestation, physical or emotional The training must state that any employee who has a reasonable basis to believe that a minor participant is or may be the victim of sexual abuse/ molestation or physical or emotional abuse must report that concern as soon as possible to his or her immediate supervisor and/or the Program Administrator. Alternatively, the employee must report the concern directly to University Security, Human Resources and/or to the Office of Counsel.

c) University approved training can be found in MyPath by searching for module “Minimum Standards for Programs for Minors and Children”.

10. Investigation and Response to Allegations or Concerns of Suspected Sexual Abuse/Molestation or Physical Abuse

a) Any credible allegation or reasonable concern that an employee involved in a Covered Program may have engaged in conduct with a minor participant inconsistent with this policy or otherwise and constituting sexual abuse/molestation, physical or emotional abuse of the minor, should result in the cessation of the employee’s involvement with the Covered Program and any other University functions requiring direct contact with minors, pending

b) All allegations, concerns, or suspicions about possible sexual abuse/molestation, physical or emotional abuse of an Minor in a Covered Program must undergo a thorough and credible investigation led by a neutral and skilled investigator, in accordance with any applicable University policy. Where no University policy applies to the investigation, the President of the University has the authority, which he/she may delegate, to appoint and charge the investigator, to evaluate the results of the investigation, and to determine the outcome of the investigation.

Addtional resources

• Questions about Covered Programs at the University? Contact the Office of Counsel, Risk Management. 
• Questions about programs at the Medical Center and Affiliates? Contact the Office of Integrity & Compliance: Compliance@URMC.Rochester.edu
• Review frequently asked questions. 
• Need to report an incident? Call the Integrity Helpline at (585) 756-8888 or complete an online report.