Safe Child Program

The Presbyterian Church in Burlington
Safe Child Program

“And they were bringing children to him, that he might touch them; and the disciples rebuked them. But when Jesus saw it he was indignant, and said to them, “Let the children come to me, do not hinder them; for to such belongs the kingdom of God. Truly, I say to you, whoever does not receive the kingdom of God like a child shall not enter it.” And he took them in his arms and blessed them, laying his hands upon them.”
Mark 10: 13-16

As human beings made in God’s image, children are a gift from God and it is the church’s responsibility to ensure that they are treated as such. Adult leaders of children’s and youth programs function as representatives of the church and are therefore responsible for providing an example of God’s loving care to His children. Adults are responsible for providing supervision and modeling adult Christian behavior for the children and youth in their care. They should endeavor to see that the example they set is consistent with the values and expectations of the church community. All leaders must follow the rules and guidelines of the church at all events, thereby providing appropriate supervision of children and youth.

Goals of the Safe Child Program

The purposes and goals of the Safe Child Program are:

  • To provide a safe place for all children and youth to be nurtured in Christian faith.
  • To provide policies and procedures that will give guidance on the issues of child safety.
  • To provide guidance on how to respond to an allegation of child abuse, being sensitive to the needs of the child and the accused in a manner befitting a Christian community.

    The screening section outlines the process to be followed in selecting and approving persons to work with children and youth.

    Application process for persons working with children or youth

  • Primary screening procedures for paid staff and adult volunteers (age 16 and older)
  • All adults (paid or volunteer) who work with children and youth on a regular basis are required to participate in a screening procedure that includes the following components:
  • A screening form – see Appendix A
  • A personal interview – see Appendix B
  • Reference checks – see Appendix C
  • Completion of a criminal records check (CORI, or complete background check) – see Appendix D
  • Secondary screening procedures for occasional volunteers
  • Adults who work with children or youth on an occasional basis such as substitute teachers are required to follow a screening procedure including the following components:
  • A screening form – see Appendix A
    Completion of a criminal records check (CORI)

    The safe child policies and procedures will be reviewed with all adults who undergo the primary and secondary screening process. Those approved to work with children and youth will sign a copy of the Understanding and Approval form (Appendix E) indicating that they have read and understand the policies and procedures of the Safe Child Program, and agree to abide by them.

    Screening Committee
    The Screening Committee is responsible for implementing the screening procedures and maintaining all records in a confidential manner. The committee is a subcommittee of the Christian Education (CE) committee and is composed of a representative from the CE committee (chair), a member of the congregation at large and one member from the Session, Deacons or Trustees. If the applicant is a paid employee, a fourth member will be appointed from the Personnel Committee. Members of the Screening Committee will be approved by the Session annually. The names of the approved members will be recorded in the minutes.

    The Screening Committee will process background checks. Only one member will see the results unless the CORI check has evidence of a conviction. If a paid employee is being screened then the Personnel Chair shall receive the background check information.

    Interviews should be conducted with two Screening Committee members.

    Members of the Screening Committee will serve for one year and on transition, at least one experienced member will continue on the committee for the following year.

    Any person considered for work with children or youth will be referred to the Screening Committee from sources such as, but not limited to, the CE Committee, Worship Committee, Session or Personnel Committee.

    The following positions in the church will be subject to the screening policies and procedures:
    1) Minister

  • Student minister
    3) Choir Director (if responsible for leading a children’s or youth choir)

  • Church schoolteachers
  • Youth group leaders
  • Nursery volunteers
  • Children’s or youth music leaders
  • Members of the Christian Education Committee
  • Drivers of children or youth
  • Others as deemed appropriate

    Refusal to undergo a CORI or complete background check will automatically disqualify a person from working with children or youth, but not from participating in any other church activity.

    The Screening Committee must promptly resubmit requests for CORI or complete background check results that are considered by the person to be in error.

    Following are the kinds of documented criminal convictions that would automatically disqualify a person from working with children or youth:

  • Any crime in which a child was a victim
  • Any crime in which violence was threatened or perpetrated against another human
  • Any crime in which there was public exposure
  • Any crime involving sexual misconduct
  • Any crime involving physical abuse or neglect
  • Any crime in which a firearm or other potentially lethal weapon was involved
  • Driving under the influence of alcohol or drugs (disqualification for transportation of children only – requalification requires a clean 5 year CORI clearance and evidence of graduation from an alcohol or substance abuse treatment program)

    Once the Screening Committee has selected a candidate, the candidate’s name will be forwarded to the Session for approval.

    Screening monitoring process
    The ongoing monitoring of the screening process is the responsibility of the CE committee.


    The supervision section deals with activities, policies and monitoring after the program has started. Policies included here are directed at people who work with children or youth, the congregation, the CE committee, the Session and parents. The supervision section is meant to give guidance and to insure that the program is implemented as intended.

    CE Committee and Session
    The CE committee oversees the implementation and monitoring of the Safe Child Program with the ultimate responsibility belonging to the Session. The CE committee will review the functioning and effectiveness of the Safe Child Program annually, and will recommend changes to Session.

    The CE committee requires registration forms for every child at the beginning of each school year. The information obtained will include but not be limited to: allergies, date of birth, grade in school, health concerns, behavioral issues, and other information the parents would like the teachers to know.

    Session Approval
    The Session will review and approve annually all persons who will work with children and youth, based on the recommendations of the Screening Committee. Interim recommendations will be handled in the same manner. The official list is kept as part of the Session minutes.

    The congregation will be informed about the Safe Child Program in the annual report. It is also recommended that the minister give an annual sermon on the importance of children and our responsibility to protect them from harm.

    Parents or Guardians
    Parents and guardians will be given written copies of the Safe Child Program with a permission form attached. (Appendix E) The parents will be asked to sign the form stating they have read and understand the program and also give the Presbyterian Church in Burlington permission to teach their children in the ways of Christian living. Parents will be informed of any changes to the Safe Child Program.
    The CE committee will collect the permission forms and they will be kept in the office.

    Initial Training
    Anyone who works with children or youth will be required to participate in Safe Child Program Training. The Screening Committee, Response Team, CE Committee and Session will also receive training. Other interested people may take the training as they desire. New church officers, teachers or volunteers will receive training in small groups (five or more) or individually. It is suggested that the training coincide with officer training or the start of the church school year.

    Initial Training should include but not be limited to:
    *An overview of the Safe Child Program with its goals and procedures.
    *Guidance for common situations involving child contact.
    *How to recognize a case of a child being abused or neglected within or outside
    the church
    *Responsibilities of mandated reporters
    *How to respond to an alleged case of child abuse or neglect
    *Support that all who work with children or youth may enlist or expect
    *Dealing with visiting adults in classes
    *Standards of behavior between adults and children and youth

    All trainees will sign a form stating they have read the Safe Child Program and understand it and will abide by it. See Appendix E

    Refresher Training
    For those who have completed initial training, a secondary and shorter training will be conducted every third year for those people requesting CORI or other background checks.

    Training for Youth aides
    Youth aides will be provided with age appropriate training. Youth aide training will be designed for those from grade 4 up to age 16.

    Training for Children
    Educational sessions will be held for children to provide age appropriate information regarding personal safety with respect to the church’s Safe Child Program. This will include identification of persons with whom children can talk if they perceive themselves to be in an unsafe situation. This training is not mandatory, and will happen only with the consent of a child’s parent. Classroom teachers will review the Children’s Code of Conduct with their classes on a regular basis. A copy of the Children’s Code of Conduct is included in this document.

    CE Responsibility
    It is the responsibility of the CE committee to see that properly qualified people perform the training and that there is feedback on its contents from the participants.

    The CE committee will maintain a list of all participants having completed training along with the dates and signed forms.

    Request for Changes
    Teachers and others have the right and obligation to request changes or clarifications in specific aspects of the Safe Child Program. Requests should be made to the CE committee in person or in writing.

    Guidance for Working with Children

    Personal Conduct
    It is expected that adults and youth aides will conduct themselves in a loving Christian manner.
    Teachers, chaperones, and youth aides, shall not drink alcohol, smoke or use recreational drugs, when in charge of children or youth.

    Two Adult rule
    Two adults or one adult and a youth aide will be present for all group activities involving children or youth. At least one adult must be trained.

    The CE committee will have the responsibility of insuring that scheduling people to be 2nd adults or youth aides follows the above rule. Teachers will have the responsibility of informing the CE committee when a second adult or youth aide is missing. The CE committee will maintain an active list of adult helpers.

    If a second adult or youth aide is not available, the activity should be cancelled unless parents are notified and give permission for only one adult to be present.

    Class order will be kept by discipline that is fair and sensitive to the group or child. No child will be disciplined by physical or verbal force. If the situation warrants, parents may be contacted for help.

    Bathroom Situations
    If at all possible children should conduct bathroom activities by themselves. If unable, there are several guidelines to follow. Two adults or one adult and a youth aide can accompany a single child or group of children. If two accompanying adults are not possible, one will be acceptable if that adult informs another adult prior to the trip. All adults or youth aides should be of the same sex as the child.

    Diapering should be performed in the presence of two adults or an adult and a youth aide, unless a parent is present or has given permission otherwise. When children are first enrolled, the parents should be consulted as to what role the nursery volunteers should take when diapering their children.

    No food will be given to any child or youth without the prior permission of that child’s or youth’s parents due to unknown food allergies the child may have.

    At the conclusion of a class or event each child is to be released only to that child’s own parent or to a previously agreed alternate adult.

    Permission Slips
    Parents, prior to any overnight activity in which the parents are not present, will fill out permission slips. The form will include who is in charge of the group, the purpose of the activity, where they are going, the length of the activity and the expected return time. Emergency contact information will be included along with information such as allergies, medications, etc. Permission slips will be kept on file for one year by the activity organizer. See Appendix F.

    In the event of retreats or other off-site activities in which children would be under the care of non-screened people, at least one screened person should be present in all activities.

    Anyone transporting children or youths must meet the following criteria:
    * Possess a valid driver’s license
    * Meet requirements of the state law for driving others.
    * Must not have a drunk driving or substance abuse driving conviction or indictment within the last 5 years with no more than one within the previous 5-10 years. Person must also show evidence of having graduated from an alcohol or substance abuse training session.
    * Have adequate car insurance (adequate means the state mandated minimum)

    Updating Background Checks
    Cori and other complete background checks will be updated every third year or when they expire. Adults and youth aides will be asked annually is there anything that has happened in the past year that would lead a reasonable person to question their ability or appropriateness to continue to work with children or youth. The response to this question will be documented and kept on file. (Appendix A)

    Response Plan
    We believe that it is the responsibility of our church to ensure that the children of the church are cared for in a safe manner. Everyone who is associated with the church and particularly those who work with children or youth should do all that they can to prevent abuse or neglect, but the church needs to be prepared to respond if a case should occur. Reporting and response procedures are critical components in our safe child program.

    The Presbyterian Church in Burlington’s procedures are based upon the following underlying principles:

  • All allegations must be made in writing and are to be taken seriously.
  • Situations must be handled quickly with due respect for people’s privacy and confidentiality.
  • Respect must be shown for alleged victims and alleged abusers. Pastoral care should be made available to all.
  • The alleged victim should not be held responsible.
  • Full cooperation must be given to civil and insurance authorities if appropriate.

    Reporting Responsibilities
    Any adult who interacts with children or youth is obligated to report any alleged incidences of abuse or neglect. According to Massachusetts law, “clergy members, ordained or licensed ministers, leaders of any church or religious body, … persons performing official duties on behalf of a church or religious body that are recognized as the duties of … clergy, ordained or licensed ministers, leaders of any church or religious body, or a person employed by a church or religious body to supervise, educate, coach, train or counsel a child on a regular basis” are defined as mandated reporters.

    See Appendix G, which is a Department of Social Services (DSS) brochure, for a listing of definitions, DSS office locations, phone numbers etc.

    In summary, all adults who are acting in the name of the church or are responsible for the governance of the church are mandated reporters.

    Reportable Incident
    The determination of what constitutes a reportable incident will be made based upon information provided in training. Once someone believes that an incident of abuse or neglect has occurred, he/she should report it to the Response Team or the DSS. The appropriate form (Appendix H) must be completed and submitted to any member of the Response Team by the accuser or a representative of the alleged victim.

    Any individual, at any time, may report an incident directly to DSS or to the Response Team.

    Guidelines for the Response Team
    If a fully filled out written report (Appendix H) is received by the Response Team, it should be forwarded to DSS and the insurance company unless the Response Team determines it is not a reportable incident. If DSS subsequently screens out the report or fails to follow up on the allegation in a timely manner, then the Response Team must follow up and make recommendations for actions.

    The Response Team shall be appointed by Session and shall be comprised of three members from the following: Session, Deacons, Trustees and the general congregation. There shall be at least one male and one female on the Response Team. In addition, one person will be designated as an alternate. In the event the accused is a member of the Response Team, the alternate will replace the accused. In the event a conflict of interest or other non-routine situation may occur involving one member, the Response Team will use the alternate. The names of the members of the Response Team will be posted throughout the church building and regularly publicized.

    Members of the Response Team will serve for one year, and on transition, at least one experienced member will continue on the committee for the following year. An exception is if the Response Team has an ongoing allegation in progress.

    Duties of the Response Team:
    The Response Team’s formal proceedings will include but not be limited to the following:
    Meet within 24 hours following receipt of a Report of Unusual Incident (Appendix H). This meeting may be held by telephone conference.

    If applicable, inform civil authorities and the insurance company. The Response Team must first inform the insurance company if a report is being referred to DSS and then inform the accused that the report is being filed with authorities. If the alleged offender is a minor, the Response Team may consider discussing the report with the parents of the alleged offender prior to calling DSS or the police.
    3. Inform the minister that the Response Team has received a report and of the individuals and circumstances involved.
    4. Treat both the accused and the alleged victim with dignity and support.
    5. The accused person should be temporarily relieved of duties or removed from class participation until a resolution is found.
    6. Inform all parties that pastoral counseling is available.
    7. Make sure that the accused and accuser are advised regarding
    steps for instituting formal PC(USA) disciplinary processes.
    The Response Team determines a timeline for action(s) and monitors implementation of actions.

    If DSS decides to screen out the incident or the Response Team deems the incident is not reportable, then the Response Team will recommend action to the Session. In instances of child-on-child offenses, options for action may include meeting with parents; meeting with parents and child; appointing a non-parental aide or supervisor for the child; an apology from the offender to the offended, etc.
    Document all activities and deliberations.

    Response Team Consultations
    The Response Team may confer with pre-approved outside consultants, the DSS, or the insurance company lawyers for advice on actions. Confidentiality must be maintained when conferring with outside consultants. The CE committee will designate the consultant(s) outside persons. The insurance contact is our agent Dan Podolsky (508-476-4488) or the claims department of Church Mutual (800-554-2642). Failure to promptly notify the insurance company of an allegation could jeopardize our coverage.

    Possible actions of Response Team are listed but not limited to
    The Response Team has several options to recommend as action:
    Inform the insurance company.
    Inform DSS.
    Inform the police.
    Broker a mutually acceptable resolution for incidents clearly not reportable to DSS.
    Refer a minister to Presbytery for disciplinary action via the Stated Clerk of Presbytery.
    Refer a church member to the Session Moderator for disciplinary action.
    Recommend counseling or pastoral care to all parties involved.
    Temporarily remove a person from a role involving child contact. Permanent removal may be recommended to Session.
    Temporarily remove a child or youth from a class or other activity. Permanent removal may be recommended to Session.

    Record keeping
    The Response Team will keep all records confidential, including detailed records of its actions and minutes of its deliberations and its conversations with the accuser, accused and other parties involved. No discussion of its activities shall be shared with anyone outside of the Response Team except the minister, nor shall anyone be provided with any of its records absent an order of the Court or appropriate civil or ecclesiastical authorities. Closed files shall be marked “Confidential” and be under the supervision of the Session.

    Designated Church Spokesperson
    The Minister shall be designated to speak to the press, community, or congregation if any allegations are made public. The Minister would make use of a prepared statement, which stresses that the church has a formal Safe Child Program with policies and procedures to cover allegations of child abuse and neglect. The program is in place and the church is following the procedures. If the Minister is unable to be the spokesperson, then the responsibility falls to the Clerk of Session.

    Church Governing Body
    In the church, judicial responses to alleged abuse are relegated to the Session (in the case of church members) and the Presbytery (in the case of ministers), according to the Rules of Discipline in the Constitution of the Presbyterian Church (U.S.A.) Part II. The Response Team should consult with the Session Moderator in the case of church members, and with the Stated Clerk of the Presbytery in the case of ministers.

    The Response Team can also pursue actions through documented procedures in the Book of Order and Rules of Discipline through the Clerk of Session or the Stated Clerk of the Presbytery.

    Response will vary according to the status of the accused. Church members and ministers are subject to inquiry and discipline under the Book of Order. The minister serving congregations is subject to oversight by the Presbytery.

    Appendix A
    Screening Form for Work with Children or Youth
    The Presbyterian Church in Burlington

    This application is to be completed by all applicants for any position (volunteer or compensated) involving the supervision of children or youth. The information requested on this form is used to help our church provide a safe and secure environment for all children and youth who participate in our programs and use our facilities.


    Last First Middle

    Address: _________________________________________________________

    City: ______________________________ State: ________________________

    Zip: __________ Home phone: ____________________

    Please indicate the type of youth or children’s work you prefer: ________________________________________________________________

    Please indicate the date you would be available to begin:______________

    What is the minimum length of commitment you can make? ________________

    Have you ever been convicted or pleaded guilty to any of the following:

    Any crime in which a child was a victim _____
    Any crime in which violence was threatened or perpetrated against another human ______
    Any crime in which there was public exposure ______
    Any crime involving sexual misconduct _______
    Any crime involving physical abuse or neglect of another person _______
    Any crime in which a firearm or other potentially lethal weapon was involved _______
    Driving under the influence _______
    If so, please explain. (You may attach a separate page if necessary.) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    Do you have a current driver’s license? ______
    If so, please list your driver’s license number ____________________________
    Do you hold current and appropriate vehicle insurance? _______

    Church History and Prior Youth Work

    List all previous church work involving youth (Please include the church’s name and address, type of work performed and dates ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    List all previous non-church work involving youth (Please include each organization’s name and address, type of work performed and dates) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    List any gifts, callings, training, education or other factors that have prepared you for work with children or youth ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    Personal references

    Please list people we may contact who know you well (not relatives)

    Name ________________________________________________________

    Address ______________________________________________________
    Phone ___________________

    Name _______________________________________________________

    Address _______________________________________________________
    Phone ___________________

    Name __________________________________________________________

    Address ________________________________________________________
    Phone ____________________

    Applicant’s Statement

    The information contained in this application is correct to the best of my knowledge. I authorize the Presbyterian Church in Burlington to contact any references or churches listed in this application.

    I (check one):
    __do not waive
    any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

    I agree to be bound by the Bylaws and policies of the Presbyterian Church in Burlington, and to be guided by scripture in the performance of my services on behalf of the church.

    Applicant’s signature ________________________Date____

    Appendix A
    Yearly Update Questionnaire for Persons Working with Children or Youth

    During the past year nothing has happened in my life that would cause a reasonable person to question my capacity or appropriateness to continue working with children or youth at the Presbyterian Church in Burlington.

    Signed______________________________ Date________

    Print Name_________________________

    Interviewer _____________________________

    Appendix B

    Personal Interview Form for Persons Working with Children or Youth
    The Presbyterian Church in Burlington


    Name of applicant ________________________________________________

    Person conducting interview _______________________________________

    Date of interview ____________

    1) Why are you interested in working with children or youth in our church? ________________________________________________________________________________________________________________________________________________________________________________________________

    What type of work with children or youth are you most interested in? __________________________________________________________________________________________________________________________________________________________________________________________

    What experiences or training do you feel has prepared you for work with children or youth? __________________________________________________________________________________________________________________________________________________________________________________________

    4) If the candidate has listed previous church work or work with other organizations – Tell me about the work you did at ______. What were your principal responsibilities? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    5.Next, I need to verify some of the information indicated on your screening form.
    Have you ever been convicted or pleaded guilty to any of the following:
    Any crime in which a child was a victim _____
    Any crime in which violence was threatened or perpetrated against another human ______
    Any crime in which there was public exposure ______
    Any crime involving sexual misconduct _______
    Any crime involving physical abuse or neglect of another person _______
    Any crime in which a firearm or other potentially lethal weapon was involved _______
    Driving under the influence _______

    If the candidate answers in the affirmative to any of the above questions, please note the explanation given. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    6) Is there anything in your past history that would lead a reasonable person to question your ability or appropriateness to work with children or youth?___________________________________________________________________________________________________________________________________________________________________________________________

    Appendix C

    Reference Contact Form
    The Presbyterian Church in Burlington


    Name of applicant ________________________________________________

    Person contacting the reference ____________________________________

    Church and/or person contacted ________________________________________________________________ Date and time of contact ________________________________________________________________
    Method of contact (phone, letter or e-mail, personal interview)
    _____________________________ ________________________________________________________

    How long and in what capacity have you known the applicant?
    Have you observed him/her interacting with children or youth?
    How would you describe his/her behavior in those situations?

    How would you describe the applicant’s character?
    Do you have any concerns about the applicant’s ability to supervise or teach children or youth?
    Do you have any knowledge of the applicant’s having any allegations of child abuse?
    What do you see as the applicant’s strengths or weaknesses in regards to working with children or youth?
    Would you recruit him/her to be a teacher or youth leader?

    Do you know if the applicant has ever been convicted of any crime or DUI?
    If so, please explain ___________________________________________
    Is there anything else that would be helpful for us to know?

    Summary of conversation (summarize the reference’s or minister’s remarks concerning the applicant’s fitness and suitability for work with children or youth) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
    Signature _______________________________________________________
    Appendix E
    Understanding and Approval Form
    Presbyterian Church in Burlington

    I __________________________ have read and understand the
    Print Name

    Safe Child Program of the Presbyterian Church in Burlington and will abide by its policies.

    1) Signed____________________________ Date_______
    parents, volunteers, employees

    If applicable
    I authorize the Church and its designated adults and youth aide volunteers to teach my children in the Christian Education Programs.

    2) Signed _______________________ Date________
    parents only


    Parents sign on lines 1 & 2
    Others just sign on line 1

    Did we miss anything that affects the safety of your child that should be added to the Safe Child Policy? Please specify.

    Appendix F
    Permission Form
    Safe Child Program
    Away from Church or Overnight Activities

    The Presbyterian Church in Burlington will be sponsoring an activity away from the church or an overnight activity at the church.

    Nature of Activity


    Person(s) in Charge


    Time of Departure

    Mode of Transportation

    Expected Time of Return

    Place of Return

    Special items of interest to know about your child such as allergies, needed medicines, or limitations, etc.

    I give my permission for ___________________________________________________
    Name child(ren)

    Signature ____________________________________Date_______

    Print name ______________________

    Appendix G
    DSS Area Office Directory
    Central Office 24 Farnsworth St. Boston, MA 02210

    Ask for the protective screening unit
    Malden 781-388-7100
    Framingham 508-424-0100
    Cambridge 617-520-8700
    Arlington 781-641-8500
    Lowell 978-275-6800
    Lawrence 978-557-2700
    Haverhill 978-469-8800
    Lynn 781-477-1600

    Appendix H

    Presbyterian Church in Burlington
    Report of Unusual Occurrence


    To be filled out by a witness, child representative or other accuser of any allegation of abuse or neglect.

    Please complete report within 24 hours of the occurrence and give to a member of the Response Team.

    Date: ___________________

    Name of child or youth: _________________________________________________

    Name of Reporter: _______________________________________________

    What is the nature and extent of the alleged incident?
    Please include specifics such as name(s) of accused, date, time and location.

    What are the circumstances under which the reporter became aware of the alleged incident? Include names of witnesses, if any.

    Please give other information which you think might be helpful in establishing the cause of the alleged incident and/or the person responsible for it. Please provide the name(s) of the alleged perpetrator(s).

    What action has been taken thus far by those involved?

    Signature of Reporter ____________________________ Date ____________

    Signature of Receiver ____________________________ Date ____________

    Finding of the Response Team:

    Action(s) recommended:

    Follow up monitoring to ensure actions completed