Active Supervision Policy Acknowledgment Form
Please complete this form to confirm your understanding and commitment to the Active Supervision Policy.
Full Name
*
First Name
Last Name
Job Title / Role
*
Department or Location
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How familiar are you with the Active Supervision Policy?
*
Not familiar
1
2
3
4
Very familiar
5
1 is Not familiar, 5 is Very familiar
Please rate your confidence in implementing active supervision strategies in your daily responsibilities.
*
1
2
3
4
5
Which of the following are key components of Active Supervision? (Select all that apply)
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Positioning yourself to see all children
Scanning and counting children regularly
Engaging with children during activities
Using mobile phones during supervision
Responding promptly to potential hazards
Other
Scenario Assessment: What steps would you take if you noticed a child wandering away from the supervised area?
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Active Supervision Practices Assessment
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Rows
Never
Sometimes
Always
I position myself so I can see all children.
1
2
3
I regularly scan and count children in my area.
4
5
6
I minimize distractions while supervising.
7
8
9
I intervene immediately when I see unsafe behavior.
10
11
12
Do you have any suggestions or feedback regarding the Active Supervision Policy?
Signature (Please sign below to confirm your acknowledgment)
*
Submit
Submit
Should be Empty: