Sex Offender Supervision Activity Request Safety Plan

1. How are you going to avoid unnecessary physical contact with a minor?

2. How are you going to avoid being left alone with a minor?

3. How are you going to avoid using the bathroom with a minor?

4. How are you going to avoid unnecessary conversations with a minor?

5. How will you avoid looking suspicious?

6. How will you avoid accusations?

7. What is your escape plan?

8. What are your chaperone’s responsibilities?

Offender’s Signature Date

Chaperone’s Signature Date