Office of Community Services SAFETY ASSESSMENT

PROGRAM: CPI INVESTIGATION FAMILY SERVICES

NAMES OF ALL CARETAKERS/POTENTIAL CARETAKERS

PRIMARY CLIENT/CASE NAME: REASON FOR ASSESSMENT:

RELATIONSHIP FAMILY OR FACILITY ID# DATE ASSESSMENT INITIATED

Caretaker Potential Caretaker CHILDS NAME / Age / Race / Sex

SAFETY FACTOR 1. 2. 3. 4. Caretakers behavior is violent or out of control. Information supporting safety factor: Caretaker describes or acts toward child in predominantly negative terms or has extremely unrealistic expectations. Information supporting safety factor: Caretaker caused, or has made a plausible threat, that has or would result in serious physical harm to the child. Information supporting safety factor: Caretaker refuses access to the child, the childs whereabouts cannot be ascertained and/or there is reason to believe that the family is about to flee. Information supporting safety factor Caretaker has not, or will not, provide sufficient supervision to protect child from potentially serious harm. Information supporting safety factor: Caretaker has not, or is unable to meet the childs immediate needs for food, clothing, shelter, and/or medical care. Information supporting safety factor: Caretaker or other person having access to the home/facility has previously harmed a child, and the severity of the harm, or the caretakers prior response to the incident, suggests that the childs safety is an immediate concern. Information supporting safety factor: Child is fearful of or in danger from caretaker(s), other family members, or other people in or having access to the home or facility. Information supporting safety factor: Childs physical living conditions are hazardous and may cause serious harm. Information supporting safety factor: Child sexual abuse is suspected and circumstances suggest that child safety may be an immediate concern. Information supporting safety factor: Caretakers drug or alcohol use seriously affects his or her ability to supervise, protect, or care for the child Information supporting safety factor: Caretakers physical or emotional health status seriously affects his or her ability to supervise, protect, or care for the child. Information supporting safety factor: Domestic violence present in the home/facility places a child in imminent danger of moderate to severe harm Information supporting safety factor: Caretakers explanation for the injury or harm is unconvincing and/or they deny the injury/harm. Information supporting safety factor: Other (specify) Information supporting safety factor:

PRESENT Yes Yes Yes Yes No No No No

5. 6. 7.

Yes Yes Yes

No No No

8.

Yes

No

9. 10. 11. 12.

Yes Yes Yes Yes

No No No No

13. 14. 15.

Yes Yes Yes

No No No

SAFETY DECISION SAFE UNSAFE No child is considered to be in immediate or impending danger of serious harm; or, a child would be considered safe, if placed with this caretaker. A child is in present or impending danger of substantial harm from abuse/neglect; or, would be unsafe if placed with this caretaker. OCS Form 5 Revised: 6/09 Replacing: 11/05

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PRIMARY CLIENT/CASE NAME:

FAMILY/FACILITY ID:

CONTROLLING INTERVENTIONS/REASONABLE EFFORTS CHECKLIST 1. Use of family/facility resources, neighbors, or other individuals in the community as safety resources. 2. Use of community agencies or services as safety resources. 3. Alleged perpetrator will leave the home or facility, either voluntarily or in response to legal action. 4. Non-maltreating caretaker will move to a safe environment with the child. 5. Other : 6. Legal action must be taken to place the child(ren) outside the home or facility. IMMEDIATE SAFETY PLAN (Specify who will do what, when, where, and what time frame for what children)

Workers Signature Reviewing Workers Signature

Date Date

Supervisors Signature Reviewing Supervisors Signature

Date Date

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OCS Form 5 Reissued: 6/09 Replacing: 11/05