SAFETY ASSESSMENT AND MANAGEMENT SYSTEM

OUT-OF-HOME SAFETY PLAN

Referral Name Worker Name

FACTS Referral # Date

This plan is to be used when Safety Responses/ Safety Services cannot be provided to the family in the home at a level needed to control the impending danger and custody is being sought or has been ordered. Thoroughly describe how each identified impending danger is occurring within the family including when (time of day), how often, under what circumstances, other influences that are involved, and caregivers access to the child(ren).
Impending Danger(s) # Description (Family Specific)

This plan replaces a current Protection Plan:

Yes____

No____

Placement Information:
Explain how the placement meets the child/childrens Safety Needs, including any background checks, kinship/relative safety screen completed and other steps taken to ensure the placement is safe and appropriate.

Initial Visitation Plan:

Type

(Can include telephone and electronic contacts) Who Where How Often

WV SAMS Revised 8-22-09

If no visitation is planned, please provide detailed explanation:

What will be the next steps in the court process? Include attorney information, MDT date, and next hearing date if known.

Review of Plan:
This plan will be reviewed by the MDT Treatment Team operating in conjunction with the Court. Change in custody status will be determined by the Court.

Out-of-Home Safety Plan Approval

I have discussed the attached Safety Plan and the consequences of non-compliance with the caregiver and all those who are responsible for carrying out the plan. I have their agreement to abide by the terms and conditions of the plan: CPS Social Worker___________________________________________________________Date_______________________ CPS Social Workers Phone #___________________________________________________ Supervisors Name and Phone #_________________________________________________ I/we have discussed the safety plan with the CPS Social Worker and understand its contents. I understand I will have the opportunity to present information to the court. Parent/Caregiver______________________________________________________________ Date_______________________ Other Parent/Caregiver_________________________________________________________ Date_______________________ Kinship/Relative Placement Provider:_____________________________________________________________________Date_______________________ Supervisor approval required prior to removal, (signature or verbal) unless emergency circumstances warrant. Supervisory Approval: Supervisor gave verbal approval by phone _______________________________ Date_______________ Time_________________ Supervisors Approval of written plan ___________________________________ Date__________ _____ Time_________________

WV SAMS Revised 8-22-09