Date 12/17/2009 IDAHO DEPARTMENT OF HEALTH AND WELFARE CHILD AND FAMILY SERVICES

PART A - SAFETY ASSESSMENT

Referral Date: Region: Priority: Date Child Seen: Family Name: Worker Name: Presenting Issue #: Time Child Seen: Family ID: Worker ID: Assessment ID:

Instructions: Complete this form within 30 days after first seeing the child.

CPS History Review (FCSIS & FOCUS) Safety Summary Narrative: Worker: Date:

( ) Family has prior referrals

Time:

SECTION 1: SAFETY ASSESSMENT

Directions: The following factors are behaviors or conditions that may be associated with safety threats to a child(ren). These threats involve both present and emerging danger. This assessment will include all children in the family who are identified as being at risk. Consider the effects that adults who have access to them could have on their safety. Identify each factor by checking 'yes' when the information currently available indicates a clear presence of the safety factor, 'No' when the information currently available does not indicate presence of the safety factor, or 'Inconclusive' when the information currently available is insufficient or contradictory.

# 1 2

Yes

No

Incon.

Question Caregiver or alleged offender's behavior is violent and/or out of control. Caregiver or alleged offender describes or acts toward child in predominantly negative terms or has extremely unrealistic expectations given the child's age or level of development. Comment: Caregiver or alleged offender causes harm or has made a plausible threat of harm to the child. Child is fearful of people living in or frequenting the home. Child sexual abuse is suspected and circumstances suggest that there may be immediate risk of harm to child. Caregiver or alleged offender has not, will not, or cannot provide sufficient supervision to protect child from immediate risk of harm. Comment: Death of a sibling or other child in the household has ever occurred due to abuse/neglect or uncertain circumstances.

3 4 5 6

SAFETY ASSESSMENT

8 9 10 11

Caregiver or alleged offender had parental rights terminated previously due to abuse or neglect. Child has positive toxicology from drugs or alcohol. Alleged offender may have previously abused/neglected this child/children and now has unrestricted access to child. The current alleged abuse or neglect is severe and suggests that there may be immediate and urgent risk to the child. Comment: Caregiver or alleged offender's alleged or observed drug or alcohol use may seriously affect his/her ability to supervise, protect, or care for the child. Caregiver or alleged offender may be a victim of family violence which affects caretaker's ability to care for and/or protect child from immediate harm. There is a pattern of escalating severity of harm. Comment: Child's whereabouts cannot be ascertained and/or there is reason to believe that the family is about to flee or refuses access to the child. Comment: Caregiver or alleged offender has not or is unable to meet the child's immediate needs for food, clothing, shelter, and/or medical care; the child's physical living conditions are hazardous and may cause harm. Comment: Caregiver, alleged offender, or child has a severe and/or chronic mental or physical illness or disability and current supports are not in place to ensure child safety. Other risk of immediate harm (specify in comment area).

12 13 14 15

16

17 18

Child Characteristics

# 1 2 3 4 Vulnerability/Lack of Self-Protection Skills/Special Needs. Comment: Behavior Problems. Comment: Previously been placed outside the home. Comment: Other (specify in comment area). Comment: Collaterals

Yes

No

Incon.

SAFETY ASSESSMENT

SECTION 2: SAFETY DECISION

Directions: Identify your safety decision by checking the appropriate box below. (You may check more than one box if different safety decisions apply to different children.) This decision should be based on the assessment of all threats of present or emerging danger and any other information known about this case

() () ()

A. Safe: B. Conditionally Safe: C. Unsafe:

There are no threats of present or emerging danger that could cause the child(ren) to be seriously harmed. A plan is being implemented to resolve the safety threats identified at the present time. One or more child(ren) is in imminent danger (requires placement)

SECTION 3: IMMEDIATE PROTECTION/SAFETY PLAN

Describe the immediate protection plan as follows: - what actions have or will be taken to protect each child in relation to current threats of present or emerging danger : and - who is responsible for implementing each plan component: and - how the plan will be monitored and by whom - address the role of family strengths (including extended family) and mitigating circumstances in the plan - address services and/or adaptive supports that could be put in place to assist a family member who has a disability Safety Plan Narrative:

Worker:

Date:

Time: Yes ( ) No ( ) If 'No' explain, if 'Yes' provide the date:

Was the interview with the child taped? Comment: Has the referring party been recontacted? Comment:

Yes ( )

No ( ) If 'No' explain, if 'Yes' provide the date:

If there is no court action, is the family willing to participate in a voluntary service plan?

Yes ( ) No ( ) N/A ( )

SAFETY ASSESSMENT

48 Hour Review for Children Ages 6 and Under:

SECTION 4: ASSESSMENT DECISION, CASE STATUS, AND DISPOSITIONAL STATEMENT

CASE STATUS (check one) ( ) Case remains open ( ) Case closed with supervisory approval ( ) Unable to locate family

PART B COMPREHENSIVE ASSESSMENT SHALL BE COMPLETED WHEN SAFETY THREATS ARE IDENTIFIED, AND THE CASE REMAINS OPEN FOR SERVICES: DISPOSITIONAL STATEMENT IS NOT REQUIRED IF A PART B COMPREHENSIVE ASSESSMENT WILL BE COMPLETED

Dispositional Statement If Substantiated, Date Notification letter sent: Child Name Suspect Name Reason Date Disposition Rmvd Frm Cntrl Reg

Disposition Narrative:

SECTION 5: SIGNATURES/DATES
Safety Assessment Review Due Date: Staff: Date:

Worker: _______________________________________________________ Date: ______________________________ Supervisor: _____________________________________________________ Date: ______________________________

SAFETY ASSESSMENT