WV SAFETY ASSESSMENT AND MANAGEMENT SYSTEM CONTINUING SAFETY EVALUATION

Family Name (referral name): Address: Assigned Worker: FACTS Referral/Case Number: Contact Phone: Date Completed:

Point in SAMS process when used: ______ Family Functioning Assessment approved but case not transferred ______ New Referral on open case ______ Significant event or change in family circumstances during Ongoing CPS ______ In conjunction with Case Plan Review ______ Prior to Reunification Section A. Information Gathering and Safety Evaluation. Gather and explore all information related to the significant event or change in the family situation; as well as any other concern for the childs safety. Additionally, gather any new information relating to the six categories of information. Document all information in the text box below.

Related Impending Danger Threats:

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Based on information gathered and documented above, indicate Yes Impending Danger exists or No Impending Danger does not exist. Remember to refer to the definitions of each of the eleven (11) impending danger threats and application of the Danger Threshold in the West Virginia Safety Assessment and Management System. Yes ____ No____ Living arrangements seriously endanger a childs physical health. Yes ____ No ____ Family does not have resources to meet basic needs. Yes ____ No ____ One or both caregivers intend(ed) to hurt child. Yes ____ No ____ Child is perceived in extremely negative terms by one or both caregivers. Yes ____ No ____ The caregiver is unwilling or unable to perform parental duties and responsibilities, which could result in serious harm to the child. Yes ____ No ____ One or both caregivers fear they will maltreat child and/or request placement. Yes ____ No ____One or both caregivers lack parenting knowledge, skills, or motivation which affects child safety Yes ____ No ____ The caregivers drug and/or alcohol use is pervasive and threatens child safety. Yes ____ No ____ One or both caregivers are violent; this includes Domestic Violence and General Violence. Yes ____ No ____ One or both caregivers cannot control behavior.

Yes ____ No ____ Child has exceptional needs which the caregivers cannot or will not meet.

SECTION B: CONCLUSION (SAFETY DECISION)

The Child(ren) is/are safe (because) no impending dangers were identified.

Based on specific case information, explain how the enhanced caregiver protective capacities ensure child safety below.

If a safety plan has been in place, discuss the decision with the family and take steps to remove the safety plan, taking all steps necessary including discussion with family members and any court action that may be necessary. Detail the actions in the text box below.

The Child(ren) is/are unsafe (because) one or more impending danger threats were identified.

Based on specific case information, explain below how the diminished caregiver protective capacities affect child safety.

Conclusion Check the action indicated. A. _______ Child(ren) in the household were identified as UNSAFE. Proceed to Section C, Safety Analysis and Planning. There were no children in the household identified as unsafe. Steps and actions will occur to process the family towards case closure paying attention to the need to consider any current safety or treatment focused services; and the familys need for case closure to proceed in an orderly manner. Proceed to Section D.

B. _______

SECTION C: SAFETY ANALYSIS AND PLANNING

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Complete safety analysis and planning on all cases where children are identified as unsafe and in need of protection. This establishes reasonable efforts and rationale for the type of safety plan developed (inhome safety plan or out of home safety plan-placement). You must staff the case immediately with a supervisor to determine the next steps. Justify any case specific information for any/all no and yes determinations: Justification for the use of an In-Home Safety Plan or the need for Out of Home Placement (Safety Plan): ____YES _ _NO The caregivers are willing for an in-home safety plan to be developed and implemented and have demonstrated that they will cooperate with all identified safety service providers. The home environment is calm and consistent enough for an in-home safety plan to be implemented and for safety service providers to be in the home safety. Safety services are available at a sufficient level and to the degree necessary in order to manage the way in which impending danger is manifested in the home. An in-home safety plan and the use of in-home safety services can sufficiently manage impending danger without the results of scheduled professional evaluations. The caregivers have a residence in which to implement an in-home safety plan. (this could include shelter, friend/relatives home, etc)

____YES _ _NO

____YES _ _NO

____YES _ _NO

____YES _ _NO

If the answer is NO to any of the safety analysis questions then the determination is that an in-home safety plan CANNOT sufficiently control impending danger and assure child safety. Any NO response indicates the need to pursue the use of an out of home safety plan (placement) and/or the determination that child(ren) must remain in placement. If the answers to the questions are yes, proceed with the development of an in-home safety plan or if there is a current in home safety plan and it remains appropriate document the reasons the current plan is still appropriate and can control the impending danger threats in the text box below.

Out of policy actionThe safety analysis confirmed the need for an out of home safety plan however the petition was either dismissed by the judge or the prosecuting attorney refused to represent the department. Please describe below the actions taken to ensure safety of the child, including the results of the Prosecuting Attorney Dispute resolution located in 49-6-10a.

SECTION D: APPROVAL OF SAFETY EVALUATION

The Safety Evaluation policies were followed: Yes/No/ Is the safety plan appropriate given the identified impending dangers, protective capacities and child vulnerabilities? Yes/No/ Are necessary parties to the safety plan in agreement and capable of assuring the childs safety? Yes/No/
Supervisory Approval of the Safety Evaluation, Safety Conclusion, and Safety Plans if appropriate: _________________________________________ Signature _____________________________ Date

Revised 08/17/2012