WV SAFETY ASSESSMENT AND MANAGEMENT SYSTEM In-Home Safety Plan

Referral Name Worker Name FACTS Referral # Date

Thoroughly describe how each identified impending danger is occurring within the family including when, 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:

Safety Resource Name, Address, phone Specific Impending Danger(s) addressed Activity

Yes____
Frequency

No____
Begin Date

SAMS Revised 8-22-09

Thoroughly explain how each identified Safety Resource, both formal and informal, will control impending dangers below.

Child Protective Services has the responsibility of monitoring the in-home safety plan as well as collaboration/coordination with all safety services providers whether formal or informal. Explain in detail how this was accomplished, future activities that will occur to ensure the safety plan is appropriate.

SAMS Revised 8-22-09

Safety Plan Review: This plan will be reviewed every ________ days or when circumstances warrant. The next scheduled review will be on ____________________. The review will include the family, formal and informal safety service providers and the Department. At that time changes to the services may be made. 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, we understand its contents and that it is voluntary, and agree to abide by the terms and conditions of the plan. If something happens which prevents us from carrying out the plan we will immediately notify the CPS Social Worker. IF the CPS Social Worker is unavailable, we will notify the supervisor. We understand that failure to agree to the plan or carry out the plan may result in a reassessment of my home and possible protective custody and or referral to the Prosecuting Attorney for a court order to remove my children from my home. I will then have the opportunity to plead my case in court. Parent/Caregiver_____________________________________Date________________________ Other Parent/Caregiver _______________________________ Date________________________ Formal and Informal Safety Resource(s) responsible for carrying out the safety plan ___________________________________________________Date________________________ ___________________________________________________Date________________________ ___________________________________________________Date________________________

Supervisor approval: __________________________________Date________________________

Signature

SAMS Revised 8-22-09