Agency Name Chapter No./Name Part No./Name Section No.

/Name Dates

Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

FORM 5 SAFETY ASSESSMENT PURPOSE: To document the initial assessment of the safety (current danger of serious physical harm which may require a protecting intervention) to the alleged child victims at the time of the initiation of a Child Protection Investigation, if needed prior to entering the safety assessment into ACESS. To document the initial assessment of safety *in a** Family Services case *for cases accepted in FS without an investigation.** To document the shared decision-making between the worker and the supervisor concerning the safety assessment and, when indicated, the safety plan. To document the review of a safety *assessment and safety plan** when the case is transferred to FS. To document the safety of a potential caretaker *** being considered as a potential *placement resource.**

***

PREPARATION: The form is completed in single copy prior to or with the supervisor during the discussion of safety for each child after the initiation of *applicable types of** Child Protection Investigations if it is completed prior to entering the investigation case into ACESS. Only one form is used to document the safety assessment for a family/household, therefore, each caretaker and child is identified on the form. When it is entered in ACESS, one assessment may be completed for all the children for whom the safety factor responses and safety decision are the same. A separate one must be completed in ACESS when any safety factor responses are different for an individual child. The form is completed whenever a child is removed and policy specifies that the FS worker is responsible for an initial assessment of the home. A separate form is completed in single copy for each potential placement resource. *** The assessment will consider the safety of each child should they be placed in the home of the potential resource. When the worker and supervisor discussion of the safety assessment occurs by phone, the worker or supervisor completes the form either during the discussion or as soon as possible thereafter. For cases in which the form is completed during an in-person discussion or conference with the supervisor, the form is completed by the worker or supervisor during the conference.

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Agency Name Chapter No./Name Part No./Name Section No./Name Dates

Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

A new safety assessment form must be completed by the Family Services worker *in the following circumstances: FS safety assessment review indicates either a change with safety factors and/or safety decision from the safety assessment conducted during the investigation A safety plan must be developed A safety plan must be significantly modified**

When there is no change in the safety assessment or safety plan for those cases with a plan, the Family Services worker and supervisor may complete the reviewing worker and supervisor *signature and date to document concurrence with the assessment/plan.** Program: The program in which the case is active is identified by a check mark in the box to the left of the appropriate program. Primary Client/Case Name: Enter the case name (primary client for CPI ACESS case *or case name for FS family**) for the family or facility in this section. The primary client/case name is also entered on Page *2.** Reason for Assessment: The policy requirement or other reason for the safety assessment is identified in this section. Examples include but are not limited to the following: Initial CPI safety assessment Assessment of a potential caretaker Initial FS safety assessment Change in family circumstances with concern for safety Names of all Caretakers/Potential Caretakers: The current caretaker or potential caretaker being assessed is identified in this item. When there is more than one caretaker in the family, each caretakers name is entered. When more than one caretaker in a facility is included in the assessment, each caretakers name is also entered. For cases in which the child is in a temporary location such as the hospital, the childs safety with the caretaker in the home is assessed and documented on the form. Relationship: The relationship as a current or potential caretaker is identified with a check mark in the appropriate box . Family or Facility ID#: The family, facility or individual TIPS number for the person whose name is used as the case name is entered in this space. Date Assessment Initiated: The date the worker initiated the assessment is entered in this space. This is usually the date of the initial CPI or FS contact with a child in the family or facility.

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Agency Name Chapter No./Name Part No./Name Section No./Name Dates

Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

Childs Name, Age and Sex: Complete with each childs full name, age and sex *for whom** safety is assessed *with** a current or potential caretaker. Safety Factor: The safety factor section is completed with information the worker has obtained about each of the 14 factors, and when appropriate, the Other safety factor category. The following are examples of each of the safety factors/concerns. They are not complete descriptions of all possible circumstances for each factor. The presence of any of these examples does not necessarily mean that a child is unsafe. Rather, these examples serve as red flag alerts that the child may be unsafe. Consider such *circumstances** as the vulnerability of the child, *parent/caretaker protective capacities** and the recency of the behavior in determining*the presence of a safety concern..** 1. Caretakers behavior is violent or out of control. Extreme physical or verbal, angry or hostile outbursts at child. Use of brutal or bizarre punishment (e.g. scalding with hot water, burning with cigarettes, forced feeding). Use of guns, knives, or other instruments in a violent way especially without regard for the safety or welfare of the child. Violently shakes or chokes baby or young child. Behavior that seems out of touch with reality, fanatical, or bizarre. Behavior that seems to indicate a serious lack of self-control (e.g. reckless, unstable, raving, explosive.) History or current pattern of violence towards others, maltreatment of a child, pattern of victimization of children, or is a danger to the point that places the child in immediate danger. Caretaker describes or acts toward child in predominantly negative terms or has extremely unrealistic expectations. Describes child as evil, stupid, ugly, or in some other demeaning or degrading manner. Curses and/or repeatedly puts child down. Scapegoats a particular child in the family. Expects a child to perform or act in a way that is impossible or improbable for the childs age (e.g. babies and young children expected not to cry, expected to be still for extended periods, be toilet trained or eat neatly, expected to care for younger siblings, expected to stay alone). Child is seen by either parent as responsible for the parents problems, the family problems, or as a burden to the parent/family. Caretaker caused or has made a plausible threat that has or would result in serious physical harm to the child. Caretaker has stated that he/she will harm the child. Other than accidentally, caretaker caused abuse or injury (e.g. fractures,
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2.

3.

Agency Name Chapter No./Name Part No./Name Section No./Name Dates

Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

poisoning, suffocating, shooting, burns, bruises/welts, bite marks, choke marks, etc.). An action, inaction, or threat that would result in serious harm (e.g. kill, starve, lock out of home, etc.). Plans to retaliate against child for the investigation. Caretaker has used torture or physical force which bears no resemblance to reasonable discipline, or punished child beyond the duration of the childs endurance. One or both caretakers fear they will maltreat child and/or request placement. There has been an act of maltreatment in which a weapon or object was used to inflict or threaten harm with a weapon and suggests the child is in immediate danger.

4.

Caretaker refuses access to the child, the childs whereabouts cannot be ascertained or there is reason to believe that the family is about to flee. Caretaker refuses to allow worker admittance to the home/facility where the child is believed to be. Family has history of keeping child at home, away from peers, school, or other outsiders for extended periods. Family has previously fled in response to an investigation. Family has removed child from a hospital against medical advice. Caretaker has not, or will not, provide supervision necessary to protect child from potentially serious harm from himself or others. Caretaker does not attend to child to the extent that the childs need for care goes unnoticed or unmet (e.g., although caretaker present child can wander outdoors alone, play with dangerous objects, play on unprotected window ledge, or be exposed to other serious hazards). Caretaker leaves the child alone for longer periods of time than reasonable for his/her age/development or in circumstances that threaten his/her safety. Caretaker makes inadequate and/or inappropriate baby-sitting or child care arrangements or demonstrates very poor planning for childs care. Caretakers whereabouts are unknown. Child is alone and is not competent to care for himself or has been left with a person unwilling or unable to provide adequate care. Caretaker is unwilling or unable to control behavior of a child living in the home/facility that threatens immediate harm to the child or others. Caretaker has not, or is unable to meet the childs immediate needs for food, clothing, shelter, and/or medical care. No food provided or available to child, or child starved or deprived of food or drink for prolonged period. Child without minimally warm clothing in cold months.

5.

6.

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Agency Name Chapter No./Name Part No./Name Section No./Name Dates

Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

Caretaker does not seek treatment for childs immediate and dangerous medical conditions(s) or does not follow prescribed treatment for such conditions(s). Child appears malnourished or has been diagnosed with non-organic failure to thrive. Child is suicidal and parents will not take protective action. Child shows effects of maltreatment, such as serious emotional symptoms and lack of behavior control of serious physical symptoms.

7.

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 may be an immediate concern. Person such as a boyfriend/girlfriend of the caretaker responsible for previous harm/injury to a child is currently in the home or has access to the child. Previous maltreatment serious enough to cause or could have caused severe injury or harm. Caretaker has retaliated or threatened retribution against child for past incidents. Escalating patterns of maltreatment. Caretaker does not acknowledge or take responsibility for prior inflicted harm to the child or explains incident(s) as justified. Person such as caretakers boyfriend/girlfriend who was responsible for a previous injury/harm to a child has current access to the child. 8. Child is fearful of or in danger from caretaker(s), other family members, or other people living in or having access to the home or facility. Current access of alleged or confirmed perpetrator to the child victim. Child cries, cowers, cringes, trembles, or otherwise exhibits fear in the presence of certain individuals or verbalizes such fear. 9. Child exhibits severe anxiety (i.e. nightmares, insomnia) related to situation(s) associated with a person(s) in the home. Child has reasonable fears of retribution or retaliation from caretakers.

The childs physical living conditions are hazardous and may cause serious harm. *Sleeping arrangement for an infant is unsafe (e.g. sleeping with a child or adult on a couch or surface that presents a danger of suffocation; co-sleeping with children on soft mattress; sleeping in older model crib with slats, drop side or other objects that present a danger of strangulation or suffocation; or arrangement that fails to protect the infant from pets, insects, rodents or other dangers)** Leaking gas from stove or heating unit. Dangerous substances or objects stored in unlocked lower shelves or cabinets, under sink or in open. Lack of water or utilities (heat, plumbing, or electricity) and no alternative provisions made, or alternate provisions are inappropriate (e.g. stove, unsafe space heaters for heat).
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Agency Name Chapter No./Name Part No./Name Section No./Name Dates

Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

10.

Exposed electrical wires. Excessive garbage or rotted or spoiled food which threatens health. Serious illness or significant injury has occurred due to living conditions and these conditions still exist (e.g. lead poisoning, rat bites). Evidence of human or animal waste throughout living quarters. Guns and/or other weapons are not locked or otherwise secured.

Child sexual abuse is suspected and circumstances suggest that child safety may be an immediate concern. Access by possible or confirmed perpetrator to child continues to exist. It appears that caretaker or other has committed rape, sodomy, or has had other sexual contact with child. Caretaker or others have forced or encouraged child to engage in sexual performances or activities. Caretakers drug or alcohol use seriously affects his/her ability to supervise, protect, or care for the child. Caretaker has misused a drug (s) or alcoholic beverages to the extent that control of his or her actions is lost or significantly impaired. As a result, the caretaker is unable, or will likely be unable, to care for the child, or has harmed the child, or is likely to harm the child. Substance abuse or other condition of a mother of a drug exposed infant severely impairs or is expected to severely impair her ability to anticipate and provide for the infants basic and/or special needs, especially the infants immediate safety needs. Caretakers physical or emotional health status seriously affects his or her ability to supervise, protect, or care for the child. Caretaker has serious/chronic mental illness with a current failure to take prescribe medication as needed to maintain minimal function. Caretaker is currently experiencing hallucinations or delusions. Caretaker has physical limitations that prevent him from caring for the child and no substitute caregiver is available to provide care, supervision or protection. Caretaker has an emotional condition that affects his ability to care for the child. Caretaker is suffering from depression, postpartum depression (blues) or postpartum psychosis that affects his/her ability to care for the child. Domestic violence present in the home/facility places a child in imminent danger of moderate to severe harm. Violent caretaker or partner or who has previously harmed caretaker and has harmed the child or threatened to harm the child. Caretaker or caretakers partners history of violence and/or current condition represents a danger.

11.

12.

13.

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Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

14.

Caretakers explanation for the injury or harm is unconvincing and/or they deny the harm/injury. Unexplained injuries. Caretaker(s) explanation for the observed injury is inconsistent with the type of injury. Caretaker(s) description of the causes of the injury minimizes the extent of harm to the child. Medical evaluation indicates injury is result of abuse, parent denies or attributes injury to accident causes. Both parents cannot or will not explain injuries and/or conditions. Serious allegations with significant discrepancies or contradictions by caretaker, or between caretaker and collateral contacts. Caretaker fabricates or induces illness in a child in order to obtain otherwise unnecessary medical care while denying knowledge of the etiology of the illness or symptoms. Other (specify) Childs behavior likely to provoke caretaker to harm the child. Abuse or neglect related to child death, or unexplained child death. Caretaker refuses to cooperate or is evasive. Criminal behavior occurring in the presence of the child, or the child is forced to commit a crime(s) or engage in criminal behavior Childs condition and/or special needs, such as a substance exposed infants drug withdrawal or a handicapped childs vulnerabilities/needs is interacting with the caretakers incapacity to provide minimum care and/or safety

15.

Present: The presence or absence of a safety factor is indicated with a check mark in the appropriate box. This item must be completed for factors 1 - 14. Factor 15 is completed when there is a safety concern due to a factor not identified in 1 - 14. When there are no other safety factors present, Factor 15 is completed with a no. When a safety factor is present *(as a safety concern with current or impending danger), document: Each caretakers name if more than one Each childs name** The specific information, behavior, condition, and/or circumstances noted by the worker as the reasons the child is at present, or will be if placed in the home, unsafe.

When necessary to accurately and thoroughly document a factor, additional information is continued on the back of the form with the factor identified by number. Safety Decision: Identify the safety decision that represents the joint decision between the worker and supervisor regarding the child/children in the home or facility. In the case of a potential caretaker, identify the appropriate safety decision, if the child were to be placed with the caretaker. When a safety
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Agency Name Chapter No./Name Part No./Name Section No./Name Dates

Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

factor has been identified for at least one child in the home/facility and all the children are included in one assessment, unsafe is the safety decision. When the safety assessment is completed in ACESS and the safety factor responses are different for individual children, *separate safety assessments are completed. The applicable safety decision is chosen** for the children in their assessment. Controlling Interventions/Reasonable Efforts Checklist: For each safety factor identified consider the resources available in the family and the community that might help to keep the child safe. Check each response taken/considered to protect the child. When an intervention is not relevant to the case circumstances, enter N/A for non-applicable. Safety Plan: When *one or more safety factors have a yes response, a safety plan is required.** Document the safety plan in this section when the parent/caretaker will not be signing nor given a copy of the safety plan. When the parent/caretaker is signing their agreement with a safety plan or will be given a copy of the plan, the Form 5-SP, Safety Plan, is used to document the safety plan. In those cases, enter Form 5-SP attached. The Form 5-SP is to be attached to the Form 5. Note: A safety plan is a short-term immediate plan for the purpose of assuring the childs safety. Do not confuse a safety plan with a case plan. A case plan addresses service needs and appropriate case activities and although may initiate immediate services it is also a long range plan to effect change. A safety plan is an immediate plan to control the factor(s) that may result in an immediate or impending serious injury/harm to a child. Identify the child(ren) and caretaker(s) when there is more than one child and/or caretaker who are involved in the plan. The plan must specify who will do what, when, where, for how long and for specifically identified children. Signatures: The CPI or FS worker who completes the Form 5 signs and dates his signature on the line for the workers signature. The date for the workers signature is the date of the completion of the form. The form is then submitted to the supervisor for their review and signature of concurrence. The supervisor signs and dates the form using the date of his signature to approve the assessment, the safety decision, and when indicated, the reasonable efforts and safety plan. When the assessment is completed in ACESS, the approval process is substituted for the signatures. When the case is transferred to Family Services and the decision regarding the review of the safety assessment completed in CPI is that no change in the assessment is needed, the Family Services worker and supervisor complete the reviewing worker and supervisor signatures and dates. When a Form 5-SP has been used to document the safety plan, both the Form 5 and the Form 5-SP must be signed by the FS worker and supervisor in order to document their concurrence with the safety assessment and the safety plan. Updates to the Safety Assessment: Minor changes to the safety assessment or plan can be made in red ink on the form, with supervisory concurrence, once signed by the supervisor. However, if major
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Office of Community Services (OCS) 25. Forms Manual Form 5 Instructions Instructions Issue/Reissued March 2011

Replacing

June 2009

changes occur which alter the safety assessment, safety decision, or a safety plan for any of the children, a new Form 5 shall be completed. Minor changes are to be initialed by the supervisor and a copy given to the parent/caretaker when they have signed the plan. Once a safety assessment has been completed in the ACESS investigation case, it is updated with the creation of a new safety assessment. DISPOSITION: The original form is filed in the investigation case record in the Bottom Left Section for CPI when the safety assessment was completed and approved prior to the creation of the investigation case in ACESS, and a paper case record has been set up for the investigation. If there is no paper case record needed, the Form 5 may be destroyed once the safety assessment is entered and approved in the ACESS investigation case. It is filed in the Family Services case record in the Top Left Section for a Family Services Case. For cases in which a Form 5-SP is used to document a safety plan, the Form 5-SP is attached to the Form 5.

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