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 caretaker’s
name is entered. When more than one caretaker in a facility is included in the assessment, each
caretaker’s name is also entered.
For cases in which the child is in a temporary location such as the hospital, the child’s 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
Child’s Name, Age and Sex: Complete with each child’s 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.
Caretaker’s 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.
2.
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
child’s 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.
3.
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,
3 of 9
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 child’s
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 child’s 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.
5.
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 child’s 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 child’s 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 child’s immediate needs for food, clothing,
shelter, and/or medical care.
6.
•
•
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.
4 of 9
Agency Name
Chapter No./Name
Part No./Name
Section No./Name
Dates
•
•
•
•
7.
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 child’s 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.
Caretaker, or other person having access to the home/facility, has previously harmed a
child and the severity of the harm, or the caretaker’s prior response to the incident,
suggests that the child’s 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 caretaker’s 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 child’s 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
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.
10.
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.
11.
Caretaker’s 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 infant’s basic and/or special needs, especially the infant’s immediate safety
needs.
12.
Caretaker’s 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.
13.
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 caretaker’s partners’ history of violence and/or current condition
represents a danger.
6 of 9
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
14.
Caretaker’s 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.
15.
Other (specify)
•
Child’s 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
•
Child’s condition and/or special needs, such as a substance exposed infant’s drug
withdrawal or a handicapped child’s vulnerabilities/needs is interacting with the
caretaker’s incapacity to provide minimum care and/or safety
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 caretaker’s name if more than one
Each child’s 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
7 of 9
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 child’s 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 worker’s signature. The date for the worker’s 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
8 of 9
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
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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