Professional Documents
Culture Documents
Complaint Date
Case Name
County #
Case Manager
C.M. ID
Case #
Date
Child #1
age
Child #2
age
Child #3
age
Child #4
age
Caretaker (CT) #1
Caretaker (CT) #2
#1
Y N
#2
Y N
#3
Y N
#4
Y N
1.
#1
Y N
#2
Y N
#3
Y N
#4
Y N
2.
#1
#2
#3
#4
Y N
Y N
Y N
Y N
3.
Caretaker caused physical harm to the child or has made a plausible threat to
cause physical harm. This is a critical factor for a child four years and
younger or any special needs child.
4.
5.
The family refuses access to the child, or there is reason to believe that the
family is about to flee or the childs whereabouts cannot be ascertained.
6.
Caretaker has not, cannot or will not provide supervision necessary to protect
child from harm.
7.
8.
9.
CT
1
2
CT
1
2
CT
#1
#2
#3
#4
Y N
Y N
Y N
Y N
1
2
CT
#1
#2
#3
#4
Y N
Y N
Y N
Y N
1
2
CT
#1
#2
#3
#4
Y N
Y N
Y N
Y N
1
2
CT
#1
#2
#3
#4
Y N
Y N
Y N
Y N
#1
#2
#3
#4
Y N
Y N
Y N
Y N
1
2
CT
1
2
CT
#1
#2
#3
#4
Y N
Y N
Y N
Y N
1
2
1 of 1
#1
#2
#3
#4
Y N
Y N
Y N
Y N
#1
#2
#3
#4
Y N
Y N
Y N
Y N
10.
11.
Child sexual abuse is suspected and circumstances suggest that the childs safety
may be an immediate concern.
12.
Caretakers drug or alcohol use affects his/her ability to supervise, protect or care
for the child
13.
1
2
CT
1
2
CT
#1
#2
#3
#4
Y N
Y N
Y N
Y N
1
2
CT
#1
#2
#3
#4
Y N
Y N
Y N
Y N
#1 #2 #3 #4
1. Use family resources, neighbors or individuals in the community as safety resources.
2. Use community agencies or services as safety resources.
3. The alleged maltreater leaves the home, either voluntarily or through legal action.
4. Have the non-maltreating caregiver move to a safe environment with the child.
5. Have the caregiver(s) place the child outside the home.
6. Legal action must be taken to place the child outside the home.
7. Other
If CPS is initiating legal action to place the children, document on a Form 452 (1) explain for each child why responses 1-5 could not be used to
keep the children safe and (2) your discussion with caretakers regarding the placement.
Safety Decision
Identify your safety decision for each chills by placing X in the box below the childs number for the childs safety decision.
Make each childs decision based on the assessment of all safety factors and any other information known about the child and this
case. Select Safe only if all of the above thirteen safety factors are marked NO.
Children
#1 #2 #3 #4
UNSAFE: child is in immediate danger of serious harm.
Conditionally Safe: Controlling safety interventions have been taken since the referral was received, and those
interventions have resolved the unsafe situation for the present.
Safe: Child is not likely to be in immediate danger of serious harm.
2 of 2
Date
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