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	NORTH CAROLINA
	SAFETY ASSESSMENT
Case Name:		Case #:	Date:
County Name:		Date Report Received:
Social Worker Name:

Children: _______________________________________________________________________________________________

Caregivers:

SECTION 1: SAFETY ASSESSMENT

Part A. Safety Factor Identification

Directions: The following is a list of factors that may be associated with a child(ren) being in immediate danger of serious harm. Identify the presence or absence of each by circling either "yes" or "no", if factor applies to any child in the household or to a child to be returned to the household. Note: The vulnerability of each child needs to be considered throughout the assessment. Younger children and children with diminished mental or physical capacity or repeated victimization should be considered more vulnerable. Complete based on most vulnerable child for each factor.

1.	Yes No Caregiver's current behavior is violent or out of control. (Some examples of this may include the following.)

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).

Domestic violence likely to have a negative impact on the child. Use of guns, knives, or other instruments in a violent way.

Shakes or chokes baby or young child to stop a particular behavior. 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).

Yes No

Caregiver describes or acts toward child in predominantly negative terms or has extremely unrealistic

expectations. (Some examples of this may include the following.)

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 to 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 parent’s problem.

Uses sexualized language to describe child or in name calling (e.g., whore, slut, etc.).

3.	Yes No Caregiver caused serious physical harm to the child or has made a plausible threat to cause serious physical

harm. (Some examples of this may include the following.)

Caregiver caused serious non-accidental abuse or injury (e.g., fractures, poisoning, suffocating, shooting,

burns, severe bruises, welts, bite marks, choke marks, etc.).

An action, inaction, or threat which would result in serious harm (e.g., kill, starve, lock out of home, etc.).

Plans to retaliate against child for CPS assessment.

Caregiver has used torture or physical force which bears no resemblance to reasonable discipline, or punished child beyond the child’s endurance.

One or both parents fear they will maltreat child and/or request placement.

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Yes No

The family refuses access to the child, there is reason to believe that the family is about to flee, and/or the

child's whereabouts cannot be ascertained. (Some examples of this may include the following.)

Family has previously fled in response to a CPS assessment. Family has removed child from a hospital against medical advice.

Family has history of keeping child at home, away from peers, school, or other outsiders for extended periods.

Yes No

Caregiver has not, or will not, provide supervision necessary to protect child from potentially serious harm.

(Some examples of this may include the following.)

Caregiver does not attend to child to such an extent that the need for care goes unnoticed or unmet (e.g., although caregiver is present, child wanders outdoors alone, plays with dangerous objects, plays on unprotected window ledge, has unsupervised access to uncovered pools, etc. or is exposed to other serious hazards).

Caregiver leaves child alone (time period varies with age and developmental stage).

Caregiver makes inadequate and/or inappropriate babysitting or child care arrangements or demonstrates very poor planning for child's care.

Parent’s whereabouts are unknown.

Yes No

Caregiver is unwilling, or is unable, to meet the child's immediate needs for food, clothing, shelter, and/or

medical or mental health care. (Some examples of this may include the following.)

No food provided or available to child, or child starved or deprived of food or drink for prolonged periods.

Child without minimally warm clothing in cold months.

No housing or emergency shelter; child must or is forced to sleep in the street, car, etc.; housing is unsafe, without heat, etc.

Caregiver does not seek treatment for child's immediate and dangerous medical condition(s) or does not follow prescribed treatment for such condition(s).

Child appears malnourished.

Child has exceptional needs which parent cannot/will not meet. Child is suicidal and parent will not take protective action.

Child shows effects of maltreatment, such as serious emotional symptoms and lack of behavior control or serious physical symptoms.

Yes No

Caregiver has previously maltreated a child and the severity of the maltreatment, or the caregiver's response

to the previous incident(s), suggests that child safety may be an immediate concern.

(Some examples of this may include the following.)

Previous maltreatment that was serious enough to cause or could have caused severe injury or harm. Caregiver has retaliated or threatened retribution against child for past incidents.

Escalating pattern of maltreatment.

Caregiver does not acknowledge or take responsibility for prior inflicted harm to the child or explains incident(s) as justified.

Both parents cannot/do not explain injuries and/ or conditions.

8.	Yes No Child is fearful of caregiver(s), other family members, or other people living in or having access to the home.

(Some examples of this may include the following.)

Child cries, cowers, cringes, trembles, or otherwise exhibits fear in the presence of certain individuals or verbalizes such fear.

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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 caregiver.

9.	Yes No The child's physical living conditions are hazardous and immediately threatening. (Some examples of this

may include the following.)

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, and electricity) and no alternate provisions made or alternate provisions are inappropriate (e.g., stove, unsafe space heaters for heat).

			Open/broken/missing windows.
			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 other weapons are not locked.
10.	Yes	No	Child sexual abuse is suspected and circumstances suggest that child safety may be an immediate concern.
			(Some examples of this may include the following.)
			Access by possible or confirmed perpetrator to child continues to exist.
			It appears that caregiver or other person has committed rape, sodomy, or has had other sexual contact
			with child.
			Caregiver or others have forced or encouraged child to engage in sexual performances or activities.
11.	Yes	No	Caregiver's drug or alcohol use seriously affects his/her ability to supervise, protect, or care for the child.
			(An example of this may include the following.)
			Caregiver has misused a drug(s) or alcoholic beverage(s) to such an extent that control of his or her
			actions is lost or significantly impaired. As a result, the caregiver is unable, or will likely be unable, to
			care for the child, has harmed the child, or is likely to harm the child.
12.	Yes	No	Other (specify):
			(Some example of this may include the following.)

Possible examples:

Child's behavior likely to provoke caregiver to harm the child. Unexplained injuries.

Abuse or neglect related to child death, or unexplained child death.

Serious allegations with significant discrepancies or contradictions by caregiver or between caregiver, and collateral contacts.

Caregiver 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.

Caretaker(s) inappropriately disciplined child.

Any mark, other than temporary redness of skin, lasting more than 24 hours as a result of discipline.

IF SAFETY FACTORS 1-12 ARE CIRCLED “NO”, GO TO SECTION 3: SAFETY DECISION.

When Safety Factors 1-12 are circled “NO”, a safety response is not needed.

THE ALLEGATIONS ALONE DO NOT CONSTITUTE THE NEED FOR A SAFETY RESPONSE

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Family Support and Child Welfare Services

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Part B. Safety Factor Description

Directions: For all safety factors which are marked "yes," note the applicable safety factor number and then briefly describe the specific individuals, behaviors, conditions, and/or circumstances associated with that particular safety factor.

_______________________________________________________________________________________________________

________________________________________________________________________________________________________

SECTION 2: SAFETY RESPONSE

Directions: For each factor identified in Section 1, consider the resources available in the family and the community that might help to keep the child safe. Check each response taken to protect the child and explain below.

1.Use family resources, neighbors, or other individuals in the community as safety resources.

2.Use community agencies or services as safety resources.

3.Have the alleged perpetrator leave the home, either voluntarily or in response to legal action.

4.Have the non-maltreating caregiver move to a safe environment with the child.

5.Other:______________________________________________________________

6.The caregiver(s) places the child outside the home (in a safe arrangement). Note: include explanation below regarding why responses 1-5 could not be used to keep the child(ren) safe, in the home.

7.Legal action may be taken to place the child(ren) outside the home. Note: include explanation below regarding why responses 1-5 could not be used to keep the child(ren) safe, in the home.

Describe all safety interventions taken or immediately planned by you or anyone else, and explain how each intervention protects

(or protected) each child. This plan is in effect until safety issues have been resolved or a service agreement has been jointly

developed.

________________________________________________________________________________________________________

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SECTION 3: SAFETY DECISION

Directions: Identify your safety decision by checking the appropriate line below. Check one line only. This decision should be based on the assessment of all safety factors and any other information known about this case. If “B” or “C” is checked, Section 2 must be completed. “A” is to be checked only if no safety factors were indicated in Section 1, Part A.

A.Safe: There are no children likely to be in immediate danger of serious harm.

B.Conditionally

Safe:	_____ Controlling safety interventions have been implemented since the report was received, and those
	interventions will adequately provide for the child’s safety for the immediate future.

C.Unsafe: ____ Child(ren) is likely to be in danger of immediate harm. Remove child(ren) from the home.

		SECTION 4: SIGNATURES
__________________________________		____________________________________
Parent/Caregiver	Date	Safety Resource	Date
__________________________________		_____________________________________
Parent/Caregiver	Date	Safety Resource’s Relationship to Child
_________________________________		_____________________________________
Parent/Caregiver	Date	Safety Resource	Date
________________________________		______________________________________
Parent/Caregiver	Date	Safety Resource’s Relationship to Child
________________________________		______________________________________
Social Worker	Date	Supervisor	Date

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NORTH CAROLINA

SAFETY ASSESSMENT

POLICY AND PROCEDURES

The purpose of the safety assessment is to help assess whether a child(ren) is likely to be in immediate danger of serious physical harm which may require a protective intervention and to determine what interventions should be maintained or initiated to provide appropriate protection.

It is important to keep in mind the difference between safety and risk when completing this form. Safety assessment differs from risk assessment in that safety assesses the child's present danger and determines the interventions immediately needed to protect the child. In contrast, the family risk assessment looks at the likelihood of future maltreatment.

Which cases: All CPS maltreatment reports assigned for an assessment that involve a family caregiver. This does not apply to reports involving childcare facilities or residential facilities such as group homes or DHHS facilities. This tool shall be used when a Child Protective Service report has been made on a non-licensed living arrangement, the non-custodial parent's home, or licensed family foster homes.

The caregiver is the adult (typically one or both parents) living in the household who is responsible for childcare. In situations where an adult relative is entrusted with the care of the child and is the alleged perpetrator, the Safety Assessment is conducted in the home where the child resides.

If the allegation involves only one parent, guardian, or custodian, a separate Safety Assessment is not required for the other parent, guardian or custodian’s household. If the allegation involves two households, a separate Safety Assessment shall be conducted on both households. An example would be allegations of inappropriate discipline with both parents living in separate households listed as perpetrators.

Who completes: Social worker assigned to complete the assessment. In reciprocal county investigations, the home county shall conduct the safety assessment and provide the assessment to the investigating county. If a child is found in one county and resides in another, the county where the child is found conducts the Safety Assessment and forwards the Safety Assessment to the county of residence.

When: The Safety Assessment shall be completed and documented:

•at the time of the first face-to-face contact with the family;

•prior to allowing the child to remain in the household;

•prior to the removal of a child from the home;

•prior to the return home in cases where the caregiver temporarily places the child outside the home as a part of the safety response;

•at any point a new report is received;

•at any other point that safety issues are revealed. (This may mean completing more than one Safety Assessment if needed). However, if the initial safety assessment reveals that the home is safe and no changes occur, one safety assessment is sufficient for the whole CPS assessment phase;

•In the event a child is placed with a relative as a component of the Safety Response, the short form of the Kinship Care Assessment needs to be completed to determine the child’s safety. A Safety Assessment would not be required on the relative home in this situation;

•The Safety Assessment should be completed on the home where the child resides. In situations where the parents/caretakers are not living together the Safety Assessment need only be completed for the home where the alleged maltreatment occurred.

•Whenever there is a CPS investigative/family assessment case decision recommending closure (findings of “unsubstantiated,” “services recommended,” or “services not recommended”), there must be a Safety Assessment documenting a finding of “Safe”.

Decision: The safety assessment is used to guide decision making in the removal and return of children to families. It also guides decision making on factors that, if not addressed, threaten immediate harm to children. A safety plan (Section 2, Safety Response) is required for all children assessed unsafe on any safety factor.

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Appropriate The Safety Assessment has four sections: Safety Assessment, Safety Response, Safety decision, and

completion: Signatures.

Each section is preceded by instructions for appropriate completion. The list of safety factors are behaviors or conditions that may be associated with a child being in danger of serious harm. The vulnerability of each child needs to be considered throughout the assessment. Younger children and children with diminished mental or physical capacity or children with repeated victimization should be considered more vulnerable. Complete each factor based on the most vulnerable child.

Section 1: Safety Assessment

The list of factors under Part A are behaviors or conditions that may be associated with a child being in immediate danger of serious harm. Identify the presence or absence of each factor by circling either "yes" or "no."

The Safety Factor examples should not be considered complete descriptions of all possible circumstances related to the factors. Other behaviors or conditions may be associated with each listed factor and may also be indicative of the possibility of immediate danger of serious harm. How recently the behavior or condition occurred should also be considered; that is, the situation currently present is likely to occur in the immediate future, or occurred in the recent past. The examples should not be construed as necessarily equating with an "unsafe" decision but rather as "red flag alerts" to the possibility that the child may be unsafe.

In Part B, for all safety factors marked "yes," note the applicable Safety Factor number and then briefly describe the specific individual's behaviors, conditions, and/or circumstances associated with that particular safety factor. If no safety factors are present, skip Part B and go to Section 3: Safety Decision.

Section 2: Safety Response

A safety intervention is any action taken by staff or others to remediate the unsafe condition identified in the Assessment while services are provided to the family. Safety Responses (1-7) are used to indicate the controlling interventions utilized by the assigned social worker.

In filling out this section, keep in mind: 1) are the Safety Response actions sufficient? and 2) is the family willing and able to participate in these actions at a level sufficient to protect the child(ren)? If safety resources are being utilized, it should be documented in the safety response area what the safety resource specifically agrees to do to ensure the safety of the children.

Note: At any point that the caregivers arrange an alternative placement with another resource (family, friend, etc.), the social worker is responsible for assessing the safety of this arrangement to include the Kinship Care tools or other means of assessment.

Section 3: Safety Decision

The assigned social worker and supervisor completing the assessment make a determination of safe, conditionally safe, or unsafe, based on whether controlling interventions can mitigate the unsafe factor(s) identified. The safety decision should reflect the situation at the time the safety assessment is being completed.

A.A child is "Safe" if no child in the family is in danger of immediate harm as indicated by scoring all Safety Factors in Section 1, Part A. "no."

B.A child is "Conditionally Safe" if Safety Responses (1-6) allow the child to remain in the family home or another safe living arrangement while services are provided.

C.A child is "Unsafe" if the only controlling intervention is legal removal of the child(ren) from the family home. This includes both short-and long-term placement.

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Section 4: Signatures

Signatures of parents/caregivers, safety resources, social worker and supervisor are required if the Safety Decision is Conditionally Safe. No signatures from the parent/caregivers or safety resources are required if the safety decision is safe; however the social worker and supervisor must still sign. In the event a child must be removed from the home due to safety concerns, the parent is not required to sign the Safety Assessment though an attempt should be made to acquire the signature. If the parent refuses to sign the Safety Assessment, the social worker shall document the reason for the parent’s refusal.

If a safety resource is utilized, the relationship of the resource to the child shall be documented in the appropriate location. The caregivers and the safety resources shall be given a copy of the Safety Assessment.

If supervisor approves the Safety Assessment, the family will not receive another copy, unless they request it. If the supervisor does not approve the Safety Assessment the social worker will contact the family within 24 hours to discuss any change or concerns.

DSS-5231 Revised 5/05

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Question	Answer
Form Name	Dss 5231 Form
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	dss 5231 form, dss 5229, dss 5231 welfare form, dss 5231 safety form

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