This document contains a safety assessment for 4 children living with 2 caretakers. It assesses 13 safety factors related to the caretakers' behaviors and conditions in the home. For each child, it indicates whether each safety factor is present with a "Yes" or "No". It then lists 7 potential safety interventions. For each child, it indicates which interventions could help keep the child safe. Finally, it makes a safety decision for each child as either "Unsafe", "Conditionally Safe", or "Safe" based on the assessment. The supervisor must sign and approve the safety plan.

1. 455A – SAFETY ASSESSMENT
Complaint Date
Case Name County # Case #
Case Manager C.M. ID Date
Child #1 age Child #2 age
Child #3 age Child #4 age
Caretaker (CT) #1 Caretaker (CT) #2
Assessment of Caretaker Behaviors and Safety Conditions
The following factors describe behaviors or conditions associated with a child being safe or unsafe. Identify the presence of
absence of each factor for each child placing an ‘X’ in each child’s ‘Yes’ or ‘No’ column. Children 4 years old and under
or any child with a disability need special safety considerations.
#1 #2 #3 #4
CT Y N Y N Y N Y N 1. Caretaker’s history indicates violent or out of control incidents or maltreatment
that is callous, deliberate or cruel.1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 2. Caretaker describes or acts toward child in negative terms or has unrealistic
expectations.1
2
#1 #2 #3 #4
CT 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.
1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 4. Caretaker has previously maltreated a child and the maltreatment, or the
caretaker’s response to the prior incident, makes child safety a concern.1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 5. The family refuses access to the child, or there is reason to believe that the
family is about to flee or the child’s whereabouts cannot be ascertained.1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 6. Caretaker has not, cannot or will not provide supervision necessary to protect
child from harm.1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 7. Caretaker is unwilling, or is unable, to meet the child’s needs for food,
clothing, shelter, medical, education, emotional or mental health care.1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 8. Explanation for the injury is unconvincing or inconsistent.
1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 9. Child is fearful of caretaker(s), other family members or other people living in
or having access to the home.1
2
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2. 455A – SAFETY ASSESSMENT (p. 2)
#1 #2 #3 #4
CT Y N Y N Y N Y N 10. Child’s physical living conditions are hazardous, threatening or unsafe.
1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 11. Child sexual abuse is suspected and circumstances suggest that the child’s safety
may be an immediate concern.1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 12. Caretaker’s drug or alcohol use affects his/her ability to supervise, protect or care
for the child1
2
#1 #2 #3 #4
CT Y N Y N Y N Y N 13. Domestic Violence / or Other (specify)
1
2
Reasonable Efforts Checklist
For each behavior or condition identified, consider the resources available in the family and the community that might help to keep
the child safe. For each child, place an ‘X’ in the space by each response that is selected to protect that child. Describe in the
“Evidence” section of Form 454 all safety interventions taken or immediately planned and explain how each intervention protects
(or protected) each child.
Children
#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 child’s number for the child’s safety decision.
Make each child’s 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.
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3. Supervisor Signature/Approval of Plan Date
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