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\Therehasbeenorisaplausiblethreat/likelihoodofseriousphysicalharm. 5vv&$xB 5 -vvvxBvv - PFxBvvv  @2.@P2. \R@z  @2. @ \Sexualabuseissuspectedorsubstantiatedandthe(alleged)perpetratorcontinuestohaveaccesstothechild. 5vv&$z 5w -vvvzvv - PFz vvv  @3.@P3. \R@!  @3. @ \_Caregiver_Ԁactionsoromissionshavecausedorarelikelytocauseseriousimpairmentofachildssocial, " emotional,orintellectualfunctioning.0  ?vv0.V#!! ?J -vvv$vv - PF%vvv  @4.@ P4. \R@&  @4. @   \_Caregiver_Ԁisunwilling,orunable,tomeetchildsneedsforfood,clothing,orshelterincludingwhereliving ' conditionsarehazardousandimminentlythreatening. 5vv&$h2(  5l -vvv)vv - PF*vvv  @5.@ P!5. \R@j+  @5. @   \_Caregiver_Ԁisunableorrefusestoseektreatmentforachildsmedicalcondition,ortoadministerprescribed j, treatmentforadiagnosedmedicalconditionthatposesaseriousthreattothechildsphysicalhealth.0 S ?vv0.D-S !S !  ?E -vvvj.vv - PFj/vvv  @6.@ P6. \R@|F0  @6. @   \_Caregiver_Ԁhasnot,cannotorwillnotprovidesupervisionnecessarytoprotectchildfrompotentiallyserious |F1 harm. 5vv&$ 2  5Si! -vvv|F3vv - PF|F4vvv  @7.@ P7. \R@X"5  @7. @   \_Caregiver_Ԁhasgivenupordesertedachildwithstatedorapparentintentiontonotresumetherelationship. 7vvv&$X"6  7^$ -vvvvX"7vvv - 4*X"8vvvv  4 Narrative (Questions17) 7-$Z9  7+!Z:  +*^Z_d dwdd wrdd r$dd $ dd dd  ZX%X%,dd ,Ydd , dd +  +!d .:d . +  &<%,OtherSafetyFactorstoConsider#,%&<"#0 @ <2$ ;  < Yes YO! <   @8. @Y8. XN@4"=   @8.  @ XExplanationfortheinjuryisunconvincing 6vvv#!4"> 6# PF4"?vvv  "@9."@P9. XN@l#6@  "@9. "@ XThefamilyrefusesaccesstothechildorthereisreasontobelievethatthefamilyisabouttofleeand/orthechilds l#6A whereaboutscannotbeascertained.0 06 # #06#6#0##0>## @vvv-+$B>#># @# QGl#6Cvvv $@10.$@Q10. YOAH% D $@10. $@ Y_Caregiver_Ԁhaspreviouslymaltreatedachildandtheseverityofthemaltreatment,orthe_caregiver_sresponsetothe H% E previousincident(s),suggeststhatchildsafetymaybeanimminentconcern. 6vvv#!% F 6& QGH% Gvvv &@11.&@Q11. YOA$'!H &@11. &@ YChildisfearfulof_caregiver_(s),otherfamilymembers,orotherpeoplelivinginorhavingaccesstothehome. 6vvv#!$'!I 66( QG$'!Jvvv (@12.(@Q12. YOA\(&#K (@12. (@ Y_Caregiver_sdrugoralcoholuseseriouslyaffectshis/herabilitytosupervise,protectorcareforthechild. 6vvv#!\(&#L 6) QG\(&#Mvvv *@13.*@Q13. YOA)^$N *@13. *@ Y_Caregiver_sbehaviorisviolentoroutofcontrol. 6vvv#!)^$O 6l+ QG)^$Pvvv ,@14.,@Q14. YOA*%Q ,@14. ,@ Y_Caregiver_Ԁdescribesoractstowardchildinpredominantlynegativetermsorhasextremelyunrealisticexpectations. 6vvv#!*%R 6, QG*%Svvv .@15..@ Q15. YOA,&T .@15. .@  Y_Caregiver_smentalillnessseriouslyaffectshis/herabilitytosupervise,protect,orcareforthechild. 6vvvv#!,&U  6k.(,&V  vvvv (0*:Z;d ddd Ydd Y dd ^Z_X%X%,Xdd ,dd ,dd , dd +  H>,'V,' 0@16.0@H16. YOA<-(W 0@16. 0@ YOTHER(Specify): 0&!<-(X 0 0vvv<-(Y 0 9/<-(Zvvv `9 Narrative (Questions816) 7-$.^)[ 70&$.^)\ `   0 X+8X, /Z*\ _ԇ*wxddXdd Xdd dd  dd :Z;X%X%,(#dd +  $66 $@!SAFETYASSESSMENT#,XX+823#^3\,Ԁ##D% Page2of3 #,\^34#X+8X,  d STATUS:  P #,XX+85#IdentifyingInformation:X+8X,"r< "#,XX+85# *l=Z>dd(#dd (#wxX%X%l,dd , dd ,dd ,dd ,Fdd ,dd +  'd.d. 'CaseName: 7Z&!  7 0&Z 0FACTSCase# 7Z&!  7 0&Z 0FACTSEvent#: 7Z&!  7(  Z (*?Z@dddd  dd dd dd Fdd Fdd =Z>X%X%,dd ,dd ,dd ,dd +  '    'SocialWorker: 0&!    0 0&   0DateofAssignment: 0&!    0 ;s*   ;D4*(x B  s 4D:*9<dddd dd dd dd ?Z@X%X%,(#dd +  $   $ X+8X,@/ / #,XX+8=<#&<%,SectionII:ImmediateMedicalConcerns(screen)#,%&<<# "P  " *leZfdd(#dd (#9<X%X%l,kdd ,,dd ,Xdd ,,dd , dd +  'X "X " '&<%,Wasamedicalexaminationortreatmentrelatedtoabuseorneglectneeded? ?vvvv,!   ? 9/! vvvv 9YES ?vvvv,!   ? 9/! vvvv 9NO =3!  =Ifyes,describethereasonableactionstakentoprovidemedicalcare.4*((    4#,%&# *8ZAddkdd k,dd ,Xdd X,dd , dd eZfX%X%,(#dd +  #0 0  #AZ) xdE`"A 8s'^    w8AZ) xdE`"A-#!|  w  s - &<%,*lyzd(d(#dd (#8ZAX%X%l,(#dd +  $   $@  SectionIII:Safety/HarmDescriptionandProtectiveActionResponse#,%&% Ifsafetyplaniscompleted,youmayreferencethesafetyplanforsafetyresponsetaken.Ifnoprotectiveaction(reasonableefforts) ' canbedevelopedtoprotectthechildexplainbelow.&<%, 'T( @'" )@  "#,%&<)L# *l|}dd(#dd (#yzX%X%l,(#dd +  !)!   N"*   #p+  $,       '  4    < _  >(#/  X+8X,*l~dd(#dd (#|}X%X%l,(#dd +  $66 $@!SAFETYASSESSMENT##D%#,XX+8(N#^3\, Page3of3 #,\^3VO#X+8X,  d  STATUS:#,XX+8O#X+8X, P  #,XX+8P#IdentifyingInformation: "r< " *lUZVdd(#dd (#~X%X%l,dd , dd ,dd ,dd ,Fdd ,dd +  'f0f0 'CaseName: 7Z&!  7 0&Z 0FACTSCase# 7Z&!  7 0&Z 0FACTSEvent#: 7Z&!  7(  Z (*WZXdddd  dd dd dd Fdd Fdd UZVX%X%,dd ,dd ,dd ,dd +  '    'SocialWorker: 7Z&!"    7 0&"  Z 0DateofAssignment: 7Z&!"    7 ;s*"  Z ; 4*(z D  s 4 U*Qd ddd dd dd dd WZXX%X%,(#dd +      X+8X,@44SectionIV:SafetyDecision #,XX+8V#Ԉ .  Identifyyoursafetydecisionbycheckingtheappropriateboxbelow.Checkonlyonebox.Thisdecisionshouldbebasedonthe   assessmentofallsafetyfactorsandanyotherinformationknownaboutthiscase. Safeshouldbecheckedonlyifnosafetyfactors   wereidentifiedinSectionI.  l  "   "*laZddd(#dd (#QX%X%l,,dd ,dd ,kdd +  $vvvv   $ , 0&R vvvv 0 Safe 9/!R   9Therearenochildren/youthinimminentdangerofseriousharmandnoprotectiveactionisrequiredatthistime. 4*!R  4 5vvvv"`  W5 4*vvvv 4 ConditionallySafe ND2  NControllingsafetyinterventionshavebeentakensincetheintakewasreceived,andthoseinterventionshaveresolved  theunsafesituationforthepresenttime.Checkanybelowthatapply: OE7T W   O =3!1 = 7-  7+!    +*iZj dd,dd ,dd kdd kaZdX%X%,wdd ,dd +  )vvvv ')` 'u?vvvv '#, Y# ,_SRS_ԀrecommendstheprotectiveactionSafetyPlanrequired.`^ 2vvvvu? '  2#, _# ,_x 'fvvvv 'Thefollowingprotectiveactionhasbeentakenbyanotheragency&/orfamilySafetyPlanoptional:%%O% ,"f  , 'r! '_Person_Ԁresponsible:Task: ,"r"   ,__ .Z# .d '$Z 'dx/`x .Z% .d xib`` '&Z 'd .Z' .d((  Z (d`b*SZgd dwdd wdd iZjX%X%,,dd ,dd ,kdd +  $vvvvl6(l6 $ 4*)vvvv  4 Unsafe ND2*~3  NWithoutcontrollinginterventions(removalfromhome),oneormorechildren/youthwilllikelybeinimminent + dangerofseriousharm. J@2l6,3 J 4*!-  4 7-z-   7+!z-    +e*PZh dd,dd ,dd kdd kSZgX%X%,Sdd ,,dd ,dd ,,dd ,dd +  '- '` Isthechildabandoned?#, _# , #, Xh# , 6vvvv#!D. 6#, şh#  , 0&D/vvvv 0Yes0  @vvvv-+D0 @#, i# , 0&D1vvvv 0#, i# ,No0  If NO ,answerthefollowing3questions.;1/D2$$  ;` h6X,X, X'4X6*lZo` d dSdd S,dd ,dd ,dd ,dd PZhX%X%,dd ,,dd ,dd ,,dd ,dd +  #, Pj# , '2 'Isthechildinimminentdanger?0 $ @vvv-+8 3$$  @ 0&8 4vvv 0Yes0 X @vvv-+8 5XX  @ 0&8 6vvv 0No 9/!8 7 9Doestheperpetratorhaveaccesstothechild? 6vvv#!|!F8  6 0&|!F9vvv 0Yes 6vvvv#!|!F:  6 0&|!F;vvvv 0No 9/!|!F< 9Isthenonabusingparentunabletoprotectthechild? 6vvvv#!"=  6 0&">vvvv 0Yes 9vvv&!"?  9 0&"@vvv 0No1'%"A   1*` d ` ddd ,dd ,dd ,dd ,dd lZoX%X%, dd +  $#jA#j $ NOTE: 󀀀Ifachildisnotabandoned,theother3responsesmustbe Yesbefore_SRS_Ԁrequestslawenforcement $B protectivecustodyorexparteorderofcustody.#, Şl# ,"$C "*lmZnd` d dd X%X%l,%dd ,,dd ,Xdd ,,dd ,dd +  '%b C%b  ' Did_SRS_Ԁrequestlawenforcementprotectivecustodyoranexparteorderofcustody? 6vvvv#!% D  6 0&% Evvvv  0Yes 6vvvv#!% F  6 0&% Gvvvv 0 No =3!% H =Childinpoliceprotectivecustody:#, ůr# ,4*(@' "I   4*[Z\ dd%dd %,dd ,Xdd X,dd ,dd mZnX%X%,dd ,dd ,Xdd ,dd +  ' ("I (" 'Date: 0&!(N#J 0 0&(N#K 0Time: 0&!(N#L 0((N#M  (*O4d  ddd dd Xdd Xdd [Z\X%X%,Ldd +  $d).$Md).$ $Expartecourtorderofprotectivecustody:#, u# ,")$N "*lbZc d4dLdd LOX%X%l,dd ,dd ,Xdd ,dd +  '*r%N*r% 'Date: 0&! +%O 0 0& +%P 0Time: 0&! +%Q 0( +%R  (#, ōy#