WPC) NJߨ/:C^&=>1K3Y/Nt=Ԉyˢ:Oϛ|\˲ 儂2%m/ߧnAOxuÖLu9@y`iUX8ȭukqxB̾v^6d}#LQTheZ=$?9+Z1-rQ8|'䗢P^F̷rd: YR$|q,Lgu&u! GHrD:! Y,-WB:ڑˑ˨c28&]3AgQUwBĞNWs} !ħ\|F(Lz 𹹆ʗJaZ/mڅGEBW,?)>'(P3:DGH鹀Kg`K\i ҏ^*Q]y$)j 应+/BZ|e]@2Um0_ʶRYSsy# UTN % 0: 1S 0V ^ 0w<4@Tc me 72|fafaf 0 c 1u? 72 0 w 0 ] 0  0  0 ; 0  0  0 D 1 72 1 72R 1 72  1= 72N 1 72 1 728 1j 72 1# 72fafaff a a f4f6a8fLaNfbfd 1f 72af5a7fKaMfaacaw 1faf(a* 72>fparfaa Bffaff B,aaf0a2fFaHf\a^fratffaafafafa Byf a f3 a5 fK aM ac w =!""# AU$ 0V% 0KV% D-%f%a%a%%'&f9)a;)fQ)aS)fi)ak)k)k)f)a)f)a)SAVIN 2055DP PCL 60(hH  Z6Times New Roman RegularX($USUS.,hC CEIMQUY]aAutoList3i)1)a)(.3$ !USUS.,  K, U,:i+003|xUcTABLE BTABLE C(;3$2#  0  .3  0  3#37=CIQYag1.a.i.(1)(a)(i)1)a)i)(O;$0  2#  a  .3  0` (#(#(b$0  0` (#(#2#   .3  0 ` (#` (#(xir$0  0` (#(#0 ` (#` (#2#(  0  )3  0 (# (#($0  0` (#(#0 ` (#` (#0 (# (#2#(  a  )3  0h(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#2#(   )3  0h(#h(#($0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#2#  0  )3  0(#(#({$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#2#  a  )3  0p(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#2#     )3  0p(#p(# xGaeimquy}Bullet ListBullets List(5hCEKQW]cioAutoList11.1.1.1.1.1.1.1.!1.hS CEIMQUY]aAutoList4i)1)a)#h3 CEIMQUY]aAutoList2i)1)a)%hc CEIMQUY]aAutoList5i)1)a)(hs CEIMQUY]aAutoList6i)1)a)*(CEKQW]cioAutoList7a)a)a)a)a)a)a)a),a)h CEIMQUY]aAutoList8i)1)a).TABLE ATABLE DP TABLE ETABLE IPTABLE FTABLE Ghk(hCEKQW]cioAutoList91.1.1.1.1.1.1.1.?1.TABLE AN<TABLE M(TABLE J<TABLE NTABLE OhHEGKOSW[_cAutoList10)1)a)TABLE LTABLE KIHTABLE PTABLE QTABLE AA  di`~TABLE RSЮ dTABLE UTABLE TЪTABLE XTABLE VUTABLE WTABLE YXi\TABLE ZTABLE ABXhTABLE ACTABLE AETABLE AD dp~TABLE AF8^TABLE AHhTABLE AGTABLE SLevel 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5x~&OLE 2.0 Box <=8C HKKKK(.3$ !USUS.,  ( $ Figure  1  )!dxdxkTABLE AITABLE AJ  _   'USUS.,  _XX^3a\XX \^3aStateofKansas X KansasSocialandRehabilitationServices0 0 % %0h%%0h%h%0%%0p%%0p%p%0 %%0x % %0 x%x%0(# % %##G%CFS2030D(#%(#% ChildrenandFamilyPolicy0 ` 0 ` %` %0 % %0h%%0h%h%0%%0p%%0p%p%0 %%0x % %0 x%x%October2001#^3a\ x#TABLE AK{TABLE ALkTABLE AMTABLE HTABLE AO !USUS.,  _XXXh__& <%XX*jkd dd Xdd Xdd XX%X%,(#dd +  $ $@ii! RISKASSESSMENT ^3a\%& <Ԁ # #D%Page1of4#& <%\^3a#Ԉ (d STATUS: 0 %& < IdentifyingInformation: #& <%#" " *lZdd(#dd (#jkX%X%l,dd , dd ,dd ,dd ,Fdd ,dd +  ' '%& <CaseName: 7Z&! H  7 0& HZ 0FACTSCase# 7Z&! H  7 0& HZ 0FACTSEvent#: 7Z&! H  7( H  Z (*Zdddd  dd dd dd Fdd Fdd ZX%X%,dd ,dd ,dd ,dd +  '0 0 'SocialWorker: 0&!X    0 0&X   0DateofAssignment: 0&!X    0(X    (#& <%F#*nod ddd dd dd dd ZX%X%,(#dd +  $@ | @ | $%& <Thefollowingquestionsareintendedtoidentifypossible riskfactorselementsoffamilyfunctioningthatmayplaceachildat   riskofabuseandneglect.#& <% #"\  "*llmd d(#dd (#noX%X%l,(#dd +  $D D  $%& < @MM SectionI:PASTABUSE,NEGLECT,ANDOTHERGENERALRISKFACTORS     Pleaseindicatethetypeofabuseorneglectinthecurrentreport(checkallthatapply) "`  "#& <% #*lOZPdd(#dd (#lmX%X%l,,dd ,A dd ,,dd , dd ,,dd , dd +  )ppppH H  Y)%& < 0& pppp 0Abuse(nonsexual)0 ; @pppp-+ ; ;   @#& <%] # 0& pppp 0%& <Sexualabuse#& <%]# 6pppp#!   6 0& pppp 0%& <Neglect#& <%#6,*  Y  6K *qred d,dd ,A dd A ,dd , dd ,dd , dd OZPX%X%,!dd +  $   $ %& <Ifabuseischecked(checkiftrue) #& <%#"A  " %& < *lQZRded!dd !qrX%X%l,,dd ,dd +  $ppp) )  $h 0&Q ppp 0_nona__ccidental_Ԁphysicalinjurytoaninfant#& <%J#%& < 6ppp#!Q  6 0&M ppp 0_nona__ccidental_Ԁphysicalinjuryrequiringhospitalormedicaltreatment#& <% #%& < 6pppp#!M  6 0&Ipppp 0perpetratorislikelytohaveaccesstothechild#& <%:#%& <1'%I   1h<*uved d,dd ,dd QZRX%X%,!dd +  $ $h Ifsexualabuseischecked(checkiftrue) #& <%#%& <"E "hA*lVZWded!dd !uvX%X%l,,dd ,dd +  $pppp $h 0&A} pppp 0#& <%#%& <perpetratorislikelytohaveaccesstothechild#& <%2#%& <1'%A}!  1#& <%#h*std d,dd ,dd VZWX%X%,(#dd +  $! $dPleasecompletethefollowinghistoricalinformation(Checkanyofthefollowingstatementsiftrue)"=y" "d%& <*lYZ[Xdd(#dd (#stX%X%l,wdd ,!dd +  $pppp "  $h 0&5q#pppp 0Current_caregiver_Ԁinthehomehashadapriorreportassignedforabuse/neglect =3!5q$ = Iftrue,(therehasbeenapriorassignedreport)answerthefollowing: <2$1m% <a) 9/!-i& 9Typeofpriorassignedabuseorneglectreport(s)1'%-i'   1h*XZ\dXdwdd w!dd !YZ[X%X%,,dd ,4dd ,,dd ,dd ,,dd , dd +  $pppp' $h 0&)e(pppp 0Abuse(nonsexual)0 @pppp-+)e)   @ 0&)e*pppp 0Sexualabuse 6pppp#!)e+  6 0&)e,pppp 0Neglect1'%)e-  1h *]Z^Xdd,dd ,4dd 4,dd ,dd ,dd , dd XZ\X%X%,wdd ,dd ,wdd ,dd +  '- 'b) 9/!%a. 9Numberofpriorassignedreportsoncurrent_caregivers_: 7Z&!%a/ 7L " 0&%a0Z 01'%%a1  1=#L"*_Z`XdXdwdd wdd wdd wdd ]Z^X%X%,wdd ,dd ,wdd ,dd ,wdd , dd +  ' I1 I 'hc) 9/!q2 9Wereanyofthesereportssubstantiated? 6pppp#!q3 6 0&q4pppp 0Yes 6pppp#!q5 6 0&q6pppp 0No1'%q7  1h$%*aZbXdXdwdd wdd wdd wdd wdd w dd _Z`X%X%,wdd ,dd ,wdd ,dd ,wdd , dd +  ' E7 E 'hd) 9/!m8 9Wasthereachilddeathasaresultofpastabuseorneglect? 9ppp&!m9 9 0&m:ppp 0Yes 9ppp&!m; 9 0&m<ppp 0No1'%m=  1hO(*cZdXdXdwdd wdd wdd wdd wdd w dd aZbX%X%,wdd ,!dd +  $ppppA=A $h 0&i>pppp 0ThereisapriorSRSchildandfamily servicehistory.1'%i?  1h&+ *0Z1dXdwdd w!dd !cZdX%X%,dd ,Vdd +  '=?= ' DescribePastAbuseNeglectifindicatedinSectionI. 0&!e@ 0 2T!eA 2+! B  T +, *Uwd ddd Vdd V0Z1X%X%,(#dd +  $q!Bq! $@SectionII:CHILDRISKFACTORS"!C " *l2Z3Xdd(#dd (#UwX%X%l,wdd ,dd , dd , dd ,dd ,Xdd ,dd ,dd ,dd ,dd ,dd +  5+"C" 5 ChildRiskFactor ?5&S#E"  ?Name .$"F .Name .$"G .Name .$"H .Name =3 "I   = ! F$I !Age * F$J * 6,!F$K 6Age * F$L * 6,!F$M 6Age * F$N * 6,!F$O 6Age * F$P * \R'F$Q 0   ?1.?\1. J@1p% R  ?1. ? JDisplayshostileoraggressivebehavior %p% S %  p% T   p% U   p% V  A7 p% W  @2.@A2. J@1&!X  @2. @ JDisplaysdisturbedorunusualbehavior %&!Y %  &!Z   &![   &!\  A7 &!]  @3.@A3. J@1'#^  @3. @ JSexuallyactsout %'#_ %  '#`   '#a   '#b  A7 '#c  @4.@A4. J@1(*$d  @4. @ JHasadevelopmentdisability %(*$e %  (*$f   (*$g   (*$h  A7 (*$i  @5.@A5. J@1*T%j  @5. @ JEitherparentfindsthischildsbehaviorprovoking %*T%k %  *T%l   *T%m   *T%n  A7 *T%o  @6.@A6. J@1B+~&p  @6. @ JHasanyphysicalimpairments %B+~&q %  B+~&r   B+~&s   B+~&t  A7 B+~&u  @7.@A7. J@1l,'v  @7. @ JEverplacedoutsidethehome %l,'w %  l,'x   l,'y   l,'z  A7 l,'{   @8. @A8. J@1-(|   @8.  @ JHasahistoryofdelinquency %-(} %  -(~   -(   -(  A7 -(  "@9."@A9. J@1.)  "@9. "@ JHasbehaviorproblemsatschool %.) %  .)   .)   .)  B8 .) $@10.$@B10. G=2/&+ $@10. $@ GOTHER(Specify): !/&+ ! (/&+ (  /&+   /&+   /&+ /&+  & <%   0+  _   _**d Xdwdd wdd  dd  dd dd Xdd Xdd dd dd dd dd 2Z3X%X%*,(#dd +  $yy $@]]!RISKASSESSMENT # %& d ddd dd dd dd 9Z:X%X%,(#dd +  +T 8  8 +1'%  T 1& <%  *ld d(#dd (#>X%X%l,(#dd +  $ b b $@ SECTIONIII:PARENT/_CAREGIVER_ԀRISKFACTORS"?  " *l;Z<Xdd(#dd (#X%X%l,wdd , dd ,Xdd ,dd ,dd ,dd ,dd ,dd ,dd ,dd +  (; ;  (%& <  % & % Name  & (primary ) % 3  %Name  & (secondary) .$3  .Name .$ & .Name .$ & .   Parent/_Caregiver_ԀContributingFactors * [   *lMAge * [  * 6,![  6Age * [  * 6,![  6Age * [  * 6,![  6Age * [  * 6,![  6K| '  ' A.ParentingSkills " ! "   "    #    $  B8  % &@11.&@B# "L# 11. G=2 & &@11. &@ GExhibitasignificantlackofparentingskills " ' "   (    )    *  B8  + (@12.(@B12. G=2* , (@12. (@ GHasunrealisticexpectationsofanychild "* - "  * .   * /   * 0  B8 * 1 *@13.*@B13. G=2:2 *@13. *@ GEmploysexcessiveand/orinappropriatediscipline ":3 "  :4   :5   :6  B8 :7 ,@14.,@B14. G=2J8 ,@14. ,@ GUnmotivatedtoimproveparentingskills "J9 "  J:   J;   J<  B8 J= .@15..@B15. G=2Z> .@15. .@ GMotivatedtoimproveparentingskillsbutisunrealistic "Z? "  Z@   ZA   ZB  B8 ZC 0@16.0@B16. G=2jD 0@16. 0@ GAdomineeringparent "jE "  jF   jG   jH  ! jI ! 'zJ ' B.SocialRelationships/Supports "zK "  zL   zM   zN  B8 zO 1@17.1@B17. G=2P 1@17. 1@ GSocialrelationshipsprimarilynegative "Q "  R   S   T  B8 U 2@18.2@B18. G=2V 2@18. 2@ GInvolvedinharmfulrelationships(nondomesticviolence) "W "  X   Y   Z  B8 [ 3@19.3@B19. G=2#\ 3@19. 3@ GRelationshipswithextendedfamilymembersunsupportive #] orconflictive "&^ "  #_   #`   #a  B8 #b 4@20.4@B20. G=26c 4@20. 4@ GSociallyisolated "6d "  6e   6f   6g  ! 6h ! 'Fi ' C.SubstanceAbuse "Fj "  Fk   Fl   Fm  B8 Fn 5@21.5@B21. G=2Vo 5@21. 5@ GHascurrentalcoholabuseproblem "Vp "  Vq   Vr   Vs  B8 Vt 6@22.6@B22. G=2fu 6@22. 6@ GHascurrentdrugabuse(otherthanalcohol)problem "fv "  fw   fx   fy  B8 fz 7@23.7@B23. G=2v{ 7@23. 7@ GCurrentsubstanceabuse,butwillingtoparticipatein v| treatment "k } "  v~   v   v  B8 v 8@24.8@B24. G=2{! 8@24. 8@ GHasahistoryofsubstanceabuse "{! "  {!   {!   {!  ! {! ! '" ' D.EmotionalWellBeing "" "  "   "   "  B8 " 9@25.9@B25. G=2#" 9@25. 9@ GLacksselfesteem "#" "  #"   #"   #"  B8 #" :@26.:@B26. G=2$2  :@26. :@ GApatheticorhopeless "$2  "  $2    $2    $2   B8 $2  ;@27.;@B27. G=2%B! ;@27. ;@ GHasasignificanthistoryofdepression "%B! "  %B!   %B!   %B!  B8 %B! <@28.<@B28. G=2&R" <@28. <@ GIfso,everattemptedsuicide "&R" "  &R"   &R"   &R"  B8 &R" =@29.=@B29. G=2'b# =@29. =@ GUnabletocopewithstress "'b# "  'b#   'b#   'b#  ! 'b# ! '(r$ 'E.DomesticRelations  "(r$ "# i#  (r$   (r$   (r$  B8 (r$ >@30.>@B30. G=2)% >@30. >@ GEverbeenaperpetratorofspouseorpartnerabuse ")% "  )%   )%   )%  B8 )% ?@31.?@B31. G=2 +& ?@31. ?@ GEverbeenavictimofspouseorpartnerabuse " +& "   +&    +&    +&  B8  +& @@32.@@B32. G=2,' @@32. @@ GRecentlydivorcedorseparatedfromhisorherspouseor ,' partner ",( "  ,'   ,'   ,' |O|,'   |an  -`) _*d Xdwdd w dd Xdd Xdd dd dd dd dd dd dd ;Z<X%X%,(#dd +  $yy $ & <% @"RISKASSESSMENT # %& <.p#^3a\ Ԉ # #D%Page3of4# \^3ap#& <% Ԉ d STATUS: 0 # %&  ! (? (  @   A   B  B8 C C@38.C@B38. G=2D C@38. C@ GOTHER(Specify): !E ! (F (  G   H   I  ! J ! +! K + G.ResponsetoInvestigation % L %   M    N    O  B8  P C@39.C@B39. KA2Q C@39. C@ KTakestheapparentabuseorneglectlessseriouslythanCPS R does %S %  T   U   V  B8 W D@40.D@B40. KA2 X D@40. D@ KUnawareof,ordenies,thefactorsplacingthechild(ren)atrisk % Y %   Z    [    \  B8  ] D@41.D@B41. KA2^ D@41. D@ KFailedtocooperatesatisfactorily %_ %  `   a   b c  p;}|ρ**fZgd Xddd dd  dd  2dd 22dd 2}dd }}dd }}dd }}dd }[dd [dd DZEX%X%*,wdd ,dd ,dd ,dd +  +!'c' +OtherRiskFactors <2$d  <Yes 9/!e"  9No ZP!f" E@42.E@Z42. YOA"g E@42. E@ YAnycaregiverinthishomehashadachildwhodiedofunexplainedorsuspiciouscauses? 2pp#!"h 2 -ppp"ipp - VL"jppp E@43.E@V43. YOA2k E@43. E@ YHouseholdisexperiencingseverefinancialdifficulty.0  <pp-+2l&& < -ppp2mpp - VL2n  ppp F@44.F@ V44. YOAGo F@44. F@  YThephysicalconditionofthehomeposesadangertoanychildshealthorsafety. 4ppp#!Gp  4 -ppppGqppp -(Gr  pppp (*d dwdd wdd dd dd fZgX%X%,(#dd +  $lrl $| @ SectionIV:NarrativeandAnalysis  Ws ForeachsignificantriskfactorinsectionIIandIII,orotherriskfactorsnotnotedabove,describeeachriskfactorandhowit ( u affectsthechildssafety.Also,describethefamilysabilitytouseitsstrengthsandresourcestomanagetheriskfactors.  [v m|]  "w   $#x   4$y  D% z  *ld d(#dd (#X%X%l,(#dd +  $%w!z%w! $ Describeanyothersignificantfamilyorchildstrengthsorresourcesnotnotedabove: T&!{   d'"|   t(#}   ) %~  *&  & <%  @+& *l47d d(#dd (#X%X%l,(#dd +  $yy $|@@" RISKASSESSMENT #%& <5#^3a\Ԉ # #D%Page4of4#\^3a#& <%Ԉ @ STATUS:  #%& <#& <% IdentifyingInformation: #%&