ࡱ> RUOPQo@ bjbjצצ BQ*tzT $z2ʞr(zH0$R Q777C7^070۫[FD -^6̬dY0>FzzTx0":VzzdFW$CzzW Michigan Department of Human ServicesFC Case Name: FORMTEXT      FC Case Number: FORMTEXT      FOSTER CARE STRUCTURED DECISION MAKING SAFETY ASSESSMENT AND PLANPS Case Name: FORMTEXT      PS Case Number: FORMTEXT      PS Referral Date: FORMTEXT      County Name: FORMTEXT      DHS FC Worker Name: FORMTEXT      DHS FC Worker Load Number: FORMTEXT      Completed for: (Check one) Updated Service Plan FORMCHECKBOX Initial Service Plan FORMCHECKBOX Assessment Date: FORMTEXT      Household Assessed: Last Name FORMTEXT      First Name FORMTEXT      Is this the household the child(ren) were removed from? FORMCHECKBOX Yes FORMCHECKBOX NoSECTION 1: SAFETY ASSESSMENTSafety Factor Identification Safety Factor Identification Directions: The following list of factors are behaviors or conditions that may be associated with a child being in danger of serious harm. Identify the presence or absence of each factor by checking either yes or no. If the factor applies to any child in the household, check any condition(s) that apply to the family. Note: Consider the vulnerability of each child individually throughout the assessment. Children ages 0-6, developmentally disabled or those repeatedly victimized may be considered especially vulnerable. However, any child subject to harm or risk of harm from an adult cannot be expected to protect him or herself. Caretaker(s) refers to the person or persons responsible for care of the child; generally a parent or legal guardian, in the home from which the child(ren) was removed or another person with legal right to reunification planning. For each factor or condition, check yes or no to indicate if it is present in the family assessed. Explain each factor that is marked yes. A comment section follows each factor.1.Caretaker(s) caused serious physical harm to a child and/or made a plausible threat to cause serious physical harm, indicated by: FORMCHECKBOX Serious injury or abuse to child other than accidental FORMCHECKBOX Threat to cause harm or retaliate against child FORMCHECKBOX Excessive discipline or physical force FORMCHECKBOX Potential harm to child as a result of domestic violence FORMCHECKBOX One or more caretaker(s) fear they will maltreat child FORMCHECKBOX Drug exposed infant FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) caused serious physical harm to the child and/or made a plausible threat to cause serious physical harm and current circumstances suggest that child safety may be an immediate concern. If yes, explain. If no and there was serious or threatened harm, explain why it is not currently a factor.  MACROBUTTON [1] "Click Here and Type"   2.Caretaker(s) has previously maltreated a child in their care. Check all that apply: FORMCHECKBOX Prior death of a child FORMCHECKBOX Prior removal of any child FORMCHECKBOX Prior serious harm to any child FORMCHECKBOX Prior CPS substantiation FORMCHECKBOX Prior Termination of parental rights FORMCHECKBOX Prior threat of serious harm to child  MACROBUTTON [1] "Click Here and Type"    FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) has previously maltreated a child in their care and the severity of the maltreatment or the caretaker(s) response to the previous incident and current circumstances suggest that child safety may be an immediate concern if placement continues with the caretaker(s) or if placement is made with the caretaker(s). If yes, explain. If no and there is prior maltreatment, explain why it is not currently a safety factor.  MACROBUTTON [1] "Click Here and Type"   3. FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) failed to protect children from serious physical harm or threatened harm and perpetrator continues to have access, will likely have access or there are individual(s) living in, or visiting the home on a regular basis, who pose a threat to safety of the child. If yes, explain:  MACROBUTTON [1] "Click Here and Type"   4. FORMCHECKBOX Yes FORMCHECKBOX NoExplanation of the injury is unconvincing. If yes, explain:( Medical evaluation indicates injury is result of abuse, caretaker(s) denies or attributes injury to accidental causes. ( Caretaker(s) explanation for the observed injury is inconsistent with the type of injury. ( Caretaker(s) description of the causes of the injury minimizes the extent of harm to the child.  MACROBUTTON [1] "Click Here and Type"   5. FORMCHECKBOX Yes FORMCHECKBOX NoThe caretaker(s) refuses access to a child, or there is a reason to believe the caretaker(s) is about to flee, or a childs whereabouts cannot be ascertained. If yes, explain:( Family currently refuses access to the child and cannot or will not provide childs location. ( Family has removed child from a hospital against medical advice. ( Family has previously fled in response to a CPS investigation. ( Family has history of keeping child at home, away from peers, school, other outsiders for extended periods.  MACROBUTTON [1] "Click Here and Type"   6. FORMCHECKBOX Yes FORMCHECKBOX NoChild is fearful of caretaker(s), other family members, or other people living in or having access to the home. If yes, explain:( Child cries, cowers, cringes, trembles, or otherwise exhibits fear in the presence of certain individuals or verbalizes such fear. ( 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 caretakers, other household members or others having access to the child.  MACROBUTTON [1] "Click Here and Type"   7. FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) is unwilling or unable to provide supervision necessary to protect child from potentially serious harm. If yes, explain:( Caretaker(s) does not attend to child to the extent that need for care goes unnoticed or unmet (e.g., caretaker is present but child can wander outdoors alone, play with dangerous objects, play on unprotected window ledge, or be exposed to other serious hazards). ( Caretaker(s) leaves child alone (time period varies with age and developmental stage). ( Caretaker(s) makes inadequate and/or inappropriate baby-sitting or child care arrangements or demonstrates very poor planning for childs care. ( Caretaker(s) whereabouts are unknown.  MACROBUTTON [1] "Click Here and Type"   8. FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) is unwilling or unable to meet the childs immediate need for food, clothing, shelter and/or medical or mental health care. If yes, explain:( No housing or emergency shelter; child must or is forced to sleep in the street, car, etc.; housing is unsafe, without heat, etc. ( 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. ( Caretaker does not seek treatment for childs immediate and dangerous medical condition(s) or does not follow prescribed treatment for such condition(s). ( Child appears malnourished. ( Child has exceptional needs which caretaker(s) cannot/will not meet. ( Child is suicidal and caretaker(s) will not take protective action. ( Child shows effects of maltreatment, such as serious emotional symptoms and lack of behavior control or serious physical symptoms.  MACROBUTTON [1] "Click Here and Type"   9. FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) physical living conditions are hazardous and immediately threatening to a child based on the childs age and developmental status. If yes, explain:( 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, electricity) and no alternate provisions made, or alternate provisions are inappropriate (e.g., stove, unsafe space heaters for heat). ( Open windows/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.  MACROBUTTON [1] "Click Here and Type"   10. FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) substance use seriously affects his/her ability to currently supervise, protect or care for the child. If yes, explain:Caretaker(s) has misused drug(s) or alcoholic beverages to the extent that control of his or her actions is lost or significantly impaired. As a result, the caretaker is unable, or will likely be unable, to care for the child, or has harmed the child, or is likely to harm the child.  MACROBUTTON [1] "Click Here and Type"  MACROBUTTON [1] "Click Here and Type"   11. FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) behavior is violent or out-of-control. If yes, explain:( Extreme physical, verbal, angry, or hostile outbursts at child. ( Use of brutal or bizarre punishment (e.g., scalding with hot water, burning with cigarettes, forced feeding, etc.). ( Domestic violence likely to have negative impact on the child. ( Use of guns, knives, or other instruments in a violent way. ( Violently 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).  MACROBUTTON [1] "Click Here and Type"   12. FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) describes or acts toward child in predominantly negative terms or has extremely unrealistic expectations. If yes, explain:( Caretaker(s) describes child in a demeaning or degrading manner (e.g., as evil, possessed, stupid, ugly, etc.). ( Caretaker(s) curses and/or repeatedly puts child down. ( Caretaker(s) scapegoats a particular child in the family. ( Caretaker(s) expects a child to perform or act in a way that is impossible or improbably for the childs age or developmental stage (e.g., babies and young children expected not to cry, expected to be still for extended periods, be toilet trained or eat neatly, expected to care for younger siblings, expected to stay alone). ( Caretaker(s) view child as responsible for the caretakers problems. ( Actions by the caretaker may be periodic but form an overall negative view of the child  MACROBUTTON [1] "Click Here and Type"   13. FORMCHECKBOX Yes FORMCHECKBOX NoChild sexual abuse is suspected or confirmed and circumstances suggest that child safety may be an immediate concern. If yes, explain:( Confirmed means that there is a preponderance of evidence that sexual abuse occurred. ( Caretaker(s) or others have committed rape, sodomy, or has had other sexual contact with child. ( Caretaker(s) or others have forced or encouraged child to engage in sexual performances or activities (including forcing a child to observe sexual performances or activities). ( Access by possible or confirmed sexual abuse perpetrator to child continues to exist.  MACROBUTTON [1] "Click Here and Type"   14. FORMCHECKBOX Yes FORMCHECKBOX NoCaretaker(s) emotional stability seriously affects current ability to supervise, protect or care for child. If yes, explain:( Caretaker(s) refusal to follow prescribed medicines may skew ability to parent the child. ( Caretaker(s) inability to control emotions such as anger results in violent or out of control behavior that threatens a child. ( Caretaker(s) exhibit distorted perception of reality that impacts ability to parent child appropriately (e.g., keeping child from school or play due to extreme fear of germs or violence). ( Depressed behavior that manifests feeling of hopelessness, helplessness, or leading caretaker to being immobilized (e.g., failure to attend to child, feed or properly clothe child, and provide suitable environment).   MACROBUTTON [1] "Click Here and Type"  MACROBUTTON [1] "Click Here and Type"   15. FORMCHECKBOX Yes FORMCHECKBOX NoOther. If yes, explain:  MACROBUTTON [1] "Click Here and Type"   IF NO SAFETY FACTORS ARE PRESENT, GO TO SECTION 3: SAFETY DECISION AND CHECK SAFESECTION 2: SAFETY RESPONSE - PROTECTING INTERVENTIONSFor each safety factor identified in Section 1, consider the resources available in the family and the community that might help keep the child safe. Check each protecting intervention taken to protect the child and explain below. Describe all protecting safety interventions taken or immediately planned by you or anyone else, and explain how each intervention protects (or protected) each child.  FORMCHECKBOX 1.Monitoring or direct services by DHS worker.Includes all activities by the worker in areas such as counseling, crisis intervention, preventative service referrals, repeated home visits, requirements to clean house, contact with collaterals, etc.  FORMCHECKBOX 2.Use of family resources, neighbors or other individuals in the community as safety resources.Includes any activity arranged or approved by the worker that is a non-traditional service.  FORMCHECKBOX 3.Use of community agencies or services as safety resources. (check one) FORMCHECKBOX Intensive Home Based FORMCHECKBOX Other communityUse of community agencies or services as safety resources (intensive home based or other community): Check the specific service type arranged or approved by the worker from an agency or private counselor in the community such as Families First, Wrap Around, Parenting, Substance Abuse, Parent Aide, Homemaker, Home Health, etc. May include monitoring by a service provider.  FORMCHECKBOX 4.Have the alleged perpetrator leave the home, either voluntarily or in response to legal action.Includes any activity where the perpetrator leaves the household such as Personal Protection Orders, arrest of the perpetrator or other similar actions or where the non-offending caretaker prevents access to the child by the perpetrator.  FORMCHECKBOX 5.Have the non-maltreating caretaker move to a safe environment with the child.Includes any move arranged or approved by the worker where the caretaker leaves the household with the victim or potential victims such as a domestic violence shelter, with friends or relatives.  FORMCHECKBOX 6.Have the caretaker(s) place the child outside the home. (Write / type)  MACROBUTTON [1] "Click Here and Type"  MACROBUTTON [1] "Click Here and Type"    FORMCHECKBOX 7.OtherOther only includes services not covered by any of the prior protecting intervention services. Use of Other should be limited to activities not covered in the preceding definitions.   MACROBUTTON [1] "Click Here and Type"    FORMCHECKBOX 8.Legal action must be continued or taken to place child(ren) outside the home.Includes action initiated or continued by the worker to place the children out of the home or to continue out of home placement if the case is open for foster care. For each intervention checked, describe all protecting interventions taken or immediately planned by you or anyone else, and explain how each intervention protects (or protected) each child.  MACROBUTTON [1] "Click Here and Type"   SECTION 3: SAFETY DECISIONIdentify your safety decision by checking the appropriate box below. Check one box only. This decision should be based on the assessment of all safety factors and any other information known about this case. If C is checked, Section 2 does not have to be completed.A. Safe FORMCHECKBOX There are no children likely to be in immediate danger of serious harm if placement is made, or maintained, with the caretaker(s).B. Safe with Services FORMCHECKBOX If in-home protecting interventions are in place that will allow the child(ren) to be placed or maintained with the caretaker(s).C. 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Caretaker(s) have not resolved safety issues leading to placement.  FORMTEXT       Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.AUTHORITY: P.A. 280 of 1939. RESPONSE: Voluntary. PENALTY: None PAGE 6 DHS-149 (Rev.11-05) Previous edition obsolete. MSWord  PAGE 1 9_kd$$Ifl4+)044 laUf4.$If-$If[kdS$$If9FO +3!4    4 9aUZwqofdb$$&`#$okdG$$Ifl0+r 044 laU $If^ $If^ $$Ifa$ 00 0"0$0&0B0D0F0H0J0f0h0j0l0n0000000ʼtcR!jPh]{CJOJQJU!jh]{CJOJQJU!jh]{CJOJQJUh]{CJOJQJjh]{CJOJQJUh]{!jh]{CJOJQJUh]{CJOJQJjh]{CJOJQJUh$`yhChSe hSe0J8jhSe0J8U*hC0J8mHnHu*jhSe0J8U$0H0l00001$1H1p1111 242\2222!  $ !+^/0 P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%2 00P xP x&P/ =!"#$%/ 0P xP x&P/ =!"#$%D FCCaseNameEnter FC case name. CaseInfo.MAIN$$IfU!vh5,5 5#v,#v #v:V 94$5,5 5/ / / / / / /  44 9aND FCCaseNoEnter FC case number.$$IfU!vh5,5 5#v,#v #v:V 94$5,5 5/ / / / / / /  44 9aND PSCaseName'Enter PS case name (primary caretaker).$$IfU!vh5,5 5#v,#v #v:V 944$+5,5 5/ / / / / / /  44 9aND PSCaseNoEnter PS case number.$$IfU!vh5,5 5#v,#v #v:V 944$+5,5 5/ / / / / / /  44 9aND ReferralDateM/d/yyyyEEnter date Protective Services received referral on child's family. $$IfU!vh5,5 5#v,#v #v:V 944$+5,5 5/ / / / / / /  44 9aND CountyNameEnter the county name $$IfU!vh5,5 5#v,#v #v:V 944$+5,5 5/ / / / / / /  44 9aND FCWorkerName Enter in assigned worker's name.$$IfU!vh5,5 5#v,#v #v:V 944$+5,5 5/ / / / / / /  44 9aND FCWorkerLoadNo'Enter in assigned worker's load number.$$IfU!vh5,5 5#v,#v #v:V 94$5,5 5/ / / / / / /  44 9aNa$$IfU!vh5)#v):V 94$5)44 9aNDeCheck42Click to check box if this is a review assessment.DeKClick to check box if this is the first safety assessment for this referralD DCompleted$Enter date assessment was completed.$$IfU!vh5 55h5555#v #v#vh#v#v#v#v:V 94$5 55h5555/ 44 9aNDHouseholdAssessedLst#Enter Household assessed last name.DHouseholdAssessedFst$Enter Household assessed first name.$$IfU!vh5 5 55 #v #v #v#v :V 94$5 5 55 44 9aNDe;Check if this is the household child(ren) were removed fromDeCheck67Check if no child(ren) were removed from this household$$IfU!vh55h55h5R #v#vh#v#vh#vR :V 94$55h55h5R 44 9aN`$$IfU!vh5)#v):V 945)44 9aNf4Z$$IfU!vh5)#v):V 9$5)44 9aNU$$IfN!vh5)#v):V 9$5)44 9aN$$IfN!vh555##v#v#v#:V 94555#44 9aNf4[$$IfN!vh5)#v):V 945)44 9aNf4rDeCheck7Check if caretaker caused serious harm to child or made plausible threat as indicated by serious injury or abuse not accidental$$IfN!vh55_5t!5#v#v_#vt!#v:V 9455_5t!544 9aNf4lDeCheck if caretaker caused serious harm to child or made plausible threat as indicated by threat to harm or retaliate against child$$IfN!vh55_5t!5#v#v_#vt!#v:V 9455_5t!544 9aNf4fDeCheck if caretaker caused serious harm to child or made plausible threat as 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9aU$$IfN!vh555##v#v#v#:V 94555#44 9aNf4 DeQCheck if caretaker(s) previously maltreated a child prior to the death of a childDeNCheck if caretaker(s) previously maltreated a child prior removal of any child$$IfN!vh55_55y5#v#v_#v#vy#v:V 9455_55y544 9aNf4DeSCheck if caretaker(s) previously maltreated a child prior serious harm to any childDeLCheck if caretaker(s) previously maltreated a child prior CPS substantiation$$IfN!vh55_55y5#v#v_#v#vy#v:V 9455_55y544 9aNf4DeXCheck if caretaker(s) previously maltreated a child prior termination of parental rightsDeYCheck if caretaker(s) previously maltreated a child prior threat of serious harm to child$$IfN!vh55_55y5#v#v_#v#vy#v:V 9455_55y544 9aNf4[$$IfN!vh5)#v):V 945)44 9aNf4[$$IfN!vh5)#v):V 945)44 9aNf4_$$IfU!vh5)#v):V 945)44 9aUf4DePCheck if yes, the child(s) safety is of immediate concern if placement continuesDeOCheck if No, the child(s) safety is of immediate concern if placement continues$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 955_55i55!44 9aU[$$IfU!vh5|)#v|):V 945|)44 9aUf4_$$IfU!vh5)#v):V 945)44 9aUf4pDeCheck if Yes, caretaker(s) failed to protect child and perpetrator continues to have access who pose a threat to safety of the childnDeCheck if No, caretaker(s) failed to protect child and perpetrator continues to have access who pose a threat to safety of the child$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 955_55i55!44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4De7Check if Yes, Explanation of the injury is unconvincingDe6Check if No, Explanation of the injury is unconvincing$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4hDeCheck if Yes, caretaker refuses access to a child, reason to believe about to flee, or child's whereabouts cannot be ascertainedfDeCheck if No, caretaker refuses access to a child, reason to believe about to flee, or child's whereabouts cannot be ascertained$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4NDesCheck if Yes, child is fearful of caretaker, family members, or other people living in or having access to the homeLDerCheck if No, child is fearful of caretaker, family members, or other people living in or having access to the home$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4PDetCheck if Yes, caretaker is unwilling or unable to provide supervision to protect child from potentially serious harmNDesCheck if No, caretaker is unwilling or unable to provide supervision to protect child from potentially serious harm$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4tDeCheck if Yes, caretaker is unable to meet the child's immediate need for food, clothing, shelter and/or medical or mental health needsrDeCheck if No, caretaker is unable to meet the child's immediate need for food, clothing, shelter and/or medical or mental health needs$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4jDeCheck if Yes, caretaker's physical living conditions are hazardous and threatening to child based on age and developmental statushDeCheck if No, caretaker's physical living conditions are hazardous and threatening to child based on age and developmental status$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4:DeiCheck if Yes, Caretaker's substance use seriously affects ability to supervise, protect or care for child8DehCheck if No, Caretaker's substance use seriously affects ability to supervise, protect or care for child$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4De?Check if Yes, Caretaker's behavior is violent or out of controlDe>Check if No, Caretaker's behavior is violent or out of control$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4lDeCheck if Yes, caretaker(s) describes or acts toward child in predominatly negative terms or has extremely unrealistic expectationsjDeCheck if No, caretaker(s) describes or acts toward child in predominatly negative terms or has extremely unrealistic expectations$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4bDe}Check if Yes, child sexual abuse is suspected or confirmed and circumstances suggest child safety may be of immediate concern`De|Check if No, child sexual abuse is suspected or confirmed and circumstances suggest child safety may be of immediate concern$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4VDewCheck if Yes, caretaker's emotional stability seriously affects current ability to supervise, protect or care for childTDevCheck if No, caretaker's emotional stability seriously affects current ability to supervise, protect or care for child$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 9 55_55i55!44 9aUZ$$IfU!vh5)#v):V 9 5)44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU_$$IfU!vh5)#v):V 945)44 9aUf4DeXCheck Yes if there is other behavior or condition associated with child being in danger.DeZCheck No if there is no other behavior or condition associated with child being in danger.$$IfU!vh55_55i55!#v#v_#v#vi#v#v!:V 955_55i55!44 9aUU$$IfU!vh5|)#v|):V 95|)44 9aU[$$IfU!vh5)#v):V 945)44 9aNf4Z$$IfU!vh5)#v):V 9$5)44 9aN^$$IfN!vh5)#v):V 9$5)44 9aNZ$$IfU!vh5)#v):V 9$5)44 9aN_$$IfU!vh5)#v):V 945)44 9aNf4Z$$IfU!vh5)#v):V 9$5)44 9aNd$$IfU!vh5)#v):V 94$5)44 9aNf4DeCheck5PCheck if monitoring or direct services by FIA 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