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Personalized Domestic Violence Safety Plan

11/06

_________________________________________________________________ (school)

_________________________________________________________________ (day care staff)

_________________________________________________________________ (babysitter)

_________________________________________________________________ (Sunday school teacher)

_________________________________________________________________ (teacher)

_________________________________________________________________ (others)

I. I can inform _____________________________________________________ (neighbor, pastor, or friend)

my partner no longer resides with me and should call the police if he or she is observed near my residence.

Step 4: Safety with a protection order. Many batterers obey protection orders, but one can never be sure which

violent partner will obey and which will violate protection orders. I recognize that I may need to ask the police and the

courts to enforce my protection order.

The following are some steps I can take to help the enforcement of my protection order:

A. I will keep my protection order ________________________________ (Always keep it on or near your person).

B. There should be a county registry of protection orders that all police departments can call to confirm the

existence and/or status of a protection order. I can check to make sure that my order is on the registry. The

telephone number for the county registry of protection orders is: ____________________________________

C. For further safety, if I often visit other counties in my state, I might file my protection order in those

counties________________________________________________________________________________

D. I can call the local domestic violence program if I am not sure about B, C, or D above or if I have some problem

with my protection order.

E. I will inform my employer, minister, and closest friend, I have an active protection order.

F. If my partner violates the protection order, I can call the police and report a violation, contact my attorney, call

my advocate, and/or advise the court of the violation.

Step 5: Safety on the job and in public. Each battered partner must decide if and when he/she will tell others that

he/she has been battered and that he/she may be at continued risk. Friends, family, and co-workers can help to

protect. Each battered partner should consider carefully who to invite to help secure his/her safety. I might do any

or all of the following:

A. I can inform my boss, the security supervisor, and ______________________________at work of my situation.

B. I can ask _______________________________________________ to help screen my telephone calls at work.

C. When leaving work, I can ____________________________________________________________________

________________________________________________________________________________________

D. When driving home, if problems occur I can _____________________________________________________

________________________________________________________________________________________

E. If I use public transit, I can ___________________________________________________________________

________________________________________________________________________________________

F. I can use different grocery stores and shopping malls to conduct my business and shop at hours that are

different than those used when residing with my battering partner.

G. I can use a different bank and take care of my banking at hours different from those I used when residing with

my battering partner.

Step 6: Safety and my emotional health. The experience of being battered and verbally degraded by partners is

usually exhausting and emotionally draining. The process of building a new life for myself takes much courage and

incredible energy. To conserve my emotional energy and resources and to support my mental and emotional well-

being, I can do some or all of the following:

A. If I feel down and ready to return to a potentially abuse situation, I can

________________________________________________________________________________________

B. When I have to communicate with my partner in person or by telephone, I can

________________________________________________________________________________________

C. I can try to use "I can..." statements with myself and to be assertive with others.

D. I can tell myself "_____________________________” whenever I feel others are trying to control or abuse me.

Telephone numbers I need to know:

Police departments: __________________________________________________________________________

Battered women's program: ____________________________________________________________________

County registry of protection orders: _____________________________________________________________

Work number: _______________________________________________________________________________

Supervisor's home number: ____________________________________________________________________

DSS-5233

Family Support and Child Welfare

Form Dss-5233 - Personalized Domestic Violence Safety Plan - Family Support And Child Welfare Page 2

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