Nevada Safety Plan printable pdf download

Nevada Safety Plan

MTL: 0510

Division of Child and Family Services

Section 0510

Family Programs Office: Statewide Policy Manual

Subject: Nevada Safety Assessment

NEVADA SAFETY PLAN

CASE NAME:

CASE NUMBER:

Describe how safety concerns will be managed. Provide specific provisions, time frames, tasks or activities and responsible parties.

List identified safety threat to

Describe safety action or task

Who will complete the task and

Describe method for monitoring

specified child and child’s age

selected to control the safety threat

When will it occur?

where will it occur?

safety action or task.

Describe how the safety provider is confirmed suitable to participate in the identified safety plan.

The child may be placed into protective custody if the participants in this plan are unwilling or unable to carry out the safety plan activities.

Caregiver Signature

Date

Caregiver Signature

Date

Worker Signature

Telephone Number

Date

Supervisory Review Signature (For file)

Date

For all safety plan participants: By signing this safety plan you are acknowledging that 1) you were informed of the action or task you have agreed to perform;

2) you understand and are in agreement with the requirements and will fulfill them to the best of your ability; 3) you agree to contact the caseworker if you are

unable to perform your responsibilities. Either you have received a copy of this plan or one will be mailed to you within the next 48 hours.

Name of Adult Responsible for Protecting Child (Safety Provider)

Relationship to Child(ren)

Telephone

Name of Adult Responsible for Protecting Child (Safety Provider)

Relationship to Child(ren)

Telephone

Safety Plan will be reviewed on:

___

Section 0510, Page 1 of 1

Date: 12/27/07

CPS & CAPTA