WV SAFETY ASSESSMENT AND MANAGEMENT SYSTEM Temporary Protection Plan

Referral Name Worker Name FACTS Referral # Date

Thoroughly describe below how each identified present danger is occurring within the family including when (time of day), under what circumstances, other influences that are involved, and caregivers access to the child (ren).

Identify the safety resources below.

Safety Resource Name, Address, phone Activity Frequency Begin Date

Thoroughly explain how each identified Safety Resources are appropriate and will control the present danger until further information can be collected below.

CPS-0747
Revised 11-17-09

Child Protective Services has the responsibility of monitoring the protection plan and ensuring the protection plan is sufficient and the safety resources are appropriate. Explain in detail how this was accomplished, including future activities that will occur to ensure the protection plan is appropriate.

(Plan may only be in effect for 7 days unless approved in accordance with policy) This protection plan begins on _______________________and will end on ______________________.

I have discussed the attached Protection Plan and the consequences of non-compliance with the caregiver and all those who are responsible for carrying out the plan. I have their agreement to abide by the terms and the conditions of the plan. CPS Social Worker ___________________________________________________Date____________ Phone_____________________________ Supervisors Name and Phone __________________________________________________________

CPS-0747
Revised 11-17-09

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I/we have discussed the Protection Plan with the worker. We understand its contents and that it is voluntary, and we agree to abide by the terms and conditions of the plan. If something happens which prevents us from carrying out the plan, we will immediately notify the worker. If the worker is unavailable, we will notify the supervisor. We understand that failure to agree to the plan or carry out the plan may result in a reassessment of my home and possible protective custody and/or referral to the Prosecuting Attorneys office for a court order to remove my children from my home. I will then have the opportunity to plead my case in court. Parent/Caregiver_____________________________________________________Date____________ Parent/Caregiver_____________________________________________________Date____________ Safety Resource_____________________________________________________Date____________ Safety Resource_____________________________________________________Date____________ Safety Resource_____________________________________________________Date____________ CPS Social Worker___________________________________________________Date____________

Supervisor Approval: Date Supervisor gave verbal approval by phone ____________________________Time ____________ Date Supervisor approved written plan ____________________________________Time____________

CPS-0747
Revised 11-17-09