DCYF Form 15-258 "Safety Assessment/Safety Plan" - Washington

What Is DCYF Form 15-258?

This is a legal form that was released by the Washington State Department of Children, Youth, and Families - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2019;
  • The latest edition provided by the Washington State Department of Children, Youth, and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DCYF Form 15-258 by clicking the link below or browse more documents and templates provided by the Washington State Department of Children, Youth, and Families.

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Download DCYF Form 15-258 "Safety Assessment/Safety Plan" - Washington

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DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Safety Assessment / Safety Plan
The Safety Assessment is used throughout the life of a case to identify whether a child is safe or unsafe. It is based on
comprehensive information about the family available at the time of its completion. Complete the Safety
Assessment/Safety Plan per DCYF policy.
CASE NAME / ID
INTAKE ID
SAFETY DECISION
PARTICIPANTS (ID)
DOB
SAFETY PLAN
DATE OF ASSESSMENT
SOCIAL SERVICE SPECIALIST
PHONE NUMBER
ASSESSMENT TYPE
Information Required for Assessing Child Safety – For Information Gathering Purposes Only.
Shaded area needs to be entered into the Case Assessment.
Shaded area is not translated.
Describe the nature and extent of the maltreatment:
Describe the circumstances that accompany the maltreatment:
Describe how the child or children function on a daily basis:
Describe how the parent / caregiver(s) disciplines the child:
SAFETY ASSESSMENT/SAFETY PLAN
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DCYF 15-258 (02/2019) INT/EXT
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Safety Assessment / Safety Plan
The Safety Assessment is used throughout the life of a case to identify whether a child is safe or unsafe. It is based on
comprehensive information about the family available at the time of its completion. Complete the Safety
Assessment/Safety Plan per DCYF policy.
CASE NAME / ID
INTAKE ID
SAFETY DECISION
PARTICIPANTS (ID)
DOB
SAFETY PLAN
DATE OF ASSESSMENT
SOCIAL SERVICE SPECIALIST
PHONE NUMBER
ASSESSMENT TYPE
Information Required for Assessing Child Safety – For Information Gathering Purposes Only.
Shaded area needs to be entered into the Case Assessment.
Shaded area is not translated.
Describe the nature and extent of the maltreatment:
Describe the circumstances that accompany the maltreatment:
Describe how the child or children function on a daily basis:
Describe how the parent / caregiver(s) disciplines the child:
SAFETY ASSESSMENT/SAFETY PLAN
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DCYF 15-258 (02/2019) INT/EXT
Describe the overall parenting / child care practices:
Describe how the parent / caregiver(s) manages his / her own life on a daily basis (this focuses on how the parent
functions in an adult role outside of his / her parenting role:
Safety Threshold
Provide information about the identified safety threat(s) to include 1 – 5 below, but not limited to this information:
How the safety threat has had or will have severe impacts on the child?
How the safety threat is immediate or will occur in the near future?
The vulnerability of the child in relation to the safety threat.
Why there is no responsible parent/caregiver or adult in the home that can prevent the threat.
The specific behaviors, conditions, etc., that are observed that make the threat clearly understood and
observable.
Safety Threats
YES
NO
1. The family / facility situation results in no adults in the home / facility performing parenting / child
care duties and responsibilities that assure the child’s safety
Describe:
2. The family / facility situation is that the living / child care arrangement(s) seriously endanger the
child’s physical health
Describe:
3. Caregiver(s) are acting (behaving) violently or dangerously and the behaviors impact child safety.
4. There has been an incident of domestic violence that impacts child safety.
If “Yes” complete the questions below.
a. The domestic violence perpetrator has caused serious harm or threats of harm against the adult
victim / caregiver of the child
b. The domestic violence perpetrator has seriously harmed or threatened serious harm to the child.
c. The level of violence and/or threats towards either the adult victim or child is increasing so that
serious harm is likely to occur
d. There are other indications of increased dangers from the domestic violence perpetrator such as
suicide threats or attempts, substance abuse or threats with weapons.
Describe:
5. Caregiver(s) will not or cannot control their behavior and their behavior impacts child safety.
Describe:
6. Caregiver(s) perceive the child in extremely negative terms
Describe:
7. Caregiver(s) do not have or do not use resources necessary to meet the child’s immediate basic
needs which present an immediate threat of serious harm to a child.
Describe:
SAFETY ASSESSMENT/SAFETY PLAN
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DCYF 15-258 (02/2019) INT/EXT
8. Caregiver’s attitudes, emotions and behavior threaten severe harm to a child, or caregivers(s) fear
they will maltreat the child and are requesting placement
Describe:
9. Caregiver(s) intend(ed) to seriously hurt the child
Describe:
10. Caregiver(s) lack the parenting knowledge, skills, or motivation necessary to assure a child’s safety
Describe:
11. Caregiver(s) overtly rejects DCYF intervention, refuses access to a child, or there is some indication
that the caregiver(s) will flee
12. Caregiver(s) are not meeting, cannot meet or will not meet the child’s exceptional physical, emotional,
medical, or behavioral needs
Describe:
13. Caregiver(s) cannot or will not explain child’s injuries or maltreating condition(s) or explanation is not
consistent with the facts
Describe:
14. A child has serious physical injuries or serious physical conditions resulting from maltreatment.
Describe:
15. A child demonstrates serious emotional symptoms, self-destructive behavior and/or lack of behavioral
control that results in provoking dangerous reactions in caregivers
Describe:
16. A child is extremely fearful of the home / facility situation or people within the home / facility.
Describe:
17. Child sexual abuse is suspected, has occurred, or circumstances suggest sexual abuse is likely to
occur.
Describe:
Safety Plan Analysis
YES
NO
There is a parent/caregiver or adult in the home
The home is calm enough to allow safety providers to function in the home.
The adults in the home agree to cooperate with and allow an In-Home Safety Plan.
Sufficient, appropriate, reliable resources are available and willing to provide safety services / tasks
If “Yes” is selected for all four above statements an In-Home Safety Plan (DCYF 15-259) must be created.
If “No” is selected on any of the four above statements, an Out-of-Home Safety Plan must be created.
SUPERVISORY APPROVAL
DATE
SAFETY ASSESSMENT/SAFETY PLAN
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DCYF 15-258 (02/2019) INT/EXT
In-Home Safety Plan
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Out-of-Home Safety Plan
Safety Plan
No Safety Plan Required
A Safety Plan is required for all children where there is a safety threat(s) indicated on the Safety Assessment. The Safety
Plan is a written arrangement between a family and DCYF that identifies how safety threats to a child will be immediately
controlled and managed. Note: When creating an In-Home Safety Plan the following criteria in the Safety Plan Analysis
must be present.
There is at least one parent/caregiver or adult in the home.
The home is calm enough to allow safety providers to function in the home.
The adults in the home agree to cooperate with and allow an In-Home Safety Plan.
Sufficient, appropriate, reliable resources are available and willing to provide safety services/tasks.
CASE NAME
CASE NUMBER
CASE WORKER NAME
TELEPHONE NUMBER
Safety Plan Analysis
Date of Birth
Safety Activities / Tasks
Identified Safety Threat(s):
START DATE
TARGET END DATE
Activities / Tasks:
What will be done (describe activities / tasks that will be done to manage the child’s safety, how the plan will work, etc.):
By Whom:
Frequency (what times, days of the week, etc.; include all those times the threat is likely to occur):
Identified Safety Threat(s):
START DATE
TARGET END DATE
Activities / Tasks:
SAFETY ASSESSMENT/SAFETY PLAN
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DCYF 15-258 (02/2019) INT/EXT
What will be done (describe activities / tasks that will be done to manage the child’s safety, how the plan will work, etc.):
By Whom:
Frequency (what times, days of the week, etc.; include all those times the threat is likely to occur):
Identified Safety Threat(s):
START DATE
TARGET END DATE
Activities / Tasks:
What will be done (describe activities / tasks that will be done to manage the child’s safety, how the plan will work, etc.):
By Whom:
Frequency (what times, days of the week, etc.; include all those times the threat is likely to occur):
Identified Safety Threat(s):
START DATE
TARGET END DATE
Activities / Tasks:
What will be done (describe activities / tasks that will be done to manage the child’s safety, how the plan will work, etc.):
By Whom:
Frequency (what times, days of the week, etc.; include all those times the threat is likely to occur):
COMMENTS
Document pertinent safety related information regarding: Conditions for Return Home, Trial Return Home, reunification
(
with a non-custodial parent, etc.)
SAFETY ASSESSMENT/SAFETY PLAN
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