Safety Information Collection Tool
Case Name:	Case Number:
Six Safety Questions
Nature and extent of maltreatment:
Circumstances surrounding the child maltreatment:
Child’s day to day functioning:
Caregiver’s discipline:
Caregiver’s overall parenting:
Caregiver’s day to day functioning:
Safety Components
What Threats of Danger exist? (Be child specific)
What are Child(ren)’s Vulnerabilities to those threats? (Be child specific)
What caregiver protective capacity would a caregiver need to control the identified threat(s) of danger? (Cognitive, Emotional, Behavior)
What caregiver protective capacity does this caregiver have? (Cognitive, Emotional, Behavior)
What caregiver protective capacity is insufficient or diminished? (Cognitive, Emotional, Behavior)
Safety Threshold Criteria – Safe or Unsafe based on the following:
Specific/ observable	Family condition is observable and can be specifically described or explained; the danger is real; can be seen; can be reported; is evidenced in explicit, unambiguous ways.
Out of control	Family conditions can directly affect a child and are unrestrained; unmanaged; without limits or monitoring; not subject to influence, manipulation or internal power; are out of the family’s control.
Severe Harm	Harm that can result in pain, serious injury, disablement, grave/debilitating physical health conditions, acute/grievous suffering, terror, impairment, death.
Imminence	Likely to occur in the present or the near future. (can become active at any time)

Six Safety Questions

What is the nature and extent of the maltreatment?

Type of maltreatment

Severity of the maltreatment, results, injuries

Maltreatment history, similar incidents

Describing events, what happened, hitting, pushing

Describing emotional and physical symptoms

Identifying child and maltreating parent

What circumstances accompany the maltreatment?

How long has the maltreatment been occurring?

Parental intent concerning the maltreatment?

Whether parent was impaired by substance use, or was otherwise out-of-control when maltreatment occurred?

How parent explains maltreatment and family conditions?

Does parent acknowledge maltreatment, what is parent’s attitude?

Were there other problems connected with the maltreatment such as mental health problems?

How does the child function day-to-day?

Capacity for attachment (close emotional relationships with parents and siblings)

General mood and temperament

Intellectual functioning

Communication and social skills

Expressions of emotions/feelings

Behavior

Peer relations

School performance

Independence

Motor skills

Physical and mental health

How does the parent discipline the child?

Disciplinary methods

Concept and purpose of discipline

Context in which discipline occurs, is the parent impaired by drugs or alcohol when administering discipline

Cultural practices

What are overall parenting practices?

Reasons for being a parent

Satisfaction in being a parent

Knowledge and skill in parenting and child development

Parent expectations and empathy for child

Decision-making in parenting practices

Parenting style

History of parenting behavior

Protectiveness

Cultural context for parenting approach

How does the parent manage his/her own life?

Communication and social skills

Coping and stress management

Self control

Problem-solving

Judgment and decision-making

Independence

Home and financial management

Employment

Community involvement

Rationality

Self-care and self-preservation

Substance use, abuse, addiction

Mental health

Physical health and capacity

Functioning within cultural norms