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					CHILDREN SERVICES
INTAKE SCREENING TOOL
Table of Contents


I.      Initial Information

        A. Information About Referent
        B. Identifying Information About Alleged Child Victim and Family Members
        C. Identifying Information About Alleged Offender(s)
        D. Identifying Information About Other collateral Contacts, Others Who May Know
           About the Alleged Maltreatment
        E. Referent’s Concern
        F. Emergency Needs of the Child

II.     Neglect Screening Questions

        G. The Current Concern
             Educational Neglect                        Inadequate Supervision of Child
             Failure to Protect/Endangering             Lack of Utilities
             Failure to Provide Sufficient Food         Medical/Dental/Mental Health Neglect
             Failure to thrive, Non-Organic             Neglect as Punishment
             Hazards in the Home                        Poor Hygiene of Child
             Inadequate Clothing                        Substance Abuse
             Inadequate Housing                         Unsafe Sleeping Conditions
        H. Previous Incidents
        I. Medical Treatment

III.    Physical Abuse Screening Questions

        G. The Current Concern
             Bruises/Welts                              Forced Ingestion: food, drugs, other
             Burns                                      Fractures, Sprains, Dislocated Joints
             Choking                                    Head Injuries
             Cuts                                       Internal Injuries
             Dangerous Acts                             Pre-Natal Exposure to Drugs
                                                        Threats
        H. Previous Incidents
        I. Medical Treatment




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IV.     Sexual Abuse Screening Questions

        G. The Current Concern
            Sexual Abuse and Exploitation
            Exposed Child to Adult Sexual Activity      Sexual Activity between Children or Children
            Invaded Child’s Privacy                         and Adolescents
            Penetration                                 Sexual Behaviors that Seem Inappropriate
            Pornography                                 Touch/Masturbation

            Convicted Sexual Offender

        H. Previous Incidents
        I. Medical Treatment

V.      Emotional Maltreatment Screening Questions

        G. The Current Concern
        H. Previous Incidents
        I. Mental Health Treatment


VI.     Dependency Screening Questions

        G. The Current Concern
            Death of Parent/Caregiver                   Parent/Caregiver Incarcerated
            Exigent (Emergency) Family                  Mental Health Concern of Caregiver
              Circumstances                             Physical Disability/Developmental Problems of the
            Parent/Caregiver Hospitalization              Parent/Caregiver


        H. Previous Incidents

VII. Family in Need of Services Questions
        G. The Current Situation
            Child Fatality (non child abuse/neglect)    Post Finalization Adoption Services
            Deserted Child/Safe haven                   Post-Natal Placement Services to
            Emancipated Youth Services (youth             Infants of Incarcerated Mothers
              only; not family)                         Preventative Services
            Home Evaluation/Visitation                  Required non-lead PCSA Interview
              Assessment                                Required Non-Lead Supervision
            Permanent Surrender to the Agency’s             (from other PCSA or CSA only)
              Custody                                   Unruly/Delinquent Youth Referred




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VIII. Child Maltreatment: Out-of-Home Care

        G. Abuse in Out-of-Home Care
        H. Neglect in Out-of-Home Care

IX.     Domestic Violence

        G. The Current Incident
        H. History of Violent Behavior in the Home

X.      Concluding the Interview

        A.   Family Strengths
        B.   Family Awareness, Reaction to Referral
        C.   Support for the Family and Child
        D.   Safety Concerns for the Investigation/Assessment Caseworker
        E.   Ending the Call




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                    INTAKE SCREENING QUESTIONS
                        INITIAL INFORMATION
These instruments are to be used for collecting screening information from people who call the
agency with information about alleged child abuse, neglect, dependency, or families in need of
services. If you determine that the caller needs information or referral to another agency, use
your agency protocol for providing information and making referrals; do not use these forms.


A. Information About Referent
      Note: Please put information about the referent only in the referent screen for SACWIS,
      and do not include information that would identify the referent in the narrative section.

      1. What is your relationship to the alleged child victim(s) and his/her family?


      2. How do you know about the alleged maltreatment? Did you witness the situation? If
         someone else informed the referent:
               How can we contact that person?


      3. What caused you to call today?


      4. If the referent is willing to provide his/her name and phone number, please record it
         here.

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Mandated Reporters
      1. Contact information of mandated referents:
            Name:

            Agency/Organization:

            Address:

            Phone Number:

            Date and time the mandated reporter called in the referral:

      2. Has the Child Advocacy Center been contacted about this case?


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B. Identifying Information About Alleged Child Victim and
   Family Members

      1. Name and age of alleged child victim, other children, non-offending parent, other
         children and anyone else living in the home.


      2. Is the child of Native American heritage? If so, follow ICWA procedures; take report
         and refer it to the sovereign nation.


      3. Is the child a member of an active military family? If yes,
               Which branch?

               Does the family live on base?


      Note: Follow your agency’s protocol for collaborating with military organizations
      regarding allegations of child maltreatment


      4. Do any family members have any limitations or concerns? (e.g., hearing or speech
         impaired, language barriers, illness, physical limitations, non-English speaking - which
         language does the family speak?) If yes, please explain.


      5. Does the parent have any problems that prevent him from meeting his child’s basic
         needs? (such as substance abuse, mental illness, developmental delays)? If yes, please
         explain. See addition questions in the “Parental and Child Conditions” section.


      6. Child’s Address:

          Child’s Phone Number:

      7. Parent(s’) Addresses:

          Parent(s’) Phone numbers:



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C. Identifying Information About Alleged Offender(s)
      1. Name:


      2. Date of birth, or age:


      3. Address:


      4. Relationship to child:


      5. Phone number:


      6. Was anyone else either directly or indirectly involved in harming (i.e. abuse, neglect,
         sexual abuse, emotional maltreatment) the child? (Note: this was the WHO question in
         each maltreatment specific section)


      7. Did this person also harm any other children or adults? If yes, follow agency protocol
         for completing additional referrals for those children.


                                                                   Return to the Table of Contents



D. Identifying Information About Other Collateral
   Contacts, Others Who May Know About the Alleged
   Maltreatment
      1. Name:


      2. Address:


      3. Relationship to child or family:


      4. Age:


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      5. Phone:


      6. Please describe the kind of information this person could provide about the situation


      7. Please describe how this person knows the child/family. (i.e. friend, neighbor,
         relative, teacher, etc.)


      8. If the referent provides information about the nature of the relationship between this
         person and the family (i.e. trusted friend, conflicted relationship, etc.) please note that
         information here.



                                                                        Return to the Table of Contents



E. Referent’s Concern
      Encourage the referent to tell you about the situation, and his concerns in his own words,
      with little interruption. Take notes, to be able to come back to points after the referent has
      finished. Above all, ensure that the caller feels that you believe him, you understand and
      share his concerns, and that it is very important that he called. Ask only clarifying
      questions, when absolutely necessary. Let the referent know that it is important for you to
      hear what he thinks about it, not “just the facts.”

      Refer to specific sections on types of maltreatment (i.e.: Neglect, Physical Abuse, Sexual
      Abuse, Dependency, FINS, Out-of-Home Maltreatment, Parental and Child Conditions)
      that apply to the referral. (You may take notes on those pages.) Gather detailed information
      to help make a correct screening decision, and to help the caseworker conduct the safety
      and risk assessment.

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F. Emergency Needs of the Child
      When the referent is finished relating his concern, ask whether there are any immediate
      concerns for the child's safety. Focus on what happened to the child….not what the child
      did. Use the name or term the referent is using for the child

      1. Do you think the child is safe right now?


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                Why or why not?
                How long will he be safe in his present situation?


      2. Does the child need immediate medical attention? If yes,

                 Why?


      3. Is the child in danger, in pain, afraid, or alone right now? If yes, please explain:


      Note: If your agency requires law enforcement assistance in this situation ask the following
      question:

      4. Has anyone called Law Enforcement? If yes,
                Which law enforcement jurisdiction?

                Did law enforcement come to the scene? If yes,

                 o What happened?


      5. Is the person who hurt the child in the home now, or does he/she have easy access to
         the child? (Explain to the referent that the person who hurt the child may threaten the
         child not to tell, if he suspects anyone has contacted law enforcement or Children
         Services)


      6. Is the other parent/caregiver able and willing to protect or care for the child– or is there
         another family member, relative, kin, friend (or anyone else) who is able and willing to
         protect the child?


                 Is anyone protecting the child now?


                                                                      Return to the Table of Contents




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                NEGLECT SCREENING QUESTIONS

G. The Current Concern
After the referent has related his story, refer to the sections covering the type of concern, and
obtain more specific information from the reporter. Make sure you have specifics of the referral,
as given below. The purpose is to get as much information as possible a) to make a screening
decision, and b) to inform the intake worker’s investigation:

Get the facts (What?..Where?..When?..Who?.. How?..Why?..) about the incident or reporter’s
concern (in a logical, comfortable way – follow his lead)

        Educational Neglect
          1. Child is school-age (5-17; unless 16 and formally withdrawn). Is the child:

                __ Not enrolled in school or educational program approved by the Board of
                   Education (e.g., home school program or digital academy)

                __ Missing excessive days (more than 15 unexcused absences) with no prior
                   history of excessive absence
                           How many days has the child missed?

                __ History of poor attendance in previous years (more than 20 days unexcused
                   absences)
                           How many days did the child miss?

                __ Missed more than 5 days in current year without proper authorization from
                   parent/caregiver or school
                           How many days has the child missed?

                __ Child is 13+ and parent/caregiver is contributing to truancy

                __ Child wants to attend but parent/caregiver not enrolling child, or preventing
                   child from attending

                __ Child cannot attend school because guardian or relative does not have custody,
                   or has not completed necessary paperwork for enrolling the child

          2. Do you know why the parent/caregiver’s have failed to send child to school? (e.g.,
             older children stay home to care for younger children) Please explain.



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          3. Does the parent/caregiver send the child to school but the child refused to attend? If
             yes,

                   Do you know why the child refuses to attend?


          4. Has the school staff or truancy officers attempted to help improve the child's
             attendance? If yes:

                   What have they done?


                   Have truancy charges been filed in court?


          5. How do you know the child do not attend school?


          6. Are you aware of any medical conditions, or any special circumstances with the
             child or other family member that may prevent the child from attending school?


                                                                      Return to the Table of Contents


        Failure to Protect/Endangering

          1. Check all that apply and explain:
                __ Parent/caregiver(s) commits criminal act that seriously endangers a child’s
                   physical or mental health. Child is present, or participates in this act.

                __ Parent/caregiver uses guns, knives, or other weapons around the child

                __ Parent/caregiver threatens violence to the child, or in the child’s presence,

                __ Parent/caregiver allows the child to be around, or live with someone who could
                   be dangerous to the child, and does not protect the child (i.e. sexual offender,
                   violent person, person who is high or drunk)

                __ Parent/caregiver does not protect child from siblings who physically or
                   sexually abuse the child
                __ Parent/caregiver encourages or allows their child to participate in inappropriate
                   sexual activity with others (moved from Inadequate Supervision)

                __ Parent/caregiver does not stop inappropriate interaction between siblings (e.g.
                   fighting, rough horseplay, sexual activity) (moved from Inadequate
                   Supervision)

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                __ Parent/caregiver has told the child not to return home without making
                   other arrangements

                __ Are the child confined to a specific area? If yes,
                       For how long?


                __ Child are locked out of their home routinely? If so.,why?


                       Is there an alternative plan for the child when the home is locked? (i.e.
                        going to the neighbors?)


          2. How frequently does this happen to the child?


                   How long has this been going on?


          3. Has the child suffered any harm as a result of any of these problems?

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        Failure to Provide Sufficient Food
          1. Please check all that apply:
                __ No food provided or available to child, or child starved or deprived of food or
                   drink for prolonged periods.

                __ Some food available to the child, but it is not enough? If yes,
                       How much food is in the home?


                       Do the parent/caregivers have food stamps?


                       Do the parent/caregivers have financial resources for food? If yes,


                            o Where do they get money for their food?



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                       What foods are the parent/caregivers giving the children?


                       How are they feeding the children? (i.e., children get free lunches at
                        school, food pantry)


                __ Parent/caregivers have food but fail to prepare it for eating

                       Do you know why they do not cook or prepare food for the children? If
                        yes, please explain:


                       Are the children allowed to cook available food?


                        Are the children able to cook?


                __ There is enough food in the home, but the child don’t want to eat it


          2. Does the child appear to be underweight or malnourished?


          3. Does the child receive breakfast or lunch at school?


          4. Does the child exhibit symptoms of malnutrition? Check all that apply.
                __ Developmental lag

                __ Weakness related to lack of food

                __ Low weight and height which is significantly out of the norm and not due to
                   organic causes

                __ Inability to concentrate in school


          Ask the referent for details if any of the above are checked)

          5. How long have the children been without adequate food?




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          6. Has the family used community resources for food? If yes,


                      What services?
              If no,
                      Do they know how to access community services?


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        Failure to Thrive, Non-Organic
          1. Has a doctor or medical professional diagnosed this child with non-organic failure
             to thrive? If yes,
                      Who is the doctor or medical


          2. If the referent is not a medical professional… What makes you think the child may
             be failure to thrive? (e.g., Child losing weight, has a weak cry, is lethargic)


                      Please give a physical description of the child.


          3. Can you describe how the parent/caregiver’s feed the child? (e.g. Holds them,
             props bottle, feeds on a schedule or on demand, feeds infrequently)


          4. Does the parent/caregiver(s) lack the basic knowledge related to
             parenting/caregiving skills such as:
                __Does not know child development or child's nutritional needs

                __Failure to access and obtain basic/emergency medical care; proper diet; or
                   adequate supervision

                __ Does this lack of knowledge seem to be due to a cognitive delay?


          5. Are you aware of any stressors the family may be dealing with?


          6. Has the child been sick? If yes,
                      What was the illness, and diagnosis?

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                   Has the child been treated? If yes,
                    o Where?

          7. Describe what child can do: (e.g., hold head up, roll over, sit up, walk, etc.)


                   Does the child appear to be developing normally?


                   Does the child have any delays in development?


          8. How long has the child been inadequately fed?


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      Hazards in the Home
          1. Please check all that apply and explain.
          Substances that could poison or sicken a child (describe location).
                __ Cleaning supplies

                __ Rat or other poison

                __ Rotten food

                __ Garbage (exposed)

                __ Meth lab or other drug manufacturing

                __ Human, animal feces in the home

                __ Bad or unexplained odor in the house

                __ Exposed lead paint

                __ Exposed asbestos

                __Other




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          Sharp Objects that could harm a child (describe location).

                __Knives

                __ Broken windows

                __ Broken glass

                __ Broken furniture

                __ Broken dishes, cooking utensils

                __Other


          Fire and Electrical Hazards (describe location)

                __ Exposed electrical wiring

                __ Exposed space heaters (electrical, propane, kerosene)

                __ Exposed cooking elements

                __ Blocked exits in the house

                __ Combustible materials near the furnace

                   No smoke detectors, or smoke detectors do not work

                __ Other

                       Has the fire department evaluated the home? If yes, when?


          Choking Hazards

                __ Small objects that infants and toddlers could access

                __ Other


          Firearms/Weapons (describe location)

                __ Guns or other weapons unlocked.

                __ Other


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          Falling Hazards (i.e., children falling or objects falling on children). Describe location.

                  __Open or broken windows, doors.

                  __Staircases without railings.

                  __ Furniture is not safe for the child to sit on.

                  __ Parts of the house or buildings could fall on children.

                  __ Other


          Drowning Hazards (describe location)

                  __ Open, uncovered well

                  __ Swimming pool without fence

                  __ Other


          Suffocating Hazards (describe location)

                  __ Abandoned refrigerators or other containers with doors

                  __ Other


          Pests

                  __ Bugs, roaches, rats, maggots etc. in the house? (Excessive)


          Hazards outside or in out buildings

                  __ Tools, vehicles etc. in the yard that would be a danger to child

                  __ High weeds that could conceal a small child or dangerous gardening or farm
                     implements

                  __ Hazards in outbuildings

          2. How did the home come to be in this condition?

          3. How long has the home been in this condition?


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          4. Has the house been condemned, or should it be? Has the Health Department been
             Contacted?


          5. Do any of the children have a medical condition that would be made worse as a
             result of any of these problems?

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        Inadequate Clothing
          1. Check all that apply, and explain
                __ Amount of clothing inadequate

                __ Clothing does not fit the child

                __ Clothing is in poor condition (rips, holes, stains, etc.)

                __ Clothing is not clean, or has odor

                __ Child is ridiculed at school, because of his clothing

                __ Clothing is inadequate for the weather


          2. Do you know why do the children have inadequate clothing?
             If yes, please explain:


          3. How long have the children had inadequate clothing?


          4. Does the family have resources to keep the clothing clean?


          5. Has the family used community resources for clothing? If no,
                   Do they know how to access community services?



                                                                       Return to the Table of Contents




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      Inadequate Housing
      1. Please check all that apply, and explain using follow up questions where applicable.

            __The housing is inadequate to protect the children from weather.

            __ The family has sufficient temporary shelter, but no permanent shelter (i.e., living
               in a homeless shelter, or with relatives)
                   How long can they stay at their current location?

            __The family does not have shelter for the children.
                   What caused them to lose their shelter/residence?

                   Is the home condemned?

                   Where are they currently residing? Or, is the family linked with community
                    shelters? If yes, Which ones?

                   Has the family ever been asked to leave a shelter program? If yes, why?

                   Are they moving from place to place, or transient (Have limited possessions,
                    no established home)?

            __Family is living in their car.
                   What type of car?

                   License plate #?

                   Do you know where they park the car?


          2. What appears to be the reason the family has inadequate housing?


          3. How long has the family been in this situation?

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    Inadequate Supervision of Child
          1.   Check all that apply, and ask the bulleted, follow up questions, as appropriate

                __ Child is alone right now



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                       Where is the child?

                __ Child is unsupervised

                       Where are the children unsupervised? (At home? Outside?)

                       When does this happen?

                       What time of day?

                       Unsupervised at night?

                       How long are they left alone?

                       How often does this happen?

                       Is the child afraid when left alone?

                       Has the child been harmed as a result of lack of supervision? Could the
                        child have been harmed? (e.g. child is alone in a dangerous environment
                        or with dangerous people?)

                __ Inappropriate Caregiver

                       Who is the child with?
                        o Address:
                        o Phone number:

                       What is the child’s relationship to the caregiver?

                       When is the child left with this person?
                        o How often?

                       Why is this person inappropriate?
                        ___ Abuses substances
                        ___ Mentally challenged
                        ___ Convicted sex offender with probation orders not to reside with
                            children
                        ___ Physically incapacitated lacking the ability to care for children
                        ___ Caregiver is too young to care for the child
                        ___ Other

                       Has the child suffered any harm as a result of exposure to the
                        inappropriate caregiver?

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                __ Parent left the child with someone and has not returned
                       Who was the child left with?
                        o Address:
                        o Phone number:

                       How long has the child been with this person?

                       When was the parent supposed to return?

                       Do you know why the parent hasn’t returned, or made alternate
                        arrangements for the child?

                       Has the child been harmed because of this? Could the child have been
                        harmed because of this?


                _ _ Parent/caregiver told the child to leave or refuses to allow the child to return
                    home
                       What were the circumstances?

                       How long has the child been gone?

                       Where is the child?

                       Has the child been harmed?

                       Could the child be harmed?


          2. Does the child know how to contact their parent/caregivers or another trusted adult?


          3. Is the parent accessible to the child by phone or in person?


          4. Is someone responsible for checking in on the well being of the child? )e.g.
             relative, neighbor, etc.) If yes,
                   Who is the responsible person?


          5. Is an older sibling in the household able to provide appropriate care? If yes,
                   How many child does the oldest child care for?



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                   How old is he/she?


          6. Why is the parent unwilling/unable to properly supervise the child? (e.g. unaware
             of child’s needs, drunk, high, preoccupied, depressed, sleeping while children are
             awake)

          7. Are the parent/caregivers’ whereabouts unknown? If yes,
                   How long have the parent(s) been missing?

                   When were the parent(s) last seen?
                    o Where?
                    o By whom?

                   Has law enforcement been notified?


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        Lack of Utilities
          1. Which utilities do the family lack?
                __ No heat in cold weather.
                __ Inoperable plumbing, if the family has no other source of water.
                __ No electricity
                __ Leaking gas
                __ Plumbing not working
                __ No water


          2. How do you know that the family is without utilities?


          3. Does any child have a medical condition that requires the utility?


          4. Is the family using an alternative heat source? If yes:
                   What type of heat source is being used?

                   What type of fuel? (i.e. wood, propane, oil, electric heaters, other?)




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          5. Does the family have access to water for personal hygiene/cooking/drinking? What
             is the source?


          6. How long has the family been without utilities?


          7. Do you know why the family lacks utilities? If yes, Please explain.


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        Medical/Dental/Mental Health Neglect
          1. Does the child have any injuries that are untreated? Please explain:


          2. Does the child have any illnesses or conditions that are not treated? Or not
             adequately treated? Please explain:


          3. Does the child have any mental health problems that are not treated? Or not
             adequately treated? Please explain:


          4. Does the child receive the following non-routine medical or mental health care, as
             needed?


                    __ Emergency care for injuries. Please explain:

                    __ Care for serious chronic or acute illnesses. Please explain:

                    __ Care for mental health or behavioral problem: (e.g., self injurious behavior,
                       suicidal, threatening to hurt others, out of control behavior, depression
                       eating disorders, etc.). Please explain:

                    __ Care for medically fragile conditions. Please explain:


          5. Is the child given medication or other treatments as prescribed? If not,
                    Why not?

                    Is the parent/caregiver using the child’s medication him/herself or selling it to
                     others?

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          6. Could the absence or delay of medical or mental health treatment seriously affect
             the child? Please explain: (e.g. permanent disability, impair life functioning,
             serious illness)


          7. What seems to be the barrier to the parent/caregiver obtaining medical or mental
             health treatment?
                __ Cultural or religious reasons

                __ Inability to pay for health care

                __ Lack of understanding of need for health care

                __ Parental condition (illness, depression, etc.)

          8. Has the parent/caregiver removed a child from psychiatric or medical
             hospitalization against medical advice? If yes,
                   Do you know why he/she removed the child?


          9. Regarding vision/hearing concerns, how do they impede the child’s educational
             process?
                   Has the school made any accommodations regarding lack of glasses or
                    hearing devices?

          10. If the referral source is a medical professional, what is the immediate needed
              intervention?


                                                                      Return to the Table of Contents


      Neglect as Punishment
          1. Was the neglect the result of an attempt to control the child’s behavior?

              Check any that apply, please explain:

                __ Denied appropriate food or water for punishment? If yes, how long?

                __ Denied access to school for punishment? If yes, how often?

                __ Failed to receive medical treatment for injury or illness, as punishment?


                                                                     Return to the Table of Contents


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        Poor Hygiene of Child
          1. Check all that apply, and explain:

                __ Bleeding

                __ Painful rash

                __ Skin condition

                __ Loss of hair

                __ Loss of teeth

                __ Chronic tooth pain

                __ Diaper rash If yes,
                       How often is the baby’s diaper changed?

                       How severe is the rash

                __ Lice that has not been adequately treated, or is chronic

          2. How long has this situation been going on?

          3. Does the child have a medical condition causing bad body odors?

          4. Is the child bathed regularly?
                   Hair combed?

          5. Is the child unable to participate in school or community activities because of his
             poor hygiene?

          6. Has this issue been addressed with the parent/caregivers prior to this call? If yes,
                   Who contacted the parent/caregiver?

                   What was the parent/caregiver’s response?


                                                                      Return to the Table of Contents




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    Substance Abuse (Also see Physical Abuse section on Exposure to Drugs)
      Access to Illegal Drugs or Alcohol

      1. What type of drugs or alcohol does the child have access to in his home?
         Please check all that apply, and explain:
            __ Prescription drugs.

            __ Alcohol.

            __ Illegal drugs.

            __ Child has access to needles or other drug paraphernalia? (please specify)


      2. Are there safety issues as a result of the presence of drugs or alcohol in the home? If
         yes,
               How so? What are the drugs of concern?

               Are drugs being sold out of the home?


      3. Have the police ever been called to this home for drug activity? If yes,
               When did this occur?

               How often has this occurred?

               Who, if anyone, was arrested?

               Was anyone charged?

      4. Are parent/caregivers manufacturing or attempting to manufacture methamphetamine?
               Storing methamphetamine waste products?


      5. Are adults manufacturing or growing any other type of drugs in the home? If yes,
               What drugs?


      6. Does the parent/caregiver provide drugs to their child?

                                                                      Return to the Table of Contents




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        Unsafe Sleeping Conditions
          1. Check all that apply and explain:
                __ Infant or toddler does not sleep in a crib (when it is age appropriate for him to
                    be in a crib)
                __ Crib is not safe (i.e. slats too far apart, sides don’t stay up, etc.)

                __ Infant is sleeping in same bed as adults (i.e. danger of rollover)

                                                                       Return to the Table of Contents


H. Previous Incidents
      1. Do you have any concerns that this child or other children in the home may have been
         neglected or have had any other type of maltreatment before?


      2. Has this child been referred to our agency, or any other public children services agency
         before? If so, when?


      3. Has there been an unexplained or suspicious death of a child in the home? Please
         explain:

                                                                      Return to the Table of Contents


 I. Medical Treatment
      1. Does the child to receive medical treatment or evaluation as a result of neglect?

               Did anyone else try to treat the child before medical intervention? If yes,
                o What did they do?


      2. Is there medical evidence of the neglect? :


      3. Has the child already received medical treatment for the current neglect incident? If yes,
               Where and when was the child treated? (Name of doctor or hospital)

               Who took the child to the doctor (or urgent care) or emergency room?



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      4. Is any follow up treatment needed? If yes,
               Do you think the parent/caregivers will follow up to provide further treatment?

               Who is the child's family doctor?


                                                                      Return to the Table of Contents




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          PHYSICAL ABUSE SCREENING QUESTIONS

G. The Current Concern
After the referent has related his story, refer to the sections covering the type of concern, and
obtain more specific information from the reporter. Make sure you have specifics of the referral,
as given below. The purpose is to get as much information as possible a) to make a screening
decision, and b) to inform the intake worker’s investigation:

Get the facts (What?..Where?..When?..Who?.. How?..Why?..) about the incident or reporter’s
concern (in a logical, comfortable way – follow his lead)



      Bruises, Welts (Be specific: part of the body, what side of the body)
      1. Where is the injury located?


      2. How did the injury occur? (Prompt for details)
            __Slapped with open hand

            __Hit with heel of hand

            __Hit with fist

            __ Hit with an object
                    Describe the object.

                   Where is the object now?


      3. What do the bruises/welts look like? (Be specific: shape, size, color, swelling)


      4. How serious is the injury?


      5. How frequently has this happened?

      6. Where did this occur (i.e., location of incident- home, backyard, etc.), and when?



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      7. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?

                                                                    Return to the Table of Contents


    Burns
      1. Where is the burn located? (Be specific: part of the body, what side of the body)


      2. How was the child burned? (Check all that apply, and describe)
            ___ Immersion
            ___ Scalding
            ___ Cigarette
            ___ Iron
            ___ Heating element
            ___ Other


      3. What does the burn look like? (Be specific: shape, size, color, blistering)


      4. What is the severity of the burn? (1st, 2nd, 3rd degree burns)


      5. Are there marks that would indicate how the child was burned?


      6. How frequently has this happened?


      7. Where did this occur (i.e., location of incident - home, backyard, etc.), and when?


      8. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?

                                                                      Return to the Table of Contents



    Choking
      1. Describe how the child was choked.
               What was the child choked with? (e.g., hands, object, restraint technique)



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               Where is that object now?

      2. Did the child lose consciousness?
               Is the child acting differently than before the choking?

               Is the child lethargic or vomiting?


      3. Are there any marks on the child's neck? (Please describe location, color, shape,
         length and width, if the marks look like the object used)


      4. How frequently has this happened?


      5. Where and when did this occur? (location of incident – home, backyard, etc.)


      6. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?

                                                                      Return to the Table of Contents



    Cuts
      1. Where is the child cut? (i.e., part of body)


      2. What was the child cut with?
               Where is that object now?


      3. What do the cuts look like? (number, depth, color, size, shape, length)


      4. How severe is the cut? (bleeding?)


      5. How frequently has this happened?


      6. Where and when did this occur? (location of incident – home, backyard, etc.)




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      7. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?
                                                                      Return to the Table of Contents


    Dangerous Acts
      1. Please check all that apply, and explain:

            __ Driving with the child while intoxicated

            __ Guns or other weapons within reach of the child
                   Is the gun locked?

                   Is the gun loaded?

                   Where is the weapon located?

            __ Uses a weapon in the child's presence, or assaulted someone in the child's
               presence.

            __ Parent gave the child substances that would harm the child or result in otherwise
               unnecessary medical procedures? (i.e., Munchhausen-by-Proxy?)

            __ Severe or bizarre punishment, or torture, even if it did not cause physical injury
               Please describe (i.e., severe chores, unusual punishment)
                   Who decided the punishment?

                   What was the reason for the punishment?

                   Did any serious harm result?

            __ Locked in a room as punishment. If yes,
                   For how long?

                   In which area of the home?

                   Did any serious harm result?

            __ Used severe force to control the child or make the child do something

            __ Forced the child into severe exercise?
                   What was the exercise



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                   How long was the child forced to do it?

            __ Locked the child outside of the home

            __ Left a young child alone in the car

            __ Exposed a child to a drug buy or drugs in the home (even if not ingested by the
               child)

            __ Shocked the child, tazered the child, or used a cattle prod?

            __ Physically fought near the child?

            __ Forced the child into excessive exercise
                   What was the exercise?

                   How long was the child made to do it?

            __ Parent has bizarre or out of control behavior. Please describe (i.e.: out of touch
               with reality; fanatical, reckless, unstable, raving, explosive)

            __Parent failed to protect the child from harm?

      2. How frequently has this happened?


      3. Where and when did the dangerous acts occur?


      4. Does this seem to happen as a result of discipline or trying to control the child's
         behavior?

                                                                      Return to the Table of Contents



    Forced Ingestion; food, drugs and other items
      1. Please describe what the child was forced to ingest. Check all that apply, and describe

            __ Forced to eat a non-food item, a painful food item (very hot and spicy; difficult to
               swallow), or an excessive amount of food.
                   What was the child forced to eat? Why?


                   Was the child allowed to spit it out?

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                   Did the child experience pain or other harm?

                   How often has this occurred?

                   Are there are injuries on the infant’s mouth from forceful spoon/bottle
                    feeding Please describe,

            __ Parent has not given medication properly (either prescription or over-the-counter
               medication)
                   What medication? or What kind of medication?

                   Was the medication prescribed for this child(ren?)

                   Too much or too little medication?

                   Did not give medication at the correct times?

                   Who decided to change the amount of medication given?

                   Why did the parent give the medication (e.g. to make the child sleep, to punish
                    the child?)

            __ Parent gives the child alcohol or illegal substances

                   What illegal substances is the child given?

                   Do the parents use substances with their child? If yes,
                           What substances?

                   What happened to the child as a result of this? (i.e. child passed out, is sick, is
                    hospitalized)

            __Parent purposely give the child a poison or dangerous substance?


      2. How often has this happened to the child?


      3. Where and when did this occur?


      4. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?

                                                                        Return to the Table of Contents


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    Fractures, Sprains, Dislocated Joints
      1. Where is the injury? (i.e., part of body)


      2. How did the injury occur?


      3. Describe the injury (fracture, sprain, dislocated joint)?
               What does it look like?


      4. How severe is the injury?


      5. How frequently has this happened?


      6. Where and when did this occur? (location of incident – home, backyard, etc.)


      7. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?

                                                                      Return to the Table of Contents



    Head Injuries
      1. Are there bruises or injuries to the head or face? Please describe (i.e., black eye, knot
         on the head, cuts or abrasions, swelling, marks on or around the neck area, bruising on
         the chest, dilated pupils)

      2. What does the injury look like? (Be specific: shape, size, color)


      3. Is the child acting different than usual?


      4. Is the child lethargic or vomiting?


      5. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?



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      6. Where did this occur (location of incident – home, backyard, etc.) and when?


                                                                      Return to the Table of Contents

    Internal Injuries
      1. Do you think the child may have internal injuries?
               Why do you think so? (Check all that apply, and explain)

                ___ Broken blood vessels in baby’s eyes, black under the eye (Shaken Baby
                    Syndrome)
                ___ Bleeding from mouth or rectum
                ___ Tenderness, swelling and/or bruising in abdomen or trunk
                ___ Dilated pupils
                ___ Headache
                ___ Lethargy
                ___ Vomiting
                ___ Child is acting different than usual


      2. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?


      3. Where did this occur (location of incident – home, backyard, etc.), and when?


                                                                      Return to the Table of Contents

    Pre Natal Exposure to Drugs
      1. What drug(s) does the infant have positive toxicology for?
               What were the drug levels?

               What tests were used to diagnose toxicology?


      2. Does the infant show signs of withdrawal? (i.e., lethargy, inconsolable crying, unable
         to sleep, shaking, unable to nurse) If a medical professional is the making the referral:
         is he/she charting the withdrawal symptoms? If not, request them to chart.


      3. Is the baby healthy?


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               What are the infants APGAR scores?

               What is the infant’s birth weight? Is this a full term baby?


      4. Is mother registered in a methadone program?


      5. Did mother test positive during her pregnancy or at the birth of her baby?


      6. Did mother receive prenatal care?


      7. Does mother acknowledge her drug use?
               What drugs?


      8. Has mother given birth to other positive toxicology infants? If yes,
               When was the previous child born?

               What was the drug?


      9. Was the mother on prescription drugs during the pregnancy, labor, or delivery? If yes,
               What prescribed medications did she receive?

               Would these medications result in a positive tox screen?


      10. How long will the mother be in the hospital after the delivery?
               Is there a plan for care of other child in the home while the mother is in the
                hospital?

                                                                      Return to the Table of Contents


    Threats
      1. Has this person(s) done any of the following to a child, pet, or spouse/partner? (Please
         check al that apply and describe)

          ___ Threatened physical abuse or harm. Towards whom?




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          ___ Threatened with a weapon, firearm, flammable liquid, or any devise designed as a
               weapon. Towards whom?

          ___ Used a gun, knives, or other instruments in a violent, threatening or intimidating
               manner. Towards whom?


      2. Has this person made threats in the past?
               Has he/she carried out the threats?


      3. How frequently has this happened?


      4. When and where were threats made?


      5. Did this injury seem to happen as a result of discipline or trying to control the child's
         behavior?

                                                                      Return to the Table of Contents



H. Previous Incidents
      1. Has anything happened to injure this child before?


      2. Has anything happened to injure other child in this home?


      3. Have the parent/caretakers been involved in the injury or death of another child? (Ex:
         other children in the home, children from previous relationships, etc.)

                                                                      Return to the Table of Contents



I.     Medical Treatment
      1. Has the child received medical treatment as a result of this injury? If yes,
               Where and when was the child treated? (Name of doctor or hospital)

               Who took the child to the doctor, urgent care, or emergency room?



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      2. Any follow up treatment needed? If yes,
               Do you think the parents will follow up to provide further treatment?

               Who is the child’s family doctor?


      3. Are there medical signs or physical indicators of the injury? If yes, please describe:


      4. Is non-emergency medical treatment or evaluation needed?


                                                                    Return to the Table of Contents




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        SEXUAL ABUSE SCREENING QUESTIONS


G. The Current Concern
After the referent has related his story, refer to the sections covering the type of concern, and
obtain more specific information from the reporter. Make sure you have specifics of the referral,
as given below. The purpose is to get as much information as possible a) to make a screening
decision, and b) to inform the intake worker’s investigation:

Get the facts (What?..Where?..When?..Who?.. How?..Why?..) about the incident or reporter’s
concern (in a logical, comfortable way – follow his lead)

    Sexual Abuse and Exploitation

    Exposed Child to Adult Sexual Activity
      1. Please describe what happened to the child. Check all that apply, and explain
            __ Engaged in or talked about sexual activity without preventing the child from
               observing.

            __ Other adults in the home did these things, and the parent did not stop it.


      2. How did this person have contact with the child? Where did this occur?

      3. What was going on just before it happened?
               After it happened?


      4. Was the child coerced, forced, bribed, or were promises made to the child? If yes,
         please explain.


      5. How often has this happened?
               How long has this been going on?


                                                                      Return to the Table of Contents




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      Invaded Child’s Privacy
      1. Please explain what happened. (e.g. peep holes in bathroom door, removed bathroom
         or bedroom doors, etc.)


      2. How often has this occurred?
               Where did this occur?


      3. How long has this been going on?
                                                                     Return to the Table of Contents



    Penetration
      1. Please explain what happened to the child. (Check all that apply, and explain)
            __ Intercourse (vaginal or anal)

            __ Penetration of anus or vagina with finger

            __ Penetration of anus or vagina with object

            __ Oral sex: performed oral sex on the child; or made the child perform oral sex on
               the alleged offender


      2. How did this person have contact with the child?
               Where did this occur?


      3. What was going on just before it happened?
               After it happened?


      4. Was the child coerced, forced, bribed, or were promises made to the child?
          If yes, please explain:


      5. How often has this happened?
               How long has this been going on?

                                                                     Return to the Table of Contents

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      Pornography
      1. Please explain what happened to the child. Check all that apply and explain

            __ Allowed or forced the child to view pornographic material.

            __ Viewed pornographic material with no attempt to conceal it from a child.

            __ Made sexually explicit or suggestive photos of the child and placed them on a
               website?

            __ Videotaped, photographed the child without clothing on or scantily clad, for the
               alleged perpetrator’s sexual gratification?

            __ Permitted the child to be photographed or videotaped without clothing or scantily
               clad, for purposes of sexual gratification.


      2. How did this person have contact with the child?
               Where did this occur?


      3. What was going on just before it happened?
               After it happened?


      4. Was the child coerced, forced, bribed, or were promises made to the child?
         If yes, please explain:


      5. How often has this happened?
               How long has this been going on?

                                                                    Return to the Table of Contents



      Sexual Activity Between Children or Between Children and Adolescents
      1. Please describe what happened.


      2. Why do you believe the sexual activity was not agreed upon by all the children
         involved?



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           Has this alleged offender had inappropriate sexual activity with any other child? If yes,
          please explain:
             Has this activity ever been reported to Children Services?


      3. Do you know if the alleged offender was sexually abused himself/herself? (get as much
         information as possible)


      Note: In cases where the alleged perpetrator is under10 years old refer to your agency
      protocol regarding making a report on him/her as a possible victim of sexual abuse.

                                                                      Return to the Table of Contents


      Sexual Behaviors That Seem Inappropriate
      Please describe the behavior. Check below if applicable.

            __ Child seems to have more knowledge about sex than other children his/her age

            __ Child engages in sexual behaviors that seem to be unusual or too advanced for
               his/her age (e.g. compulsive masturbation, touching others in a sexual way)

                                                                      Return to the Table of Contents


    Touch/Masturbation
      1. Please explain what happened to the child. Check all that apply, and explain.
            __ Forced the child to touch the alleged offender’s genitals or other body parts.

            __ Touched the child’s genitals or other parts of the body, or used an object on the
               child (other than penetration)

            __ Masturbated in front of the child.

            __ Made the child masturbate.

            __ Adult forced the child into sexual play with enticing, tickling, wrestling or brute
               force?

            __ Rubbed his/her genitalia on the child’s body

            __ Made the child rub his/her genitalia on the alleged perpetrator’s body.




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      2. How did this person have contact with the child? Where did this occur?


      3. What was going on just before it happened? After it happened?


      4. Was the child coerced, forced, bribed, or were promises made to the child? If yes,
         please explain.


      5. How often has this happened?
               How long has this been going on?

                                                                     Return to the Table of Contents



      Convicted Sexual Offender
      1. Do you believe the child has been victimized?


      2. Have you witnessed inappropriate sexual behavior?


      3. Has the child told you that he/she is being victimized?


      4. Has the alleged perpetrator had opportunity to be alone with the child?


      5. What are your reasons for thinking this person may have harmed a child? Check all that
         apply:

            __ The person is making efforts to befriend the child, or to convince the parents to let
               him see the child alone (i.e. grooming behaviors)
                   Does the parent(s) know about the alleged perpetrator's status as a sexual
                    offender?

                   Does the parent(s) continue to let the alleged perpetrator have contact with the
                    child?

            __ The person is pre-occupied with the child

            __ The person is pre-occupied with sex


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            __ The person exposes him/herself

            __ The person peers in windows (i.e. "peeping Tom")


      6. Is the sexual offender on parole or on probation? If yes,
               How long? With whom? For how long?

               Are there any conditions of the parole/probation ( e.g., the sexual offender is not
                to have contact with child


(Note: There is a website available to determine if a person is on probation or parole. Consult
your supervisor for information about the website. A law enforcement officer can also provide
information about probation or parole.)

                                                                      Return to the Table of Contents




H. Previous Incidents
      1. Do you have any concerns that this may have happened before to this child? To other
         children?


      2. Has any other maltreatment happened before to this child or another child in the home?
         If so, please describe.


                                                                      Return to the Table of Contents


I. Medical Treatment
      1. Has the child received medical treatment as a result of this situation? If yes,
               Where and when was the child treated? (Name of doctor or hospital)

               Who took the child to the doctor, urgent care, or emergency room?


      2. Are there medical signs or indicators of the sexual abuse? If yes:
               Are there physical signs or indicators of sexual abuse?



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      3. Is non-emergency medical treatment or evaluation needed?


      4. Does the child have any sexually transmitted infection? If yes:
               What is it?


      5. Any follow up treatment needed? If yes,
               Do you think the parents will follow up to provide further treatment?

               Who is the child’s family doctor?

                                                                   Return to the Table of Contents




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         EMOTIONAL MALTREATMENT SCREENING
                    QUESTIONS

G. The Current Concern
      1. Please explain what happened to the child. Check all that apply, and explain:
          The parent….
              __ Humiliates, ridicules, or belittles the child.

              __ Has unrealistically high expectations for the child

              __ Yells at, curses at, threatens, bullies, or frightens the child

              __ Threatens, bullies, or frightens a family pet

              __ Terrorizes the child

              __ Ignores the child repeatedly, or withholds love or affection

              __ Rejects the child

              __ Isolates the child (i.e. from normal social experiences, prevents him/her from
                 forming friendships, and makes child believe he/she is alone in the world)

              __ Corrupts the child (i.e. makes the child engage in destructive, or antisocial
                 behavior)
          Further explain:

          Note: If the referrant has information about how this situation has affected the child
          please note it here.

      2. Where did this occur?


      3. How often does this occur? How long has this being going on?


      4. Has the child talked about suicide? Do you think he/she may try to commit suicide, or
         hurt another person, property, or animal?

      5. Do you think the child needs immediate help because of these problems?

                                                                         Return to the Table of Contents


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 H. Previous Incidents
      1. Has anything happened to harm this child before?


      2. Has anything happened to harm any other child in the household?


      3. Has there been emotional maltreatment in the past? If yes,
         Please describe:


      4. What seems to trigger the emotional maltreatment?


      5. Has there been an escalating pattern of maltreatment? (Have the incidents been
         happening more often? Has it gotten worse, or more severe over time?)


                                                                      Return to the Table of Contents




I. Mental Health Treatment
      1. Has the child already received any treatment, assessment, or been hospitalized as a
         result of the current emotional maltreatment? If yes,
               Where and when was the child treated? (Name of doctor, hospital, crisis or mental
                health center)

               Who took the child for treatment or assessment?


      2. Any follow up treatment needed? If yes,
               Do you think the parents will follow up to provide further treatment?

               Who is the child’s family doctor?


      3. Is the child in counseling? If yes,
               Who is the therapist and where is he/she located?




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      4. Was the child in treatment due to prior incidents of maltreatment? If yes,
               Where and when was the child in treatment?

                                                                   Return to the Table of Contents




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                DEPENDENCY SCREENING QUESTIONS


G. The Current Concern
      After the referent has related his story, refer to the sections covering the type of concern,
      and obtain more specific information from the reporter. Make sure you have specifics of
      the referral, as given below. The purpose is to get as much information as possible a) to
      make a screening decision, and b) to inform the intake worker’s investigation:

      Get the facts (What?..Where?..When?..Who?.. How?..Why?..) about the incident or
      reporter’s concern (in a logical, comfortable way – follow his lead)

                                                                      Return to the Table of Contents


      Death of Parent/Caregiver

          1. How did the parent/caregiver die?


          2. When did the parent/caregiver die?


          3. Was the child present at the time of the parent/caregiver’s death?


          4. Who is the child’s father?
                   Has he established paternity?

                   Does he have a relationship with the child? If so, please explain.

                   Does he have relatives that may be able to care for the child? If so, who are
                    they, and how can we contact them?


          5. Are law enforcement or the coroner involved because of the parent/caregiver’s
             death? If yes:
                   Which law enforcement department?




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          6. Did the parent/caregiver have a will? Do you know if will contained arrangements
             for care of the child after the parent/caregiver’s death? If yes, what were those
             arrangements?
                                                                     Return to the Table of Contents



      Exigent (Emergency) Family Circumstances
      Is the child in immediate danger now because of a crisis in the family’s situation? If so,
      please describe the child’s situation and the danger. Use sections below, to record
      information, if appropriate.

                                                                     Return to the Table of Contents



      Mental Health Concerns of the Parent/Caregiver(s)
          1. What makes you think the parent/caregiver has a mental health concern?


          2. Has the parent/caregiver been diagnosed with a mental health problem? If yes,
                    What is the diagnosis?

                    Who made the diagnosis?

                    When was this diagnosis made?


          3. Has the parent/caregiver’s mental health condition affected the child, or the
             parent/caregiver’s ability to care for them? If yes:
                    How?


          4. Is the parent/caregiver in the hospital? If yes:
                    When and where?


          5. Does the parent/caregiver have a counselor (or mental health therapist or case
             manager) If yes:
                    Who?

                    What is that person’s phone number?



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          6. Does the parent/caregiver appear depressed or suicidal? (Prompt for specific
             behavioral, emotional indicators)


          7. Does the parent/caregiver seem to be dangerous to him/herself, or the child?


          8. Do the child take on the parent/caregiver’s responsibilities? Is yes:
                   How?

          9. How long has the parent had this problem?


                                                                    Return to the Table of Contents



      Parent/Caregiver Hospitalization

          1. When will the parent/caregiver be admitted to the hospital?


          2. Which hospital?


          3. Why is he/she going into the hospital? Is this an emergency?


          5. How long will the parent/caregiver be unable to care for the child?


                                                                    Return to the Table of Contents


      Parent/Caregiver Incarcerated

          1. Why is the parent/caregiver in jail (or prison)?


          2. If the parent/caregiver is in jail because of probation or parole violation: Does the
             parent/caregiver have a parole or probation officer? If so, what is the officer’s
             name?


          3. Which jail (or prison) is the parent/caregiver in?



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          4. Has the parent/caregiver made a plan for care of the child while he/she is
             incarcerated If yes:
                a. Who?

                b. How often can they help?
                c. Has the parent/caregiver made arrangements for medical and educational
                   authorization (i.e.: Power of Attorney, notarized statement, etc.). If so, what
                   are those arrangements?

              d. Are there other people (i.e., friends, school staff, church members or staff)
                 who may have information about other family members?
          5. How long will the parent/caregiver be in jail (or prison)?
                   Has the parent/caregiver posted a bond?

                   Is there a scheduled court hearing? If yes, what is the date?


                                                                      Return to the Table of Contents



      Physical Disability/Developmental Problems of the Parent/Caregivers

          1. What is the parent/caregiver’s physical/developmental or learning disabilities (or
             problems)? (Prompt for details about the nature and extent of the disability)


          2. Is this a permanent or temporary disability?


          3. How long has the parent/caregiver had this problem?
          4. Does the parent/caregiver’s physical disability put the child at risk of being hurt or
             neglected? If yes:
                   How?


          5. Does the parent/caregiver have a case manager through the Department of Mental
             Retardation/Developmental Disabilities? If yes,
                   Who? At which agency?

                   How could we contact that person?


                                                                      Return to the Table of Contents

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H. Previous Incidents
          1. Has anything happened in this home to harm this child before?

          2. Has anything happened in this home to harm other child in the home?


          3. Has there been any type of accident resulting in serious injury or death of a child in
             this home, or that has involved his parent/caregivers?


          4. Has the family been involved with Children Services in the past? If so:
               Please explain


          5. Have you had concerns about this family in the past? If so:
                   Please explain


                                                                   Return to the Table of Contents




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         FAMILY IN NEED OF SERVICES QUESTIONS


        G.The Current Situation
                                                                      Return to the Table of Contents

    Child Fatality (non-child abuse/neglect)
    Ensure that all available contact information about the referent, child(ren),
    parent/caregivers/caregivers and other family members is posted on the Data Sheet.

      1. What is the name of the deceased child(ren)?
               Name and location of child(ren)’s parent/caregivers or caregivers?


     2. What were the circumstances of the child(ren)’s death?
               What was listed on the death certificate?
               Was there an autopsy? (Please provide all documentation)

      3. Had the child(ren) or parent/caregivers/caregivers ever been involved with a child
         protection agency, or in court action, in this or any other county?


      4. Does the family need financial assistance for the funeral?

      5. What services would benefit the family?


      6. Are there any other service providers working with the family? If yes:
               Who are they, and how can we contact them?


      7. How has the family reacted to the loss of their child?


      8. Do you have other information related to this situation?


      9. Are there any other children in the home?




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      10. Is law enforcement involved? Which law enforcement agency?

                                                                    Return to the Table of Contents
Deserted Child/Safe Haven
      1. Where was the child left?
               Where is the child now?


      2. Is the parent/caregiver present? If so,
               Has he/she provided any information about the child? (Please explain)


      3. How old is the child(ren)?


      4. Has the child been harmed, have an injury, sick, or in distress?
               Has the child been taken to the hospital?


      5. Are there immediate medical/health concerns for this child?


      6. Do you have any other information about this situation?


                                                                    Return to the Table of Contents



    Emancipated Youth Services (youth only; not family)
      1. Are you in need of services and support to enable you to live independently in the
         community?


      2. Where are you living now?
               Who are you living with now?


      3. What type of services/supports do you need?


      4. Are you currently receiving services from a community agency or faith-based
         organization?

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               What is the organization and name of the person you work with?

               What services do you receive?

               When did you begin receiving services?


      5. Who can help to prepare you to make the move to independence?


      6. Do you have any other information related to this request?

                                                                   Return to the Table of Contents



    Home Evaluation/Visitation Assessment (Court, CSA, PCSA only)
      1. What type of evaluation/assessment are you requesting? Check all that apply.

            __Assessment of safety
            __Assessment to establish visitation
            __Recommendations regarding services
            __Recommendations regarding placement
            __Kinship assessment


      2. What specific information are you requesting that we gather?


      3. What home needs to be assessed?
               What is the address?


      4. What is the SACWIS identification number?


      5. Where is the family/child(ren) living now?
            ___Parent/caregiver
            ___Kinship placement
            ___Foster care placement
            ___Adoptive home
            ___Friends

      7. Child(ren)’s name(s):


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            Parent/caregivers’ or caregivers’ names:

            Addresses:

            Telephone numbers:

            Other contact information:


      8. Are the children or family members currently receiving services from a community
         agency or faith-based organization?
               What is the organization and name of the contact person who works with the
                family?

               What services do family members receive? (specific family member and services)

               When did family members begin receiving the services?


      9. What specific information do you need from this evaluation or visitation assessment?


      10. When do you need the information?


      11. Do you have any other information about this request?


                                                                   Return to the Table of Contents



    Permanent Surrender to the Agency’s Custody
      1. What is your situation and current circumstances that you feel you need/want to
         surrender your child to the child welfare agency’s custody? What has led you to this
         decision?


      2. Are there any support or services that would enable you to keep your child(ren)?
               Is there any way we can help with your immediate needs?


      3. Who is the father of the baby?
               Is he aware of your plan to surrender the baby?


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               Could he provide a home for the child?

               Could his relatives provide care for the child?

               How can we contact him?


      4. Are there kin/family members or friends that could help support you in keeping your
         child(ren)?


      5. Would temporary placement of your child(ren) in kinship or foster care help you decide
         if you do want to permanently surrender your child(ren)?


      6. Do you have any other information related to this request?


      7. Do you understand what permanent surrendering your child(ren) means? (Explain if the
         parent/caregiver does not have thorough understanding.)


      8. Do you think you want to permanently surrender (give up custody) of your child(ren) to
         the agency’s custody?


                                                                    Return to the Table of Contents


    Post-Finalization Adoption Services
      1. When was the adoption finalized? Which agency finalized the adoption? (Was it a
         PCSA or PCPA?)


      2. What are the current circumstances in your family that have led you to request
         supportive services?


      3. Are you currently receiving post finalization services from a community agency or
         faith-based organization?
               What is the organization and name of the person you talk to there?

               What services do you or your family members receive? (specific family member
                and services)
                o When did you or your family members begin receiving the services?

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      4. What services or support would help your family now?


      5. Have you received post adoption finalization services in the past?


      6. Do you have any other information related to this request?


                                                                      Return to the Table of Contents



    Post Natal Placement Services to Infants of Incarcerated Mothers

      1. Name of referent, agency, address, phone numbers


      2. What is the name of the incarcerated mother?
                   Where is she incarcerated?

                    How long will she be incarcerated?

                   For what crime?


      3. Do you have names/contact information for the father or other relatives?


      4. Has the mother expressed plans for the infant’s care, or persons she would like to be
         contacted as possible caregivers for her baby?
               What are her plans?


      5. What is expected date of birth?


      6. Do you have any information about the mother’s medical history, current medical
         conditions, any mental health or substance abuse issues? (If yes, please describe)


      7. Do you have any other information about this situation?




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      8. Does the mother have any other children? If yes,
               Where are those children?

                                                                   Return to the Table of Contents



    Preventive Services (only at request of family)
      1. What are your current concerns or circumstances that have led you to ask for preventive
         help with your child(ren)?


      2. Are you concerned you or someone else may harm your child(ren)? (Please explain).


      3. What type of preventive supportive services would help you and your child(ren) right
         now?


      4. Are you, your child(ren) or any family members currently receiving services from a
         community agency or faith-based organization? (List the information below separately
         for each family member receiving services)
               What is the organization and name of the person the family member(s) talks to
                there?

               What services does the family member(s) receive? (specific family member and
                services)

               When did the family member(s) members begin receiving the services?


      5. Do you have family members or friends who could help you and your children?
               What would they need to do to help?

                                                                    Return to the Table of Contents



    Required Non-Lead PCSA Interview
      1. What is the current case situation?
               What have you already found out about the alleged maltreatment?


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               What are your concerns about the child(ren)?


      2. What information do you need for this agency to gather?


      3. Who is to be interviewed?


      4. By what date should the interview(s) be completed?


      5. How would you like the interview to be documented?


                                                                    Return to the Table of Contents



    Required Non-Lead Supervision (from other PCSA or CSA only)
      1. Does this family have court ordered supervision? If so,
               What are the requirements of the court order and the case plan?


      2. When did the child(ren) and/or family move to this county?
               What were the case circumstances when they left your county?

               What is your concern about the child(ren)?


      3. Where is the family/child(ren) living now? Who is the child living with?


      4. What services are you requesting from this agency?


      5. When do you need our services to begin?


      6. How would you like our activities to be documented?
               Activity log on visits?

               Case review?



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      7. Is there a plan to request transfer of jurisdiction? Please explain.


      8. Do you have any other information about this request?


      9. What is the current SACWIS ID number?


                                                                      Return to the Table of Contents



    Unruly/Delinquent Youth Referred by Juvenile Court for Court-
    Ordered Home Evaluation, Intervention or Placement


      1. What is the name and age of the child(ren)?
               Where is the child(ren) now?



      2. Who are the child(ren)’s parent/caregivers?
               What is their address:
               telephone no:
               other contact information:


      3. Who has custody of this child(ren)?


      4. How did the child become involved with the court (or probation, parole, etc.)? When
         did this happen? (Ask referent to send court documentation.)


      5. Are there any issues that seem to be affecting the child or family? (Check any that
         apply, and explain)
            __Homelessness

            __Domestic/Family Violence

            __Parent/caregiver/child conflict

            __Substance abuse


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            __Other


      6. Are the children and/or family members currently receiving services from a community
         agency or faith-based organization?
               What is the organization and name of the contact person who works with the
                family?


               What services do family members receive? (specific family member and services)


               When did family members begin receiving the services?


      7. Do you know of family/kin members or friends who would have information about
         these children and their parent/caregivers/family?


      8. What does the court want the children services agency to do? (evaluation, intervention,
         placement)


      If evaluation:
               Why does the court want the agency to do an evaluation? (Ask for court
                documentation.)


               When is the next scheduled court hearing? Does our agency staff member need to
                attend the court hearing? Or, will a report to the court be adequate?


               Is there specific information the court needs?


               When do you need the agency’s evaluation?


               Do you have other information related to this request?


        If intervention:
               Why is the court asking the agency to intervene? (Ask for court documentation.)



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               What does the court want the agency to do?


               Is there need for immediate placement? Why?


               Do you know of relatives/kin or friends that could be possible caregivers for the
                child(ren)?

               Do you have other information related to this request?


                                                                   Return to the Table of Contents




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     CHILD MALTREATMENT: OUT-OF-HOME CARE

G. Abuse in Out-of-Home Care
Please complete the appropriate sections in Physical Abuse, Emotional Abuse, or Sexual Abuse,
then complete the following section.

    1. Have caregivers/staff/staff ever withheld food and/or water from the child as
       punishment?


    2. Do caregivers/staff make threats of physical abuse or physical harm?
       Do you believe they will carry through with threats?


    3. Has the child received significant bruising or pain as a result of a restraint? If yes,
               What type of restraint was used?

               Who was present during the restraint?

               What staff member(s) executed the restraint?

               Did the child resist the restraint?

               What is the resultant injury?


    4. Why was restraint used?


    5. Were any staff members injured during the restraint? If yes,
               What are their injuries?

               How did it happen?

               When did this happen?


    6. Did the child require medical treatment? If yes,
               What medical facility treated the child?

               When?


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    7. Were there any other witnesses to the restraint? If yes,
               Who witnessed the restraint?

               What is their contact information?

               Are there any incident reports available?


    8. Is there an incident report available about the incident?


    9. Was the restraint videotaped?


    10. Does the child continue to have contact with caretaker who was responsible for his
        injury?


    11. Has residential staff involved in the incident attended Restraint Training? When and
        where?


    12. What steps is the facility taking in response to this incident? Is there an internal
        investigation?

                                                                      Return to the Table of Contents



H. Neglect in Out-of-Home Care
Please complete the appropriate sections in Physical Abuse, Emotional Abuse, or Sexual Abuse,
then complete the following section.

Failure to Complete Treatment Recommendations

    1. What are the treatment recommendations that are not being followed?


    2. Who is the doctor or therapist?


    3. How are treatment recommendations not being followed?


    4. How do you know the recommendations are not being followed?


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    5. Do you know why the caretakers do not comply with treatment recommendations?


    6. What is the risk to the child if the recommendations are not followed?


    7. Does the caregiver/treatment facility have a process for administering medication? If yes,
       please explain.


                                                                     Return to the Table of Contents




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                              DOMESTIC VIOLENCE

G. The Current Incident
      1. Who was involved in the violence?


      2. Please explain what happened.
               Was anyone hurt? If yes, please explain

               When did this occur?

               Where did this occur?

               Who or what caused the incident?

               Were any weapons used?


      3. Were you a witness to the violence? If yes,
               Were you present in the home at the time of the incident, or did you hear or see it
                happening?

               Were you involved in the violence? Were you hurt?

               Were there other witnesses to the violence? Who? Do you have contact
                information for them


      4.   If you were not a witness to the violence, how did you learn of this incident?


      5. Was the child in the home at the time of the violent incident? If yes, was the child:
               Was the child involved in any way? How?

               Was the child asleep during the incident?

               Where was the child? (i.e. in the same room where the violence occurred or in
                another room?)

               A witness (see or hear?) to the violence?


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               If the child was not in the home at the time of the violence, where was the child?


      6. Has a child been injured as a result of parents’ violence? ? If yes,
               How was the child injured?

               What injuries did the child receive?

               Were the child and a parent being mistreated at the same time?


      7. Did the adult victim try to protect the child or ask for help? Please explain:


      8. What was the child’s reaction to this incident?


      9. Was the child is in fear for their life, or the life of the parent, or another person
         responsible for their care, or anyone else?


      10. Was anyone else involved in the incident injured? If yes,
               Who?

               What was the injury?


      11. Were there threats of kidnapping, suicide, or homicide during the domestic violence
          incident?


      12. Was the perpetrator under the influence of drugs or alcohol at the time of the violent
          incident?


      13. Have the police been out to the home for this violent incident? If yes:
               What happened?

               Who called the police?

               Were charges filed? Against whom?


               Was anyone in the home anyone arrested? If yes:


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                    o Is the person in jail? Where?

                    o Has the person been released from jail? When?


      14. Have charges been pressed? If yes:

               Is there an order of protection?

               Where and when and where the charges were filed?

               Is the violent person on probation, or ever served prison time for domestic
                violence or assault?


      15. Is there evidence of property damage resulting from this violence?


      16. Are there weapons in the home? If so, where are they located?


                                                                     Return to the Table of Contents



H. History of Violent Behavior in the Home
      1. Is there a history of violent behavior in the home? If so, please describe:


      Follow up questions

               Is it arguing with no physical fighting?

               How long has fighting been going on?

               Is the fighting becoming more severe?

               How often does violence occur?

               Is there a pattern of violence?

               Is there a pattern of intimidation?




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      2. Does the violence impact the parents’ ability to meet the child’s physical, emotional,
         safety needs? If so, how?


      3. Has law enforcement ever been called to the home to stop fighting between family
         members?


      4. Does either parent have a history of violence in previous relationships?
         If yes:
               Who?

               Is it more severe in this relationship? Is it more frequent?

               Were charges filed?


      5. Do any family members have a history of violent or explosive behavior? If yes,
         describe:


      6. Has anyone in the home ever been arrested for violence?


      7. Do household members use guns, knives, or other instruments in a violent, threatening,
         and/or intimidating manner?


      8. Has anyone in the home ever received medical treatment due to injuries from domestic
         violence?


      9. Has anyone ever left the home to escape violence?


      10. Have previous incidents of violence resulted in maltreatment of the child?


      11. What effect has the violence had on the child?


      12. Does the violence affect the child’s ability to function? If yes, how?
               Does the child exhibit severe anxiety (e.g., nightmares, insomnia) related to
                situations associated with violence?



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               Does the child cry, cowers, cringes, trembles, or otherwise exhibits fear as a result
                of violence in the home?


      13. Does the child’s behavior increase his risk of injury (e.g., attempting to intervene
          during a violent dispute to protect a parent, participating in the violent dispute)?
               Was the child ever used as a shield during violent incidents?


      14. Have there been credible verbal threats the child has heard? If yes:
               Who made the threats, and to whom?


      15. Has the victim of violence ever pressed charges? If yes:
               Have they received an order of protection? When?

               Do you know where these charges were filed? (e.g., county, city, state)

               Is the violent person probation or have they ever served time for domestic violence or
                assault?

                                                                   Return to the Table of Contents




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                   INTAKE SCREENING QUESTIONS
                    CONCLUDING THE INTERVIEW

A. Family Strengths
      1. What are the parents' strengths that may help the family? (Prompt for specifics.)
         Following are some examples of family strengths:

          Family members:

             love the child, recognize the child’s needs and put the child's needs first
             have a support group of extended family, friends, faith group, etc. that can help
             know their strengths and needs, and are willing to ask for help
             know how to use social services in the community
             want to provide safe care for their child

      2. How has the family used these strengths in the past to help the family?


      3. What would you say is good about the mother’s/father’s/caregiver’s parenting?


      4. Are there positive aspects of the parent – child relationship?


      5. If this situation has happened before, how has the family tried to deal with it?


      6. Are there times when the parents provide good care to the child? Can you tell me about
         those times?


      7. Knowing the strengths and issues of this family, what do you think the family needs?


      8. Are there people who can support the parents in their parenting role, if needed?



                                                                     Return to the Table of Contents




Children Services Intake Screening Tool.
Developed by the PCSAO Intake Screening Task Force February 2010                      Page 73 of 77
B. Family Awareness, Reaction to Referral
      1. How have other family members, including the other parent, reacted to this situation?
         Has the other parent protected or supported the child?


      2. Have other family members, including the other parent, been able to protect and
         support the child? If not, what barriers are there to doing so?


      3. Have you spoken to the parents about your concern? If yes,
               What did the parents say?
               Does the parents' explanation make sense to you? If not, why not?


      4. Do the parents know you are making this report?


      5. Did the child talk to you about what happened? If yes,
               What specifically did the child tell you?


      6. Will the child be afraid to talk to us? Will the child talk to you?


      7. Do you think the child’s parents will talk to us?
               Why or why not?


      Encourage the caller to have other people with direct knowledge of this incident call the
      agency.

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C. Support for the Family and Child
      1. Has the child told anyone about this situation? If yes,


               Who did the child tell? How can we contact that person?


.

Children Services Intake Screening Tool.
Developed by the PCSAO Intake Screening Task Force February 2010                      Page 74 of 77
      2. Do the parents or children have any relatives or close friends, (i.e. kinship
         relationships) who can help the parents or the children? If yes,
                   Who are they?

                   Can they help take care of the child?
                        o How could they help?
                        o If they can’t help, why not?

                   Would the parents be willing to let this person help?

                    How can we contact that person?

      3. Are there other people (i.e. friends, school staff, church members or staff) who may
         know of people who could help the family and children?

      4. Has the family been linked with any services? If yes, which ones?

                                                                       Return to the Table of Contents



D. Safety Concerns for the Investigation/Assessment
   Caseworker
      1. Do you think the person responsible for the incident, other family member, or anyone
         involved with the situation may become violent toward the caseworker for any of the
         following reasons? (Prompt for details; check any of the following that apply):

            ___ Suspected of a violent crime, or history of violence

            ___ Mental health problem, and not taking medications

            ___ Substance Abuse – in the past or presently

            ___ Volatile/explosive behavior

            ___ Domestic violence

      2. Are any of the family members suspected of sexually abusing a child?


      3. Are there any guns or weapons in the home? If yes,
               What weapons?


Children Services Intake Screening Tool.
Developed by the PCSAO Intake Screening Task Force February 2010                       Page 75 of 77
               Are the guns locked up?

               Are the guns loaded?

               Where are they located in the home?


      4. Are there any known problems with authority figures?


      5. Are there any cultural or racial prejudices?


      6. Has any family member ever made a threat against children services staff?


      7. Does the family have any pets or non-domesticated animals? If yes,
               What kind?
               Are the animals dangerous?
               Are they chained up or otherwise kept away from visitors?

      8. Do you have any concerns that the animals have been mistreated?


      9. Are drugs being sold out of this home? If yes,
               What drugs?

               Is meth or any other drug being manufactured in this home?


      10. Do any family members belong to a gang? If yes,
               What gang?

               How long have they been involved with the gang?


      11. Do any family members belong to a radical or satanic group? If yes,
               Which group?

               How long have they been a member?


      12. Is the home isolated from a community/neighborhood or isolated in the country?


Children Services Intake Screening Tool.
Developed by the PCSAO Intake Screening Task Force February 2010                 Page 76 of 77
      13. Do any family members have mental illness? If yes,
               What family member?

               What condition?

                                                                      Return to the Table of Contents


E. Ending the Call
      1. Make sure you have recorded information as completely as possible.


      2. If the referent is comfortable doing so, record his name and phone number, so that you
         or the investigator can contact him/her to clarify any information, if needed.


      3. Mandated Referents:

               Ask mandated referents if they would be willing to testify in court, if needed.

               For doctors’ referrals: Ask doctors to please ensure that the medical record is
                consistent with the information he/she has given in this referral.


      4. If needed, address issues of ethical communication and full disclosure for mandated and
         non-mandated referents.


      5. Ensure the referent that he made the right decision to call, because if the child is in
         danger, we need to help him.


      6. Ask the referent what he thinks can be done to help the child and keep them safe.


      7. Encourage the referent to call again if he remembers other important information, or if
         there is more to referral.


      8. Encourage the referent to encourage others who have information about this situation to
         call us.


      9. Thank the referent for calling in the referral.
                                                                       Return to the Table of Contents

Children Services Intake Screening Tool.
Developed by the PCSAO Intake Screening Task Force February 2010                       Page 77 of 77

				
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