Neglect (Check all that apply) Hygiene/clothing Food Clothing does not protect from elements Dehydration Illness or exposure due to clothes Dietary needs not met Regularly wears soiled clothes Feeding children non-human food items Repeated infestations of lice/bedbugs Food poisoning No issues Malnourished Symptoms of failure to thrive No issues Educational (Check all that apply) Exploitation Engages child in criminal activities Numerous unexcused absences Uses child’s financial resources for personal gain No issues Victim of Human Trafficking No issues Medical (Check all that apply) Failure to seek medical attention Life threatening unmet health needs Unmet health needs may have long term effects No issues Risk of Harm (Check all that apply) Risk of Physical Abuse Risk of Sexual Abuse Child has fear of caretaker Caretaker has previous sex abuse finding or conviction Caretaker has caused death/serious injury Child exhibiting physical/ behavioral indicators of sexual to a child abuse Child exposed to bizarre forms of Child unsupervised with person listed on the sex offender punishment registry No issues No issues
Neglect (Check all that apply) Hygiene/clothing Clothing does not protect from elements Illness or exposure due to clothes Regularly wears soiled clothes Repeated infestations of lice/bedbugs No issues Food Dehydration Dietary needs not met Feeding children non-human food items Food poisoning Malnourished Symptoms of failure to thrive No issues Educational (Check all that apply) Numerous unexcused absences No issues Exploitation Engages child in criminal activities Uses child’s financial resources for personal gain Victim of Human Trafficking No issues Medical (Check all that apply) Failure to seek medical attention Life threatening unmet health needs Unmet health needs may have long term effects No issues Risk of Harm (Check all that apply) Risk of Physical Abuse Child has fear of caretaker Caretaker has caused death/serious injury to a child Child exposed to bizarre forms of punishment No issues Risk of Sexual Abuse Caretaker has previous sex abuse finding or conviction Child exhibiting physical/ behavioral indicators of sexual abuse Child unsupervised with person listed on the sex offender registry No issues
ADT%20CPS%20Assessment%20for%20Abuse%20or%20Neglect.docx