Child Protective Services Neglect Screening Checklist
Date:
Child Name:
Caseworker Name:
Signs of Neglect:
Failure to provide adequate food, shelter, or clothing
Unsanitary living conditions
Lack of supervision for age and development
Unattended physical or medical needs
Educational neglect (e.g., chronic absenteeism)
Other
Risk Factors Present:
Parental substance abuse
Parental mental health concerns
Domestic violence in the home
History of child welfare involvement
Recent family crisis or instability
Other
Describe Observations or Concerns:
Immediate Safety Issues Identified?
Yes
No
Actions Taken/Recommendations: