To be filled out separately (one for offender/one for safe guard) (Use extra paper if needed and attach)

I feel that the following child(ren) will be safe alone in the presence of the offender.

Child: ___________ Age:_____ Gender:_____ Relationship to offender:______________

Child: ___________ Age:_____ Gender:_____ Relationship to offender:______________

Child: ___________ Age:_____ Gender:_____ Relationship to offender:______________

Child: ___________ Age:_____ Gender:______ Relationship to offender:_____________

List each child in the appropriate category below:

I feel it would be safe for the following reasons:

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I feel it would be unsafe for the following reasons:

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I believe the offenders thinking errors for feeling he/she can be alone with this child are:

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I feel it would be safe the offender to have only supervised exposure to the child for the following reasons:

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I feel it would be unsafe for the offender to have supervised exposure to the child for the following reasons:

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I believe the offenders thinking errors for feeling he/she can be in the supervised company of this child because:

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I have checked for my own thinking errors regarding safety in the following ways:

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Signature: _____________________________________ Date: _______________