To be filled out by the safe guard

1. To the best of your ability state the offender's risks to each member of the family, including yourself. (Use extra paper if necessary)

2. State your plan and role to reduce these risks.

3. State who the Offender's support system is.

4. State who your support system is.

5. Give examples of a series of lapsed behaviors by the offender and list the concrete steps you would take in each situation.

Signature Safe guard:___________________________ Date:_________________