SASKATCHEWAN
SDM® INTAKE ASSESSMENT
Case Name:
Date of Report:
Intake Case Reference #:
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Time of Report:
Intake Worker Name:
STEP 1: SCREENING
A. SCREENING CRITERIA
Mark ALL that apply based on available intake information. Some criteria have an automatic immediate response. For all others,
complete a Response Priority tree for each maltreatment criteria type marked where the final screening decision is screen in.
Physical Abuse
Non-accidental injury
Death of child/another child in home (automatic immediate response)
Severe non-accidental injury (automatic immediate response)
Other injury
Cruel or excessive corporal punishment
Threat of physical abuse
Dangerous behaviour in immediate proximity of child–domestic violence
Dangerous behaviour in immediate proximity of child–non-domestic violence
Threats of physical harm
Prior death of a child due to abuse, and new child in household
Prior substantiated abuse, failed reunification, or failed services for abuse; and new child in household
Sexual Abuse
Any sexual act on a child by an adult caregiver or other adult in the household, or unable to rule out household member as
alleged perpetrator
Sexual act(s) among siblings or other children
Sexual exploitation
Threat of sexual abuse
Known or highly suspected sexual abuse perpetrator lives with child
Severely inappropriate sexual boundaries
Caregiver possesses or is suspected of possessing/accessing child pornography
Emotional Abuse
Severe emotional abuse
Threat of emotional abuse
Domestic/intimate partner discord
Bizarre or cruel behaviour
Caregiver’s mental health concerns
Caregiver’s substance abuse concerns
Neglect
Severe neglect (automatic immediate response)
Diagnosed malnutrition
Non-organic failure to thrive
Child health/safety endangered
Death of a child, neglect is suspected, and other children are in the home
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General neglect
Inadequate food
Inadequate clothing
Inadequate/hazardous shelter
Inadequate supervision
Inadequate medical/mental health care or rehabilitative services
Child has no parent or guardian capable of providing appropriate care
Failure or inability to protect
Involving child in criminal activity
Child less than 12 years/criminal act/parents unable or unwilling to provide for needs
Threat of neglect
Prior severe neglect, failed reunification or failed services for neglect, and new child in household
Prior death of a child due to neglect, and new child in household
Prenatal substance use
Allowing a child to use drugs and/or alcohol
Other high-risk birth
B. SCREENING DECISION
If any of the above criteria are checked, the decision must be screen in. If no criteria are checked, the decision must be screen out.
Mark the appropriate recommended decision and then consider whether any override conditions exist.
Recommended Screening Decision:
Screen in: One or more criteria are marked
Screen out: No criteria are marked
Overrides: Consider both policy and discretionary overrides. If no policy or discretionary overrides are present, check the ‘No
overrides’ box and record the final screening decision.
No override
Policy Override
Screen in: No criteria are marked, but referral will be assigned. No further SDM assessments required.
Courtesy interview at law enforcement’s request
Report does not require screening but does require a non-investigatory response by the agency
Provincial/Territorial Protocol on Children and Families Moving Between Provinces and Territories
Response required by court order
Screen out: One or more criteria are marked, but referral will not be assigned. (Check all that apply.)
Insufficient information to locate child/family
Another community agency has jurisdiction
Report of historical event and no current risk of harm described. (Record the time since alleged incident in months
and years:
)
Previously investigated incident and same allegation
Discretionary Override
Discretionary override to screen in. (Complete all required assessments.)
Discretionary override to screen out.
Discretionary Override Reason
Final Screening Decision: Record the final screening decision following any overrides. If there are no overrides, the final decision
will be the same as the recommended decision.
Screen in
Screen out
Worker signature*:
*Required only if screened out.
Supervisor signature*:
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Date:
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Date:
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© 2014 by NCCD, All Rights Reserved
STEP 2: RESPONSE PRIORITY
A. DECISION TREES
Complete the decision tree(s) corresponding to each type of alleged abuse/neglect criteria identified in Step 1A by circling or
checking the recommended response. When there are multiple allegation types, it is not necessary to complete all decision
trees once an immediate response is reached on any tree. Do not complete if any of the criteria in Step 1A require an
automatic immediate response. In that case, go directly to the override section.
Response priority levels are as follows.


Immediate—Same working day as receipt of the referral
Five days—Within five calendar days of the receipt of the referral
Physical Abuse
Is the child under 3 years of age or
vulnerable due to disability or in need of
immediate medical attention, or were
parent/caregiver actions or threats brutal
or extremely dangerous?
No
Does the alleged perpetrator have
access to the child within the next
five days?
No
Five days
Yes
Yes
Is there prior history of physical abuse, current
domestic violence, parent/caregiver mental
health concerns, or substance abuse concerns?
OR
Is the child fearful or vulnerable?
Immediate
No
Five days
Yes
Is there a protective adult in the home?
No
Immediate
Yes
Five days
Neglect
Does the child need immediate
medical/mental health evaluation, and
care is not being provided?
Yes
Immediate
No
Are the child’s physical living conditions
immediately hazardous to his/her health
or safety?
Yes
Immediate
No
Yes
Is the child currently
unsupervised?
Immediate
No
Is the child a drug-exposed newborn
who will be discharged within five
days AND no parent/caregiver
appears willing and/or able to provide
for the child upon discharge?
Yes
Immediate
No
Five Days
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Sexual Abuse
Is there current abuse as evidenced by disclosure, credible witnessed
account, or medical evidence?
No
Yes
Is there a current physical injury as a result
of the abuse, or is the child suffering severe
emotional trauma?
Five days
No or unknown
Yes
Immediate
Is the non-offending parent/caregiver willing and
able to protect and cooperate?
No or unknown
Yes
Does the perpetrator have access to the
child within the next five days?
Immediate
Yes
No
Five days
Immediate
Emotional Abuse
Does the child need mental
health evaluation, and care is not
being provided?
Yes
Immediate
No
Is the parent/caregiver
behaviour cruel, bizarre, or
extremely dangerous?
Yes
Immediate
No
Five Days
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B. RESPONSE PRIORITY DECISION
Based on completion of the appropriate tree(s) or if any of the criteria identified require an automatic immediate response, indicate
whether the decision is immediate or within five days from the date and time of the report.
Recommended Response Priority:
Immediate/same working day
Within five days
OVERRIDES: Consider both policy and discretionary overrides to the recommended response priority. If there are no overrides,
check ‘No override’. If policy or discretionary overrides are appropriate, check the appropriate reason and record the final response
priority below.
No override
Policy
Increase to immediate whenever:
Law enforcement is requesting immediate response;
Forensic considerations would be compromised by slower response; or
There is reason to believe that the family may flee.
Decrease to five days whenever:
Child safety requires a strategically slower response;
The child is in an alternative safe environment; or
The alleged incident occurred more than six months ago AND no maltreatment is alleged to have occurred in the
intervening time period.
Discretionary
Increase; OR
Decrease response level (requires supervisory approval).
Reason:
Final Response Priority: Based on overrides, indicate the final response priority level. If there are no overrides, it will be the
same as the recommended response.
Immediate/same working day
Within five days
Worker signature:
Date:
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Supervisor signature:
Date:
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© 2014 by NCCD, All Rights Reserved