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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families


Safety Alerts and Plan (SAP)


An additional aspect of the initial service plan is the development with the family and child of a specific plan to address identified safety issues. The HCBS Waiver Safety Alert Plan is used for this purpose. It is essential that the family agree with the components of the plan to better assure compliance. The Safety Alert Plan must be in place for each child and family. All elements on the Waiver Safety Alert Plan must be completed, signed and dated  by the child, family member, ICC, ICC supervisor and school representative, if indicated. If a child is unable to sign, the reason is to be stated on the plan. A copy must be given to the family. A Safety Alert Plan is developed with the child and family by completion of the Initial Service Plan. They are reviewed, signed and updated at each Service Plan Review and as needed. A “child–friendly” contract, HCBS Waiver and Child Safety Contract may be used in addition to the Safety Alert Plan and this may be adapted to each agency’s needs.

Sample forms can be found in the HCBS Waiver Guidance Document, Section 800