Personal Safety Plan To avoid a violent incident in my home:
1. I will keep my purse and car keys accessible by putting them_________________________ so I can leave quickly.
2. I will talk to my children about violence. We will plan how to leave and where to go if violence occurs.
3. I will use the code word______________ with my children so they will prepare to leave. I will inform my friends/family that if I speak this word to them they should call the police.
4. When I leave I/we will go out___________________________________________ (which window, door, is best for escape)
5. When I feel myself or children are in danger and I am unable to leave, I will move to a safe room with few items that can be used as weapons and if possible an outside door. I will try to avoid the garage or kitchen. The safe room in my house is__________________.
6. I can tell 2 neighbors to call the police if they hear suspicious noises coming from my house. I will tell__________________and____________________.
Staying safe when preparing to leave:
1. I will prepare an emergency bag containing:
ï‚· Copies of important documents Birth Certificate Social Security Cards Driver’s License/ID Card Ex parte or Order of Protection Divorce Decree Lease, rental agreement, property deed, mortgage payment book Medical and Vaccination Records Insurance Card School Records
ï‚· Clothing for myself and children
ï‚· Extra set of keys ï‚· Money and bank account information ï‚· VIP Contacts; attorney, doctors, police department, taxi, safe friends/family
2. I will leave my emergency bag with______________________ so I can leave quickly.
3. The nearest domestic violence shelter to me is______________I can call them at______________. If that shelter is full, I can call this shelter________________at____________________.
4. I have a close friend or family member who can drive me to a shelter. Their phone number is_______________. If they are unable to drive me I can call a taxi at this number__________________.
5. I will rehearse my escape plan and include my children is appropriate. Staying safe with an Order of Protection:
1. I will keep my Order of Protection with me at all times as well as a copy in a safe place. A copy of my Order of Protection will be kept here__________________.
2. I will give a copy of my Order of Protection to the police departments in the towns where I live, work, and visit.
3. I will check the county registry to make sure my Order of Protection is on file. The number for the county registry for my Order of Protection is________________________.
4. If I have questions about my Order of Protection and do not have an attorney, I can call a domestic violence shelter at_______________________.
5. I will inform my employer, school, trusted close friends and family that I have an Order of Protection. If I have a Child Order of Protection I will inform their school or daycare of the situation.
6. If my abuser destroys my Order of Protection, I can get another copy from the county courthouse.
Keeping my Children safe:
1. I will teach my children how to use a telephone to call 911 or __________________(a trusted person) in an emergency.
2. I will provide the names of people who have permission to pick up my children at their school, babysitter or daycare. People who can pick up my children____________________________________________________________________.
3. I will teach my children a code word to use when they are feeling unsafe. Our code word is_____________.