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:

 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

 Clothing for myself and children

 Extra set of keys  Money and bank account information  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_____________.

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