ABA Risk Assessment Form

General Information

Applicant Name *

Applicant Job Title *

Business Name *

Mailing Address *

Website Address *

When was the business started? *

FEIN# *

Type of Business (LLC, Corp, Partnership, etc.) *

Contact Phone # *

Contact Email Address *

Are you a member of CalABA? *

Yes
No

Are you BHCOE accredited? *

Yes
No

General Business Information

Estimated Annual Revenue *

Estimated Annual Payroll *

Total Number of Clients *

Total Number of Employees *

Training Information

Do you provide any of the following training programs? (Select all that apply.) *

ABA Program Information

Please provide the number of 1-5 yr. old clients. *

Please provide the number of 6-12 yr. old clients. *

Please provide the number of teenage clients. *

Please provide the number of adult clients. *

What percentage of your clients receive services at home? *

What percentage of your clients receive services at a community center? *

What percentage of your clients receive services at a public or private school? *

What percentage of your clients receive services at a clinic/other location? *

Employment Information

Which of the following checks are performed on prospective employees? *

Have you hired any independent contractors? *

Yes
No

Are there other employees or contractors that aren't listed above? (Please note the number, employment type, part- or full-time status, and job titles.) *

Abuse / Molestation

Do you have any of the following policies or procedures in place for dealing with abuse/molestation? (Please select all that apply.)

Written procedures for dealing with physical and sexual abuse
Supervision plan that monitors staff in day-to-day relationships with clients
Procedures in place to avoid one-on-one situations with clients
Documented staff training on recognizing and reporting physical/sexual abuse

Property

Do you have a physical location requiring coverage? *

Yes
No

Current Insurance Information

Current Policy - General Liability

Do you currently have general liability insurance? *

Yes
No

Current Policy - Automobile Liability

Do You currently have automobile liability insurance?

Yes
No

Current Policy - Professional Liability

Do you currently have professional liability insurance? *

Yes
No

Current Policy - Abuse/Molestation Liability

Do you currently have abuse/molestation liability insurance?

Yes
No

Ready to Get Started?