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New Jersey Department of Children and Families Policy Manual




Child Protection and Permanency

Effective Date:













CP&P Form 11-10, Health Passport and Placement Assessment


Click here to view, print or complete the CP&P Form 11-10, Health Passport and Placement Assessment.




CP&P Form 11-10, Health Passport and Placement Assessment, is located in the Medical/Mental Health window within NJ SPIRIT and only becomes available in the Options drop-down menu. The form documents a child's health history and follows a child throughout placement.  The form is updated to document new health information while a child is in placement and the updated version is distributed as set forth below.


The form is used to:


    •       Record a child's basic past and current health information at or near the time of the child's entry into placement. See CP&P-IV-A-1-100, Procedures Related To Federal And State Requirements For Children In Placement, and CP&P-IV-B-8-100, Health Care Services.


    •       Provide the resource parent with health information concerning the child within 72 hours of placement. See CP&P-III-C-6-100  for procedures related to Recording for Children Entering Placement; CP&P-IV-A-4-100, Preparation of Foster Family; and CP&P-IV-A-4-200, Day of Placement.


    •       Document the health care needs of children, the acuity level of children, the skills and knowledge required of the resource parent and provide information to the Division in making a safe placement decision.


    •       Provide the residential placement provider with health information concerning the child being placed in the facility within 72 hours of placement.


Note:  Health Care Professionals use the CP&P Form 11-3, Pre-Placement/Re-Placement Assessment, to record the results of the health assessment, when a child has been removed from the home for initial placement or re-placement.


   •        Provide required health information as an attachment to the CP&P Form 26-81,

Family Summary/Case Plan.


   •        Provide an adolescent who is exiting care at or beyond age 18, in accordance with the federal Safe and Timely Interstate Placement of Foster Children Act of 2006, with his or her medical history.  See CP&P-III-A-1-500, Services to Adolescents Age 18 to 21.


   •        Alert the child's health care practitioner to the child's health history.


   •        Aid the CP&P Worker and Child Health Unit nurse in monitoring and planning adequate health services for the child, as part of the child's overall case plan.


   •        Include as part of the interstate referral packet.  See CP&P-VIII-D-2-300, Referral Packet, and CP&P-VIII-D-2-700, Adoption Home Study and Placement.




The Child Health Unit nurse completes the CP&P Form 11-10, Health Passport and Placement Assessment, in NJ SPIRIT, by obtaining the information from the child and his or her family, the case record, and NJS Medical/Mental Health windows.  A blank form may be printed from the manual to use for note-taking purposes.


   •        Access CP&P Form 11-10  through the NJ SPIRIT Desktop > Create Casework > Medical/Mental Health Window > Options Dropdown.


The CP&P Form 11-10, Health Passport and Placement Assessment, is a template located in the on-line Forms Manual.


Only complete a template outside of the NJ Spirit application as part of a contingency plan when the application is unavailable.  However, in doing so, you are still required to create the form in NJ Spirit when the application becomes available.






Most information will prefill once the form is available through NJ SPIRIT.


Please complete all other information and indicate source of history. 




1. Birth History -The information comes from hospital or pediatrician records or history obtained from biological family.  Record information available that is significant to the birth history, such as in-utero exposure to HIV or Hepatitis C or B.  Be specific, state that it is the infant's exposure not the maternal history. 


2. Health History - Remember this is information for the resource parent to give to the primary provider who will be the medical home for this child. List in this section any information about the child that is noteworthy.


     •      History of hospitalizations - If the family from whom the child was removed reports, or the physician's record includes information about a hospitalization, give the name of the hospital, reason for admission, date, and any treatments or procedures. 


     •      History of injuries and/or illnesses - Record any history of injury the child suffered and the treatment prescribed.  Include in this section history of illness.


     •      History of significant childhood diseases - Simply list and date all significant childhood illnesses; examples include, but are not limited to: RSV, meningitis, scarlet fever. 


     •      Developmental History - Note any developmental milestones attained and concerns observed during a Pre-Placement Assessment or noted in medical records.


     •      Note any other therapies that the child receives; note if child is enrolled in Early Intervention Program (EIP).


     •      If the child has an education classification, note it, and confirm it through school records, EIP, Special Child Health Services Program (SCHS), or the CP&P Worker.


     •      If the child is receiving counseling, enter identifying information about the counselor or agency.  Document the frequency and reason. Update with specifics as information becomes available. If it is ongoing, record the number of months the child has been in counseling.


     •      Explain any special transportation needs of the child.


3. Family History - Enter family history of significant medical problems.  Enter any family history of insulin dependent diabetes, strong family history of sudden cardiac arrest under age 40, family history of behavior health problems (name condition, with documented evidence).  Do not identify the family member who has the disease or condition, just that there is a family history.  Do not identify the family member as mother, father or sibling; refer to the family member as a first degree relative. 


4. Current Health Problems / Illnesses/ Conditions - Detail the child's health record during the placement. List and date all sick and well visits during placement. Include each provider's name.


     •      Report if the child has allergies and describe. Note if the child's medical record indicates that an Epinephrine Auto-Injector is required.


     •      Dental health - Fill out information as received.  State a diagnosis, procedure, or recommendations from the dental records.  Document if the child needs a dental appointment for caries repair or for prophylactic care.  


5. Current Medications - List any medications along with the person prescribing the medication. Use to pull up patient information on side effects, and attach to the form.  Check "yes" if medication sheets are attached.


     •      List all medical providers - Including dentists, specialists, and therapists with address and telephone contact number.


6. Record Any Testing of the Child - Enter date of testing and results.


7. Summary / Assessment / Specific Care Needs / Transportation - Provide a written summarization and assessment of the child's health and list any specific care or transportation needs for the child.


8. Acuity Level - List the acuity level of the child.


9. Care Giver Requirements - List any requirements the care giver must have to properly care for the child.


10. Health Plan - Provide a health plan for the child.


11. Signature - The nurse signs and dates the form. Provide the initial date the form was completed. Add each revision to the original document, and provide the most recent date in the space "Date Updated."




The Child Health Unit nurse completes this form.


The form is maintained in the Local Office Child Health Unit record and updated on a periodic basis.


Note: Attach whatever immunization records are available.




Original          -           CP&P case record


Original          -           Child Health Unit record


Copy               -           Parent(s)/Guardian


Copy               -           Resource parent/Caregiver/Facility


Copy               -           Internal Placement Review and Child Placement Review Board


Copy               -           Adolescent


Copy               -           Interstate Services Unit