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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

05-10-2010

Subchapter:

1

Forms

Issuance:

14.126

Pre-Adoptive Medical Report

 

Click here to view, complete, or print the form, CP&P Form 14-126, Pre-Adoption Medical Report.

 

WHEN TO USE IT

 

Use the CP&P Form 14-126 before placing a child in an adoption home to:

 

·         Provide a permanent record of the child's physical examination, medical treatment, and recommendations for further medical care before adoption;

·         Alert the pediatrician to the child's health history;

·         Aid the child's Adoption Worker in monitoring and planning adequate health services for the child; and

·         Record the pediatrician's recommendation about the child's medical suitability for adoption placement.

HOW TO USE IT

 

The Worker completes "Part A:  MEDICAL HISTORY" before the child is examined by the pediatrician.  Use the resources below to complete the form:

 

·         CP&P Form 26-53c, Individual and Family Assessment Outline-Adoption, Child Summary Outline Parts A and B;

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

·         CP&P Form 14-177, Family Medical History;

·         Child's hospital birth records; and

·         Other medical records and reports.

The pediatrician completes and signs "Part B: EXAMINATION" at the time of the child's examination.

 

TIPS FOR COMPLETING THE FORM

 

At I, "Significant Medical History of Mother and Father," specify the parent, illness, and diagnosis.

 

At III F, "History of illness, injuries, operations, or defects," list the child's illnesses, injuries, operations or defects, and corresponding dates, as applicable.

 

At III G, "Difficulties in sleeping or eating," list any significant problems sleeping or eating which the child has at present or has had in the past.

 

DISTRIBUTION

 

Original and copy

-

Office of Adoption Operations

Copy

-

Child's case record

Copy

-

Adoptive family

Copy

-

Pediatrician