Click here to view or print the CP&P Form 14-177, Family Medical History.

Click here to view or print this form in Spanish, CP&P Form 14-177(S).

WHEN TO USE IT

This form is used to record the medical history of the birth parent(s) and relatives of a child to be adopted.  The form also records the child's birth history information, immunization record, special medical examinations/diagnoses and psychological evaluations/diagnoses.

HOW TO USE IT

Complete the English version of the form in the NJ SPIRIT (NJS) application only, by accessing it through the NJS Desktop > Create > Casework > Medical/Mental Health > drop-down selection.

After completing the English CP&P Form 14-177 in NJS, complete the Spanish version by hand, when needed to give to an adoptive parent whose preferred language is Spanish.

Only complete the English form outside of NJS 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 NJS when the application becomes available.

TIPS FOR COMPLETING THE FORM

·         Identifying information is prefilled on the form, based on the case and case participants selected.

·         The Worker obtains the information from the birth parent(s), resource parent, birth records of the child and any other medical/hospital records known to be available and enters it directly onto the form.

·         The information on the form is shared with the selected adoptive parent(s) at the pre-placement interview.  On the day of placement of the child in the home, a signed copy of the form is given to the adoptive parent(s) for their records.  See CP&P-IV-C-6-100, Child's Placement.

·         In the case of a resource home adoption, the information is shared with, and given to, the resource parent(s) at the time of the pre-consent interview. A signed copy of the form is submitted to the Local Office Manager with all other material required to obtain the Consent of Custodian/Guardian to Adoption.

·         The English version of the form saves to the electronic case record and can be edited at any time.

DISTRIBUTION