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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

5-21-2012

Subchapter:

1

Forms

Issuance:

21.11

CP&P Form 21-11, Child Fatality/Near Fatality Report

 

 

Click here to view, print, or complete CP&P Form 21-11, Child Fatality/Near Fatality Report.

 

WHEN TO USE IT

 

Use this form to report a child fatality when the child:

 

·        Is under CP&P supervision at the time of death, regardless of the cause of death; or

 

·        Is not under CP&P supervision but the death appears to have been due to suspected or confirmed abuse or neglect by his or her parent or caregiver.

 

·        Use this form to report a near fatality which has been certified by a physician when, as a result of abuse or neglect, a child:

 

·        Suffers a severe, permanent mental or physical impairment;

 

·        Suffers a life-threatening injury; or

 

·        Suffers a condition that creates a probability of death within the near future.

 

See policy at CP&P-VIII-A-1-100, Child Fatality and Near Fatality Reporting.

 

Do not use this form to report a critical incident; instead use the Critical Incident Report template, CP&P Form 21-10.  See policy at CP&P-IX-D-1-100, Critical Incident Reporting.

 

HOW TO USE IT

 

CP&P Form 21-11 is a template, prepared by using the on-line form in the computerized Forms Manual.

 

The form is prepared by the Area Director or Designee (with the assistance of the Local Office), completed within 24 hours of receipt of the report from SCR.  Upon completion of the form, the Area Director forwards the form to the Office of the CP&P Director.

 

Reports of a child fatality or near fatality received during non-business hours are handled by the State Central Registry (SCR) in consultation with the on-call SPRU Supervisor or Local Office Manager.

 

If a child fatality or near fatality occurs over the weekend, the report is due by close of business on Monday.

 

If a child fatality or near fatality occurs on a State holiday, the report is due by close of business on the next working day.

 

The CP&P Director is responsible for distributing required copies of the CP&P Form 21-11 to other relevant DCF staff, including, but not limited to, the Commissioner; the Deputy Commissioner; the Chief of Staff; the Assistant Commissioner of Quality Improvement, Performance Management, and Accountability; and the Office of Communications and Public Affairs.  See "Distribution."

 

Note: The Area Director provides an update to the CP&P Director within 14 calendar days of the initial report, using CP&P Form 21-12, Child Fatality/Near Fatality Update Summary. A summary of the handling of the entire incident may also be provided to the CP&P Director upon the completion of the investigation, when appropriate, using CP&P Form 21-13, Child Fatality/Near Fatality Concluding Summary.

 

TIPS FOR COMPLETING THE FORM

 

Complete check boxes and text boxes for required fields.  Text boxes for fields requiring a narrative will expand as they are completed. 

 

Complete text boxes in detail, as follows:

 

·        Nature of the Incident

 

Enter the summary of the incident, including pertinent background information; where the incident occurred; details about, and cause of death or near fatality.  Include the activity that occurred as a direct result of the report of the child's death or near fatality.  Include media involvement and names of news reporters, newspapers, TV stations, Internet sites, if known.  Attach or refer to relevant reports, if available, such as newspaper articles and police or medical reports.

 

·         Current Situation

 

Enter a concise description of all actions taken as a result of the report.  Include significant interviews, visits to the child's residence, services provided, placement/removal of other children in the family/facility, and any litigation activity.  For near fatalities, identify the hospital or location of the child and the expected stay.  Identify the physician who classified the incident as a near fatality.  List other agencies and professionals providing services to the child/family or who otherwise have information about the circumstances of the child's death or near fatality.

 

·        Prior Involvement

 

Provide a thorough summary of CP&P involvement during the past three years.  Include dates, allegations, and findings.  If the history is longer than three years, provide a summary of the number of reports and referrals and the findings of each report.

 

·        Follow-Up

 

Indicate further action to be taken or recommended; additional information/reports to be forwarded; and anticipated changes in the case plan.  Indicate the date when the Child Fatality/Near Fatality Update Summary, CP&P Form 21-12, is due (within 14 calendar days).

 

·        Contact Information

 

Include Area Director/Designee name and office before submission.  Include Area Office contact person, if necessary.

 

DISTRIBUTION

 

Original

-

CP&P Director

 

Copy

-

CP&P Director

 

Copy

-

DCF Commissioner

 

Copy

-

Deputy Commissioner

 

Copy

-

Chief of Staff

 

Copy

-

Assistant Commissioner of Quality Improvement, Performance Management, and Accountability

 

Copy

-

Office of Communications and Public Affairs

 

Copy

-

Supervisor of Child Fatality and Near Fatality Review Board