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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

7-12-2010

Subchapter:

1

Forms

Issuance:

21.31

CP&P Form 21-31, SAFE HAVEN Notice of Emergency Removal Pursuant to N.J.S.A. 9:6-8.29 and 9:6-8.30, Without Court Order

 

 

Click here to view or print CP&P Form 21-31, SAFE HAVEN Notice of Emergency Removal Pursuant to N.J.S.A. 9:6-8.29 and 9:6-8.30, Without Court Order.

 

PURPOSE AND USE

 

The Safe Haven Notice of Emergency Removal Pursuant to N.J.S.A. 9:6-8.29 and 9:6-8.30, Without Court Order, CP&P Form 21-31, is a form letter used by CP&P to:

 

·                  Notify a hospital or medical center, in writing, when CP&P assumes the care, control and custody of a child pursuant to N.J.S.A. 9:6-8.29, N.J.S.A. 9:6-8.30 and P.L. 2000, c. 58, the New Jersey Safe Haven Infant Protection Act (which took effect August 7, 2000);

 

·                  Advise hospital staff that the Act authorizes CP&P to consent to the examination and treatment of the child and permits the hospital to release medical reports resulting from such examination or treatment to CP&P; and

 

·                  Advise hospital staff that the Act specifies that any person or health care facility acting in good faith in the examination of, or the provision of care or treatment to, the child, or in the release of medical records about the child shall have immunity from any liability, civil or criminal, that might otherwise be incurred or imposed as a result of such act.

 

INSTRUCTIONS FOR COMPLETING THE FORM

 

GENERAL INSTRUCTIONS

 

The form is prepared in duplicate when CP&P responds to a report of a Safe Haven infant. The letter is completed by:

 

·                  The assigned Worker, when the report of a Safe Haven infant is received and assigned during CP&P business hours; or

 

·                  A SPRU Worker, when the report of a Safe Haven infant is received after hours.

 

The Worker prepares the form (letter) when responding at the hospital.

 

SPECIFIC INSTRUCTIONS

 

Complete the form as follows:

 

·                  DATE:  Enter today's date.

 

·                  TO: Enter the name and address of the hospital.

 

·                  FIRST PARAGRAPH:

 

-       Hospital or Police Department Name:  Enter the name of the hospital or police department which is processing the Safe Haven infant report.

 

-       Name/Hospital Identification Number:  Enter the infant's name, if known.

 

-       If the infant's name is not known or if the infant does not yet have a name, enter the patient identification number from the hospital wrist band, or other identifier from the infant's medical chart.

 

-       Hospital Name:  Enter the name of the hospital.

 

-       Date:  Enter the date the child was brought to the hospital pursuant to the Safe Haven Infant Protection Act.

 

·                  CP&P CASEWORKER SIGNATURE/NAME/OFFICE/TELEPHONE NUMBER:  The Worker signs his or her name, enters his or her name, and identifies the CP&P Local Office responsible for handling the case.

 

·                  NOTICE RECEIVED BY:

 

-       Signature - Hospital Representative:  The hospital representative signs his or her name, to document receipt of CP&P Form 21-31.

 

-       Name and Title:  The hospital representative enters his or her name and title (or indicates the position he or she holds at the hospital).

 

-       Date:  The hospital representative enters today's date, to date his or her signature/receipt of CP&P Form 21-31.

 

DISTRIBUTION

 

Original

-

 

 

Safe Haven infant's medical chart Safe Haven infant's medical chart

 

Copy

-

Child's case record