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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

12-10-2012

Subchapter:

1

Forms

Issuance:

21.7

CP&P Form 21-7, Request for Information Pursuant to N.J.S.A. 9:6-8.40

 

 

CP&P Form 21-7: Form    12-10-2012

 

Click here to view or print the CP&P Form 21-7, Request for Information Pursuant to N.J.S.A. 9:6-8.40.

 

CP&P Form 21-7: Instructions    12-10-2012

 

PURPOSE AND USE

 

The form is used to request and obtain information which is needed in investigating child abuse and neglect reports whenever the Worker or IAIU Investigator has reason to believe that agencies (e.g., law enforcement, school, medical facility) or private practitioners have knowledge of the child alleged to be abused or neglected or other children under the same care and custody. Use the form when a parent or caregiver is not available or is not willing to provide written consent. See CP&P-II-C-5-175, CP&P Legal Authority Relative to Collateral Contacts. This form may not be used to obtain information about adults in the child's family.

 

Collateral contacts must be made in person or by telephone in accordance with policy. The Worker/Investigator may use this form (CP&P Form 21-7) to request additional or written information from those agencies or professionals contacted. Fax a copy of the completed form, to save time and facilitate case documentation. Sources are not required to release the requested information, however, but those who agree to do so are given immunity from civil or criminal liability. Sources that refuse to release information are advised of the law, and given a copy of the relevant section of the statute.

 

INSTRUCTIONS FOR COMPLETING FORM

 

Complete the form when it is determined that the child is or may be known to an agency or private practitioner. This form is a template, to be completed on-line. Using the "Tab" key, the Worker or IAIU Investigator navigates the form. Note: The "Tab" key functions left to right on the screen. This directional use means that the Worker will need to ensure they properly document the correct information in the correct field.

Print the form on approved State letterhead. The Worker (for incidents investigated by or coming under the jurisdiction of the Local Office), or the IAIU Investigator (for institutional abuse/neglect incidents), signs the CP&P Form 21-7. When seeking to obtain medical information from a private practitioner or a medical facility, attach CP&P Form 21-40, Medical Request Letter, to CP&P Form 21-7

 

COMPLETE THE FORM AS FOLLOWS

 

Date:  Enter the date the form is completed.

To:  Name and Title/Agency

Enter the name of the agency and/or the name and title of the practitioner from whom information is being requested.

 

Street Address:

Enter the agency's/practitioner's street address.

 

City/State/Zip:

Enter the agency's or practitioner's city, state, and zip code.

 

Re:  Child’s Name:

Enter the first name and surname of the child (or children) for whom the information is being requested.

 

Child's Date of Birth:

Enter the child's (children's) birth date(s).

 

Address:

Enter the child's home address at the time the child was known to the agency or practitioner. If the child's address was a resource family home, enter the Local Office or IAIU Office address.

 

Parent's Name:

Enter the first name and surname of the child's birth or adoptive parent(s).

 

Street Address:

Enter the street address of the parent(s).

 

City/State/Zip:

Enter the parent(s) city, state, and zip code.

 

Local Office/IAIU:

Enter the name of the Local Office or Institutional Abuse Investigation Unit Office.

 

Street Address:

Enter the LO or IAIU Office address.

 

City/State/Zip:

Enter the LO or IAIU Office's city, state, and zip code.

 

Worker/IAIU Investigator

The Worker or IAIU Investigator signs his or her name. The Worker or IAIU Investigator signs his or her name.

 

Telephone Number:

Enter the DCF office telephone number, including area code.

 

 

DISTRIBUTION

 

Original

-

Agency/practitioner from whom information is being sought

 

Copy

-

Child's case record or IAIU file