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NJ DCF Logo with reverse copy


New Jersey Department of Children and Families Policy Manual




Child Protection and Permanency

Effective Date:













CP&P Form 22-10, Congregate Care Questionnaire


Click here to view or print CP&P Form 22-10, Congregate Care Questionnaire.




This form is used to assess a child's safety in a congregate care facility (a children's residential treatment center, a youth shelter, or a group home) and, in an independent living setting (private home or apartment, transitional living, youth supported housing), at the following intervals:


      •     Within one month of placement (completed by the assigned Worker);


      •     Every six (6) months thereafter (completed by the assigned Worker); and


      •     At the time of a child protective services investigation, where it is completed by:


       -    The responding IAIU Investigator;


       -    A CP&P Special Response Unit (SPRU) Worker, if responding after business hours; or


       -    A Public Defender Conflict Investigation Unit Investigator, when responding to CPS allegations in a CP&P or DCF operated residential treatment center or facility.




      •     Print the form and complete it on-site, by hand (at the congregate care facility, independent living setting, etc.) upon interviewing the child/youth.


      •     If "comment" entries are extensive, check the "continue" box, and use page 3.  (Page 3 can be completed by hand or electronically.)


      •     Page one is the actual questionnaire, completed during an in-person meeting with the child/youth.  Use the form to guide the interview.

      •     Page two is used for administrative and documentation purposes to:


      -     Indicate whether the facility Social Worker, Administrator, "house parent", or other adult, was contacted to discuss any concerns raised by the adolescent.  If so, space is provided for details;


      -     Document the steps followed by the responding Worker/Investigator, when assessing child/youth safety in the congregate care facility or independent living setting; and


      -     Document that CP&P, IAIU, Office of Licensing, and others were advised that child/youth safety was assessed.




Use CP&P Form 22-10 as the initial response report (the "eight day report") for congregate care setting investigations. 


Enter the investigation number, as generated by NJS, in the space provided near the top of page 1.


Record remedial action, in narrative format, in "Comments" (at the bottom of page 1).   Document concerns, risks, recommendations for further action, the need for collateral contacts (specify who to contact), and any service needs of the child.   Check the "continuation on page 3" box, then enter detailed narrative text on page 3.  (Information can be entered by hand or electronically on page 3, which is set up as a template in the on-line Forms Manual.)


Forward additional copies of CP&P Form 22-10 as directed by IAIU Central Office.




Original          -           Child's/youth's case record or IAIU file


Copy               -           Office of Licensing (OOL) - Youth Residential Licensing.


Copy               -           IAIU, when appropriate


Copy             -            Area Office Contract Unit responsible for the contract with the facility


Copy               -           DCF Interstate Services Unit, if the facility is located out of state


Copy             -            DCF Children's System of Care, if the facility is located out of state, or as notification of a problem at the facility