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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

3-15-2018

Subchapter:

1

Forms

Issuance:

22.42

CP&P Form 22-42 Participant List and Agreement to Confidentiality

 

Click here to view or print the CP&P Form 22-42, Participant List and Agreement to Confidentiality.

 

Click here to view or print the CP&P Form 22-42(S).

 

Instructions 9-29-2006

 

PURPOSE AND USE

 

Use this form to:

 

•           Inform participants of the requirement to maintain the confidentiality of all personal and identifying information regarding the family and their involvement with the Division.

 

•           Provide a mechanism for participants to acknowledge their responsibility to keep CP&P client information confidential.

 

•           Document attendance of participants.

 

•           Record the number of individuals who agreed to participate in the meeting.

 

INSTRUCTIONS FOR COMPLETING THE FORM

 

CP&P Form 22-42 is completed at the meeting with the family.

 

The Worker enters the case identification number (the NJ SPIRIT system-generated case ID#) at the top of the form.

 

The Worker enters the Name of the Family, the Name of the Worker, the Date, and the Location of the meeting in the spaces provided.

 

The Worker explains the importance of keeping client information confidential, and reads the confidentiality statement aloud to meeting participants.

 

The Worker prints his or her name and enters his or her relationship to the family, and signs the form in the "Attendance and Agreement to Confidentiality" box.

 

Each participant prints his or her name, enters his or her relationship to the family, and signs the form in the "Attendance and Agreement to Confidentiality" box.

 

The Worker addresses any questions raised about the form and its purpose.

 

The Worker enters the total number of individuals who agreed to attend the meeting prior to the meeting date, including CP&P Staff and other agency personnel.

 

DISTRIBUTION

 

Original          -           Case Record