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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

9-23-2005

Subchapter:

1

Forms

Issuance:

25.67

CP&P Form 25-67, Request for Approval - Placement of Child Under Age 10 in a Congregate Care Facility

 

Click here to view CP&P Form 25-67.

 

PURPOSE AND USE

 

CP&P Form 25-67, Request for Approval - Placement of a Child Under 10 in a Congregate Care Facility, is used to request approval to place a child under the age of ten (10) with special/medical/other needs in a congregate care facility, an exceptional placement, requiring Area Director approval. The request is completed by the Worker. If placed for medical reasons, the Child Health Unit Nurse supplies pertinent medical information and signs the form to document approval. The Worker's Supervisor reviews the form and any attachments, signs, and forwards the form to the Local Office Manager. Written approval of the Area Director is required to place the child.

 

INSTRUCTIONS FOR COMPLETING

 

The form is a template, available as a web-based application.

To complete the form, the Worker:

 

1.           Enters the information listed below in Section One:

      The child's name.

      The CP&P Case Identification Number.

      The Child's Person Identification Number.

      The Medicaid Number.

      The Local Office, responsible for the case.

      The case goal.

      The child's legal status.

2.           Enters the information listed below in Section Two:

      The child's current placement.

      Identifies and explains what family members have been explored as placement resources before congregate care placement is considered.

      Provides details regarding all CP&P placement options that have been explored, including resource family homes, and statewide search efforts.

3.           Enters the information listed below in Section Three:

      The reasons for placement in a congregate care facility.

      A description of the child's special needs, medications and treatments.

      The name and address of the facility identified as willing to accept the child.

      A description of the Discharge Plan.

4.           Medical Placements Only

      Consults the Child Health Unit Nurse and enters the information listed below in Section Four:

      Answers "yes" or "no" to indicate whether the Nurse reviewed the child's case record.

      If yes, indicate the child's medical issues that necessitate this congregate care placement.

      Lists the Nurse's recommendations.

5.           Enters the information listed below in the last section:

      The Worker signs his or her name, and enters his or her telephone number with extension and the date the request is completed.

The Child Health Unit Nurse:

1.    If medical placement is required, reviews recommendations and provides attachments.

2.    Signs his or her name, provides his or her telephone number with extension, and dates his or her signature.

The Supervisor:

1.         Reviews the case information and attachments.

2.         Signs his or her name, provides his or her telephone number with extension, and dates his or her signature.

3.         Forwards the completed document and attachments to the Local Office Manager.

The Local Office Manager:

1.    Reviews and signs the completed request form, if approving the placement. Dates his or her signature/approval.

2.    Forwards the document to the Area Director for input and approval.

The Area Director:

1.    Reviews and signs the completed request form, if approving the placement, to authorize the exceptional placement. Dates his or her signature/approval.

 

DISTRIBUTION

 

Original          -     

Child's case record

Copy             - 

Child Health Unit Nurse (for medical placements)

Copy             - 

Local Office Manager

Copy             - 

Area Director

Copy             - 

Deputy Director of Case Practice