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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

10-30-2006

Subchapter:

1

Forms

Issuance:

5.2c

CP&P Form 5-2c, Medical Reference

 

Click here to view or print the CP&P Form 5-2c, Medical Reference.

 

Instructions

 

PURPOSE AND USE

This form is used to obtain medical information about:

      Prospective and licensed resource parents (foster, adoptive, relative or family friend), their children, and any other persons living in their household

      Volunteer applicants

 

INSTRUCTIONS FOR COMPLETING THE FORM

Send the form, with a pre-addressed stamped envelope, to the physician or physicians listed on the:

              CP&P Form 5-2, Resource Family Home Application

 

The Medical Reference is sent with a copy of the CP&P Form 26-15, Authorization to Release Information, and the following:

      CP&P Form 5-23, Cover Letter, for prospective and licensed resource parents and their household members

 

Medical References are required for prospective resource parents, their children, and any other person living in their household at the time of application.  The Medical Reference is based on the physician's examination of the prospective resource parents or household members within one year of completion of the Medical Reference.

A Medical Reference is required for each new household member.

Every three years from the date of issuance of the resource home license by the Office of Licensing (OOL), updated Medical References are required for resource parents, their children, and any other person living in the household.  The Medical Reference is submitted at the time of the home's license renewal conducted by OOL.

When the Medical Reference is requested at the time of renewal, it is based on the physician's examination of the resource parents and household members within one year of completion of the Medical Reference.

Medical References are also required for volunteer applicants.

This form is not valid if received from or through the subject of the reference - the form must be mailed to the CP&P office or sponsoring agency by the person completing the reference.

File a copy of the cover letter and the CP&P Form 26-15 in the applicant's file to verify that the reference was sent.  When the CP&P Form 5-2c is returned, file it in the resource family home folder.

 

DISTRIBUTION

Original

-

Doctor, with CP&P Form 26-15, Authorization for Release of Information, and appropriate cover letter with stamped, pre-addressed envelope

Prospective resource family parent's record when returned to CP&P