1. Information About Newborn Surrended Under Safe Haven Law

 

Please complete the following questions relating to an infant that was turned over to you under the Safe Haven for Newborns law. The surrendering parent is NOT REQUIRED to give any information but we would like to have as much detail as possible, for purposes of tracking and evaluating the program. It may also be very helpful for the adoptive family in the future. Thank you for your help.

Baby's date of birth

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* 1. Baby's date of birth

Date and time surrendered.

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* 2. Date and time surrendered.

Gender of baby

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* 3. Gender of baby

Baby's race/ethnicity

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* 4. Baby's race/ethnicity

Does the baby have any health related issues, or any other pertinent issues?

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* 5. Does the baby have any health related issues, or any other pertinent issues?

Please describe the circumstances of the surrender.

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* 6. Please describe the circumstances of the surrender.

Where was the baby born? (at home, in a hospital, etc.)

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* 7. Where was the baby born? (at home, in a hospital, etc.)

The baby was surrendered to (name of organization)

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* 8. The baby was surrendered to (name of organization)

Address of organization

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* 9. Address of organization

Phone number of organization

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* 10. Phone number of organization

Name of the person submitting this information

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* 11. Name of the person submitting this information

Your phone number and/or email address

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* 12. Your phone number and/or email address

Today's date

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* 13. Today's date

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