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.

* 1. Baby's date of birth

* 2. Date and time surrendered.

* 3. Gender of baby

* 4. Baby's race/ethnicity

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

* 6. Please describe the circumstances of the surrender.

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

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

* 9. Address of organization

* 10. Phone number of organization

* 11. Name of the person submitting this information

* 12. Your phone number and/or email address

* 13. Today's date