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.

Question Title

* 1. Baby's date of birth

Question Title

* 2. Date and time surrendered.

Question Title

* 3. Gender of baby

Question Title

* 4. Baby's race/ethnicity

Question Title

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

Question Title

* 6. Please describe the circumstances of the surrender.

Question Title

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

Question Title

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

Question Title

* 9. Address of organization

Question Title

* 10. Phone number of organization

Question Title

* 11. Name of the person submitting this information

Question Title

* 12. Your phone number and/or email address

Question Title

* 13. Today's date

T