Child Fatality/Near Fatality Report
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CP&P 21-11 (rev. 5/2012)
State of New Jersey DEPARTMENT OF CHILDREN AND FAMILIES Child Protection and Permanency Child Fatality/Near Fatality Report
Near Fatality Summary Fatality Summary
CCAPTA Non-CCAPTA Notification
Today’s Date: Date Reported:
CHILD
Name of Child: NJS Case ID#:
DOB: Case Status:
Gender: Race: Foster Care: Yes No
REFERRAL
Date of Call: Local/IAIU Office:
County: Area Office:
Investigating Worker: Date of Incident:
Investigating Supervisor: Date of Fatality:
Permanency Worker: Last CP&P Contact before incident:
Permanency Supervisor: CPS CWS
Will there be an Autopsy? Yes No Unknown
CASE STATUS
Unknown to CP&P Date Opened:
Open or active with CP&P at incident Date Opened:
Re-opened with this incident Date Re-opened:
Prior CP&P Involvement Date Last Closed:
Open or active with DCBHS Date Opened: CP&P 21-11 (rev. 5/2012)
State of New Jersey DEPARTMENT OF CHILDREN AND FAMILIES Child Protection and Permanency
Child Fatality/Near Fatality Report
CAREGIVERS
Parent/Guardian(s): Address:
Mother:
Guardian:
Father:
Guardian:
Resource Parent(s): 1.
2.
Other Persons/Relationship:
1.
2.
3.
4.
SIBLINGS
Gender Sibling(s): DOB: : Address:
1.
2. 3. 2 CP&P 21-11 (rev. 5/2012)
State of New Jersey DEPARTMENT OF CHILDREN AND FAMILIES Child Protection and Permanency
Child Fatality/Near Fatality Report
4.
PROBABLE CAUSE OF DEATH
Suspected Abuse Self-inflicted
Suspected Neglect Prematurity
Natural Genetic Deformities
Medical Problems SIDS/SUID
Accidental Vehicle Possible Overlay
Accidental Non-Vehicle Other: (specify)
Homicide
Is Substance Abuse a factor in the child death: Yes No Unknown
Is Domestic Violence a factor in the child death: Yes No Unknown
PROBABLE CAUSE OF NEAR FATALITY
Suspected Abuse Attempted Homicide
Suspected Neglect Prematurity
Medical Problems Genetic Deformities
Accidental Vehicle Possible Overlay
Accidental Non-Vehicle Other: (specify)
Self-inflicted
Is Substance Abuse a factor in the near fatality: Yes No Unknown
Is Domestic Violence a factor in the near fatality: Yes No Unknown 3 CP&P 21-11 (rev. 5/2012)
State of New Jersey DEPARTMENT OF CHILDREN AND FAMILIES Child Protection and Permanency
Child Fatality/Near Fatality Report
S U M M A R Y
NATURE OF INCIDENT:
CURRENT SITUATION:
PRIOR INVOLVEMENT:
FOLLOW-UP:
A Child Fatality/Near Fatality Update Summary is due by:
C O N T A C T I N F O R M A T I O N
AREA OFFICE CONTACT PERSON (completing the form):
CALLED IN BY:
AREA DIRECTOR/OFFICE:
Review Date:
Distribution:
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