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