PLEASE DO NOT PRINT THIS FORM - USE THE PDF VERSION MEDICAL INFORMATION FOR NEWBORN BABIES Delaware Safe Arms for Babies Program BABY I.D.#: Hospital Name: Hospital Staff Name: NOTICE: The baby you have brought in today may have serious medical needs in the future that we don’t know about now. Some illnesses, including cancer, are best treated when we know about the family medical histories. To make sure this baby will have a healthy future, your assistance in fully completing this questionnaire is essential. Thank you. PARENT INFORMATION: Mother’s Age: _____ Mother’s Race: __________________ Father’s Age: ______ Father’s Race: _________________ How long was the mother pregnant: ___________________________________ Problems during baby’s delivery: (explain) ___________________________________________________________________ BABY INFORMATION: Baby’s Date of Birth:__________a.m.____p.m.___ Baby’s hair color: ____________________ Approximate weight at birth: ____________________ FAMILY MEDICAL HISTORY Mother Father Grandmother Grandfather (Check Yes or No) Yes No Yes No Yes No Yes No Prenatal care XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Diabetes Tuberculosis Kidney disease Heart disease High blood pressure Bleeding disorder Sickle cell disease HIV-AIDS Sexually transmitted disease XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Explain: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Cancer (Type) Asthma Explain: Allergies to food or medicine Explain: Drug use during pregnancy XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Explain: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Alcohol use during pregnancy XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Type: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX How often: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Smoking during pregnancy XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX How often: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Mental Health/Emotional Problems Explain Other: SAFE ARMS FOR BABIES MEDICAL FORM INSTRUCTIONS Medical information about a baby and his/her parent(s) is critical for the proper health care of a child as they grow. This information is also critical for adoptive parents as they obtain medical care for the child in the future. Every effort should be made, without risking the safe placement of the baby, to obtain medical information. Also, all efforts should be made to provide counseling information to those parent(s). A person may voluntarily surrender a baby directly to an employee or volunteer of the emergency department of a Delaware hospital inside of the emergency department, provided that said baby is surrendered alive, unharmed and in a safe place therein. A Delaware hospital shall be authorized to take temporary emergency protective custody of the baby who is surrendered pursuant to this section. The person who surrenders the baby shall not be required to provide any information pertaining to his or her identity nor shall the hospital inquire as to same. If the identity of the person is known to the hospital, the hospital shall keep the identity confidential. However, the hospital shall either make reasonable efforts to directly obtain pertinent medial history information pertaining to the baby and the baby’s family or attempt to provide the person with a postage paid medical history information questionnaire.* The postage paid envelope and completed form, upon return to the hospital, should be mailed by the hospital to: ADOPTION PROGRAM MANAGER, DIVISION OF FAMILY SERVICES, 1825 FAULKLAND ROAD, WILMINGTON, DE 19805 (DFS Report Line number 1-800-292-9582). The hospital should also include the hospital name and name of staff member receiving the baby on the medical history information questionnaire. The Medical information should be distributed to, and included in, both the hospital’s medical record and the Adoption Program Manager, Division of Family Services. The hospital shall attempt to provide the person leaving the baby with the following: (1) Information about the Safe Arms program; (2) information about adoption and counseling services, including information that confidential adoption services are available and information about the benefits of engaging in a regular, voluntary adoption process; and (3) brochures with telephone numbers for public or private agencies that provide counseling or adoption services. The hospital shall attempt to provide the person surrendering the baby with the number of the baby’s identification bracelet to aid in linking the person to the baby at a later date, if reunification is sought. Such an identification number is an identification aid only and does not permit the person possessing the identification number to take custody of the baby on demand. If a person possesses an identification number linking the person to a baby surrendered at a hospital under this section and parental rights have not already been terminated, possession of the identification number creates a presumption that the person has standing to participate in an action. Possession of the identification number does not create a presumption of maternity, paternity, or custody. Any hospital taking a baby into temporary emergency protective custody pursuant to this section shall immediately notify the Division of Family Services and the State Police of its actions. The Division of Family Services shall obtain exparte custody and physically appear at the hospital within four hours of notification under this subsection unless there are exigent circumstances. Immediately after being notified of the surrender, the State Police shall submit an inquiry to the Delaware Missing Children Information Clearinghouse. The Division of Family Services shall notify the community that a baby has been abandoned and taken into temporary emergency protective custody by publishing notice to that effect in a newspaper of statewide circulation. The notice must be published at least 3 times over a 3-week period immediately following the surrender of the baby unless the Division of Family Services has relinquished custody. The notice at a minimum shall contain the place, date and time where the baby was surrendered, the baby’s sex, race, approximate age, identifying marks, any other information the Division of Family Services deems necessary for the baby's identification and a statement that such abandonment shall be: (1) the surrendering person's irrevocable consent to the termination of all parental rights, if any, of such person on the ground of abandonment; and (2) the surrendering person's irrevocable waiver of any right to notice of or opportunity to participate in any termination of parental rights proceeding involving such child, unless such surrendering person manifests an intent to exercise parental rights and responsibilities within thirty days of such abandonment. When the person who surrenders a baby pursuant to this section manifests a desire to remain anonymous, the Division of Family Services shall neither initiate nor conduct an investigation to determine the identity of such person, and no Court shall order such an investigation, unless there is good cause to suspect child abuse or neglect other than the act of surrendering such baby. Abandonment of a baby as provided in §907A of Title 16 shall be final thirty days after such abandonment, and such abandonment shall be: (i) the surrendering person’s irrevocable consent to the termination of all parental rights, if any, of such person on the ground of abandonment; and (ii) the surrendering person’s irrevocable waiver of any right to notice of or opportunity to participate in any termination of parental rights proceeding involving such child, unless such surrendering person has manifested an intent to exercise parental rights and responsibilities within thirty days of such abandonment. * To obtain reimbursement for the cost of postage and envelope, the hospital may submit an invoice to the “Safe Arms For Babies Program”, Delaware Division of Public Health, 417 Federal Street, Dover, DE 19901.