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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

4-22-2013

Subchapter:

1

Forms

Issuance:

5.41

CP&P Form 5-41, Acknowledgement of Understanding in the Use of Universal Precautions

 

 

Click here to view, print or complete the CP&P Form 5-41, Acknowledgement of Understanding in the Use of Universal Precautions.

 

PURPOSE AND USE

 

The form is used to:

 

·         Acknowledge the agreement between the Division and a caregiver, i.e., resource parent or other out-of-home caregiver, who provides direct care to a child, under CP&P supervision, who has been exposed to or is diagnosed with an infectious disease (e.g., Human Immunodeficiency Virus, Hepatitis B, Hepatitis C).

 

·         Ensure that the caregiver is aware that no extraordinary precautions are necessary beyond well-established hygienic precautions in caring for a child who has been exposed to, or is diagnosed with, an infectious disease.

 

·         Acknowledge the universal precautions to be used in caring for a child who has been exposed to, or is diagnosed with, an infectious disease.

 

INSTRUCTION FOR COMPLETING THE FORM

 

Print or type the name(s) of the caregiver(s) in the space provided on the first line of the form. The form is signed and dated by the caregiver(s). The CP&P Worker witnesses the caregiver’s signature by signing and dating the agreement in the spaces designated.

 

DISTRIBUTION

 

Original

 

-

Resource home record

 

Copy

-

Caregiver

 

Copy

 

-

Child’s case record