[Code of Federal Regulations]
[Title 45, Volume 4]
[Revised as of October 1, 2008]
From the U.S. Government Printing Office via GPO Access
[CITE: 45CFR1355 App B]
[Page 295-298]
TITLE 45--PUBLIC WELFARE
CHAPTER XIII--OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH
AND HUMAN SERVICES
PART 1355_GENERAL--Table of Contents
Sec. Appendix B to Part 1355--Adoption Data Elements
Section I--Adoption Data Elements
I. General Information
A. State_______________________________________________________________
B. Report Date ----(mo.) ----(day) ----(yr.)
C. Record Number_______________________________________________________
D. Did the State Agency Have any Involvement in This Adoption? ----
----
Yes: 1
No: 2
II. Child's Demographic Information
A. Date of Birth ----(mo) ----(day) ----(yr.)
B. Sex ----
Male: 1
Female: 2
C. Race/Ethnicity
1. Race
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Unable to Determine
2. Hispanic or Latino Ethnicity------
Yes: 1
No: 2
Unable to determine: 3
III. Special Needs Status
A. Has the State child welfare agency determined that this child has
special needs? --------
Yes: 1
No: 2
B. If yes, indicate the primary basis for determining that this
child has special needs --------
Racial/Original Background: 1
Age: 2
Membership in a Sibling Group to be Placed for Adoption Together: 3
Medical Conditions or Mental, Physical or Emotional Disabilities: 4
Other: 5
1. If III. B was ``4,'' indicate with a ``1'' the type(s) of
disability(ies)
Mental Retardation --------
Visually or Hearing Impaired --------
Physically Disabled --------
Emotionally Disturbed (DSM III) --------
Other Medically Diagnosed Condition Requiring Special Care --------
IV. Birth Parents
A. Year of Birth --------
Mother, If known --------
Father (Putative or Legal), if known --------
B. Was the mother married at the time of the child's birth? --------
Yes: 1
No: 2
Unable to Determine: 3
V. Court Actions
A. Dates of Termination of Parental Rights
Mother ----(mo.) ----(day) ----(yr.)
Father ----(mo.) ----(day) ----(yr.)
B. Date Adoption Legalized ----(mo.) ----(day) ----(yr.)
VI. Adoptive Parents
A. Family Structure --------
Married Couple: 1
Unmarried Couple: 2
Single Female: 3
Single Male: 4
B. Year of Birth
Mother (if Applicable) --------
Father (if Applicable) --------
C. Race/Ethnicity
1. Adoptive Mother's Race (If Applicable)
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Unable to Determine
2. Hispanic or Latino Ethnicity of Mother (If Applicable)------
Yes: 1
No: 2
Unable to Determine: 3
3. Adoptive Father's Race (If Applicable)
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Unable to Determine
4. Hispanic or Latino Ethnicity of Father (If Applicable)------
Yes: 1
No: 2
Unable to Determine: 3
D. Relationship of Adoptive Parent(s) to the Child (Indicate with a
``1'' all that apply)
Stepparent
Other Relative of Child by Birth or Marriage --------
Foster Parent of Child --------
Non-Relative --------
VII. Placement Information
A. Child Was Placed From --------
Within State: 1
Another State: 2
Another Country: 3
B. Child Was Placed by --------
Public Agency: 1
Private Agency: 2
Tribal Agency: 3
Independent Person: 4
Birth Parent: 5
VIII. Federal/State Financial Adoption Support
A. Is a monthly financial subsidy being paid for this child? ------
--
Yes: 1
No: 2
B. If yes, the monthly amount --------
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C. If VIII. A is yes, is the subsidy paid under Title IV-E adoption
assistance? --------
Yes: 1
No: 2
Section II--Definitions of Instructions for Adoption Data Elements
Reporting population
The State must report on all children who are adopted in the State
during the reporting period and in whose adoption the State title IV-B/
IV-E agency has had any involvement. All adoptions which occurred on or
after October 1, 1994 and which meet the criteria set forth in this
regulation must be reported. Failure to report on these adoptions will
result in penalties being assessed. Reports on all other adoptions are
encouraged but are voluntary. Therefore, reports on the following are
mandated:
(a) All children adopted who had been in foster care under the
responsibility and care of the State child welfare agency and who were
subsequently adopted whether special needs or not and whether subsidies
are provided or not;
(b) All special needs children who were adopted in the State,
whether or not they were in the public foster care system prior to their
adoption and for whom non-recurring expenses were reimbursed; and
(c) All children adopted for whom an adoption assistance payment or
service is being provided based on arrangements made by or through the
State agency.
These children must be identified by answering ``yes'' to data
element I.D. Children who are reported by the State, but for whom there
has not been any State involvement, and whose reporting, therefore, has
not been mandated, are identified by answering ``no'' to element I.D.
I. General Information
A. State--U.S. Postal Service two letter abbreviation for the State
submitting the report.
B. Report Date--The last month and the year for the reporting
period.
C. Record Number--The sequential number which the State uses to
transmit data to the Department of Health and Human Services (DHHS). The
record number cannot be linked to the child except at the State or local
level.
D. Did the State Agency Have Any Involvement in This Adoption?
Indicate whether the State Title IV-B/IV-E agency had any
involvement in this adoption, that is, whether the adopted child belongs
to one of the following categories:
A child who had been in foster care under the
responsibility and care of the State child welfare agency and who was
subsequently adopted whether special needs or not and whether a subsidy
was provided or not;
A special needs child who was adopted in the
State, whether or not he/she was in the public foster care system prior
to his/her adoption and for whom non-recurring expenses were reimbursed;
or
A child for whom an adoption assistance payment
or service is being provided based on arrangements made by or through
the State agency.
II. Child's Demographic Information
A. Date of Birth--Month and year of the child's birth. If the child
was abandoned or the date of birth is otherwise unknown, enter an
approximate date of birth.
B. Sex--Indicate as appropriate.
C. Race/Ethnicity
1. Race--In general, a person's race is determined by how they
define themselves or by how others define them. In the case of young
children, parents determine the race of the child. Indicate all races
(a-e) that apply with a ``1.'' For those that do not apply, indicate a
``0.'' Indicate ``f. Unable to Determine'' with a 1'' if it applies and
a ``0'' if it does not.
American Indian or Alaska Native--A person having origins in any of
the original peoples of North or South America (including Central
America), and who maintains tribal affiliation or community attachment.
Asian--A person having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.
Black or African American--A person having origins in any of the
black racial groups of Africa.
Native Hawaiian or Other Pacific Islander--A person having origins
in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.
White--A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
Unable to Determine--The specific race category is ``unable to
determine'' because the child is very young or is severely disabled and
no person is available to identify the child's race. ``Unable to
determine'' is also used if the parent, relative or guardian is
unwilling to identify the child's race.
2. Hispanic or Latino Ethnicity--Answer ``yes'' if the child is of
Mexican, Puerto Rican, Cuban, Central or South American origin, or a
person of other Spanish cultural origin regardless of race. Whether or
not a person is Hispanic or Latino is determined by how they define
themselves or by how others define them. In the case of young children,
parents determine the ethnicity of the child. ``Unable to Determine'' is
used because
[[Page 297]]
the child is very young or is severely disabled and no other person is
available to determine whether or not the child is Hispanic or Latino.
``Unable to determine'' is also used if the parent, relative or guardian
is unwilling to identify the child's ethnicity.
III. Special Needs Status
A. Has the State Agency Determined That the Child has Special Needs?
Use the State definition of special needs as it pertains to a child
eligible for an adoption subsidy under title IV-E.
B. Primary Factor or Condition for Special Needs--Indicate only the
primary factor or condition for categorization as special needs and only
as it is defined by the State.
Racial/Original Background--Primary condition or factor for special
needs is racial/original background as defined by the State.
Age--Primary factor or condition for special needs is age of the
child as defined by the State.
Membership in a Sibling Group to be Placed for Adoption Together--
Primary factor or condition for special needs is membership in a sibling
group as defined by the State.
Medical Conditions of Mental, Physical, or Emotional Disabilities--
Primary factor or condition for special needs is the child's medical
condition as defined by the State, but clinically diagnosed by a
qualified professional.
When this is the response to question B, then item 1 below must be
answered.
1. Types of Disabilities--Data are only to be entered if response to
III.B was ``4.'' Indicate with a ``1'' the types of disabilities.
Mental Retardation--Significantly subaverage general cognitive and
motor functioning existing concurrently with deficits in adaptive
behavior manifested during the developmental period that adversely
affect a child's/youth's socialization and learning.
Visually or Hearing Impaired--Having a visual impairment that may
significantly affect educational performance or development; or a
hearing impairment, whether permanent or fluctuating, that adversely
affects educational performance.
Physically Disabled--A physical condition that adversely affects the
child's day-to-day motor functioning, such as cerebral palsy, spina
bifida, multiple sclerosis, orthopedic impairments, and other physical
disabilities.
Emotionally Disturbed (DSM III)--A condition exhibiting one or more
of the following characteristics over a long period of time and to a
marked degree: An inability to build or maintain satisfactory
interpersonal relationships; inappropriate types of behavior or feelings
under normal circumstances; a general pervasive mood of unhappiness or
depression; or a tendency to develop physical symptoms or fears
associated with personal problems. The term includes persons who are
schizophrenic or autistic. The term does not include persons who are
socially maladjusted, unless it is determined that they are also
seriously emotionally disturbed. Diagnosis is based on the Diagnostic
and Statistical Manual of Mental Disorders (Third Edition) (DSM III) or
the most recent edition.
Other Medically Diagnosed Conditions Requiring Special Care--
Conditions other than those noted above which require special medical
care such as chronic illnesses. Included are children diagnosed as HIV
positive or with AIDS.
IV. Birth Parents
A. Year of Birth--Enter the year of birth for both parents, if
known. If the child was abandoned and no information was available on
either one or both parents, leave blank for the parent(s) for which no
information was available.
B. Was the Mother Married at the Time of the Child's Birth?
Indicate whether the mother was married at time of the child's
birth; include common law marriage if legal in the State. If the child
was abandoned and no information was available on the mother, enter
``Unable to Determine.''
V. Court Actions
A. Dates of Termination of Parental Rights--Enter the month, day and
year that the court terminated parental rights. If the parents are known
to be deceased, enter the date of death.
B. Date Adoption Legalized--Enter the date the court issued the
final adoption decree.
VI. Adoptive Parents
A. Family Structure--Select from the four alternatives--married
couple, unmarried couple, single female, single male--the category which
best describes the nature of the adoptive parent(s) family structure.
B. Year of Birth--Enter the year of birth for up to two adoptive
parents. If the response to data element IV.A--Family Structure, was 1
or 2, enter data for two parents. If the response was 3 or 4, enter data
only for the appropriate parent. If the exact year of birth is unknown,
enter an estimated year of birth.
C. Race/Ethnicity--Indicate the race/ethnicity for each of the
adoptive parent(s). See instructions and definitions for the race/
ethnicity categories under data element II.C. Use ``f. Unable to
Determine'' only when a parent is unwilling to identify his or her race
or ethnicity.
D. Relationship to Adoptive Parent(s)--Indicate the prior
relationship(s) the child had with the adoptive parent(s).
Stepparent--Spouse of the child's birth mother or birth father.
[[Page 298]]
Other Relative of Child by Birth or Marriage--A relative through the
birth parents by blood or marriage.
Foster Parent of Child--Child was placed in a non-relative foster
family home with a family which later adopted him or her. The initial
placement could have been for the purpose of adoption or for the purpose
of foster care.
Non-Relative--Adoptive parent fits into none of the categories
above.
VII. Placement Information
A. Child Was Placed From: Indicate the location of the individual or
agency that had custody or responsibility for the child at the time of
initiation of adoption proceedings.
Within State--Responsibility for the child resided with an
individual or agency within the State filing the report.
Another State--Responsibility for the child resided with an
individual or agency in another State or territory of the United States.
Another Country--Immediately prior to the adoptive placement, the
child was residing in another country and was not a citizen of the
United States.
B. Child Was Placed By: Indicate the individual or agency which
placed the child for adoption.
Public Agency--A unit of State or local government.
Private Agency--A for-profit or non-profit agency or institution.
Tribal Agency--A unit within one of the Federally recognized Indian
Tribes or Indian Tribal Organizations.
Independent Person--A doctor, a lawyer or some other individual.
Birth Parent--The parent(s) placed the child directly with the
Adoptive parent(s).
VIII. State/Federal Adoption Support
A. Is The Child Receiving a Monthly Subsidy?
Enter ``yes'' if this child was adopted with an adoption assistance
agreement under which regular subsidies (Federal or State) are paid.
B. Monthly Amount--Indicate the monthly amount of the subsidy. The
amount of the subsidy should be rounded to the nearest dollar. Indicate
``0'' if the subsidy includes only benefits under titles XIX or XX of
the Social Security Act.
C. If VIII.A is ``Yes,'' is Child Receiving Title IV-E Adoption
Subsidy?
If VIII.A is ``yes,'' indicate whether the subsidy is claimed by the
State for reimbursement under title IV-E. Do not include title IV-E non-
recurring costs in this item.
[58 FR 67929, Dec. 22, 1993; 59 FR 42520, Aug. 18, 1994; 65 FR 4084,
Jan. 25, 2000]