TITLE 45 - PUBLIC WELFARE

SUBTITLE B - REGULATIONS RELATING TO PUBLIC WELFARE

CHAPTER XIII - OFFICE OF HUMAN DEVELOPMENT SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER G - THE ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES

PART 1355 - GENERAL

Appendix B to Part 1355 - Adoption Data Elements

Section IAdoption 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 ____ C. If VIII. A is yes, is the subsidy paid under Title IV-E adoption assistance? ____ Yes: 1 No: 2 Section IIDefinitions 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. StateU.S. Postal Service two letter abbreviation for the State submitting the report.

B. Report DateThe last month and the year for the reporting period.

C. Record NumberThe 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 BirthMonth 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. SexIndicate as appropriate.

C. Race/Ethnicity 1. RaceIn 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 NativeA 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.

AsianA 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 AmericanA person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific IslanderA person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

WhiteA person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Unable to DetermineThe 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 EthnicityAnswer 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 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 NeedsIndicate only the primary factor or condition for categorization as special needs and only as it is defined by the State.

Racial/Original BackgroundPrimary condition or factor for special needs is racial/original background as defined by the State.

AgePrimary 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 TogetherPrimary factor or condition for special needs is membership in a sibling group as defined by the State.

Medical Conditions of Mental, Physical, or Emotional DisabilitiesPrimary 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 DisabilitiesData are only to be entered if response to III.B was 4. Indicate with a 1 the types of disabilities.

Mental RetardationSignificantly 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 ImpairedHaving 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 DisabledA 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 CareConditions 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 BirthEnter 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 RightsEnter 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 LegalizedEnter the date the court issued the final adoption decree.

VI. Adoptive Parents A. Family StructureSelect from the four alternativesmarried couple, unmarried couple, single female, single malethe category which best describes the nature of the adoptive parent(s) family structure.

B. Year of BirthEnter the year of birth for up to two adoptive parents.

If the response to data element IV.AFamily 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/EthnicityIndicate 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).

StepparentSpouse of the child's birth mother or birth father.

Other Relative of Child by Birth or MarriageA relative through the birth parents by blood or marriage.

Foster Parent of ChildChild 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-RelativeAdoptive 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 StateResponsibility for the child resided with an individual or agency within the State filing the report.

Another StateResponsibility for the child resided with an individual or agency in another State or territory of the United States.

Another CountryImmediately 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 AgencyA unit of State or local government.

Private AgencyA for-profit or non-profit agency or institution.

Tribal AgencyA unit within one of the Federally recognized Indian Tribes or Indian Tribal Organizations.

Independent PersonA doctor, a lawyer or some other individual.

Birth ParentThe 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 AmountIndicate 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]