N.J. Admin. Code § 10:47-3.14 - Pre-admission

Current through Register Vol. 54, No. 7, April 4, 2022

(a) Individual records shall include the following data:
1. The full name and sex of the individual;
2. A copy of the individual's birth certificate or a written statement of the individual's birth date and birth place, including a copy of any guardianship determination made in accordance with 30:4-165.5;
3. Documentation of the current custody and legal guardianship; which shall include the name, address, telephone number of the parent(s) or guardian;
4. Consent forms signed by the parent(s) of a minor or court appointed guardian allowing the facility to authorize all necessary medical care, routine tests, immunization, and emergency medical or surgical treatment;
5. Documentation of the existence of a developmental disability prior to the age of 22 (for example, medical diagnosis, psychological evaluation, social history);
6. A social and developmental history;
7. A previous placement history;
8. Behavioral information, including, if applicable, the most recent psychological evaluation, current behavior plan and history of previous attempts to modify the behavior;
9. A psychiatric evaluation, if applicable;
10. A medication history and immunization history;
11. Documentation for known allergies;
12. Seizure records and/or neurological examination;
13. A history of serious illness, serious injury, or major surgery and all hospitalizations;
14. A certificate which certifies that the person is free from contagious disease within 48 hours prior to admission;
15. A summary of the latest physical examination, including Mantoux testing, Hepatitis B status and lead levels;
16. A current audiological evaluation, if available;
17. Vision testing, if available;
18. Dental information, if available;
19. An IHP from the sending agency indicating the individual's programmatic and service needs and corresponding recommendations; and
20. Education records and reports as required.

Notes

N.J. Admin. Code § 10:47-3.14
Recodified from N.J.A.C. 10:47-3.15 by R.2007 d.72, effective 3/5/2007.
See: 38 N.J.R. 4352(a), 39 N.J.R. 777(a).
Former N.J.A.C. 10:47-3.14, Admission policies, recodified to N.J.A.C. 10:47-3.13.

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