Appendix B to Part 1355 - Adoption Data Elements
45:5.1.2.7.20.0.8.33.6 : Appendix B
Appendix B to Part 1355 - Adoption Data Elements Link to an
amendment published at 81 FR 90584, Dec. 14, 2016. This amendment
was delayed until Oct. 1, 2020, at 83 FR 42225, Aug. 21, 2018. This
amendment was further delayed until Oct. 1, 2022, at 85 FR 28410,
May 12, 2020. Section I - Adoption Data Elements
I. General Information
A. Title IV-E agency__
B. Report Date __(mo.) __(day) __(yr.)
C. Record Number__
D. Did the Title IV-E 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 title IV-E 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/Tribal Service Area: 1
Another State/Tribal Service Area: 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. 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 II - Definitions of Instructions for Adoption Data Elements
Reporting Population
The title IV-E agency must report on all children who are
adopted in the State or Tribal service area during the reporting
period and in whose adoption the title IV-E agency has had any
involvement. Failure to report on these adoptions will result in
assessed finding of noncompliance. 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 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 or
Tribal service area, 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 title IV-E agency.
These children must be identified by answering “yes” to data
element I.D. Children who are reported by the title IV-E agency,
but for whom there has not been any title IV-E agency involvement,
and whose reporting, therefore, has not been mandated, are
identified by answering “no” to element I.D.
I. General Information
A. Title IV-E agency - For a State, the U.S. Postal Service two
letter abbreviation for the State submitting the report. For a
Tribal title IV-E agency, the two letter abbreviation provided by
ACF.
B. Report Date - The last month and the year for the reporting
period.
C. Record Number - The sequential number which the title IV-E
agency 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 title IV-E agency level.
D. Did the title IV-E Agency Have Any Involvement in This
Adoption?
Indicate whether the title 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 child welfare agency and who was subsequently
adopted whether special needs or not and whether a subsidy was
provided;
• A special needs child who was adopted in the State or Tribal
service area, 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 title
IV-E 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 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 title IV-E Agency Determined That the Child has
Special Needs? Use the title IV-E agency 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 title IV-E agency. Racial/Original
Background - Primary condition or factor for special needs is
racial/original background as defined by the title IV-E agency.
Age - Primary factor or condition for special needs is age of
the child as defined by the title IV-E agency.
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 title IV-E agency.
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 title IV-E agency, 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 or Tribe.
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.
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 or Tribal service area - Responsibility for the
child resided with an individual or agency within the State or
service area of the Tribal title IV-E agency filing the report.
Another State or Tribal service area - Responsibility for the
child resided with an individual or agency in another State, Tribal
service area, 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, Indian Tribal organizations, or Indian Tribal
consortia.
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. 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, State,
or Tribal) 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 title IV-E agency for reimbursement under title IV-E. Do not
include title IV-E non-recurring costs in this item.
[77 FR 934, Jan. 6, 2012]