STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SAFELY SURRENDERED BABY
REPORT TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INSTRUCTIONS:
The county child welfare services agency is required to immediately notify the California Department of
Social Services (CDSS) of each child surrendered under the Safely Surrendered Baby (SSB) Law (Health
and Safely Code § 1255.7) upon taking temporary custody of the child. No personal identifying
information regarding the parent or individual who surrendered the baby should be included on
this form.
PART A: SURRENDERED CHILD INFORMATION
Please complete the fields below with the requested information regarding the baby who has been safely
surrendered.
Please enter the requested information exactly as it appears in the Child Welfare Services Case
Management System (CWS/CMS) – this should be a non-identifying pseudonym – such as “Baby Boy
Doe” or “Safe Surrender 123456.”
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Gender:
Male
Female
Child’s first name (as it appears in CWS/CMS)
Child’s last name (as it appears in CWS/CMS)
Ethnicity
Date of Birth
Referral Number
County in which Referral was opened
PART B: COUNTY CONTACT INFORMATION
Please provide county CWS staff contact information in the event CDSS needs to clarify information
regarding the safely surrendered baby:
Name of person reporting SSB
Title
Phone
E-mail
Date of Submission
Please save as PDF file format and send via SECURE e-mail to:
ssb@dss.ca.gov
Confidential data supplied by the county to CDSS shall be encrypted in storage and in
transmission, using non-proprietary, secure, generally-available encryption software. Proprietary
encryption algorithms shall not be acceptable. Passwords or biometrics used for user
authentication shall be encrypted using data encryption standard, or better, one-way only
encryption. Data encryption shall meet the National Institute of Standards and Technology
Advanced Encryption. Data encryption shall equal or exceed 128-bit key encryption.
SOC 880 (11/11)
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