Form Pub 400b - Safely Surrended Baby Kit
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1ORDER FORM
SAFELY SURRENDERED BABY KIT
Kit Includes:
Procedures for accepting a newborn,
Coded ankle bracelets for the newborn, and surrendering individual
Materials for surrendering individual:
o
Optional Medical Questionnaire*,
o
Safely Surrender Baby program fact sheet,
o
Prepaid envelope**
Ordering Information
Languages
English
Spanish
Chinese
Russian
Quantities
Requestor Name: ___________________________________________________________________________
Requesting Organization: _____________________________________________________________________
Requesting County: __________________________________________________________________________
Telephone: ________________________________________________________________________________
Email: ____________________________________________________________________________________
County Health and Human Services Agency: ______________________________________________________
County Health and Human Services Agency USPS Business Reply Mail Permit Code**: ____________________
Requestor Shipping Address: __________________________________________________________________
City, State, Zip: _____________________________________________________________________________
The bracelets for the newborn and matching adult are pre-coded. If you would like additional code, please specify:
Example 1: Jane COUNTY
Example 2: 12345 COUNTY
Additional Bracelet Coding: ____________________________________________________________________
* Optional Medical Questionnaire
Although a person surrendering a baby under the Safely Surrendered Baby Law will be asked to complete a medical
questionnaire, the form is optional and is intended solely for the purpose of collecting medical information critical to the health
and survival of the child. The surrendering party may complete the form at the site or complete it later and send it back using
the pre-paid envelope. Any information that may identify the person surrendering the baby will be removed in order to
maintain that personʼs confidentiality. The form is available in English, Spanish, Chinese and Russian. Additional
questionnaires can be downloaded at
** A surrendering individual may complete the optional medical questionnaire and mail the questionnaire to the local county
health program at no expense. The County Health and Human Services Agencyʼs USPS Business Reply Mail Permit Code
would be used for the optional medical questionnaire return envelope.
Submit competed order forms to PublicationRequests@DSS.ca.gov, or via fax at (916) 651-6328 or mail to The Office of Child
Abuse Prevention at 744 P Street, MS 8-11-82, Sacramento, CA 95814. Please allow three weeks for shipping.
For more information regarding the Safely Surrendered Baby Kit materials, or the Safely Surrendered Baby Law, please
contact the Baby Safe hotline at 1.877.BABY.SAF (1-877-222-9723) or the Office of Child Abuse Prevention at
(916) 651-6160.
PUB 400B (9/16)
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