Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD
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1 Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD Responsible Party Telephone Number Date Name of Child Date of Birth Time of Birth Sex Resident County Placement County Race/Ethnic ALL RELATIONSHIPS ARE TO THE CHILD CHILD S NAME CHILD S MOTHER GRANDMOTHER GRANDFATHER FATHER GRANDMOTHER GRANDFATHER RACE / ETHNIC WEIGHT: HEIGHT: & CAUSE WEIGHT: HEIGHT: & CAUSE: CHILD S AUNTS & UNCLES CHILD S AUNTS & UNCLES Form 413 Background Information for Non-State Agency Child (Rev. 6-05) Page 1 of 7
2 ALL RELATIONSHIPS ARE TO THE CHILD SIBLINGS OF CHILD FULL OR HALF SIBLING: SEX: SCHOOL GRADE AND ACHIEVEMENT: FULL OR HALF SIBLING: SEX: SCHOOL GRADE AND ACHIEVEMENT: ALL RELATIONSHIPS ARE TO THE CHILD Form 413 Background Information for Non-State Agency Child (Rev. 6-05) Page 2 of 7
3 FAMILY OF CHILD S MOTHER CHILD S GREAT GRANDMOTHER GREAT GRANDFATHER GREAT GRANDMOTHER GREAT GRANDFATHER CHILD S GREAT AUNTS AND UNCLES GREAT AUNTS AND UNCLES Form 413 Background Information for Non-State Agency Child (Rev. 6-05) Page 3 of 7
4 ALL RELATIONSHIPS ARE TO THE CHILD FAMILY OF CHILD S FATHER CHILD S GREAT GRANDMOTHER GREAT GRANDFATHER GREAT GRANDMOTHER GREAT GRANDFATHER CHILD S GREAT AUNTS AND UNCLES GREAT AUNTS AND UNCLES Form 413 Background Information for Non-State Agency Child (Rev. 6-05) Page 4 of 7
5 FAMILY MEDICAL INFORMATION Click YES or NO to each of the following diseases or conditions, if the answer, is YES give family member, and brief description of disease/condition, its effect, age of onset, age if cause of death, in the space below. YES NO YES NO YES NO 1. Allergies 7. Congenital Birth Abnormalities b) premature births a) drugs b) foods 8. Cleft Lip c) still births c) asthma 9. Cleft Palate d) incompetent cervix d) hay fever 10. Cystic Fibrosis e) ectopic pregnancies e) other 11. Diabetes f) eclamptogenic toxemia 2. Alcoholism/Drug 12. Dwarfism g) spontaneous abortion Addiction 3. Blood Diseases 13. Epilepsy h) other a) hemophilia 14. Hearing Disorders 29. Respiratory Diseases b) Rh disease 15. Huntington Disease a) emphysema c) sickle cell 16. Hyperactivity (ADHD) b) bacterial pneumonia disease/trait d) thalassemia (cooly s 17. Immune System Disease c) tuberculosis anemia) e) other a) HIV Positive d) other 4. Bone Diseases b) AIDS 30. Skin Disorders a) arthritis 18. Learning Disability (specify) a) psoriasis b) curvature of spine 19. Liver Disease b) other c) other structural 20. Mental Illness 31. Speech Disorders malformation d) other a) bi-polar a) stuttering 5. Cancer b) schizophrenia b) tongue tie a) breast c) other c) sound omissions b) bowel 21. Mental Retardation d) sound distortions c) colon a) Downs Syndrome e) delayed speech d) ovarian b) PKU f) other e) skin c) Lesch-Nyham syndrome 32. Sudden Infant Death f) stomach d) Hunters 33. Systemic Lupus Erythematosis g) lungs e) tuberous sclerosis 34. Thyroid Disorders h) leukemia f) other 35. Tay-Sachs Disease i) other 22. Migraine Headache 36. Tourettes Syndrome 6. Cardiovascular Disease 23. Multiple Births 37. Visual Disorders a) atherosclerosis 24. Multiple Sclerosis a) cataracts b) congenital heart 25. Muscular Dystrophy b) dyslexia defect c) heart attack 26. Myasthenia Gravis c) glaucoma d) hyperlipidemia 27. Obesity d) retinitis pigmentosa e) stroke 28. Pregnancy Complications e) strabismus f) high blood pressure a) drug/alcohol use during f) other pregnancy g) other 38. Any other diseases which have occurred repeatedly in family (specify) Biological Mother s age at onset of menses Code number and letter when describing disease/condition. (attach additional page if needed) Form 413 Background Information for Non-State Agency Child (Rev. 6-05) Page 5 of 7
6 FAMILY MEDICAL INFORMATION Click YES or NO to each of the following diseases or conditions, if the answer, is YES give family member, and brief description of disease/condition, its effect, age of onset, age if cause of death, in the space below. YES NO YES NO YES NO 1. Allergies 7. Congenital Birth b) premature births a) drugs Abnormalities b) foods 8. Cleft Lip c) still births c) asthma 9. Cleft Palate d) incompetent cervix d) hay fever 10. Cystic Fibrosis e) ectopic pregnancies e) other 11. Diabetes f) eclamptogenic toxemia 2. Alcoholism/Drug 12. Dwarfism g) spontaneous abortion Addiction 3. Blood Diseases 13. Epilepsy h) other a) hemophilia 14. Hearing Disorders 29. Respiratory Diseases b) Rh disease 15. Huntington Disease a) emphysema c) sickle cell disease/trait 16. Hyperactivity (ADHD) b) bacterial pneumonia d) thalassemia (cooly s 17. Immune System Disease c) tuberculosis anemia) e) other a) HIV Positive d) other 4. Bone Diseases b) AIDS 30. Skin Disorders a) arthritis 18. Learning Disability (specify) a) psoriasis b) curvature of spine 19. Liver Disease b) other c) other structural 20. Mental Illness 31. Speech Disorders malformation d) other a) bi-polar a) stuttering 5. Cancer b) schizophrenia b) tongue tie a) breast c) other c) sound omissions b) bowel 21. Mental Retardation d) sound distortions c) colon a) Downs Syndrome e) delayed speech d) ovarian b) PKU f ) other e) skin c) Lesch-Nyham syndrome 32. Sudden Infant Death f) stomach d) Hunters 33. Systemic Lupus Erythematosis g) lungs e) tuberous sclerosis 34. Thyroid Disorders h) leukemia f) other 35. Tay-Sachs Disease i) other 22. Migraine Headache 36. Tourettes Syndrome 6. Cardiovascular Disease 23. Multiple Births 37. Visual Disorders a) atherosclerosis 24. Multiple Sclerosis a) cataracts b) congenital heart defect 25. Muscular Dystrophy b) dyslexia c) heart attack 26. Myasthenia Gravis c) glaucoma d) hyperlipidemia 27. Obesity d) retinitis pigmentosa e) stroke 28. Pregnancy Complications e) strabismus f) high blood pressure a) drug/alcohol use during f) other pregnancy g) other 38. Any other diseases which have occurred repeatedly in family (specify) Code number and letter when describing disease/condition. (attach additional page if needed) Form 413 Background Information for Non-State Agency Child (Rev. 6-05) Page 6 of 7
7 ALL RELATIONSHIPS ARE TO THE CHILD NAMES AND ADDRESSES CHILD: NAME DATE OF BIRTH ADDRESS MOTHER: GRANDMOTHER: GRANDFATHER: AUNTS & UNCLES: NAME DATE OF BIRTH ADDRESS SIBLINGS: FATHER: GRANMOTHER: GRANDFATHER: AUNTS & UNCLES: NAME DATE OF BIRTH ADDRESS SIBLINGS: Is mother aware of the provision of (f) Reunion Registry YES NO Is father aware of the provision of (f) Reunion Registry) YES NO Form 413 Background Information for Non-State Agency Child (Rev. 6-05) Page 7 of 7
Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD
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