TO:	Chairperson, Medical Review Board
From:
Date:	Telephone Number:
child’s name	LINK/CONDOIT NUMBER	date of birth	DATE OF REFERRAL
RELIGION	ETHNICITY	SEX Male Female
LEGAL STATUS	Begin date:	End date:
Committed Abused/Neglected/Uncared for	Statutory Parent	Order of Temporary Custody
Committed Delinquent	Committed/FWSN	Voluntary Services
Dual Commitment (Abuse/Neglect/ Delinquent)	Not Committed	Other (Specify):
What is the permanency plan?
Notifications and communication: (Check all that apply and attach documentation of all contacts. Documentation must indicate whether each individual understands why the procedure is necessary, understands the risks and benefits and agrees with the recommendation. If the individual is not in agreement, document reason for disagreement.)
Child's Attorney is aware of the surgery or medical plan including the procedure, its risks and benefits (Always required); and is in agreement with the plan. If not in agreement document reason for disagreement. Child's GAL is aware of the surgery or medical plan including the procedure, its risks and benefits (Always required); and is in agreement with the plan. If not in agreement document reason for disagreement.
Name and phone number of child's attorney:
Name and phone number of child's guardian ad litem:
Mother is aware of the surgery or medical plan including the procedure, its risks and benefits; and is in agreement with the plan. (Not required if DCF is the statutory parent of the child.) If Parent is not in agreement document reason for disagreement.
Name and phone number of mother:
Father is aware of the surgery or medical plan including the procedure, its risks and benefits; and is in agreement with the plan. (Not required if DCF is the statutory parent of the child.) If Parent is not in agreement document reason for disagreement.
Name and phone number of father:
Mother's Attorney is aware of the surgery or medical plan including procedure, its risks and benefits; and has ensured mother is aware. (Not required if DCF is the statutory parent of the child.) Father's Attorney is aware of the surgery or medical plan including procedure, its risks and benefits; and has ensured parent(s) are aware. (Not required if DCF is the statutory parent of the child.)
Name and phone number of mother's attorney:
Name and phone number of father's attorney:
Foster parent(s) is/are aware of the surgery or medical plan including the procedure, its risks and benefits; and is/are in agreement with the plan. (Only required if foster parent is a permanent resource for the child.)
Name and phone number of foster parent(s):
Primary Care Provider is aware of the surgery or medical plan and in agreement with the plan.
Specialty Provider(s) is/are aware of the surgery or medical plan and in agreement with the plan.
Area Director is aware of the plan and the results of all notifications and is in agreement with the plan.

Current placement (foster parent/residential/facility, etc) is/are aware of the post-op requirements and can properly care for the child upon return to the placement. If placement cannot fully care for the child upon return, please specify what alternative arrangements have been developed:

Name AND ADDRESS of CURRENT PLACEMENT	TELEPHONE NUMBER
primary health provider (local physician) NAME	TELEPHONE NUMBER
sub-specialist/clinic NAME(s)	TELEPHONE NUMBER
is child hospitalized now? Yes No	why?
CURRENT MEDICATION(s)	allergies
Description of the circumstances requiring MRB review:
Action requested:

area office/parole services address	FAX NUMBER
area office/parole services director name	TELEPHONE NUMBER
social worker/parole officer name	SIGNATURE	TELEPHONE NUMBER
RRG NURSE name	SIGNATURE	TELEPHONE NUMBER

Disposition:

Requires full Medical Review Board review

Requires Director of Pediatrics review