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]