ATTACHMENT A

AFFIDAVIT

 

The undersigned ___________________________ having been duly sworn, does hereby depose and say:

1.                   I am over the age of eighteen and understand the nature and obligations of an oath.

 2.                   This affidavit is based on my personal knowledge.

 3.                   I am employed as an emergency room nurse at _____________________ Hospital and have been designated by ______________________ Hospital as an employee authorized to take physical custody of an infant pursuant to the Safe Haven Act, Public Act 00-207.

 4.                   The identity of the [choose one:  parent or lawful agent of the parent] is not disclosed in this affidavit.

 5.                   On [date] the [choose one:  parent or lawful agent of the parent] voluntarily surrendered physical custody of an infant to me and did not clearly express an intent to return for the infant and as of the date of this affidavit has not returned for the infant.

 6.                   The [choose one:  male or female] infant is [insert age of the child:       days old] and [describe health of the infant, and include if there are any indications of abuse or neglect].

 7.                   I asked the [choose one: parent or lawful agent of the parent] to provide me with the name of the parent or agent and information on the medical history of the infant and parents.

 8.                   The [choose one:  parent or agent of the parent] provided the following medical history of the infant and the parents:  [insert medical information provided].

 9.                   I provided the [choose one:  parent or agent of the parent] with a numbered identification bracelet to link the [choose one:  parent or lawful agent of the parent] to the infant.

 10.               I provided the [choose one:  parent or agent of the parent] with a pamphlet describing the process established under the Safe Haven Act.

 11.               The [choose one:  parent or lawful agent of the parent] [choose one:  did or did not] provide me with identifying information concerning the parent or agent.

 

Signature_____________________________________

  

STATE OF CONNECTICUT)   ss.

COUNTY OF                       )  Subscribed and sworn to before me this ______day of _______, 200__

                                       ___________________________________

   Notary  Public

   My Commission Expires: