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SOCIAL
WORKER AFFIDAVIT FORMAT
In
Re: (child's name)
Superior
Court for Juvenile Matters at: (address)
Date:
(month, day, year)
SOCIAL WORKER AFFIDAVIT
I
am, (name), Social Worker for the Department of Children and Families at
(number and name of street) in (town name), Connecticut.
I
am over the age of eighteen and understand and believe in the obligations
of an oath.
Being
duly sworn, I do hereby depose and say that the following is the truth to
the best of my knowledge and belief:
Child
for whom motion is filed:
·
(Name and current address or placement address)
·
(Date of Birth)
·
(Indian tribe)
Parents:
·
(Name)
·
(Date of Birth)
·
(Address)
[The
next statements should recount what was observed or heard by the affiant
personally. For example:]
1.
On October 5, 1996, DCF received a referral from Jean Jones, Social
Worker at the hospital regarding Jill Smith. Jill had been born with
cocaine in her system at twenty-six (26) weeks gestation.
Mother had not been in to visit Jill and was not providing care for
her other two children.
2.
On October 12, 1996, I met with Jane Smith, maternal grandmother.
She stated that mother heavily uses cocaine and alcohol and that
she has been the caretaker of mother's other two children for years.
Mother's legal address is with her but she doesn't stay there.
Maternal grandmother feels that mother would not be able to care
for Jill nor is maternal grandmother able to take her into her home. Grandmother was not aware of mother's address.
3.
On October 13, 1996, I spoke to Jean Jones who stated that mother
had been in twice once for three minutes. The other time she came in, she
fell asleep holding the baby and almost dropped her.
4.
On October 18, 1996, I located mother at the above address. She
admits that she smoked cocaine throughout her pregnancy, but said that she
has stopped since delivery. She
denies the need for any treatment. She
refused to accept the names and numbers of treatment facilities.
She stated that she plans to bring her baby home when she is ready
for discharge. She stated
that she has been visiting regularly and that the nurses at the hospital
are lying.
5.
On November 3, 1996, I spoke with Jean Jones who stated that Jill
will be ready for discharge in a few days and that mother has still not
visited regularly and the hospital staff feels that mother will not be
able to care for Jill upon discharge.
Mother reports that the hospital staff lied about her visits with
the child.
6.
On November 5, 1996, I spoke to maternal grandmother.
She states that mother is still heavily using drugs and that she is
a "lost cause". She
feels that mother wants Jill to come home but will quickly tire of her and
will just leave her somewhere. Maternal
grandmother also stated that the only time mother comes to see her other
two children is when she has no money for drugs and nothing else to do.
7.
On November 9, 1996, I spoke to Jean Jones who stated that Jill
will require an apnea monitor upon discharge.
The doctor indicated that Jill is at risk for Sudden Infant Death
Syndrome and will require close medical follow-up and constant attention.
Jill's caretaker will need to know cardiopulmonary resuscitation,
how to use an apnea monitor and what to do should Jill have an episode of
apnea or bradycardia. Jill is
ready for discharge as of November 14, 1996.
[The
hypothetical information above would not necessarily be sufficient to get
an OTC by itself. However, an
affidavit from the doctor as to the child's needs and an affidavit from
the hospital social worker with respect to mother's lack of understanding
of baby's needs will complete picture.
It
is important to remember that a witness can only testify to what he or she
directly heard or saw and can only offer an opinion related to his or her
specialty. Therefore,
although the nurse may know the baby's diagnosis and needs, it is
important that a doctor discuss the prognosis and medical diagnosis. If
hospital staff is unable or unwilling to provide the needed affidavits,
they must be subpoenaed to the evidentiary hearing to give testimony
personally.
With
respect to abuse cases, the information necessary for the judge includes
the nature of the injury or injuries and a statement that the injury is
most likely non-accidental and not self-inflicted.
Also, if the reason for suspecting abuse is that the parents'
statements are at a variance with the nature of the injury, this should be
explained. For example:
1.
John Doe was brought to the Emergency Room of UCONN Health Center
on March 5, 1996 at 4 a.m. Child has second-degree burns on both feet.
Mrs. Doe claimed that child had received the burns by climbing into
a bathtub full of hot water.
2.
Child is eight months of age and, in my professional opinion, does
not appear to be walking or able to climb into a bathtub.
3.
In addition, the lack of splash marks or burns on any other part of
the body indicates that child was immersed in water forcibly and did not
try to get out. An eight-month-old child will instinctively attempt to
escape from scalding water.]
CLOSING STATEMENT - WHEREFORE, based on the
aforementioned allegations, this Department believes this/these child(ren)
is/are suffering from serious physical injury or illness, are in immediate
physical danger from his/her/their surroundings [choose one or both
depending on allegations], and that immediate removal from such
surroundings is necessary to ensure the child(ren)’s safety, and further
that the conditions or circumstances surrounding the care of said
child(ren) requires that custody be immediately assumed to safeguard the
welfare of said child(ren)
[Note: This
statement will always be required.]
THE
AFFIANT:
(Social
Worker signature)
Social
Worker’s name typed in
SUBSCRIBED
AND SWORN TO before me on this (date) day of (month),
20___ (year)
Attest:
(Social Worker's signature)
_______________________________________
(Notary
Public's signature)
My
Commission Expires: __________________
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