New Jersey Department of Health

Vital Statistics and Registry

PO Box 370

Trenton, NJ 08625-0370	NEW RECORDS SYSTEM FOR BIRTH PARENTS

CONTACT PREFERENCE	A
A birth parent of an adopted person may submit a Contact Preference document to the State Registrar indicating his or her preference regarding contact with the adopted individual. The birth parent may change his or her preference at any time by submitting a revised Contact Preference document to the State Registrar.

We need the following information in order to find and match your request with our existing files. If you fail to provide complete and accurate information, then we may be unable to accept and process your request.

NOTE: You must also complete and submit a Family History Information form, which includes medical, cultural and social history information, in order for your Contact Preference form to be accepted for filing.
ORIGINAL BIRTH CERTIFICATE INFORMATION
Please provide complete and accurate information. While the Department will diligently search its files for an adoption record that matches your request, it does not warrant, promise or guarantee that it will be able to locate an adoption record that matches the information you provide in your request.
CHILD’S INFORMATION
Child’s FIRST Name on Child’s Original Birth Certificate:
Child’s MIDDLE Name on Child’s Original Birth Certificate:
Child’s LAST Name on Child’s Original Birth Certificate:
Suffix:
Note: If you are unsure of the exact date of the child's birth, please enter your best estimate.
Child’s Date of Birth:	__ __ / __ __ / __ __ __ __	[ ] Actual [ ] Estimate
Sex:	[ ] Male [ ] Female
Country of Birth:
State of Birth:
County of Birth:
Municipality of Birth:
MOTHER’S INFORMATION
Mother’s FIRST Name on Child’s Original Birth Certificate:
Mother’s MIDDLE Name on Child’s Original Birth Certificate:
Mother’s LAST Name on Child’s Original Birth Certificate:
Mother’s Date of Birth:	__ __ / __ __ / __ __ __ __
FATHER’S INFORMATION
Father’s FIRST Name on Child’s Original Birth Certificate:
Father’s MIDDLE Name on Child’s Original Birth Certificate:
Father’s LAST Name on Child’s Original Birth Certificate:
Father’s Date of Birth:	__ __ / __ __ / __ __ __ __
BIRTH PARENT INFORMATION
NOTE: The birth parent information requested below is for processing purposes and will not be released to a requester if you wish to retain your privacy at this time.
Birth Parent’s Current First Name:
Birth Parent’s Current Middle Name:
Birth Parent’s Current Last Name:
Birth Parent’s Date of Birth:	__ __ / __ __ / __ __ __ __
Birth Parent’s Relationship to Child: [ ] Mother [ ] Father
Phone 1:	[ ] Home [ ] Mobile [ ] Work
Phone 2:	[ ] Home [ ] Mobile [ ] Work
Phone 3:	[ ] Home [ ] Mobile [ ] Work
Email Address:
Mailing Address:
City:	State:	Zip:
The Contact Preference form is only an expression of the birth parent's wishes regarding contact with the adoptee. There is no law requiring the adoptee to follow the preference selected by the birth parent on the form.
BIRTH PARENT’S CONTACT PREFERENCE
State your preference about contact with the adopted child.

Note: Selection is required.
A.	I would like to be contacted directly.

I have provided the required contact preference information and an updated Family History Information document and am submitting them to the State Registrar as set forth in this document. (Complete required information on the previous page.)
B.	I would prefer to be contacted only through an intermediary.

I have provided the required contact preference information and an updated Family History Information document. I am submitting both to the State Registrar as set forth in this document. I have named the listed individual to act as an intermediary. (Complete the following required information.)
Name of Individual or Agency:
Mailing Address:
City:	State:	Zip:
Phone 1:	Home Mobile Work
Phone 2:	Home Mobile Work
Phone 3:	Home Mobile Work
Email Address:
C.	I would prefer to not be contacted at this time.

If I decide later that I would like to be contacted, I will submit a revised Contact Preference form to the State Registrar. While I do not wish to be contacted at this time, I have completed the Family History Information form and am submitting it to the State Registrar. Additionally, I understand that because I have indicated a no contact preference I must update the Family History Information form and submit it to the State Registrar every ten (10) years until I reach the age of forty (40) and every five (5) years thereafter.
By signing, I certify that I am the birth parent of the adoptee and, that, to the best of my knowledge, the information I am supplying is correct and accurate. I understand that if I falsely represent that I am the birth parent of the adoptee on this form, then I may be subject to penalties pursuant to N.J.S.A. 26:8-69.
Signature of Birth Parent:
Date:

New Jersey Department of Health

Vital Statistics and Registry

PO Box 370

Trenton, NJ 08625-0370	NEW RECORDS SYSTEM FOR BIRTH PARENTS

FAMILY HISTORY INFORMATION	B
ORIGINAL BIRTH CERTIFICATE INFORMATION
Please provide complete and accurate information. While the Department will diligently search its files for an adoption record that matches your request, it does not warrant, promise or guarantee that it will be able to locate an adoption record that matches the information you provide in your request.
CHILD’S INFORMATION
Child’s FIRST Name on Child’s Original Birth Certificate:
Child’s MIDDLE Name on Child’s Original Birth Certificate:
Child’s LAST Name on Child’s Original Birth Certificate:
Suffix:
Child’s Date of Birth:	__ __ / __ __ / __ __ __ __	[ ] Actual [ ] Estimate
Sex:	[ ] Male [ ] Female
Country of Birth:
State of Birth:
County of Birth:
Municipality of Birth:
MOTHER’S INFORMATION
Mother’s FIRST Name on Child’s Original Birth Certificate:
Mother’s MIDDLE Name on Child’s Original Birth Certificate:
Mother’s LAST Name on Child’s Original Birth Certificate:
Mother’s Date of Birth:	__ __ / __ __ / __ __ __ __
FATHER’S INFORMATION
Father’s FIRST Name on Child’s Original Birth Certificate:
Father’s MIDDLE Name on Child’s Original Birth Certificate:
Father’s LAST Name on Child’s Original Birth Certificate:
Father’s Date of Birth:	__ __ / __ __ / __ __ __ __
BIRTH PARENT INFORMATION
NOTE: The birth parent information requested below is for processing purposes and will not be released to a requester if you wish to retain your privacy at this time.
Birth Parent’s Current First Name:
Birth Parent’s Current Middle Name:
Birth Parent’s Current Last Name:
Birth Parent’s Date of Birth:	__ __ / __ __ / __ __ __ __
Birth Parent’s Relationship to Child: [ ] Mother [ ] Father
Phone 1:	[ ] Home [ ] Mobile [ ] Work
Phone 2:	[ ] Home [ ] Mobile [ ] Work
Phone 3:	[ ] Home [ ] Mobile [ ] Work
Email Address:
Mailing Address:
City:	State:	Zip:
BIRTH PARENT DEMOGRAPHIC INFORMATION
Your Current Age:	Eye Color:
Blood Type:
Height (inches):	Hair Color
Primary Language Spoken:
Weight (lbs.)	Race:
Nationality (Citizenship):
Religion:	Skin Color:
Highest Level of Education:
Ethnic Background:
Your Place of Birth:
Country:	State:	City:
BIOLOGICAL INFORMATION ON DECEASED FAMILY MEMBERS
List your family members who have passed away, age at death, and cause of death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
Relationship*:
Age at Death:	Cause of Death:
*Relationship choices:	•Mother	•Son	•Maternal Grandmother	•Paternal Grandmother	•Sister	•Aunt

•Father	•Daughter	•Maternal Grandfather	•Paternal Grandfather	•Brother	•Uncle

•Other Biological Parent
MEDICAL HISTORY
For each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed.

Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc.

Note: All fields under this section are required.
Heart and Blood Vessels
Medical Condition	Response	Comments
Congenital Heart Defect	No	Yes (Self)

Not Known	Yes (Relative)
Congestive Heart Failure	No	Yes (Self)

Not Known	Yes (Relative)
Atherosclerosis	No	Yes (Self)

Not Known	Yes (Relative)
Hypertension (High Blood Pressure)	No	Yes (Self)

Not Known	Yes (Relative)
Stroke	No	Yes (Self)

Not Known	Yes (Relative)
Heart Attack	No	Yes (Self)

Not Known	Yes (Relative)
Other Cardiovascular Problems	No	Yes (Self)

Not Known	Yes (Relative)
Brain and Nerves
Medical Condition	Response	Comments
Cerebral Palsy	No	Yes (Self)

Not Known	Yes (Relative)
Seizures, Convulsions or Epilepsy	No	Yes (Self)

Not Known	Yes (Relative)
Lungs
Medical Condition	Response	Comments
Chronic Bronchitis	No	Yes (Self)

Not Known	Yes (Relative)
Emphysema	No	Yes (Self)

Not Known	Yes (Relative)
Asthma	No	Yes (Self)

Not Known	Yes (Relative)
Hay Fever or Other Allergies; Food or Drug Allergies	No	Yes (Self)

Not Known	Yes (Relative)
Tuberculosis	No	Yes (Self)

Not Known	Yes (Relative)
Kidney
Medical Condition	Response	Comments
Kidney Disease	No	Yes (Self)

Not Known	Yes (Relative)
MEDICAL HISTORY, CONTINUED
For each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed.

Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc.

Note: All fields under this section are required.
BLOOD DISORDER
Medical Condition	Response	Comments
Sickle Cell Anemia or Tay-Sachs Disease	No	Yes (Self)

Not Known	Yes (Relative)
JOINTS / SKELETON
Medical Condition	Response	Comments
Scoliosis	No	Yes (Self)

Not Known	Yes (Relative)
Any Other Malformations	No	Yes (Self)

Not Known	Yes (Relative)
ENDOCRINE (GLANDS)
Medical Condition	Response	Comments
Thyroid Disorder	No	Yes (Self)

Not Known	Yes (Relative)
Diabetes	No	Yes (Self)

Not Known	Yes (Relative)
Other Hormonal Disorder	No	Yes (Self)

Not Known	Yes (Relative)
PSYCHOSOCIAL
Medical Condition	Response	Comments
Schizophrenia, Bipolar Disorder, or Chronic Depression	No	Yes (Self)

Not Known	Yes (Relative)
Alcoholism, Drug Addiction or Tobacco Use	No	Yes (Self)

Not Known	Yes (Relative)
Anorexia or Bulimia	No	Yes (Self)

Not Known	Yes (Relative)
Other Mental or Emotional Illnesses	No	Yes (Self)

Not Known	Yes (Relative)
SKIN DISORDERS
Medical Condition	Response	Comments
Eczema or Other Skin Conditions	No	Yes (Self)

Not Known	Yes (Relative)
DEVELOPMENTAL
Medical Condition	Response	Comments
Learning Disability	No	Yes (Self)

Not Known	Yes (Relative)
Mental or Physical Development Deficiencies	No	Yes (Self)

Not Known	Yes (Relative)
Autism Spectrum	No	Yes (Self)

Not Known	Yes (Relative)
MEDICAL HISTORY, CONTINUED
For each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed.

Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc.

Note: All fields under this section are required.
NEUROLOGICAL
Medical Condition	Response	Comments
Blindness, Glaucoma or Other Visual Problems	No	Yes (Self)

Not Known	Yes (Relative)
Deafness or Other Ear Problems	No	Yes (Self)

Not Known	Yes (Relative)
Speech Problem	No	Yes (Self)

Not Known	Yes (Relative)
Muscular Dystrophy	No	Yes (Self)

Not Known	Yes (Relative)
GENETIC
Medical Condition	Response	Comments
Club Foot, Cleft Lip or Palate	No	Yes (Self)

Not Known	Yes (Relative)
Down’s Syndrome	No	Yes (Self)

Not Known	Yes (Relative)
MOTOR DEFICIENCIES
Medical Condition	Response	Comments
Multiple Sclerosis	No	Yes (Self)

Not Known	Yes (Relative)
Other Paralysis or Crippling Disorder	No	Yes (Self)

Not Known	Yes (Relative)
CANCER
Medical Condition	Response	Comments
Cancer (Breast, Ovarian, Cervical, Prostate, etc.)	No	Yes (Self)

Not Known	Yes (Relative)
Tumors	No	Yes (Self)

Not Known	Yes (Relative)
Cystic Fibrosis	No	Yes (Self)

Not Known	Yes (Relative)
Huntington’s Disease	No	Yes (Self)

Not Known	Yes (Relative)
MEDICAL HISTORY, CONTINUED
For each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed.

Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc.

Note: All fields under this section are required.
OTHER CONDITIONS
Medical Condition	Response	Comments
Any Other Conditions You or Others in Your Family May Have	No	Yes (Self)

Not Known	Yes (Relative)
SOCIAL/CULTURAL BACKGROUND
Cultural Background	Response	Comments
Prescription Drugs Taken During Pregnancy	No	Yes (Self)

Not Known
Non-Prescription Drugs Taken During Pregnancy	No	Yes (Self)

Not Known
Alcohol Use During Pregnancy	No	Yes (Self)

Not Known
Amphetamines or Barbiturates Used During Pregnancy	No	Yes (Self)

Not Known
Are birth parents related to each other (other than by marriage)?	No	Yes (Self)

Not Known
Were there special circumstances surrounding conception, pregnancy or delivery?	No	Yes (Self)

Not Known
Can you provide information about the mother's reproductive life (for example, the age at first menses; age at menopause, miscarriages or fertility issues)?	No	Yes (Self)

Not Known
Please provide any additional information related to the Medical / Social / Cultural History section:
By signing, I certify that I am the birth parent of the adoptee and, that, to the best of my knowledge, the information I am supplying is correct and accurate. I understand that if I falsely represent that I am the birth parent of the adoptee on this form, then I may be subject to penalties pursuant to N.J.S.A. 26:8-69.
Signature of Birth Parent:
Date:

REG-36A	For questions or additional Information:

JAN 17	www.nj.gov/health/vital ( 866-649-8726, EXT. 582	Page 1 of 3.

REG-36B	For questions or additional Information:

JAN 17	www.nj.gov/health/vital ( 866-649-8726, EXT. 582	Page 7 of 7.

New Jersey Department of Health

Elaine

2016-12-31

NJDOH