IEPS Notification

Infants Exposed Prenatally to Substances Notification

For completion by health care providers and birthing facility staff only
Fill out this form only if an infant has been exposed to substances prenatally/in utero.

If an infant was not exposed to substances in utero but there are other safety concerns, call your local child welfare intake number or 844-CO-4-KIDS to make a report of your concerns.

For questions specific to Colorado’s Plan of Safe Care and/or the IEPS Notification Portal, email cdhs_IEPS@state.co.us.
Important: Please read before completing this form

As a result of the federal Child Abuse Prevention and Treatment Act, the Colorado Department of Human Services (CDHS) is required to submit data to the United States Department of Health and Human Services regarding the frequency of infants being born affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure (42 U.S.C. §§ 5106(a)(7)(D)(v), (E); 5106a(d)(18). Additionally, CDHS must ensure there are policies and procedures in place to address the needs of infants born with and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder, including a process for health care providers involved in the delivery or care of such infants to notify the child protective services system of the occurrence of such condition of such infants (42 U.S.C. §§ 5106(b)(2)(B)(ii)).

While the State must collect data for all infants identified as being prenatally exposed to substances, not all infants identified as being prenatally exposed are at risk for abuse and/or neglect require a report to child welfare (CRS 19-1-103(1)(a)(IV)). As such, Colorado has developed a separate pathway for completing a notification versus making a report for child safety concerns. Healthcare providers may now notify the Colorado child protective services system when they are involved in the delivery or care of infants affected by substance abuse or withdrawal symptoms by filling out this Infants Exposed Prenatally to Substances (IEPS) Notification form.

Information is anonymous and strictly used for the required federal reporting and for quality improvement by the Colorado Department of Human Services. Information will not be shared or used for any other purpose.

A notification is not the same as a report to child welfare. This notification form does not act as a report to Child Protective Services for potential abuse and/or neglect. If you have a concern about the safety or wellbeing of the infant, please call 844-CO-4-KIDS.
Reporter role*

Healthcare provider (eg: MD, DO, NP, PA, CNM)Birthing facility social worker or care coordinatorOther role at birthing facility (fill in)
Date of infant's birth*

MonthDayYear
Date
Hospital/birth center name*
County in which birth hospital/birth center is located*
Birth parent identifies their race/ethnicity as (select all that apply):*

American Indian/Alaskan NativeAsianBlack/African AmericanHispanic/LatinXMiddle Eastern/North AfricanWhitePrefer not to sayUnknownPrefer to self identify (fill in)
Infant race/ethnicity (select all that apply):*

American Indian/Alaskan NativeAsianBlack/African AmericanHispanic/LatinXMiddle Eastern/North AfricanWhitePrefer not to sayUnknownPrefer to self identify (fill in)
Type of substance(s) the infant was exposed to in utero (select all that apply)*

AlcoholAmphetamines (Prescribed)Amphetamines (Non-prescribed)Benzodiazepines (Prescribed)Benzodiazepines (Non-prescribed)Buprenorphine (Prescribed; e.g. Subutex, Suboxone, etc.)Buprenorphine (Non-prescribed)CocaineEcstasy/MDMAFentanylHallucinogens (e.g. LSD, psilocybin)HeroinInhalantsKratomMethamphetamineMethadone (Prescribed)Methadone (Non-prescribed)Other Prescribed OpioidsOther Non-prescribed OpioidsTHC/CannabisTobacco/NicotineXylazineOther (fill in)
Were all prescribed substances taken as directed?*

YesNoUnknown
What prescriptions were not taken as directed?
How was infant exposure identified? (select all that apply)*

Birth parent displays signs or symptoms of intoxication or withdrawalDisclosure by birth parentPositive toxicology test of birth parentPositive toxicology test of infantInfant displays withdrawal symptomsInfant displays symptoms of Fetal Alcohol Spectrum Disorder (FASD)Other (fill in)
If the birth parent had a positive toxicology test, was consent obtained?

YesNoUnknown
If the infant had a positive toxicology test, was parental consent obtained?

YesNoUnknown
Has the infant been scheduled for follow-up care?*

YesNoUnknown
Please select the type of follow-up care (select all that apply).

Pediatric care/medical homeSpecialty care providerChild Development/Early Intervention ServicesInfant mental health provider (Child First, Right Start,etc)Public health nursing servicesHome visiting programsOther (fill in)
During the birth hospitalization/birth event, has the caregiver been offered resources or services to address parenting education, infant needs, physical health, behavioral health and/or substance use treatment needs?*

YesNoUnknown
Which resources or services has the caregiver been offered? (Select all that apply)

Inpatient Substance Use TreatmentOutpatient Substance Use TreatmentPeer Recovery SupportHarm Reduction ProgrammingMedication Assisted TreatmentMental Health CounselingSmoking CessationFinancial Assistance/TANFFood Assistance/WIC/SNAPHousing Support/ResourcesBaby SuppliesParenting GroupsHome Visiting ProgramEarly Childhood Development/ Early InterventionPrimary Medical / Postpartum Care for Birth ParentLactation/Feeding SupportPrimary Care Provider for InfantSpecialty CareOther (fill in)
Why have no resources or referrals been offered? (Select all that apply)

Birthing parent declinedLack of timeBarriers to servicesUnsureOther (fill in)
What were the barriers to services?
Has a Plan of Safe Care been developed?*

Yes, by the birthing hospitalYes, prior to birth hospitalizationNo
Why was no Plan of Safe Care developed?

Birthing parent declinedLack of timeHospital does not have a template or knowledgeUnsureOther (fill in)
Was the infant born with physical, developmental and/or behavioral impairments due to prenatal substance exposure?*

YesNoUnknown
Is the infant experiencing withdrawal symptoms?*

YesNoUnknown
Is there a care plan in place to manage withdrawal symptoms?

YesNo
Have the parent(s)/caregiver(s) received education on how to meet the care taking needs of the infant?*

YesNo
Has at least one safe and sober caregiver been identified to meet the care taking of the infant? (This can include the birth parent.)*

YesNoUnknown
Please make a report to child welfare

Because you indicated that no safe and sober caregiver has been identified, we ask that you make a report to child welfare so that a team of child welfare professionals can review and decide if the situation requires further assessment or involvement of the child welfare team. Call your local child welfare intake number or 844-CO-4-KIDS to make a report of your concerns for abuse and/or neglect. In addition to making a report to child welfare, we ask that you also complete and submit this form.
Do the parents/caregivers display an ability to fully meet the caretaking needs of the infant (i.e. medical care, feeding, soothing, diapering, safe sleep)?*

YesNo
Please make a report to child welfare

Because you indicated that the parents/caregivers do not display an ability to fully meet the caretaking needs of the infant, we ask that you make a report to child welfare so that a team of child welfare professionals can review and decide if the situation requires further assessment or involvement of the child welfare team. Call your local child welfare intake number or 844-CO-4-KIDS to make a report of your concerns for abuse and/or neglect. In addition to making a report to child welfare, we ask that you also complete and submit this form.
Is there evidence of ongoing substance use by the birthing parent that creates safety concerns for the infant?*

YesNo
Please make a report to child welfare

Because you indicated that there is evidence of ongoing substance use by the birthing parent that creates safety concerns for the infant, we ask that you make a report to child welfare so that a team of child welfare professionals can review and decide if the situation requires further assessment or involvement of the child welfare team. Call your local child welfare intake number or 844-CO-4-KIDS to make a report of your concerns for abuse and/or neglect. In addition to making a report to child welfare, we ask that you also complete and submit this form.
Are there other current safety concerns for the infant not related to the caregiver's substance use?*

YesNo
Please make a report to child welfare

Because you indicated that there other current safety concerns for the infant not related to the caregiver's substance use, we ask that you make a report to child welfare so that a team of child welfare professionals can review and decide if the situation requires further assessment or involvement of the child welfare team. Call your local child welfare intake number or 844-CO-4-KIDS to make a report of your concerns for abuse and/or neglect. In addition to making a report to child welfare, we ask that you also complete and submit this form.
Please click the Submit button to submit your responses.
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Infants Exposed Prenatally to Substances Notification

Important: Please read before completing this form

Please make a report to child welfare

Please make a report to child welfare

Please make a report to child welfare

Please make a report to child welfare