He Take Kōhukihuki | A Matter of Urgency
The role of Oranga Tamariki—the Ministry for Children (the Ministry) is to promote the wellbeing of tamariki, rangatahi and their whānau. Under the Oranga Tamariki Act 1989 (the Act) the Ministry has the power to take custody of, and remove, tamariki and rangatahi from their whānau when they are at risk of harm. This includes newborn pēpi.
Under section 78 of the Act, the Ministry is able to apply for, and be granted, interim custody of tamariki in cases where other options to ensure their safety are not available. Further, in urgent cases it is able to do so without providing the parents and whānau of newborn pēpi the opportunity to be heard or respond before interim custody orders are granted. This should be in the context where other legal avenues, such as place of safety warrants and truncated notice periods, are not available. Given that without notice applications are a departure from the fundamental natural justice requirements enshrined in law, it is critical that there is independent oversight of the Ministry’s policies, procedures and practices connected to the removal of newborn pēpi in such circumstances.
My role as an Officer of Parliament is to provide such independent oversight. By conducting investigations into the administrative conduct of public sector agencies, such as the Ministry, I promote government accountability and transparency. This in turn enables Parliament and the public of Aotearoa to have high levels of trust and confidence in government.
I have examined whether there are any systemic issues connected to the Ministry’s policies, procedures, and practices relating to the removal of newborn pēpi under without notice interim custody orders.
In doing so, I acknowledge that the Ministry operates within a wider system. The work undertaken by other agencies will, at times, impact the Ministry’s ability to meet its core purpose of ensuring ‘all tamariki are living with loving whānau and in communities where oranga tamariki can be realised’.
The timeframe for my investigation is from 1 July 2017 to 30 June 2019. This covers the Ministry’s actions and decisions during the first two years of its five-year programme of transforming Aotearoa’s care and protection operating model.
As part of my investigation, I arranged for visits to nine out of 50 of the Ministry’s care and protection sites and undertook interviews with the relevant staff there. I also arranged for interviews with key third parties who play a role in the removal of newborn pēpi at a site level. This included staff from the associated District Health Boards (DHBs), the New Zealand Police, and, where possible, relevant social service providers.
Interviews were also undertaken with staff from the Ministry’s National Office, and with other stakeholders and interested parties. This included Family Court judges, iwi social service providers and organisations, representatives from the disability community, National Māori Women’s Welfare League, Nga Maia Māori Midwives Aotearoa, the New Zealand College of Midwives, the Public Service Association and the Social Workers Registration Board.
I analysed the Ministry’s case files for 74 newborn (and unborn) pēpi in respect of whom the Ministry applied for interim custody under section 78 during the period between 1 July 2017 and 30 June 2019. These were all the section 78 files in the relevant period from the nine care and protection sites visited for my investigation. In all 74 files, the Ministry applied for without notice interim custody. I am not aware of any cases from these nine sites where, over the relevant period, a section 78 interim custody order for pēpi was applied for with notice. These 74 cases represent between 20 and 25 percent of all section 78 cases involving newborn pēpi during the relevant timeframe. In the 74 cases I examined, 56 pēpi (75 percent) were physically removed.
Between 1 July 2017 and 31 June 2019, the Ministry received reports of concern relating to over 4000 pēpi. In this period, across all sites, the Ministry removed approximately 300 newborn pēpi from their parents under section 78. The Ministry was unable to identify the exact number of newborn pēpi removed without the parents and whānau being notified of the decision to seek interim custody. However, its own review in 2019 of half of these cases identified that the majority of the parents and whānau were not given notice before the Ministry removed their newborn pēpi. Further, data supplied by the Ministry of Justice has shown that over 94 percent of all section 78 orders for 2017/18 and 2018/19 were granted on the basis of without notice applications by the Ministry.
The Ministry's policies and procedures
I examined the Ministry’s operating policies and procedures as they relate to the decision to apply without notice for interim custody of, and remove, newborn pēpi.
In order to understand the Ministry’s policies and procedures, I first considered the relevant legal framework—in particular, the Oranga Tamariki Act 1989. The wording of the legislation generally reflects the obligations arising from te Tiriti o Waitangi and international law. The Act has been in a state of transition, with many amendments coming into force after I commenced my investigation. However, the obligations and expectations on the Ministry have been in place for a considerable period. In particular, I identified the following principles enshrined in law that should inform the Ministry’s policies, procedures, and practices relating to the removal of newborn pēpi under section 78.
- Pēpi have the right, as far as is possible, to know and to be cared for by their parents, whānau, hapū, and iwi.
- Any intervention in family life should be the minimum necessary to ensure pēpi’s safety and protection.
- Where pēpi are at risk, the parents and whānau should be provided assistance to support them in discharging their responsibilities to their pēpi, and they have a right to fully participate in the decision making processes.
- The use of without notice section 78 applications for interim custody should be reserved for urgent cases where all other options to ensure the safety of pēpi have been considered, and the delay caused by making an on notice application would create a risk to the safety of pēpi.
The Ministry's policies and procedures
In general, the content of the Ministry’s overarching Practice Standards adequately reflect the objects and principles of the Act. However, the rights of disabled parents are a significant omission from the Practice Standards.
The Ministry has a wealth of other operating policies and guidance available on its publicly accessible online Practice Centre, most of which is consistent with the objects and principles of the Act and the obligations under international law. I appreciate that the Ministry is in the process of updating and reviewing the content of the Practice Centre (as it is required to do to meet its transformation programme). However, as it currently stands, I found its Practice Centre is difficult to navigate and the links back to the overarching Practice Standards are not readily apparent.
For the period I considered, I identified a number of gaps in the Ministry’s operating policies and guidance.
Critically, I found the Ministry did not have any specific operating guidance on the use of without notice section 78 applications. It had some general guidance on the use of emergency powers (of which interim custody under section 78 is one) but this did not address the use of without notice applications. The available guidance did not sufficiently articulate clear criteria for how staff are meant to identify and assess the viability of other options to secure the safety of tamariki. Further, I found the Ministry’s staff training material for 2017 was very brief and included inaccurate advice about the use of without notice applications. While the training material for 2018 remedied this, it did not emphasise the need for the Ministry to consider all other options before applying for interim custody under section 78.
The lack of appropriate guidance on this issue is a serious failing in the context of the Ministry’s routine reliance on such applications as a way to establish safety for pēpi.
The Ministry had one policy document, 'Strengthening our response to unborn babies', that provided specific guidance for unborn or newborn pēpi. I found this to be generally adequate, with the following exceptions.
- There was no reference to trauma-informed social work practice vis-à-vis assessing the parents’ own childhood histories of abuse or neglect.
- It did not explicitly require specialist assessments for parents with alcohol or drug misuse, mental health needs or intellectual disabilities.
- It did not reflect the legal obligation on the Ministry to ensure that, where pēpi are at risk, the parents and whānau are provided assistance to support them in discharging their responsibilities to their pēpi.
I found there was very limited guidance in respect of disabled parents. It was not apparent from the available material that the Ministry appreciated alcohol or drug misuse and other mental health needs require a disability rights-based response. In terms of the specific guidance for parents with intellectual disability, I am concerned that the Ministry may have been operating in an outdated medical (deficits-based) model of disability. In addition, the guidance did not sufficiently emphasise that IQ should not be used as a sole measure of parenting capacity. Nor did it explicitly refer to the obligation under international law that no tamariki should be separated from their parents based on a disability of one or both of the parents.
With the exception of breastfeeding, I found the Ministry did not have any guidance and policy specifically developed for the process of removing pēpi once section 78 interim custody orders are granted. None of the memoranda of understanding between the Ministry and the District Health Boards referred to this process. Nor was it apparent from the material made available to me that the Ministry had agreements in place, during the period of my investigation, about the required or expected practice with other third parties who may be involved in, or impacted by, the removal process. This situation is highly unsatisfactory, given the potential long-term impacts of a removal.
Finally, the available guidance on breastfeeding could be improved by including an explicit acknowledgment of the rights to breastfeeding as provided for under the United Nations Convention on the Rights of the Child (UNCROC), and the recommendations of the World Health Organization and the Ministry of the Health about exclusive breastfeeding.
The Ministry's practices
I considered the Ministry’s decision making practices in two distinct but related phases: the time before an application is made to the Family Court for a without notice section 78 interim custody order; and the removal of pēpi, if that occurred, once the section 78 order was granted.
First phase—applications for without notice interim custody
In general, I found the Ministry has sufficient tools and processes to enable the objects and principles of the Act to be achieved. For example, the Ministry was able to utilise hui ā‑whānau, family group conference (FGC), Māori specialist roles, Child and Family Consults, professionals meetings, Tuituia reporting (the Ministry’s assessment tool), and Care and Protection Resource Panels (CPRP). However, my investigation found that the Ministry did not consistently apply the available tools and processes in practice, and was instead resorting to removing these pēpi without notice.
In terms of engagement with parents and whānau, during the period covered by my investigation, the Ministry piloted new ways to engage, which were shown to be much more effective for Māori. Māori have a long history of problem solving in a way that allows things to be tika and pono—concepts understood and seen as beneficial by the Ministry’s staff in how they engage successfully with Maori. Hui ā-whānau and FGCs are extensions of this and, if they were utilised in the way intended, could have made a major impact on the outcomes for pēpi and whānau. Therefore, I consider it concerning that in over half of the 74 cases I reviewed, hui ā‑whānau or FGCs did not occur prior to the birth of pēpi. I was also disappointed to find that, for the timeframe of my investigation, there appeared to be a lack of an agreed national strategy within the Ministry to promote and encourage Māori to take more of a lead in decisions affecting them.
I did find that the involvement of kairāranga was transformative. However, there were only 33 kairāranga engaged by the Ministry (as at April/May 2019) and the support given to them was not consistent across regions visited during my investigation. One of the barriers identified to using kairāranga was the lack of ‘site readiness’. However, it is unclear how a site could be ‘ready’ until the Māori specialist positions were effectively embedded to provide leadership in this space. I found that the slow progress to change was self‑perpetuating and appeared to reflect, and potentially inflame, a fundamental distrust of a different way of operating.
It also appeared to me that trauma-informed practice was not entrenched within the Ministry. I was unable to find any evidence that the Ministry’s staff saw the parents’ childhood histories, as well as experiences of being in care themselves and the Ministry’s prior removal of their children, as traumatic events for parents that required a different response.
I found disabled parents were a group that was poorly served by the Ministry. All the cases I reviewed involved a parent with a disability, ranging from intellectual disability to alcohol or drug misuse and other mental health needs. However, the Ministry did not demonstrate any understanding of their rights in this regard. Over 20 percent of the cases involved a parent with an intellectual disability, but less than 17 percent of those cases had up‑to‑date specialist assessments relating to this. This reflects a general failure by the Ministry to operate within a human rights framework and to recognise the social model of disability for parents who may have disability-related needs.
When the Ministry has concerns about the wellbeing of an unborn pēpi, it is crucial that the Ministry takes advantage of the time before the pēpi is born to assess the situation and plan. This should start as early as possible and involve whānau, as well as other professionals and organisations supporting the parents and whānau. However, my investigation found that the Ministry did not take advantage of the unique opportunity to act early and with whānau and external parties before pēpi were born.
I found that in 77 percent of the cases I reviewed, the Ministry was aware of the pregnancy, and the reported concerns, 60 working days or more before the birth of pēpi. Yet, it took over 50 working days in nearly half of the cases to complete a Child and Family Assessment. This was well outside the maximum expected timeframe of 36 working days.
High caseloads and limited numbers of kairāranga appeared to be contributing factors to the delays in these cases. These delays were exacerbated by mixed caseloads, where the focus was understandably on the immediate safety of other tamariki identified to be at risk, rather than the long-term wellbeing of an unborn pēpi and their whānau. When combined with workload pressures, this appeared to result in cases involving unborn pēpi not being prioritised until the birth was imminent. Many of those interviewed described kairāranga as transformative, and said they made a difference in terms of finding and engaging with whānau early. Unfortunately, except in a few sites, they were either not available or struggling with acceptance or workload.
I found the outcome in many of these cases was that decisions for pēpi were being made late and without expert advice or whānau involvement. I also found that urgency and the need for without notice applications were created through the Ministry’s inaction and lack of capacity to follow its own processes in a timely and effective way. As a consequence, the parents were disadvantaged—first, by not having an opportunity to respond to the allegations or challenge the information relied upon by the Ministry before their pēpi were removed, and second, by having to challenge orders after they were made, and when the parents were vulnerable because they were either heavily pregnant or had just given birth.
My investigation, and the Ministry’s own reviews, identified much variability in the application and quality of key checks and balances. In particular, 20 percent of the cases I reviewed had no record of the matter being referred to a Care and Protection Resource Panel, despite this being a statutory obligation. In a third of the cases I reviewed, there was no evidence on the files of the Ministry undertaking a Child and Family Consult, which was required in all cases where a removal was being considered. In 77 percent of the cases I reviewed, there was no evidence of consultation with the Ministry’s solicitors. Professionals meetings did not occur in 64 percent of cases I reviewed, and in half of the cases, the Tuituia report was not completed within the expected timeframe of 36 working days. Significantly, in 7 percent of cases, there was no Tuituia report completed at all. Further, in 46 percent of cases, there was no evidence of professional supervision. Where there were records of professional supervision, 90 percent of these were focused on tasks, actions and next steps, rather than the required critical and reflective practice.
Overall, the failure to undertake the Ministry’s own key checks and balances that have been built into the system severely compromised the quality, robustness, and transparency of the Ministry’s decision making. This is particularly concerning because of the wide-reaching and coercive nature of the Ministry’s powers, and the overwhelming impact the use of these powers can have on individuals and their whānau.
The Ministry must act in a way that is lawful, fair and reasonable, transparent, and open. Crucially, the Ministry must be guided by the legislative presumption that tamariki are entitled to know and be cared for by their parents. Additionally, the parents’ rights to know the allegations against them, and to have an opportunity to respond, are at the heart of Aotearoa’s legal system, and are of central importance in the context of the coercive powers of the Ministry.
In practice, I found that without notice applications seemed to be the default position in cases involving unborn or newborn pēpi. Although I accept that the applications were made because the Ministry had serious concerns for pēpi, it is essential that all Ministry staff understand the law, plan carefully, and apply it consistently. I note the Ministry has accepted that without notice applications needed more oversight, following the Hastings Practice Review.
The Ministry must ensure that the fundamental safeguards in the Act are understood and complied with. This is especially critical in the context of the subsequent child provisions, where custody of a previous child has been removed. These provisions have been interpreted as reversing the onus of proof, so parents have to prove that they are not a risk to their tamariki. I consider this to be highly problematic for parents who struggle to advocate for themselves. In my view, the issue was made worse because of the Ministry’s failure to understand and follow the statutory requirements in applicable cases, resulting in the Court not having the oversight expected in these cases, and parents not having access to independent advice and representation.
Second phase—removal of newborn pēpi
I found minimal evidence that parents and whānau had been involved by the Ministry in planning the removal process. Late and limited pre-birth planning, communication and information sharing with DHBs and midwives, and variable information provided in safety/birth plans are also key issues that I identified.
I observed that where there have been good planning and improvements in practice, these flowed from the efforts of individual staff. The Ministry had no set guidance or established agreements with its health partners to identify the expected or required practice for social workers specifically in the area of newborn removals.
I am concerned about the consequences of poor planning on parents, whānau, and on hospitals. For parents and whānau, it was likely to cause uncertainty, fear, and anxiety. In the hospital setting, interviewees were concerned that the Ministry’s late planning resulted in uncertain, rushed decision making, which compromised practice and increased escalation.
I also found insufficient support was offered to breastfeeding mothers. In around half of the cases where the mother planned to breastfeed, initial contact with pēpi was just once or twice a week. I found the Ministry’s guidance in this regard was not followed, and I was not assured that the Ministry was therefore prioritising and taking sufficient steps to support exclusive breastfeeding where that was appropriate and desired by the mother. I also found the Ministry’s practices were inconsistent with the United Nations Convention on the Rights of the Child and the recommendations of the World Health Organization and Ministry of Health around exclusive breastfeeding for the first six months of pēpi’s life.
When a removal decision was executed, I found parents and whānau were not provided with the opportunity for ngākau maharatanga me te ngākau aroha; a period of ‘quality time’ that reflects consideration, empathy, sympathy and love. In addition, the Ministry did not ensure that the parents and whānau had their support people present. Nor did it provide them with clear information on next steps. There was no record of support being offered to parents and whānau to deal with the trauma and grief of child removal, or to help their healing. There was little evidence that trauma-informed practice had occurred consistently.
In my opinion, the content of the Ministry’s overall operating policies and guidance, effective during the period covered by my investigation, were generally adequate and reflective of the objects and principles of the Act. However, I identified some gaps in the Ministry’s policies and guidance.
In particular, my opinion is it was unreasonable that:
- there was no comprehensive guidance on the use of without notice section 78 applications, and the available guidance on emergency powers did not articulate clear criteria for how staff were meant to identify and assess the viability of other options to secure the safety of pēpi;
- the subsequent children provisions, and the Ministry’s corresponding guidance, have placed the responsibility on parents for gathering evidence to demonstrate that the risk of harm has been satisfactorily removed;
- there was limited specific guidance for unborn and newborn pēpi, and the available guidance did not:
- include reference to trauma-informed social work practice vis-à-vis assessing the parents’ own childhood histories of abuse and/or neglect, as well as experiences of being in care themselves, and the Ministry’s prior removal of their children as traumatic events for parents that required a different response; or
- reflect the legal obligation on the Ministry to ensure that, where pēpi are at risk, parents and whānau are provided assistance to support them in discharging their responsibilities to pēpi;
- the rights of disabled parents were not reflected in the Ministry’s overarching Practice Standards;
- there was an overall lack of guidance in respect of disabled parents, and the available guidance:
- did not identify that alcohol or drug misuse and other mental health needs of parents require a disability rights-based response;
- in relation to parents with intellectual disability:
- appeared to be based on an outdated medical (deficits-based) model of disability;
- did not emphasise that IQ should not be used as a sole measure of parenting capacity;
- did not specify the obligation under international law that no pēpi is separated from their parents based on a disability of one or both of the parents;
- with the exception of breastfeeding, the Ministry did not have any guidance and policy specifically developed for the process of removing pēpi once section 78 interim custody orders are granted;
- the available guidance on breastfeeding did not include explicit acknowledgements of:
- the rights to breastfeeding as provided for under the United Nations Convention on the Rights of the Child; and
- the recommendations of the World Health Organization and the Ministry of Health on exclusive breastfeeding for the first six months of pēpi’s life.
It is also my opinion that, during the period covered by my investigation, the Ministry’s decision making practices connected with the removal of newborn pēpi under section 78 of the Act were unreasonable. The evidence I have considered did not demonstrate that the Ministry consistently met the objects and principles of the Act and the obligations under international law. In particular, I do not consider that the Ministry had adequately ensured:
- without notice applications for interim custody were reserved for urgent cases where all other options to ensure the safety of pēpi had been considered;
- a pēpi’s right, as far as is possible, to know and to be cared for by their parents and whānau;
- no pēpi was separated from their parents based on a disability of one or both of the parents;
- the primary role in caring for and protecting pēpi was with their whānau, hapū, iwi, and family group;
- the parents and whānau were provided assistance to support them in discharging their responsibilities to their pēpi;
- (where possible) whānau, hapū, and iwi were able to participate in decision making and regard was given to their views;
- (where possible) the relationship between pēpi and their whānau, hapū, and iwi was maintained and strengthened;
- endeavours were made to obtain the support of pēpi’s parents;
- (where possible) decisions affecting pēpi were made and implemented within a timeframe appropriate to their age and development;
- the primary role in caring for and protecting pēpi was with their whānau, hapū, iwi, and family group;
- whānau, hapū, and iwi were supported, assisted, and protected as much as possible, and any intervention in family life was minimised;
- pēpi and their mothers were supported in their rights to breastfeeding; and
- parents and whānau were given assistance when their relationship with pēpi was disrupted.
Pursuant to section 22(3) of the Ombudsmen Act 1975 I recommend the following:
- The Ministry:
- ensures its current policies, training material and practices make explicit that without notice interim custody applications are reserved for exceptional urgent cases where all other options to ensure the safety of pēpi are unavailable;
- develops comprehensive guidance with clear criteria to enable its staff to assess the viability of other options to ensure the safety of pēpi in urgent cases;
- exercises best endeavours, in all but the most exceptional of cases, to use a place of safety warrant or truncated notice period when the Ministry learns of a pregnancy at a late stage and determines pēpi to be at imminent risk;
- takes immediate measures in terms of reports of pēpi at risk to ensure that all statutory requirements are met, and in particular:
- commences an investigation as soon as practicable (section 17(1)(a) of the Act);
- consults a Care and Protection Resource Panel in all cases and as soon as practicable after an investigation has commenced (section 17(1)(b), and at subsequent stages where required (sections 21(1)(a) and 31(1)(e) of the Act);
- convenes a family group conference (section 18(1) of the Act);
- establishes timeframes, reporting frameworks, quality assurance and monitoring to demonstrate appropriate ongoing compliance with all statutory requirements as these relate to without notice removals of newborn pēpi; and
- reports publicly against the framework for monitoring detailed in recommendation 1(e) every six months.
- Additionally, the Ministry:
- reviews its processes to ensure that all cases involving unborn or newborn pēpi are given the necessary priority;
- reviews its policies and practices to ensure whānau engagement is prioritised in all cases involving unborn or newborn pēpi, including family group conferences and hui ā‑whānau where appropriate;
- develops, in partnership with iwi and other Māori groups a national strategy for:
- effective engagement with whānau, hapū, and iwi, including provision for localised relationship-based implementation with centralised support; and
- enhanced cultural competency of staff;
- develops memoranda of understanding with the Ministry of Health, the DHBs midwifery representatives, and other relevant parties to ensure appropriate information sharing, clear and defined roles, and effective early planning for at-risk pēpi;
- works with the relevant providers to ensure that all social workers are trained in, and engage, trauma-informed practice that is underpinned by te ao Māori, and consults with the Social Workers Registration Board to assist with the achievement of this;
- develops specific guidance for cases involving unborn and newborn pēpi that:
- requires trauma-informed social work practice when parents have experienced childhood abuse and/or neglect, been themselves in care or had tamariki previously removed by the Ministry;
- reflects the obligations on the Ministry to ensure that where pēpi are at risk, parents and whānau should be provided assistance to support them in discharging their responsibilities to pēpi;
- develops clear guidance, with supporting tools, for social workers to ensure all legislative and procedural safeguards are engaged with respect to subsequent tamariki, pending the outcome of the Ministry’s review of the subsequent children provisions;
- amends its policies and practices relating to the subsequent children provisions to make clear that social workers are responsible for actively seeking out up to date information and conducting a full assessment of the parents’ current circumstances;
- works with relevant agencies to assist parents who have had previous tamariki removed with access to independent advocacy during the Ministry’s assessment and intervention phases;
- amends its overarching Practice Standards, as well as its policies, procedures, and practices to recognise the rights of disabled parents and ensure full compliance with the United Nations Convention on the Rights of Persons with Disabilities;
- ensures all its policies, procedures, and practices are consistent with the social model of disability and a rights based framework by:
- providing reasonable accommodation;
- explicitly recognising that drug and/or alcohol misuse and mental health needs require a disability rights-based response;
- ensuring disabled parents have access to specialist advocacy during the assessment and intervention phases;
- in implementing recommendations 2(j) and (k) above, closely consults with and actively involves disabled people, their whānau and organisations that represent disabled people, as well as other relevant agencies within the system;
- ensures all parents have information about their legal rights, including information about accessing legal aid, in an accessible format;
- develops specific policies and procedures for the process of removing newborn pēpi, once section 78 interim custody orders are granted, that:
- ensure, to the fullest extent possible, planning, communication and information sharing with parents, whānau, DHBs and midwives;
- ensure, to the fullest extent possible, the removal of pēpi takes place in a manner that reflects ngākau maharatanga me te ngākau aroha, a period of quality time that encompasses consideration, empathy, sympathy and love; minimises trauma; and provides parents and whānau with support and clear information on next steps;
- explicitly recognises the right of pēpi to be breastfed consistent with the United Nations Convention on the Rights of the Child, as well as guidance from the World Health Organization and the Ministry of Health;
- reflect best practice to support breastfeeding;
- ensure appropriate therapeutic and other support is available to all parents who have had pēpi removed from their care; and
- regularly audits case files to ensure compliance with policy and practice guidance.
- The Ministry reports back to me on its achievement of recommendations 1 and 2 on a quarterly basis for the next year, with the first report by 4 November 2020.
My office is available to assist the Ministry with the implementation of these recommendations.
 For the purposes of this investigation, newborn pēpi are defined as those aged 0–30 days old.
 The Ministry has noted that the ‘the available evidence shows that the majority of unborn/newborn pēpi brought to its attention do not enter care and those that do may enter under different orders’.
 Refer to the glossary in Appendix 1 at page 181 of this report for an explanation of these terms.
 Refer to page 214 of this report for an explanation of reasonable accommodation.