Successful Foster Home Licensing in NC - Training Matters

Handouts for the Webinar
Successful Foster Home Licensing
June 15, 2010
Presented by
Bob Hensley, Rhoda Ammons, and Nicole Jensen
Produced by
Family and Children’s Resource Program, part of the
Jordan Institute for Families
UNC-Chapel Hill School of Social Work
Sponsored by
North Carolina Division of Social Services
Contents
Year-By-Year Comparison of New Foster Home Applications,
July 2003– May 2010 .............................................................................. 2
Tips for Using the DSS-5015 .................................................................. 3
DSS-5015 ................................................................................................. 4
Tips for Using Other Licensing Forms .................................................. 5
DSS-5157 ................................................................................................. 7
DSS-1515 ............................................................................................... 12
DSS-5150 ............................................................................................... 13
DSS-5017 ............................................................................................... 14
DSS-5056 ............................................................................................... 15
Tips for Using the DSS-5016 ................................................................ 16
DSS-5016 ............................................................................................... 20
Race Codes ............................................................................................ 34
County Codes ......................................................................................... 35
Important Contacts for Foster Care Licensing .................................... 36
Webinar Slides ....................................................................................... 37
June 15, 2010 Webinar
Jordan Institute for Families, UNC‐CH School of Social Work

YEAR BY YEAR COMPARISON OF NEW FOSTER HOME APPLICATIONS
SFY 2003 SFY 2004 SFY 2005 SFY 2006 SFY 2007 SFY 2008 SFY 2009
July 158 179 140 172 184 158 212
August 164 198 197 176 159 135 197
September 150 142 148 148 128 134 178
October 145 118 160 146 145 147 163
November 124 127 160 165 131 125 156
December 142 146 121 154 146 162 173
January 112 156 149 140 116 135 163
February 133 139 128 131 110 131 181
March 167 145 166 136 136 134 144
April 139 149 123 141 151 192 112
May 155 156 154 170 140 147 117
June 173 196 144 172 140 187
Average 147 154 149 154 141 149 107
Total 1,762 1,851 1,790 1,851 1,686 1,787 1,176
SFY 2009
Public Agencies Private Agencies
July 101 111
August 90 107
September 58 120
October 67 96
November 72 84
December 56 117
January 70 93
February 95 86
March 46 98
April 42 70
May 48 69
June
Average 68 96
Total 745 1051
Number of Currently Licensed Foster Homes
Family Foster Homes 3,684
Therapeutic Foster Care Homes 4,000
Total Number of Foster Homes 7,684
Capacity of FFH 10,695
Capacity of TFC 6,187
Total Capacity 16,882
June 1, 2009 -- May 31, 2010
Number of Foster Homes Relicensed – 1,842 (average 167 per month)
Number of Foster Homes Terminated – 500 (average 45 per month)
Number of Transfers –
647 (average 61 per month)
Number of Change Requests – 1,017 (average 92 per month)
100 County Departments of Social Services
127 Private Child-Placing Agencies – Foster Care

Tips for Using the DSS-5015
Submit a DSS-5015 every time you submit a request to the Licensing Office.
Make sure you are using the 5015 dated Rev 11/7 that is on the forms web site.
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5015.pdf
Make sure the form is legible and only use Black Ink when completing the 5015.
Complete the following Fields on Form 5015: 1—29.
Do Not complete Fields 24, 41, 42 and 43.
Do not complete fields 30-40 (gray box with heading State Office Use Only)
Field Number 2—County Number. For county departments of social services put the number of the
county dss supervising the foster parents. For private agencies put the number of the county where the
foster parents reside. County numbers can be found on page 149 in the document “A Supplemental
Guide to Foster Home Licensing” at the following web site:
http://www.ncdhhs.gov/dss/licensing/docs/Guide-appendix.pdf
Field Number 4 is the name of the supervising agency.
Field Number 5 is the address and phone number of the foster parents NOT the address and phone
number of the agency. Rather than Facility Address, Field 5 should be labeled Foster Parent Address
(this will be corrected when the form is updated).
Foster Parent Names should be recorded exactly as they appear on the fingerprint clearance letter. (No
nicknames or middle names should be used as first name). If it is a two parent home the male name is to
be entered first.
Make sure the Social Security Number matches the Social Security Number on the fingerprint clearance
letter.
Race codes can be found on page 150 in the document “A Supplemental Guide to Foster Home
Licensing” at the following web site: http://www.ncdhhs.gov/dss/licensing/docs/Guide-appendix.pdf
In the top field for Education list the highest grade the applicant completed. If the applicant completed
high school or received a GED put 12. In the bottom field indicate the number of years of higher
education.
Please remember to fill in Field 26—Family Income
Field 27-Type of Care: Check either 1, 2 or 5. The other fields do not apply to foster care.
Field 28-Type of Facility: Always check 1, Family Foster Home.
When submitting a Relicense, Change or Termination use the last DSS-5015 that you received from the
Licensing Office. Make sure you include training hours if it is a relicense. If the last DSS-5015 is not
available and you have to complete a new one make sure ALL fields are complete and fill in the correct
Facility ID # in Field 30. Do not complete in other fields the State Office Use Only Section. The Licensing
Office will determine the Licensing Action from your cover letter.
When submitting a Transfer, include the current DSS-5015 from the previous agency and complete a
NEW DSS-5015 from your agency. DO NOT USE THE PREVIOUS AGENCY’S DSS-5015 FOR YOUR
AGENCY. The Licensing Office will determine the Licensing Action (do not fill this in)

3
1 AGENCY CASE NO.
AGENCY TYPE
1 COUNTY DSS
NORTH CAROLINA DIVISION OF SOCIAL SERVICES
FOSTER CARE FACILITY ACTION REQUEST
4 NAME OF SUPERVISING AGENCY
2 CO.NO
NEW LICENSE
CHANGE
RELICENSE
TERMINATE/REVOKE
WAIVER REQUESTED
RELICENSE/CHANGE
2 PUBLIC AGENCY
3 PRIVATE AGENCY 5 FACILITY ADDRESS 6 AREA CODE HOME PHONE NUMBER
CITY STATE ZIP CODE
7 FOSTER PARENT NAME OR FACILITY NAME 8 SOC. SEC. NUMBER
9 DATE OF BIRTH 10 RACE 11 SEX 12 EDUCATION 13 TRAINING
1 MALE
2 FEMALE
GRADE COMPLETED
OR
POST SECONDARY
YEARS
HOURS
TYPE
1 ORIENTATION
2 SKILLS DEVELOPMENT
3 SPECIFIC CHILD
14 FOSTER PARENT NAME
15 SOC. SEC. NUMBER
16 DATE OF BIRTH 17 RACE 18 SEX 19 EDUCATION 20 TRAINING
1 MALE
2 FEMALE
GRADE COMPLETED
OR
HOURS
TYPE
1 ORIENTATION
POST SECONDARY
2 SKILLS DEVELOPMENT
YEARS
3 SPECIFIC CHILD
21 CAPACITY 22 SEX AGE 24 RATE
1 MALE
2 FEMALE
23 FROM TO
3 BOTH
26 FAMILY INCOME 29 OTHER HH MEMBERS 18 OR OLDER LASTNAME FIRST MI
27 TYPE CARE PROVIDED
1 UNDER 10,000
2 10-19,999
3 20-29,999
4 30-39,999
5 40-49,999
6 50,000
1 FOSTER CARE
2 KINSHIP/RELATIVE FOSTER CARE
3 SPECIALIZED FOSTER CARE
4 EMERGENCY SHELTER CARE
5 THERAPEUTIC FOSTER CARE
6 SPECIAL PROGRAM
1
2
3
28 TYPE OF FACILITY
4
1 FAMILY FOSTER HOME
2 GROUP HOME
3 INSTITUTION
4 MATERNITY HOME
5 RES. TREATMENT
6 THER. CAMP
41 MEDICAID ID # 43 NPI NUMBER
42 PROFIT INDICATOR
PROFIT
NON-PROFIT
STATE OFFICE USE ONLY
30 FACILITY I.D. 31 SUPERVISING AGENCY LICENSE ACTION
LICENSE ISSUED 32 FROM 33 TO
34 OTHER LICENSING ACTIONS 38 OTHER 39 PROCESSING INFORMATION
1 CHANGE 35 EFFECTIVE DATE
2 TERMINATION
3 RELICENSE
40 WAIVER GRANTED
4 NEW
36 LICENSE TYPE
1 FULL
2 PROVISIONAL
REASONS FOR
37 PROVISIONAL
1 SANITATION STANDARD
2 OTHER-EXPLAIN IN #38
DSS-5015 (Rev. 11/07)
FSCW

Tips for Using the Other Licensing Forms
DSS-5157
This form was updated on 2/10. It is an interactive form that must be typed. Do not submit a
handwritten form. If your agency needs the word format of the document send an e-mail
request to one of the Program Consultants at the Licensing Office.
I. Relicense Application
1. Background Checks: Document the specific findings and dates. Include explanations when
there are findings. Why/how did it happen Why there will not be a reoccurrence
10. Complete each blank when documenting the total number of children in the home.
15. If a waiver is currently in place or you are requesting an additional waiver, you must submit
a DSS-5199 Waiver Request (http://info.dhhs.state.nc.us/olm/forms/dss/dss-5199-ia.pdf) to
continue the current waiver or request a new waiver.
II. License Termination Request
1. Terminate this License Effective date needs to be the date the foster parents signed the
application or a future date. No back dating
3. Document attempts to contact the foster parent, what kind of contact (telephone, letter) and
include the dates. Always send a letter.
III. License Change Request
1. The effective date cannot be a past date unless there has been prior verbal approval. If
verbal approval was given document conversation and date in the cover letter. Send the
change request ASAP. When a verbal approval is given to increase capacity in an
emergency situation the date of the verbal approval will be the effective date if the change
request packet is sent immediately. The effective date of a change will not be made
retroactively unless this emergency situation exists and paperwork follows immediately.
3. When increasing capacity document on the sleeping arrangements chart where family
members and foster children are sleeping and the bed type. Also complete I. # 10 to show
the total number of children in the home.
4. & 5. Should be answered if there is a waiver request.
7 (a thru d). Complete this entire section for a change of address for the foster family.
10. Complete this section before someone is added to the household. This includes the
birth/adopted children of foster parents that turn eighteen. This also includes any relatives
or friends of the adoptive parents that plan to live in the home. Foster parents should be
advised that they are required to apprise the supervising agency of any changes in
household composition. This includes prospective changes. Adults who plan to move into
the foster home must have fingerprint clearances, background checks, child registry checks
from other states and medicals before moving into the foster home.
DSS-1515
This form was updated 2-1-10 (http://info.dhhs.state.nc.us/olm/forms/dss/dss-1515.pdf). Please
provide this form to foster parents and the fire inspectors.
The 2-1-10 form has a new requirement that Carbon Monoxide detectors should be installed in
foster homes that use fuel oil products, coal, wood, or gas heat, cool, cook, operate a hot water
heater or gas logs.
The fire inspector should check either Yes or N/A for each question. If No is checked please
refer to the sentence under the signature section. It states that any item marked NO will result
in non-approval of the home.
Send original to Licensing Office.

2
DSS-5150
This form was updated on 9/1/07 (http://info.dhhs.state.nc.us/olm/forms/dss/dss-5150-ia.pdf).
This form needs to be completed within 180 days of being received by the Licensing Office. All
13 items need to be completed. If the household does not have firearms, explosives or pets
write N/A on Items (8) and (9). Please make sure the form is signed and dated by the foster
parent and social worker.
Send original to Licensing Office.
DSS-5017
This form was updated on 9/28/09 (http://info.dhhs.state.nc.us/olm/forms/dss/dss-5017-ia.pdf).
This form needs to be completed for all members of the household and must be current within
180 days of being received by the Licensing Office. All items must be completed. Please make
sure the form is signed and dated.
Send original to Licensing Office.
DSS-5156
This form was updated on 9/1/02 (http://info.dhhs.state.nc.us/olm/forms/dss/dss-5156-ia.pdf).
This form needs to be completed for all members of the household and must be current within
12 months of being received by the Licensing Office. All items must be completed. Please
make sure the form is signed and dated. Make sure the questions about the TB test are
answered on the form or a separate TB test result is attached.
Send original to Licensing Office.

FOSTER HOME RELICENSE, TERMINATION AND CHANGE REQUEST APPLICATION
Print Foster Parent(s) Name(s):
Facility ID#:
Attach: Cover Letter and a copy of DSS-5015 License Action Request form for all requests
I. RELICENSE APPLICATION
I. Relicense Application (foster parent(s), licensing social worker, and agency head/designee signatures required)
1. Background Checks {Must be completed on each foster parent and each adult (18 years old and up)}
Name of Each Adult in the Home:
Type of Background Check
Check Date Conducted
Findings: document new charges in Cover Letter as needed Conducted
Local Court Record Checked by Agency Staff YES NO Date :
Findings:
Explanation of Findings:
NC Department of Corrections Offender Information
http://www.doc.state.nc.us/offenders/
Findings:
Explanation of Findings:
NC Sex Offender and Public Protection Registry
http://sexoffender.ncdoj.gov/
Findings:
Explanation of Findings:
YES NO Date:
YES NO Date:
Health Care Personnel Registry https://www.ncnar.org/nchcpr.html YES NO Date:
Findings:
Explanation of Findings:
2. North Carolina Child Abuse Neglect History
Child Abuse or Neglect Reported: YES NO
Substantiation: YES , Date of Substantiation: NO N/A
Explanation of Findings:
3. Are any new adults (18 years old and up) residing in the home YES NO
a. Are these adults included in the Background checks above YES NO N/A
b. Are Fingerprint Clearance letters attached YES NO N/A
c. Are Child Central Registry Checks from other State(s) attached if the
adult did not reside in N.C for the past five years YES NO N/A
4. Each foster parent received the required 20 hours of in-service training YES NO
5. Each foster parent received the required training in First Aid, CPR, Universal Precautions
and Medication Administration prior to initial placement YES NO
DSS-5157 (Rev. 02/10)
Child Welfare Services

6. Foster parent(s) using physical restraint holds receive required training prior to use of
physical restraint holds YES NO N/A
7. Annual written approval to use physical restraint holds from the Executive Director
provided to foster parent(s) and placed in file YES NO N/A
8. Foster parent(s) using physical restraints only do so when a second trained foster
parent or adult is present YES NO N/A
9. Therapeutic foster parent(s) have received additional training within first two years
of licensure as required by 10A NCAC 70E .1117 YES NO N/A
10. Total number of children in the home. Complete Each Blank.
# foster parent(s) minor children including birth, adoptive, guardian
# relative children who are not in foster care
# non-relative children (do not count foster children or daycare children)
# In-Home Daycare License Capacity, attach copy of license
# Community Alternative Program (CAP) clients in the home
# foster care license capacity as printed on most current DSS-5015
Total of numbers above
11. Required forms attached
DSS-5156 Request for Medical Information YES NO
DSS-1515 Fire Safety Inspection Report YES NO
DSS-5150 Environmental Conditions and Health Regulations Checklist YES NO
12. DSS-1796 Agency/Foster Parent Agreement reviewed and signed; a copy retained in
agency foster parent file and a copy given to foster parents YES NO
13. Discipline Agreement reviewed and signed; a copy retained in agency foster parent
file and a copy given to foster parents YES NO
14. Waiver of licensure rule previously granted YES NO
15. Waiver of licensure rule being requested If YES attach DSS-5199 Waiver Request
Form YES NO
II. LICENSE TERMINATION REQUEST
II.
License Termination Request ( social worker and foster parent(s) signature required)
(This form is not used for Revocations. Use DSS-5279 Request for a Revocation of a Foster Home License)
1. Terminate this license effective:
2. Reason for Termination: Adopted No longer desires to foster Other obligations
3. If foster parent(s) is NOT available for signature, indicate reason below:
Moved No reply to agency attempts to contact Other:
Document Attempts to Contact (including dates):
DSS-5157 (Rev. 02/10)
Child Welfare Services
2

III. LICENSE CHANGE REQUEST
III. License Change Request (social worker signature required)
1. Desired Effective Date:
2. Please Change Capacity to: Complete Part I. #10 above.
3. Document Sleeping Arrangements
SLEEPING
ARRANGEMENTS
CHART
Bed Type / Occupant(s) Bed Type / Occupant(s) Bed Type / Occupant(s) Bed Type / Occupant(s)
Example Bedroom 1. Queen / Mr. & Mrs. Applicant Crib / foster child
Bedroom 1.
Bedroom 2.
Bedroom 3.
Bedroom 4.
Bedroom 5.
4. Request for total number of children in a family foster home is greater than 5 YES NO N/A
5. If ‘YES’ are the following criteria met
(a) The capacity change request is to allow siblings to remain together YES NO N/A
(b) Social worker has verified that the out-of-home family services agreement
for each sibling specifies the children shall be placed together YES NO N/A
(c) Foster parents have the skill, stamina, and ability to care for the children YES NO N/A
6. Change Age Range from : to
7. Change Address to:
(a) Complete Sleeping Arrangements Chart. (III. 3.)
(b) Briefly describe house, kitchen and dining areas, family or living areas, bathing facilities and the
setting in which the home is located.
(c) Home’s design allows children privacy while bathing, dressing and using toilet
facilities YES NO
(d) Exterior spaces around the foster home are clear of bodies of water such as swimming
pools, beaches, rivers, lakes, streams, ponds, etc. YES NO
If you answered ‘NO’ to (c) or (d) document how access to these objects, hazardous items, and/or
bodies of water is avoided:
8. DSS-1515 Fire Inspection attached YES NO
9. DSS-5150 Environmental Checklist attached YES NO
10. Add to the household: Name: SSN: Relationship to foster parent(s)
(a) Complete Sleeping Arrangements Chart (III. 3.).
DSS-5157 (Rev. 02/10)
Child Welfare Services
3

(b) Attach DSS-5017 Medical History Form.
(c) Attach DSS-5156 Request for Medical Information and TB tests results.
(d) New Household member 18 years of age or up YES NO
If ‘YES’ Complete I. (1) Background Check and (2) Child Abuse/Neglect History Table.
Attach Fingerprint Clearance Letter and Child Abuse/Neglect Central Registry Checks
from other states if new household member has not resided in NC for the past five years.
11. Change from: Therapeutic to Family Foster Care.
12. Change from: Family Foster Care to Therapeutic; Complete I.(8) above.
Foster parents have received additional 10 hours of required pre-service training, and
agree to receive additional training within first two years of licensure as a therapeutic
foster parents as required by 10A NCAC 70E .1117 (3) (a-e). YES NO
Date foster parents received additional 10 hours of required pre-service training:
13. Remove Foster Parent from license (signature required below) Name:
Remove Adult Household Member Name:
Document reason:
14. Other: Change DSS-5015 field from to
DSS-5157 (Rev. 02/10)
Child Welfare Services
4

FAMILY FOSTER HOME RELICENSURE, TERMINATION, AND CHANGE REQUEST
CERTIFICATION
We certify that agency staff has reviewed this application and confirm that the home is in compliance with all rules and
policies governing foster home licensure. We understand that according to GS 131D-10.6C this information may be
furnished to others upon proper request.
Print Name of Foster Parent
Foster Parent Signature / Date
Print Name of Foster Parent
Foster Parent Signature / Date
Print Name of Social Worker
Social Worker Signature
Social Worker Phone Number:
Social Worker E-Mail Address:
Date
Print Name of Agency Director – OR - his / her Designee*
Signature of Agency Director or Designee
*I certify that the Agency Director has appointed me as Designee for the
purpose of signing documents for Regulatory and Licensing Services.
Date
DSS-5157 (Rev. 02/10)
Child Welfare Services
5

FOSTER HOME FIRE INSPECTION SAFETY REPORT
NORTH CAROLINA DIVISION OF SOCIAL SERVICES
NAME OF FOSTER HOME_________________________________
PERSON IN CHARGE____________________
STREET ADDRESS_______________________________________ PHONE #______________________________
DOCUMENT THE APPROPRIATE ANSWERS AS TO THE
CONDITIONS IN THE HOME RELATING TO THE INSPECTION
YES NO N/A
1 Does the occupant utilize listed extension cords These cords shall not be substituted for
permanent wiring and must be used only for portable appliances and shall be listed by
Underwriters Laboratory (UL).
2 Is a Carbon Monoxide (CO) detector installed in homes that use fuel oil products, coal, wood
or gas to heat, cool, cook, operate a hot water heater or gas logs
3 Is a working, mounted “ABC” fire extinguisher(s), with a rating not less than 1-A installed and
readily available in the residence
4 Do emergency telephone numbers and a fire evacuation plan remain posted continually
in a prominent location, and are they visible to all residents and guests
5 Does the home have a working telephone
6
Are there working smoke alarms in the residence that comply with the appropriate rule
CHECK ONE OF THE FOLLOWING
• Houses built prior to 1976: must have a battery or electric smoke alarm
installed outside every sleeping area.
• Houses built 1976 – June 30, 1999: electric smoke alarms shall be placed
outside sleeping areas as required by the code in effect at construction time.
• Houses built after June 30, 1999: must have smoke alarms in every sleeping
room, outside bedrooms and other areas, interconnected as required in the
N.C. Building code.
7 Are all hallways, doorways, entrances, ramps, steps, and corridors unobstructed, free of
storage, and readily accessible
8 Do doors and windows in rooms used for sleeping open properly with little effort
9 Are all designated egress (exit) doors free of double key dead bolt locks
10
Designate Primary heat source:______________________________________________
Designate Secondary heat source (if applicable):________________________________
11 List any substandard components or hazards found which are not addressed above or which
require additional inspections.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
INSPECTOR’S SIGNATURE / TITLE__________________________________ DATE OF INSPECTION__________________
PRINT NAME OF INSPECTOR_____________________________________ INSPECTOR’S PHONE#____________________
FOSTER PARENT’S SIGNATURE__________________________________________________ DATE_____________________
Foster Parent’s signature on this form indicates that he/she understands that any item marked NO on this form will result in non-approval of the home
until the items in question are brought into compliance with licensing regulations.
DSS-1515 (Rev. 02-01-2010)
North Carolina Division of Social Services
Child Welfare Services

Foster Home Environmental Conditions and Health Regulations Checklist
Name: ____________________________________________________
Address: __________________________________________________
City, State, Zip: _____________________________________________ Telephone: ________________________
Yes
No
1) Home and yard are maintained, repaired, and are not hazardous to
children in care. _____ _____
2) The house is free of uncontrolled rodents and insects. _____ _____
3) Windows and doors used for ventilation are screened. _____ _____
4) The kitchen is equipped with an operable stove, refrigerator, and
running water. _____ _____
5) There are sufficient eating, cooking and drinking utensils to
accommodate all household members. _____ _____
6) Household equipment and furniture are in good repair. _____ _____
7) Flammable and poisonous substances, medications, and cleaning
materials are stored out of reach of children placed for foster care. _____ _____
8) Explosive materials, ammunition and firearms are stored in separate
locked places. _____ _____
9) Documentation that household pets have been vaccinated for rabies
is maintained by the foster parents. _____ _____
10) Home has heating, air cooling or ventilating capability to maintain
comfort range between 65° and 85° Fahrenheit. _____ _____
11) Rooms including toilets, baths, and kitchens without operable windows
have mechanical ventilation to outside. _____ _____
12) Discussion of water quality, and sanitary toilet and bathing facilities held. _____ _____
13) Discussion of Building Code held. _____ _____
Remarks and recommendations:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Foster Parent Signature: _________________________________________________________________________
Social Worker Signature: ________________________________________________________________________
Social Worker Title: _____________________________________________ Date: __________________________
DSS-5150 (Rev. 09-01-07)
North Carolina Division of Social Services
Family Support and Child Welfare Services

Foster Home / Residential Child Care
Medical History Form
Name: ______________________________________________________________________
Home Address: _______________________________________________________________
Phone: ___________________________________ Birth date: __________________________
Health History
Any history, past, or present of:
Yes No
Head or back injuries _____ _____
Neurological disorders, convulsions, etc. _____ _____
Heart disease, high blood pressure, or rheumatic fever _____ _____
Lung disorders, asthma, tuberculosis _____ _____
Stomach, gall bladder, or other gastro-intestinal disorders _____ _____
Allergies to food, drug, plant, etc. _____ _____
Blood disorders, anemia, leukemia, etc. _____ _____
Kidney trouble _____ _____
Venereal disease _____ _____
Diabetes or other glandular disorders _____ _____
Surgery _____ _____
Reproductive system problems _____ _____
Psychological disorders, mental health illness _____ _____
Physical disabilities _____ _____
Other chronic illnesses, diseases, or disorders _____ _____
If any of the above questions were answered yes, please elaborate:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What do you consider your state of health: Excellent _____
Fair _____
Good _____
Poor _____
To the best of my knowledge, the above information is correct.
_______________________________________
Signature
DSS-5017 (Rev. 09/28/09)
North Carolina Division of Social Services
Family Support and Child Welfare Services
________________
Date

NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF SOCIAL SERVICES
(Name of Agency Requesting Information)
In order to protect the agency/facility and the children who may reside in the family foster home
or residential child care facility, the agency must obtain medical information on the person
whose name appears below in order to be in compliance with licensure rules. The person named
below has given the agency permission to obtain their medical report and to the release of
information by the licensed medical provider, also named below.
I, , agree to the release of pertinent
information by the licensed medical provider,
. Date:
______________________________________________________________________________
Name
Age
Address
Height Weight Blood Pressure Pulse
History of Illnesses: Yes No Yes No
Tuberculosis or other
Fainting and dizzy spells
pulmonary defects
Venereal disease
Heart Trouble
Seizures
Serious defects of bones and
joints
Mental or emotional
disturbance
Other chronic or
communicable diseases
Hypertension
Specify if yes:
Physical Examination (Circle all that were examined.)
Heart Lungs Abdomen Genitalia
ENT Extremities Hernia Eyes
Date of examination:
Date of tuberculin skin test: Result: Positive Negative
Date of chest X-ray*:
Findings:
*(Required only if tuberculin test positive)
Please comment on any physical, mental or emotional condition or communicable/infectious
disease apparent from your examination or any knowledge of the above-named person that might
affect the health, safety or welfare of children residing in the home of facility:
Physician’s, PA’s or NP’s Signature:
Address:
Date:
Phone:
DSS-5156 (9-1-02)
Children’s Services

Tips for Using the DSS-5016
This form was updated on 2/10. It is an interactive form that must be typed. Do not submit a
handwritten form. If your agency needs the word format of the document send an e-mail
request to one of the Program Consultants at the Licensing Office.
I. Name, Criminal History & Background Check information
A. Provide middle names and all married names of applicants. Please note that you do not need
to request waivers for applicants who do not have a high school diploma or a GED. If applicants
do not have a high school diploma or GED they must have the ability to read and write as
evidenced by administering medications as prescribed by a licensed medical provider, maintain
medication administration logs and maintain progress notes.
C. You must list all of the court findings. The findings must be listed as they appear in the court
documents. This means that specific traffic findings with specific charges and dates have to be
listed. You cannot state minor traffic offenses, nothing serious, etc. In the explanation of
findings section provide documentation as to why the applicant has criminal charges and what
has changed to prevent the reoccurrence of these criminal charges. Background checks need
to be dated within 180 days of receiving the packet at the Licensing Office.
E. Supervising agencies are required to check any child abuse and neglect registry in each
State the prospective foster parent(s) and any other adult(s) living in the home have resided in
the preceding five years. These clearance letters/documents are to be sent to the Licensing
Office and placed after the signature page of Form 5016. This is a federal requirement and
there are no exceptions. If a state agency refuses to provide a clearance letter the foster home
cannot be licensed.
F. If the family has been previously licensed as foster parents contact the previous supervising
agency for a report on the family and the agency’s recommendations concerning the family’s
ability to provide foster care services. Write a brief summary of what was learned from the
previous agency.
G. Any applicant babysitting in their home on a regular basis meets the definition of an in-home
day care for licensing purposes.
II. Foster Home Qualifications
D. List the full names of all children the applicants have parented and their relationship to these
children (some may be adults now).
III. Standards for Licensure
Read all the questions and check the boxes accordingly. Frequently we receive 5016’s where
the licensing worker has checked YES to all the questions. Please note that some answers
should be NO or NA. For example, if the agency does not utilize Physical Restraints (Item C)
the answer should be NA.
D. Physical Restraints
Pay particular attention to this item. This question has to be answered for every application
whether the agency does or does not utilize physical restraints. The answer should always be
YES. Foster parents must agree to not use drugs to restrain children.
IV. Conflict of Interest
This is another instance where some licensing workers automatically check YES and the
answers probably should be NO. If the answer is YES you will need to request a waiver.

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V. Day Care Center Operation
If the applicants do not operate a day care center or do not plan to operate a day care center
check NO and NA for B 1, 2, 3. If the applicants operate a day care center or plan to operate a
day care center check YES. If the applicants operate a day care center or plan to operate a day
care center the answers to the three questions at B. 1, 2, 3 should be YES.
VII. Physical & Environmental Safety
A. Errors on the fire inspection form (DSS-1515) cause the most delays in completing the
licensing and relicensing process.
D. Exterior Setting and Safety
2. If there is a pool it has to be fenced. If there is a body of water such as a pond or stream,
describe distance away from the home, if it is visible from the applicant’s home and are there
any barriers in between the home and the water.
Supervision alone is not enough to meet safety requirements. You must consider more than the
chronological age of a child when assessing safety factors. What is the maturity level of the
child Are there developmental delays
E. Room Arrangements and Environment
1. A description of the home and the setting in which the home is located have to be completed.
3. Sleeping Arrangements Chart
Need to show enough space and beds for the number of foster children requested in the
capacity. Each foster child must have his/her own bed. Futons and day beds cannot be used.
Bedrooms cannot be used for dual purposes.
List the names of all household members, except prospective foster children, in the bedroom
and type of bed where they sleep. For foster children use the initials FC immediately before the
type of bed (i.e. FC/twin, FC/crib, FC/queen) in the appropriate bedroom (1, 2, 3, 4, 5) to
designate the bedroom and type of bed where the prospective foster child will sleep.
VIII. Training Requirements
A. Put the date the pre-service training was completed. If it has been more than two years since
the applicants completed pre-service training they must repeat the training or the supervising
agency must review the pre-service requirements and provide documentation that they continue
to understand and are able to operationalize the requirements. The requirements are: (a)
General Orientation to Foster Care and Adoption Process; (b)Communication Skills; (c)
Understanding the Dynamics of Foster Care and Adoption Process; (d) Separation and Loss;
(e) Attachment and Trust; (f) Child and Adolescent Development; (g) Behavior Management; (h)
Working with Birth Families and Maintaining Connections; (i) Lifebook Preparation; (j) Planned
Moves and the Impact of Disruptions; (k) The Impact of Placement on Foster and Adoptive
Families; (l) Teamwork to Achieve Permanence; (m) Cultural Sensitivity; (n) Confidentiality; and
(o) Health and Safety.
X. Criteria for the Foster Family & Mutual Home Assessment
A. Review Forms 5017 and 5156. If a family member or the medical professional completing
Form 5017 or Form 5156 indicates that there are medical or mental health issues discuss this in
the gray block below the chart. Please note that if you check YES to good physical and good
mental health you need to explain why the answer is YES after the family member or the
medical professional has indicated an issue/concern. This explanation is to be documented in
the gray block below the chart.

3
B. Mutual Home Assessment
I. Family History
A thorough explanation is needed for the 13 items listed under Family History in the appropriate
blocks on form 5016 (Information about parents and siblings to Day Care Plans). In the
Marriages and other significant relationships section, provide more information than just
previously married. Include significant relationships especially when children are born from
these relationships. In the Parenting Experiences section, provide more information about who
and how they parented. If they are not parents, describe any important relationships with
relative children or other children in youth groups (Big Brother & Big Sister) or church
involvement.
If you substitute a preplacement assessment for the Family History the preplacement
assessment must meet all the rule requirements in 10A NCAC 70H .0405 found at this web site:
(http://www.ncdhhs.gov/dss/licensing/docs/70H%20June12010.pdf). There are 28 items that
must be addressed in the preplacement assessment: (1) the applicants' reasons for wanting to
adopt; (2) the strengths and needs of each member of the household; (3) the attitudes and
feelings of the family, extended family, and other individuals involved with the family toward
accepting adoptive children, and parenting children not born to them; (4) the attitudes of the
applicants toward the birth parents and in regard to the reasons the child is in need of adoption;
(5) the applicants' attitudes toward child behavior and discipline; (6) the applicants' plan for
discussing adoption with the child; (7) the emotional stability and maturity of applicants; (8)the
applicants' ability to cope with problems, stress, frustrations, crises, and loss; (9) the applicants'
ability to give and receive affection; (10) the applicants' child-caring skills and willingness to
acquire additional skills needed for the child's development; (11) the applicants' ability to provide
for the child's physical and emotional needs; (12) whether the applicant has ever been
convicted of a crime other than a minor traffic violation; (13) the strengths and needs of birth
children or previously adopted children; (14) the applicant's physical and mental health,
including any addiction to alcohol or drugs; (15) financial information provided by the applicant,
including property and income; (16) the applicants' personal character references; (17) the
applicant's religious orientation, if any; (18) the location and physical environment of the home;
(19) the plan for child care if parents work; (20) recommendations for adoption in regard to the
number, age, sex, characteristics, and special needs of children who could be best served by
the family; (21) any previous request for an assessment or involvement in an adoptive
placement and the outcome of the assessment or placement; (22) whether the individual has
ever been a respondent in a domestic violence proceeding or a proceeding concerning a minor
who was allegedly abused, neglected, dependent, undisciplined or delinquent, and the outcome
of the proceeding or whether the individual has been found to have abused or neglected a child
or has been a respondent in a juvenile court proceeding that resulted in the removal of a child or
has had child protective services involvement that resulted in the removal of a child; (23)
documentation of the results of the search of the Responsible Individual's List as defined in 10A
NCAC 70A .0102 for all adult members of the household that indicates they have not had child
protective services involvement resulting in a substantiation of child abuse or serious neglect;
(24) whether the applicant has located a parent interested in placing a child for adoption with the
applicant, and a brief, non identifying description of the parent and the child; (25) the applicants'
age, date of birth, nationality, race or ethnicity; (26) the applicant's marital and family status and
history, including the presence of any children born to or adopted by the applicant, and any
other children in the household; (27) the applicant's educational and employment history and
any special skills; and (28) any additional fact or circumstance that may be relevant to a
determination of the applicant's suitability to be an adoptive parent, including the quality of the
home environment and the level of functioning of any children in the household.
II. 12 Skills
The assessment of 12 skills must include specific behavioral language:
• Example - Helping children placed in the home maintain and develop relationships that
will keep them connected to their pasts - Strength: “Mrs. Smith expresses an

4
understanding of the importance of maintaining attachments and family and cultural
identity”) followed by specific examples to support that conclusion (Example - “Mrs.
Smith supports her sister’s efforts to keep her adopted niece and nephew connected to
their culture of origin by celebrating Vietnamese new year with them and by preparing
Vietnamese food”) (Need – Mrs. Smith will research traditions and cultural values of the
foster children as they enter her care.
• Example - Strength: “Mrs. Smith communicates effectively and develops successful
partnerships.” followed by specific examples - “Mrs. Smith is a deacon in her church and
teaches Sunday school.” “Mrs. Smith is a store manager who leads team meetings and
supervises five employees.” “Mrs. Smith was an active member of the pre-service group
who asked appropriate questions at the right time and listened to others.” Need – Mrs.
Smith wants to be a better listener and will seek out training to develop this skill.
• Avoid affective/cognitive language such as “understands,” “knows,” “feels,” and
“appreciates” in the examples you give to support your conclusions
• Instead, support your conclusions by describing the applicant’s specific behaviors or the
words that she used. “Mrs. Smith, who lost her grandmother five years ago, says she
recovered from the loss through prayer, increased involvement in her church, and by
spending additional time in her garden.”
• Remember that applicants can demonstrate the 12 skills in ways that don’t involve
children, such as in their job, volunteer work, or hobbies.
• For further guidance concerning the 12 skills refer to pages 19-24 in the document “A
Supplemental Guide to Foster Home Licensing” at the following web site:
http://www.ncdhhs.gov/dss/licensing/docs/Guide-chp3.pdf
III. Assessment of Shared Parenting
Provide more information than they understand and are willing to participate. For further
guidance see page 26 in the document “A Supplemental Guide to Foster Home Licensing” at
the following web site: http://www.ncdhhs.gov/dss/licensing/docs/Guide-chp3.pdf
IV. Financial Ability
Give the TOTAL monthly income of applicants and the anticipated TOTAL monthly expenses.
You do not have to itemize the income or expenses, just give a grand total. We ask agencies to
pay close attention to the suitability of applicants who are in arrears for child support payments.
The income needs to be more than the expenses. Applicants need to be able to absorb the
extra financial strain that can come from providing foster care.
V. Dates and Locations of visits
Please note that Rule 10A NCAC 70E .0802 requires the applicant(s) to be interviewed by the
licensing social worker in the family's home and in the supervising agency’s office. For twoparent
homes, separate as well as joint discussions with both parents shall be arranged. For
foster homes with more than two parents, separate as well as joint discussions with all parents
shall be arranged. Interviews should also be scheduled with the children of the prospective
foster parents to determine their feelings and response to foster children being placed in the
home.
Training, phone, e-mail contacts do not count.
XI. Recommendations
Unless your agency is recommending the applicant you should not send an application to the
Licensing office.
Signature Page
Make sure Applicant(s), Social Worker and Director or Designee have signed and dated the
application.

FOSTER HOME LICENSE APPLICATION
Required Applicants (10A NCAC 70E .1104 (d)). Foster parent applicants who are married are presumed to be coparents
in the same household and both shall complete all licensing requirements. Adults 21 years of age or older,
living in currently licensed or newly licensed foster homes who have responsibility for the care, supervision, or
discipline of the foster child shall complete all licensing requirements. The supervising agency shall assess each
adult's responsibility for the care, supervision, or discipline of the foster child.
I. NAME, CRIMINAL HISTORY & BACKGROUND CHECK INFORMATION (10A NCAC 70E .1114 & .1116)
A. Name & Education Level
Applicant’s Full Name
(First, Middle., Last)
Maiden Name Previous Married Name *Education
Level
*Education Level (Indicate HS, GED, BA, BS, MS, PhD)
Applicants without a High School Diploma or GED have the ability to read and write as evidenced by their ability
to administer medications as prescribed by a licensed medical provider, maintain medication administration logs
and maintain progress notes. YES NO
B. Mailing address, if different than home address:
C. North Carolina Criminal History & Background Check Information
Type of Background Check
Check Date
Findings:
Conducted Conducted
Local Court Record Checked by Agency Staff YES NO Date :
Findings:
Explanation of Findings:
NC Dept. of Corrections Offender Information http://www.doc.state.nc.us/offenders/ YES NO Date:
Findings:
Explanation of Findings:
NC Sex Offender and Public Protection Registry http://sexoffender.ncdoj.gov/ YES NO Date:
Findings:
Explanation of Findings:
Health Care Personnel Registry https://www.ncnar.org/nchcpr.html YES NO Date:
Findings:
Explanation of Findings:
D. North Carolina Child Abuse Neglect History
Child Abuse or Neglect Reported: YES NO
Substantiation: YES , Date of Substantiation: NO N/A
Explanation of Findings:
E. Complete Section E if applicant has NOT resided in NC for the past five years.
Previous Address(es)
Dates of Residency
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Child Central Registry Check from above State(s) of residence regarding applicant as a
perpetrator of abuse or neglect if he/she DID NOT reside in NC for the past five years.
Date Conducted:
Place child abuse/neglect clearance letters from other state(s) after the signature page. Any findings of child
abuse/neglect, criminal history or background check offenses will require a letter of explanation and support
from the agency director.
F. Have any of the applicants been previously licensed as foster parents YES NO
If Yes, Document information provided by the previous agency regarding the foster parenting
experiences of the
applicant.
G. Does Applicant have an In-Home Day Care YES NO If ‘YES’ attach copy of Day Care License (Place this
document after the signature page).
II. FOSTER HOME QUALIFICATIONS (10A NCAC 70E .1001)
A. Applicants' Own Children in Home
Name
(First, Middle., Last)
DOB Sex Education
Level
B. Others in Household
Name-include relatives, non-related boarders, day
care, babysitting children, etc.
(First, Middle, Last)
DOB Sex Relationship to Family
C. Foster Children Presently in Home Indicate if court ordered placement of relative, non-relative or child in
custody of an out-of state agency. Indicate with an asterisk (*) children placed for therapeutic services.
Name
(First, Middle., Last)
DOB Sex Education Level Date of Placement
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D. Applicants’ Own Children Not in Home including children applicant has parented in the past (step, relative,
non-related, etc.) (This does NOT include foster children.)
Name
(First, Middle, Last Name prior to marriage)
DOB Sex Address (City/State)
ANSWERS TO THE FOLLOWING QUESTIONS SHOULD RELATE TO OWN CHILDREN, RELATIVE AND/OR
FOSTER CHILDREN. IF APPLICANT HAS NO PARENTING EXPERIENCE, ANSWERS SHOULD REFLECT
RESPONSES DURING DISCUSSION OF THESE TOPICS.
III. STANDARDS FOR LICENSURE (10A NCAC 70E .1100)
A. Clients Rights and Care of Children (10A NCAC 70E .1101)
Applicants agree to ensure that each foster child: YES NO
(1) has clothing to wear that is appropriate to the weather;
(2) is allowed to have personal property;
(3) is encouraged to express opinions on issues concerning care;
(4) is provided care in a manner that recognizes variations in cultural values and traditions;
(5) is provided the opportunity for spiritual development and is not denied the right to practice religious
beliefs;
(6) is not identified in connection with the supervising agency in any way that would bring the child or the
child's family embarrassment;
(7) is not forced to acknowledge dependency on or gratitude to the foster parents;
(8) is encouraged to contact and have telephone conversations with family members, when not
contraindicated in the child's visitation and contact plan;
(9) is provided training and discipline that is appropriate for the child's age, intelligence, emotional
makeup, and past experience;
(10) is not subjected to cruel or abusive punishment;
(11) is not subjected to corporal punishment;
(12) is not deprived of a meal or contacts with family for punishment or placed in isolation time-out except
when isolation time-out means the removal of a child to an unlocked room or area from which the child
is not physically prevented from leaving. The foster parent may use isolation time-out as a behavioral
control measure when the foster parent provides it within hearing distance of a foster parent. The
length of time alone shall be appropriate to the child's age and development;
(13) is not subjected to verbal abuse, threats, or humiliating remarks about himself/herself or his/her
families;
(14) is provided a daily routine in the home that promotes a positive mental health environment and provides
an opportunity for normal activities with time for rest and play;
(15) is provided training in good health habits, including proper eating, frequent bathing, and good
grooming. Each child shall be provided food with nutritional content for normal growth and health.
Any diets prescribed by a licensed medical provider shall be provided;
(16) is provided medical care in accordance with the treatment prescribed for the child;
(17) of mandatory school age maintains regular school attendance unless the child has been excused by the
authorities;
(18) is encouraged to participate in neighborhood and group activities, have friends visit the home and visit
in the homes of friends.
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(19) assumes responsibility for herself/himself and household duties in accordance with her/his age, health,
and ability. Household tasks shall not interfere with school, sleep, or study periods;
(20) is provided opportunities to participate in recreational activities;
(21) is not permitted to do any task which is in violation of child labor laws or not appropriate for a child of
that age;
(22) is provided supervision in accordance with the child's age, intelligence, emotional makeup, and
experience; and
(23) if less than eight years of age and weighs less than 80 pounds is properly secured in a child passenger
restraint system that is approved and installed in a manner authorized by the Commissioner of Motor
Vehicles.
B. Medication (10A NCAC 70E .1102)
Foster parents agree to be responsible for the following regarding medication: YES NO
(1) General requirements:
(a) Retain the manufacturer's label with expiration dates visible on non-prescription drug
containers not dispensed by a pharmacist;
(b) Administer prescription drugs to a child only on the written order of a person
authorized by law to prescribe drugs;
(c) Allow prescription medications to be self-administered by children only when
authorized in writing by the child's licensed medical provider;
(d) Allow non-prescription medications to be administered to a child taking prescription
medications only when authorized by the child's licensed medical provider; allow nonprescription
medications to be administered to a child not taking prescription medication, with
the authorization of the parents, guardian, legal custodian, or licensed medical provider;
(e) Allow injections to be administered by unlicensed persons who have been trained by a
registered nurse, pharmacist, or other person allowed by law to train unlicensed persons to
administer injections;
(f) Immediately record in a Medication Administration Record (MAR) provided by the
supervising agency all drugs administered to each child. The MAR shall include the
following: child's name; name, strength, and quantity of the drug; instructions for
administering the drug; date and time the drug is administered, discontinued, or returned to the
supervising agency or the person legally authorized to remove the child from foster care; name
or initials of person administering or returning the drug; child requests for changes or
clarifications concerning medications; and child's refusal of any drug; and
(g) Follow-up for child requests for changes or clarifications concerning medications with an
appointment or consultation with a licensed medical provider.
(2) Medication disposal:
(a) Return prescription medications to the supervising agency or person legally authorized to
remove the child from foster care; and
(b) Return discontinued prescription medications to a pharmacy or the supervising agency for
disposal, in accordance with 10A NCAC 70G .0510(c).
(3) Medication storage:
(a)
(b)
Store prescription and over-the-counter medications in a locked cabinet in a clean, welllighted,
well-ventilated room other than bathrooms, kitchen, or utility room between 59º F
(15 º C) and 86º F (30° C);
Store medications in a refrigerator, if required, between 36º F (2º C) and 46º F (8º C). If the
refrigerator is used for food items, medications shall be kept in a separate, locked compartment
or container within the refrigerator; and
(c) Store prescription medications separately for each child.
(4) Psychotropic medication review:
(a) Arrange for any child receiving psychotropic medications to have their drug regimen reviewed
by the child's licensed medical provider at least every six months;
(b) Report the findings of the drug regimen review to the supervising agency; and
(c) Document the drug review in the MAR along with any prescribed changes.
(5) Medication errors:
(a) Report drug administration errors or adverse drug reactions to a licensed medical provider
or pharmacist; and
(b) Document the drug administered and the drug reaction in the MAR.
C. Physical Restraints (10A NCAC 70E .1103)
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(1) Foster parents who utilize physical restraint holds agree to not engage in discipline or behavior
management, which includes: YES NO N/A
(a) protective or mechanical restraints;
(b) drug used as a restraint, except as outlined in Paragraph (b) of this Rule;
(c) seclusion of a child in a locked room; or
(d) physical restraint holds except for a child who is at imminent risk of harm to himself/herself or
others until the child is calm.
(2) Foster Parents agree to meet the following regarding training requirements and the use to physical
restraints: YES NO N/A
(a) Before a foster parent shall administer physical restraint holds, each foster parent shall
complete training that includes at least 16 hours of initial training in behavior management,
including techniques for de-escalating problem behavior, the appropriate use of physical
restraint holds, monitoring of vital indicators, and debriefing children and foster parents
involved in physical restraint holds.
(b) Foster parents authorized to use physical restraint holds shall annually complete at least eight
hours of behavior management training including techniques for de-escalating problem
behavior.
(c) This training shall count toward the training requirements as set forth in 10A NCAC 70E
.1117(f)(6).
(d) Only foster parents trained in the use of physical restraint holds shall administer physical
restraint holds.
(3) Foster parents agree to the following regarding the administration of physical restraints:
YES NO N/A
(a) foster parents shall use only those physical restraint holds approved by the North Carolina
Interventions (NCI) Quality Assurance Committee. Approved physical restraint holds can be
found at the following web site:
http://www.dhhs.state.nc.us/mhddsas/training/rscurricula/reviewedcurriculabyname.pdf
(b) before employing a physical restraint hold, the foster parent shall take into consideration the
child's medical condition and any medications the child may be taking;
(c) no child shall be restrained utilizing a protective or mechanical device;
(d) no child or group of children shall be allowed to participate in the physical restraint of another
child;
(e) physical restraint holds shall:
(ii) not be used for purposes of discipline or convenience;
(ii) be used only when there is imminent risk of harm to the child or others and less
restrictive approaches have failed;
(iii) be administered in the least restrictive manner possible to protect the child or others
from imminent risk of harm; and
(iv) end when the child becomes calm.
(f) The foster parent shall:
(i) ensure that any physical restraint hold utilized on a child is administered by a trained
foster parent with a second trained foster parent or with a second trained adult in
attendance. Concurrent with the administration of a physical restraint hold and for a
minimum of 15 minutes subsequent to the termination of the hold, a foster parent
shall monitor the child's breathing, ascertain the child is verbally responsive and
motorically in control, and ensure the child remains conscious without any complaints
of pain. The supervising agency may seek a waiver from the licensing authority for a
foster parent to administer a physical restraint hold without a second trained adult in
attendance, based on the following criteria: completion of the waiver request form.
The licensing authority shall grant the waiver if it receives approval from the child's
parent, guardian, or custodian that the administering of a physical restraint hold
without a second trained person present is acceptable, written approval from the
supervising agency that the foster parent is authorized to administer a physical
restraint hold without a second trained person present, and documentation that there is
approval by the child and family team and documented in the person-centered plan or
out-of-home family services agreement that it is acceptable for the foster parent to
administer a physical restraint hold without a second trained person present;
(ii) immediately terminate the physical restraint hold or adjust the position to ensure that
the child's breathing and motor control are not restricted, if at any time during the
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administration of a physical restraint hold the child complains of being unable to
breathe or loses motor control;
(iii) immediately seek medical attention for the child, if at any time the child appears to be
in distress; and
(iv) conduct an interview with the foster child about the incident following the use of
a physical restraint hold.
(g) The foster parent shall cooperate with and provide information to the supervising agency
who shall:
(i) interview the foster parent administering the physical restraint hold about the incident
following the use of a physical restraint hold;
(ii) document each incident of a child being subjected to a physical restraint hold on an
Incident Report provided by the licensing authority. The incident report shall include
(1) the child's name, age, height, and weight; (2) the type of hold utilized; (3) the
duration of the hold; (4) the trained foster parent administering the hold; (5) the
trained foster parent or trained adult witnessing the hold; (6) the less restrictive
alternatives that were attempted prior to utilizing physical restraint; (7) the child's
behavior that necessitated the use of physical restraint; and (8) whether the child's
condition necessitated medical attention.
(4) Foster parents agree to annually receive written approval from the executive director or his/her designee
of the supervising agency before administering physical restraint holds. The foster parent shall retain a
copy of the written approval and a copy shall be placed in the foster home record.
YES NO N/A
D. Physical Restraints (10A NCAC 70E .1103)
Foster parents agree to the following regarding physical restraints and the use of drugs:
YES
NO
(a) Drugs shall not be used for the purpose of restraining a child.
(b) A drug used as a restraint means a medication used only to control behavior or to restrict a
(c)
child's freedom of movement, and is not a standard to treat a psychiatric condition.
A drug shall not be used for the purpose of punishment, foster parent convenience, or
substitution for adequate supervision.
IV. CONFLICT OF INTEREST (10A NCAC 70E .1105)
A. Applicant supervised by a Public or Private child-placing agency is a member of agency board of
directors, governance structure, social services board, county commission or is an agency employee or
relative of an agency employee YES NO
B. Applicant to be supervised by a Private child-placing agency and is an owner of that Private child placing
agency YES NO
V. DAY CARE CENTER OPERATION (10A NCAC 70E .1106)
A. Do the applicants operate or plan to operate a day care center YES NO
B. If the applicants operate or plan to operate a day care center do they meet the following criteria
(1) the foster home living quarters shall not be part of the day care operation YES NO NA
(2) there shall be a separate entrance to the day care operation YES NO NA
(3) staff specified in day care center rules shall be available to provide care for
the day care children YES NO NA
VI.
RELATIONSHIP TO SUPERVISING AGENCY & COMPLIANCE VISITS (10A NCAC 70E .1107 &
.1113)
A. Applicants agree to work with the supervising agency in the following ways: YES NO
(1) Work with the child and the child's parent(s) or guardian(s) in the placement
process, reunification process, adoption process, or any change of placement process;
(2) Consult with social workers, mental health personnel, licensed medical providers, and
other persons authorized by the child’s parent(s), guardian(s), or custodian(s) who are involved with the
child;
(3) Maintain confidentiality regarding children and their parent(s) or guardian(s);
(4) Keep records regarding the child's illnesses, behaviors, social needs, educational needs, and
family visits and contacts; and
(5) Report to the supervising agency any changes as required by 10A NCAC 70E .0902
(6) Complete in-service training as required in 10A NCAC 70E .1117 and obtain required documentation
for relicensure 180 days prior to expiration of license biennially
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B. Quarterly Visits: Applicants agree to allow licensing social workers from the supervising agency to visit
the home or meet with the licensing social worker outside of the home on at least a quarterly basis for the
specific purpose of assessing licensing requirements. Minimally, two of the quarterly visits each year
shall take place in the foster home. Visits outside of the home may occur at a location of the licensing
social workers preference. YES NO
C. Foster parents who provide therapeutic foster care services agree to allow weekly supervision and support
from a qualified professional as defined in 10A NCAC 27G .0104 and .0203. YES NO N/A
VII. PHYSICAL & ENVIRONMENTAL SAFETY (10A NCAC 70E .1108, .1109, .1110, .1112)
A. Fire & Building Safety
(1) Fire and Building Safety regulations met as evidenced by DSS-1515 Fire and Building Safety
Inspection Form attached. YES NO
B. Health Regulations
(1) Discussion was held regarding water quality and sanitation. Family is not aware of any health
hazards caused by the family’s water supply and sanitation facilities, and has informed the
supervising agency about any water testing that has been done and any immediate or past problems
concerning water quality and sanitation. There is no reason to believe the water supply is not safe or
the toilet and bathing facilities are not sanitary. YES NO
C. Environmental Regulations
(1) Environmental regulations met as evidenced by DSS-5150 Environmental Conditions Checklist
attached YES NO
D. Exterior Setting & Safety
(1) Exterior spaces around the foster home, including any yard spaces are clear of any
dangerous objects or hazardous items YES NO
(2) Exterior spaces around the foster home are clear of bodies of water such as: swimming pools,
beaches, rivers, lakes, streams, ponds, etc. YES NO
If you answered ‘NO’ to (1) or (2) document how access to these objects, hazardous items, and/or
bodies of water is avoided:
E. Room Arrangements and Environment
(1) Briefly describe house, kitchen and dining areas, family or living areas and bathing facilities, and the
setting in which the house is located.
(2) Home’s design allows children privacy while bathing, dressing, and using toilet facilities
YES
NO
(3) Indicate sleeping arrangements in Table Below for all members of the household including prospective
and current foster children. Bedrooms shall be identified as such and not serve dual purposes. Each
child must have his/ her own bed. Identify types of beds in each bedroom and who occupies each bed.
Only describe beds that are available or in use as of the date of application.
Bed Type: Twin, Full, Queen, King, Bunk-Twin/Twin, Bunk – Full/Twin, Crib.
Occupant(s): To signify occupant list name of Applicant(s), Applicant’s Minor Child, Applicant’s
Relative Child, any Non-relative child, or Adult household member occupying each bed. Enter
“FC”(Foster Child) as the occupant where applicable to signify beds available for foster children.
SLEEPING
ARRANGEMENTS
CHART
Example Bedroom 0.
Bedroom 1.
Bedroom 2.
Bedroom 3.
Bedroom 4.
Bed Type / Occupant(s) Bed Type / Occupant(s) Bed Type / Occupant(s)
Queen / Mr. & Mrs.
Applicant
Crib/FC
Bed Type /
Occupant(s)
DSS-5016 (Rev. 02/10)
Child Welfare Services
Bedroom 5.
(4) Each bed is provided with comfortable, supported mattress, two sheets, blanket and
bedspread YES NO
7

(5) Separate and accessible drawer space and closet space for personal belongings and clothing
available for each child YES NO
VIII. TRAINING REQUIREMENTS
A. Each applicant has successfully completed 30 hours of pre-service training covering the components
listed in 10A NCAC 70E .1117 (1). YES NO Date Completed: / /
B. Each applicant agrees to receive training in medication administration and; first-aid, cardiopulmonary
resuscitation (CPR) and universal precautions such as those provided by the American Red Cross, the
American Heart Association or equivalent organizations before a foster child is placed with the foster family.
YES
NO
C. Each applicant agrees and understands they must successfully complete at least 10 hours annually
of in-service training to be re-licensed. YES NO
D. Each applicant agrees to receive six hours of advanced medical training consisting of issues relevant
to human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) annually if
they care for a child with HIV or AIDS. YES NO
E. Each family foster parent applicant agrees to receive child specific training as outlined in the out-of-home family
services agreement. This training will count towards the 20 hours of in-service training requirement.
YES
NO
F. Each therapeutic foster parent applicant has successfully completed 10 hours of additional pre-service training
covering the components listed in 10A NCAC 70E .1117 (2).
YES NO N/A Date Completed: / /
G. Each therapeutic foster parent applicant understands and agrees to receive additional training as specified in 10A
NCAC 70E .1117 (3). This training will count towards the 20 hours of in-service training requirement.
YES NO N/A
H. Each therapeutic foster parent applicant understands and agrees to receive additional child-specific training and
supervision as required in 10A NCAC 70E .1117 (5). This training will count towards the 20 hours of in-service
training requirement. YES NO N/A
IX. OTHER (10A NACA 70E subsections .0806, .0902, .1101, .1116, .0804)
A. Foster Parent Agreement signed and copy given to applicant(s) YES NO
B. Discipline Agreement signed and copy given to applicant(s) YES NO
C. Written notice regarding criminal history checks as required by G.S. 131D-10.3A(e) given to applicant(s)
and adult household member(s) YES NO
D. At least 3 References obtained on all adult members of the foster home, copies in agency file
YES NO
E. Agency Foster Parent Handbook with information on services, policies, standards, and expectations has been
discussed with and reviewed by applicant(s) YES NO
F. Waiver of licensing rule requested and DSS-5199 Waiver Request form attached. YES NO
X. CRITERIA FOR THE FOSTER FAMILY & MUTUAL HOME ASSESSMENT (MHA) (10A NCAC 70E .0800,
.0802, .0803 & .1104) Applicants are persons whose behaviors, circumstances and health are conducive to the safety and
well-being of children.
A. Physical and Mental Health of Applicants: The foster family shall be in good physical and mental health as
evidenced by: DSS-5017, DSS-5156, and TB test results attached. YES NO
(1) Answer ‘YES’ in the chart below regarding Physical Health if there is NO indication of significant
Physical Health needs as reported on DSS 5017 – Medical History form, DSS 5156 – Request for
Medical Information form, and TB test results (TB tests required for all adults 18 years old and up;
children under 18 only need to be tested if an adult in the home has tested positive).
(2) Answer ‘YES’ in the chart below regarding Mental Health if there is NO indication of significant
Mental Health needs as reported on DSS 5017 – Medical History form, DSS 5156 – Request
for Medical Information form, and as indicated by the following factors:
Name of Applicant/ Household Member
Good Physical Health
Check Yes or No
Good Mental Health
Check Yes or No
Example Mr. Applicant YES NO YES NO
YES NO YES NO
YES NO YES NO
DSS-5016 (Rev. 02/10)
Child Welfare Services
8

YES NO YES NO
YES NO YES NO
Answer here regarding all Children in the home. YES NO YES NO
If the answer is ‘NO’ for any applicant, household member or child, explain how the identified medical or mental health
need(s) will affect the ability of the applicant(s) to care for the children in foster care.
Attach doctor, psychologist, counselor, therapist notes as needed.
(3) Is there an indication of alcohol abuse, drug abuse or illegal drug use by a member of the foster family
YES
NO
(4) Is there an indication that a member of the foster family is a perpetrator of domestic violence
YES
NO
(5) Is there an indication that a member of the foster family has abused, neglected, or exploited a disabled
adult YES NO
(6) Is there an indication that a member of the foster family has been found to have abused or
neglected a child or has been a respondent in a juvenile court proceeding that resulted in the
removal of a child or has had child protective services involvement that resulted in the removal
of a child YES NO
If the answer to any of the above questions (3,4,5,6) is YES provide an explanation.
B. Mutual Home Assessment: The mutual home assessment shall be carried out in a series of planned
discussions between the supervising agency staff, the prospective foster parent applicants and other
members of the household. The family shall be seen by the social worker in the family's home and in
the supervising agency's office. For two or more applicants, separate as well as joint discussions with
all applicants shall be arranged. The mutual home assessment is completed by the licensing
professional or social worker.
There are Five Parts ( I – V) to the Mutual Home Assessment.
Part I. Documentation of Family History – A preplacement assessment (adoption study) can be
substituted for the Family History. MAPP profiles, agency questionnaires/applications are unacceptable. Are
you substituting a preplacement assessment for the Family History YES NO (If YES, attach after the
signature page). A preplacement assessment (adoption study) CANNOT be substituted for the assessment of
the 12 Skills in Part II.
Foster Parent Applicant Foster Parent Applicant
Name:
Race:
Birth Date:
Place of Birth:
Marital Status:
Date of Marriage:
Place of Marriage:
County of Residence:
DSS-5016 (Rev. 02/10)
Child Welfare Services
9

Present Employment:
Phone Number:
Information about parents and siblings (who raised applicants, describe relationship with parents and siblings, describe
parents’ relationship with each other):
Family Support Systems in family of origin and currently:
Disciplinary methods used by the applicants’ parents:
Personal experiences of abuse, neglect and domestic violence in family of origin and currently:
Significant experiences of loss and ability to cope with loss, grief, problems, stress, frustrations, crises:
Drug or alcohol abuse (in family of origin and currently):
Education and Employment History:
Religious orientation {(if any) in family of origin and currently}:
Marriages and other significant relationships:
Parenting Experiences:
Emotional stability and maturity:
Ability to give and receive affection:
Child Care Plans (if applicable):
Part II. Documentation of Assessment of 12 Skills – completed by licensing professional. Foster parents
shall be selected on the basis of demonstrating strengths in the skill areas of 10A NCAC 70E .1004 (a), (1)
through (12)which permit them to undertake and perform the responsibilities of meeting the needs of
children, in providing continuity of care, and in working with the supervising agency. Foster parents shall
demonstrate skills in:
Skill 1: Assessing individual and family strengths and needs and building on strengths and meeting needs.
Strength:
Need:
DSS-5016 (Rev. 02/10)
Child Welfare Services
10

Skill 2: Using and developing effective communication.
Strength:
Need:
Skill 3: Identifying the strengths and needs of children placed in the home.
Strength:
Need:
Skill 4: Building on children's strengths and meeting the needs of children placed in the home.
Strength:
Need:
Skill 5: Developing partnerships with children placed in the home, parents or the guardians of the children placed in
the home, the supervising agency and the community to develop and carry out plans for permanency.
Strength:
Need:
Skill 6: Helping children placed in the home develop skills to manage loss and skills to form attachments.
Strength:
Need:
Skill 7: Helping children placed in the home manage their behaviors.
Strength:
Need:
Skill 8: Helping children placed in the home maintain and develop relationships that will keep them connected to their
pasts.
Strength:
Need:
Skill 9: Helping children placed in the home build on positive self-concept and positive family, cultural, and racial
identity.
Strength:
Need:
Skill 10: Providing a safe and healthy environment for children placed in the home which keeps them free from harm.
Strength:
Need:
Skill 11: Assessing the ways in which providing family foster care or therapeutic foster care affects the family.
Strength:
Need:
DSS-5016 (Rev. 02/10)
Child Welfare Services
11

Skill 12: Making an informed decision regarding providing family foster care or therapeutic foster care.
Strength:
Need:
Part III. Assessment of applicant’s willingness to participate in Shared Parenting requirements.
Part IV. Assessment of applicant’s Financial Ability to provide foster care.
Monthly Income:
Monthly Expenses: (Rent, Mortgage, Car Payments, Utilities, Food, Child Support, Miscellaneous, Other)
Part V. Dates and Locations (Home Visit, Office Visit, Etc.) of Contacts with each applicant and family
members. (Do Not include the dates applicants attended training.)
Dates of Visits Locations of Visits Individuals Present
C. Submit the following documents with application:
DSS-5016 (Rev. 02/10)
Child Welfare Services
(1) DSS 5015 – Foster Care Facility License Action Request
(2) DSS 1515 – Fire Safety Inspection Report
(3) DSS 5150 – Environmental Conditions Checklist
(4) DSS 5017 – Medical History Form(s) for each applicant, household member and child
(5) DSS 5156 – Request for Medical Information for each applicant, household member
and child
(6) TB test results for all adult household members 18 years old and up: TB test results for
children are required if any adult member has a positive TB skin test
(7) Fingerprint Clearance Letters for each applicant and household member 18 years old
and up
(8) Letter of support if any adult household members have criminal convictions
(9) Letter of support if any adult household members have child protective service history
as a perpetrator
12

XI.
Recommendation for Licensure.
Recommendation for licensure:
Document agency’s plan for supporting the family when placements occur:
DSS-5016 (Rev. 02/10)
Child Welfare Services
13

SIGNATURES
I have reviewed and am in agreement with the above information, declare that it is true and accurate, and
understand that according to G. S. 132-1 this information may be furnished to others upon proper request.
Application must be signed by all applicants, social worker, and agency head for licensure to be considered
by the licensing authority.
Type Name of Applicant
Applicant Signature / Date
Type Name of Applicant
Applicant Signature / Date
Type Name of Applicant
Applicant Signature / Date
Type Name of Applicant
Applicant Signature / Date
Type Name of Social Worker
Social Worker Signature / Date
Social Worker Phone Number:
Social Worker E-Mail Address:
Type Name of Agency Director or Designee*
Signature of Agency Director or Designee / Date
*I certify that the Agency Director has appointed me as Designee for the purpose of signing documents for
Regulatory and Licensing Services.
DSS-5016 (Rev. 02/10)
Child Welfare Services
14

A. NORTH CAROLINA COUNTY NUMBERS
1 Alamance 35 Franklin 69 Pamlico
2 Alexander 36 Gaston 70 Pasquotank
3 Alleghany 37 Gates 71 Pender
4 Anson 38 Graham 72 Perquimans
5 Ashe 39 Granville 73 Person
6 Avery 40 Greene 74 Pitt
7 Beaufort 41 Guilford 75 Polk
8 Bertie 42 Halifax 76 Randolph
9 Bladen 43 Harnett 77 Richmond
10 Brunswick 44 Haywood 78 Robeson
11 Buncombe 45 Henderson 79 Rockingham
12 Burke 46 Hertford 80 Rowan
13 Cabarrus 47 Hoke 81 Rutherford
14 Caldwell 48 Hyde 82 Sampson
15 Camden 49 Iredell 83 Scotland
16 Carteret 50 Jackson 84 Stanly
17 Caswell 51 Johnston 85 Stokes
18 Catawba 52 Jones 86 Surry
19 Chatham 53 Lee 87 Swain
20 Cherokee 54 Lenoir 88 Transylvania
21 Chowan 55 Lincoln 89 Tyrrell
22 Clay 56 Macon 90 Union
23 Cleveland 57 Madison 91 Vance
24 Columbus 58 Martin 92 Wake
25 Craven 59 McDowell 93 Warren
26 Cumberland 60 Mecklenburg 94 Washington
27 Currituck 61 Mitchell 95 Watauga
28 Dare 62 Montgomery 96 Wayne
29 Davidson 63 Moore 97 Wilkes
30 Davie 64 Nash 98 Wilson
31 Duplin 65 New Hanover 99 Yadkin
32 Durham 66 Northampton 100 Yancey
33 Edgecombe 67 Onslow
34 Forsyth 68 Orange
June 15, 2010 Webinar
Jordan Institute for Families, UNC‐CH School of Social Work

B. RACE CODES
Race codes and possible combinations that could be selected for DSS-5015 fields 10 and 17 are:
01 = White Native (Non Hispanic or Latino)
02 = White (Hispanic or Latino)
03 = Black (Non Hispanic or Latino)
04 = Black (Hispanic or Latino)
05 = American Indian or Alaskan Native (Non Hispanic or
Latino)
06 = American Indian or Alaskan Native (Hispanic or
Latino)
07 = Asian (Non Hispanic or Latino)
08 = Asian (Hispanic or Latino)
09 = Native Hawaiian or Other Pacific Islander (Non
Hispanic or Latino)
10 = Native Hawaiian or Other Pacific Islander (Hispanic or
Latino)
11 = Unable to Determine (Non Hispanic or Latino)
12 = Unable to Determine (Hispanic or Latino)
13 = White/Black (Non Hispanic or Latino)
14 = White/Black (Hispanic or Latino)
15 = White/American Indian or Alaskan Native (Non
Hispanic or Latino)
16 = White/American Indian or Alaskan Native (Hispanic or
Latino)
17 = White/Asian (Non Hispanic or Latino)
18 = White/Asian (Hispanic or Latino)
19 = White/Native Hawaiian or Other Pacific Islander (Non
Hispanic or Latino)
20 = White/Native Hawaiian or Other Pacific Islander
(Hispanic or Latino)
21 = Black/American Indian or Alaskan Native (Non
Hispanic or Latino)
22 = Black/American Indian or Alaskan Native (Hispanic or
Latino)
23 = Black/Asian (Non Hispanic or Latino)
24 = Black/Asian (Hispanic or Latino)
25 = Black/Native Hawaiian or Other Pacific Islander (Non
Hispanic or Latino)
26 = Black/Native Hawaiian or Other Pacific Islander
(Hispanic or Latino)
27 = American Indian or Alaskan Native/Asian (Non
Hispanic or Latino)
28 = American Indian or Alaskan Native/Asian (Hispanic or
Latino)
29 = American Indian or Alaskan Native/Native Hawaiian or
Other Pacific Islander (Non Hispanic or Latino)
30 = American Indian or Alaskan Native/Native Hawaiian or
Other Pacific Islander (Hispanic or Latino)
31 = Asian/Native Hawaiian or Other Pacific Islander (Non
Hispanic or Latino)
32 = Asian/Native Hawaiian or Other Pacific Islander
(Hispanic or Latino)
33 = White/Black/American Indian or Alaskan Native (Non
Hispanic or Latino)
34 = White/Black/American Indian or Alaskan Native
(Hispanic or Latino)
35 = White/Black/Asian (Non Hispanic or Latino)
36 = White/Black/Asian (Hispanic or Latino)
37 = White/Black/Native Hawaiian or Other Pacific Islander
(Non Hispanic or Latino)
38 = White/Black/Native Hawaiian or Other Pacific Islander
(Hispanic or Latino)
39 = White/American Indian or Alaskan Native/Asian (Non
Hispanic or Latino)
40 = White/American Indian or Alaskan Native/Asian
(Hispanic or Latino)
41 = White/American Indian or Alaska. Native/Native Hawaiian
or Other Pacific Islander (Non Hispanic or Latino)
42 = White/American Indian or Alaskan. Native/Native
Hawaiian or Other Pac. Islander (Hispanic or Latino)
43 = White/Asian/Native Hawaiian or Other Pacific Islander
(Non Hispanic or Latino)
44 = White/Asian/Native Hawaiian or Other Pacific Islander
(Hispanic or Latino)
45 = Black/American Ind. or Alaskan/Asian (Non Hispanic
or Latino)
46 = Black/American Ind. or Alaskan/Asian (Hispanic or
Latino)
47 = Black/American Ind. or Alaskan/Native/Hawaiian (Non
Hispanic or Latino)
48 = Black/American Ind. or Alaskan Native/Hawaiian
(Hispanic or Latino)
49 = Black/Asian/Native Hawaiian or Other Pacific Islander
(Non Hispanic or Latino)
50 = Black/Asian/Native Hawaiian or Other Pacific Islander
(Hispanic or Latino)
51 = American Indian/Asian/Native Hawaiian (Non Hispanic
or Latino)
52 = American Indian/Asian/Native Hawaiian (Hispanic or
Latino)
53 = White/Black/American Indian/Asian (Non Hispanic or
Latino)
54 = White/Black/American Indian/Asian (Hispanic or
Latino)
55 = White/Black/American Indian/Native Hawaiian (Non
Hispanic or Latino)
56 = White/Black/American Indian/Native Hawaiian
(Hispanic or Latino)
57 = White/Black/Asian/Native Hawaiian (Non Hispanic or
Latino)
58 = White/Black/Asian/Native Hawaiian (Hispanic or
Latino)
59 = White/American Indian/Asian/Native Hawaiian (Non
Hispanic or Latino
60 = White/American Indian/Asian/Native Hawaiian
(Hispanic or Latino)
61 = Black/American Indian/Asian/Native Hawaiian (Non
Hispanic or Latino)
62 = Black/American Indian/Asian/Native Hawaiian
(Hispanic or Latino)
63 = White/Black/American Indian/Asian/Native Hawaiian
(Non Hispanic or Latino)
64 = White/Black/American Indian/Asian/Native Hawaiian
(Hispanic or Latino)
June 15, 2010 Webinar
Jordan Institute for Families, UNC‐CH School of Social Work

C. IMPORTANT CONTACTS FOR
FOSTER CARE LICENSING
Fingerprints
Send to:
NC Division of Child Development
Criminal Records Check Unit
2201 Mail Service Center
Raleigh, NC 27699-2201
800/859-0829 (Ask to speak to someone in the Criminal Record Check Unit)
Financial, Rates, and Reimbursement Issues
Tina Bumgarner, Foster Care Financial Resource Coordinator
NC Division of Social Services
828-397-3901
Tina.Bumgarner@dhhs.nc.gov
Licensing Authority
Rhoda Ammons, Licensing Consultant
828/669-3388
rhoda.ammons@ncmail.net
Nicole Jensen, Licensing Consultant
828/669-3388
Nicole.Jensen@dhhs.nc.gov
NC Division of Social Services
Regulatory and Licensing Services Team
952 Old U. S. 70 Highway
Black Mountain, NC 28711
828/669-3388
June 15, 2010 Webinar
Jordan Institute for Families, UNC‐CH School of Social Work

June 15, 2010 Webinar
Successful Foster Home
Licensing
Welcome!
Please click on the colored link below to download the
handout for today:
6-15-10 webinar handout
Successful Foster Home Licensing
Agenda
Brief Orientation
Introductions
Suggestions and advice for foster
home licensing success
Q & A
June 15, 2010 Webinar • UNC-CH CH School of Social Work
2
Panel Participants today are:
Bob Hensley
Rhoda Ammons
Nicole Jensen
Other Licensing Office Staff
Your facilitator is:
Mellicent Blythe
Technical support is
provided by:
Phillip Armfield
John McMahon
Cindy Norton Joyce Moore Julie Smith
June 15, 2010 Webinar • UNC-CH CH School of Social Work
3
June 15, 2010 Webinar • UNC-CH CH School of Social Work 4
Goals of this Webinar
‣ Save you time, make your life
easier
‣ Do same for us
Ultimate Goal
Ensure children in foster care
are safe and well cared for.
Key Take Home Messages
‣ Licensing is a PARTNERSHIP centered on
common desire to ensure children have
safe, appropriate, nurturing foster families.
• Supervising Agencies recruit, train, and
supervise foster families.
• Licensing Authority makes the final decision
about all licensing requests/actions.
In every licensing action, you
“tell us a story” (i.e., provide key
information) so we can make a decision.
6
Jordan Institute for Families, UNC-CH
School of Social Work 37

June 15, 2010 Webinar
Snapshot of NC’s Infrastructure
Foster Home Licensing
Today
June 15, 2010 Webinar • UNC-CH CH
School of Social Work 7
1. 7,684 licensed foster homes
• 3,684 Family Foster Homes
(10,695 beds)
• 4,000 Therapeutic Foster Homes
(6,187 beds)
2. 227 licensed child-placing agencies
• 100 county DSS agencies
• 127 private agencies
3. 9,003 children in foster care
as of April 30, 2010
Concerning Trends
‣ Declining and/or
uneven quality of
applications
‣ Increase in
maltreatment
substantiations in
foster homes
‣ Increase in revocations
June 15, 2010 Webinar • UNC-CH CH School of Social Work 9
General Tips for Success
1. Would I feel safe placing my child with
this family and in this home
2. Make sure we know how to contact you
(phone and e-mail)
3. Follow the “Yellow Brick Road” (boxes)
4. Proofread
5. No staples
6. Black ink
7. Always make copies of everything
June 15, 2010 Webinar • UNC-CH CH School of Social Work 10
Foster Care Facility
License Action Request
(DSS-5015)
June 15, 2010 Webinar • UNC-CH CH
School of Social Work 11
Using the DSS-5015
‣ Submit every time you submit a request
‣ Use DSS-5015 dated Rev 11/07
‣ Make sure the form is legible
• Black Ink only
‣ Making a change to the 5015:
• Mark out and fill in any changes
• Draw a single line in black ink
through old data you are correcting/updating
June 15, 2010 Webinar • UNC-CH CH School of Social Work 12
Jordan Institute for Families, UNC-CH
School of Social Work 38

June 15, 2010 Webinar
DSS-5015 (continued)
‣ After the initial application: always send in
a copy of the updated, typed version
‣ Clarify “grade completed”
‣ Returned 5015
• Don’t complete a brand
new one
• Fix what’s marked wrong on existing form and
resubmit
• Never print on both sides of the paper
‣ Complete the following Fields: 1—29
June 15, 2010 Webinar • UNC-CH CH School of Social Work 13
DSS-5015 (continued)
‣ Do not complete:
• Fields 24 and 30-43
‣ Don’t put agency address, should be
foster parent’s address
June 15, 2010 Webinar • UNC-CH CH School of Social Work 14
Important Tips for Other
Licensing Forms
Relicense, Termination and Change
Request Application (DSS-5157)
‣ Provide all relevant information for action
requested
‣ No. of children
‣ TFC training
‣ Background
checks
‣ Transfers
We cannot move forward if data
is omitted or missing.
June 15, 2010 Webinar • UNC-CH CH
School of Social Work 15
June 15, 2010 Webinar • UNC-CH CH School of Social Work 16
Foster Home Fire Inspection
Safety Report (DSS-1515)
‣ Updated Feb. 1, 2010
‣ Carbon monoxide detectors
‣ Fire inspector checks Yes or N/A for each
question.
• Any item marked NO will result in non-
approval of the home
‣ Submit original
Environmental Conditions and Health
Regulations Checklist (DSS-5150)
‣ Updated September 1, 2007
‣ Complete within 180 days
‣ Complete all 13 items
‣ If no firearms, explosives, or pets write
N/A on Items (8) and (9)
‣ Foster parent and sw sign and date
‣ Submit original
June 15, 2010 Webinar • UNC-CH CH School of Social Work 17
June 15, 2010 Webinar • UNC-CH CH School of Social Work 18
Jordan Institute for Families, UNC-CH
School of Social Work 39

June 15, 2010 Webinar
Foster Home/Residential Child Care
Medical History Form (DSS-5017)
‣ Updated September 28, 2009
‣ Complete for all household members
‣ Must be current within 180 days of receipt
by Licensing i Office
‣ Complete all items and explain when
appropriate
‣ Sign and date
‣ Submit original
Request for Medical Information
(DSS-5156)
‣ Updated September 1, 2002
‣ Completed for all household member
‣ Must be current within 12 months of
receipt by the Licensing i Office
‣ Be sure doctor has completed all items,
signed, and dated
‣ Answer TB questions or attach test results
‣ Submit original
June 15, 2010 Webinar • UNC-CH CH School of Social Work 19
June 15, 2010 Webinar • UNC-CH CH School of Social Work 20
Foster Home License
Application
(DSS-5016)
Foster Home License
Application (DSS-5016)
‣ Criminal conviction
• Child abuse and neglect
‣ Financial stability
• In arrears on child support payments
‣ What is status with their own children
‣ Shared parenting
‣ Visits required in the assessment process
June 15, 2010 Webinar • UNC-CH CH
School of Social Work 21
June 15, 2010 Webinar • UNC-CH CH School of Social Work 22
Assessing the 12 Skills
‣ Expands the family’s story
‣ Describe specific behaviors that demonstrate the
skill
• “Mrs. Smith effectively managed her
children’s behavior during home visits by
setting clear boundaries.”
• Avoid using only affective/cognitive language:
“Mr. Smith appreciates/understands shared
parenting.”
Assessing the 12 Skills, cont.
‣ Include life experience: jobs, volunteer work, etc.
‣ We don’t expect perfection
• But explain how you will meet needs
‣ Resources:
• Supplemental Guide, , 5016 instructions
June 15, 2010 Webinar • UNC-CH CH School of Social Work 23
Jordan Institute for Families, UNC-CH
School of Social Work 40

June 15, 2010 Webinar
Perfect New Application
Send to Licensing Authority:
‣ Cover letter
‣ Foster Care Facility License
Action Request (DSS-5015)
‣ Foster Home License Application
(DSS-5016) & Mutual Home
Assessment
‣ Fire Safety Inspection Report
(DSS-1515)
‣ Environmental Conditions and
Health Regulations Checklist
(DSS-5150)
‣ Medical History Form (DSS-5017)
& TB test results
‣ Request for Medical Information
(DSS-5156)
‣ Finger Print Clearance Letter
For Agency Foster Parent File:
‣ Copy of all documents at left
‣ DSS-1796
‣ DSS-5280
‣ Discipline Agreement
‣ Results of Local Court Record
Check
‣ Results of NC Sex Offender &
Public Prot. Registry Search
‣ Results of Nurse Aide I and Health
Care Personnel Registry Search
‣ Results of NC Offender
Information Search
‣ Documentation of training
requirements
‣ References on all applicants
25
Other Topics and
Licensing i Resources
June 15, 2010 Webinar • UNC-CH CH
School of Social Work 26
Waivers
‣ Waiver = request to temporarily forgo a rule
‣ Some rules may be waived on a case-by-
case basis, especially for
• Keeping siblings groups together
• Placing children with relatives
‣ Some may not:
• Fingerprinting and criminal record checks
If you think a non-safety rule is preventing
a placement that is in the best interest of an
individual child, contact us.
June 15, 2010 Webinar • UNC-CH CH School of Social Work 27
Specific to
Therapeutic Foster Care
‣ In-home daycare
‣ Capacity limits
‣ Babysitting on a regular basis
June 15, 2010 Webinar • UNC-CH CH School of Social Work 28
Supplemental Guide
‣ A few rules
have changed
• Being updated
Implications for Practice
‣ Use your chat pod:
What have learned today that
will be helpful
http://www.dhhs.state.nc.us/dss/licensing/foster_c
are_rules.htm
June 15, 2010 Webinar • UNC-CH CH School of Social Work 29
What questions do you still
have about North Carolina’s
foster home licensing process
June 15, 2010 Webinar • UNC-CH CH School of Social Work
30
Jordan Institute for Families, UNC-CH
School of Social Work 41

June 15, 2010 Webinar
Licensing Office Contact Info
‣ Rhoda Ammons and Nicole Jensen
NC Division of Social Services
Regulatory and Licensing Services
952 Old U. S. 70 Highway
Black Mountain, NC 28711
828/669-3388
June 15, 2010 Webinar • UNC-CH CH School of Social Work 31
Final Steps
1. Please take a brief survey
• Will provide link for those logged on
• Can also access thru ncswlearn.org
2. To receive training credit, must “Complete
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June 15, 2010 Webinar • UNC-CH CH School of Social Work 32
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Follow-up Document from the Webinar
Successful Foster Home Licensing
Webinar delivered June 15, 2010
Follow‐up document date: June 30, 2010
Presented by
Bob Hensley, Rhoda Ammons, Nicole Jensen, and Mellicent Blythe
Produced by
Family and Children’s Resource Program, part of the
Jordan Institute for Families
School of Social Work
University of North Carolina at Chapel Hill
Sponsored by
North Carolina Division of Social Services
Be sure to consult the handouts for this webinar, which contained valuable information. Presenters
particularly emphasized the importance of looking at pages 3, 5, and 16 of the handouts. You will find
these handouts at the following location:
http://www.ncswlearn.org/ncsts/webinar/handouts/5_Webinar%206‐15‐10%20Handouts.pdf
Questions and Answers from 6/15/10 Webinar
1. DSS-5015 Questions
What is the proper way to fill out the education field (page 2, item 10) on the 5015
Post secondary years should not be added to the high school years. Put 2 years for an Associate degree
or 4 years for a four year college degree.
If a sibling group is placed together and it goes over the capacity, do we need to change the
capacity
The action you are requesting is a change in capacity. If the capacity change goes over the maximum
number of children allowed according to the administrative rules, a waiver is required. (See also the
response below under the “Waivers” category.)
Do we hand write our 5015 for a transfer
Yes, the agency receiving the foster home will need to type or write a new 5015. If you don’t have the
capacity to type it, then write legibly. Many people are able to type in the form on the computer—it can
not be saved, however.
2. DSS-5157 Questions
Do you have to complete a 5157 if you are transferring agencies
Typically, no. You only need to submit a 5157 with a transfer if there is a change as well.
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 1

If you don't have to send in a 5157 for a transfer, how do we show you that we know the
family
You must complete a brief mutual home assessment on any family that you request a transfer on. Please
add that your agency has contacted the previous agency and discuss what the previous agency reported
to you about the family.
Do we have to do the 12 skills assessment for transfers
You are not required to document the 12 skills for a transfer. If you do submit that, please do not copy
the previous agency’s assessment. That is already in our files. Some agencies do the 12 skills according
to their own policy at transfer; that is fine. Please send updated information such as the reason the
family wants to transfer, what their fostering experiences have been since the last time they were
licensed, their concerns, etc.
How do you handle a transfer when the previous agency has gone out of business and there
is no way to obtain the required documentation
Communicate with the Regulatory and Licensing Services office when this happens. When an agency
goes out of business we are usually aware of it and are working toward assisting the families that are
licensed to locate a new agency, especially when there are children in the home.
Do we have to send the mutual home assessment if we answer all of the questions on the
5157
This question is unclear. The 5157 doesn’t contain the same information as a mutual home assessment.
If the action request is for a transfer yes, you need to do a mutual home assessment. If the action
request is a relicensure you should do the biennial update for your files but you do not have to send this
information to the Regulatory and Licensing Services office.
In therapeutic foster care, good agencies have relationships with kids based on gathering
assessment information and providing treatment. Does the Division have thoughts on the
effect of this child’s treatment when a foster parent decides to transfer their license for
reasons such as money
We are very concerned when the primary motivation to foster is based on financial gain. This is the basis
of the rules regarding the family’s ability to show financial stability. However, foster parents have the
right to choose their supervising agency. Parents, guardians, or custodians also have the right to choose
the supervising they want to work with.
Is a transfer date retroactive What is the length of time you are able to back-date a
license transfer
The transfer date may be retroactive for a short period of time. The key is that the two agencies agree
on a date and that date needs to be on the first day of the month. The Regulatory and Licensing Services
office will determine the date the transfer occurs if an agreed upon date is not stated in the cover letters
from the two agencies involved. It is preferable if the date is a future date so that the current agency
knows that they are responsible to supervise the home until it is actually transferred. Otherwise there
may be a period of time that the home is not being supervised and no one is aware of that.
The 5157 is not an interactive form - it downloads as a PDF and we cannot type/edit it.
If anyone needs the Word format of the 5157 or 5016 please send an email request to
Nicole.jensen@dhhs.nc.gov or Rhoda.Ammons@dhhs.nc.gov.
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 2

If adding a new adult to the household, do we submit a change form or wait to report it at
relicensing
You need to send a change form. You also need to send a fingerprint clearance letter, physical (5156), TB
test results, Foster Home Medical History Form (5017), results of local criminal record checks, NC
Department of Corrections Offender Information, NC Sex Offender and Public Protections Registry,
Health Care Personnel Registry, NC Child Abuse and Neglect History, and Central Registry Checks (Child
Abuse and Neglect) from other states if the adult household member has not lived in NC the past five
years.
When do capacity change requests become effective
Capacity changes are effective on the date that it is stamped as received in the Regulatory and Licensing
Services office. If an emergency placement must be made during non‐business hours you may call and
discuss this at the earliest possible time after business hours resume.
3. DSS-1515 Questions
I have 4 new licenses to send in next week but did not have the new fire inspection form.
Do I have to have the foster parent redo the whole form
Please call and discuss this individually. The newest fire inspection forms have been available since
February 2010. Workers need to assure that the fire inspectors have a supply of them and that they
understand the changes that have been made to them, particularly the questions about use of extension
cords and carbon monoxide detectors. Remember that an answer of “no” to any of the questions
indicates that the license will not be approved. If the family does not use extension cords at all the
appropriate answer is “N/A”.
Are there specific topics that need to be addressed concerning the building codes
There are no additional requirements beyond the information on the 1515 and 5150.
If the inspector marks “no” on #1, how do we handle that prior to sending it in to you We
have had some difficulty getting fire inspectors to make corrections on this form.
You can document that this is an error and that the question was misunderstood, if you have personal
knowledge that this is the case. You may have to make a home visit in order to verify that the foster
home uses extension cords properly. Please do not ask the fire inspectors to change the forms. It is
important to educate fire inspectors about rules and new forms. Be respectful of their time and
schedules and develop a good working partnership with them. These are courtesy inspections and we
want them to continue to do them for us.
Will you clarify for me the current requirement for fire extinguisher type and size
A working, mounted “ABC” fire extinguisher(s), with a rating not less than 1‐A shall be installed and
readily available in the residence. Fire inspectors will make the determination that the foster home has
acceptable fire extinguishers.
In some counties, foster parents are charged as much as $75.00 for a fire inspector to
return to the foster home to complete the form correctly.
We do not want you to have homes inspected again if a question is misunderstood. You can provide
written documentation to show that those particular requirements have been met if you have
knowledge of that yourself. If you do not have personal knowledge you must make a visit to the foster
home and verify that the requirement has been met.
Do the fire inspectors get training on how to fill out the forms from the state
Fire inspectors get training on many things from different sources. It is the responsibility of the
supervising agencies to provide information to the fire inspectors related to completing the 1515. It is
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 3

also the supervising agency’s responsibility to make sure the form is filled out correctly before sending
the packet to the Regulatory and Licensing Services Office. This is also true of the medical forms and any
other forms in the licensing request packets.
Telephone can be a cell phone, correct
Cell phones can be used. They must work throughout the house. The family must have a reliable way to
get emergency assistance when they need it. If fire inspectors do not feel that cell phones are reliable in
certain locations and they check “no” to Question 4 on the 1515, the foster home will not be approved.
What if a therapeutic foster parent is transferring and has a copy of the fire inspection
form which was completed within the last 6 months Must the home be re-inspected
If the home is transferring and there is not a change in residence, there is no need to do a new fire
inspection unless the previous agency has not kept this up to date.
4. DSS-5150 Questions
I have had at least one family that had an old home and did not have ventilation in their
bathroom, so I was not able to check “yes” for #11. Would that cause a licensing problem
Yes: if they don’t have the proper ventilation they cannot be approved.
5. DSS-5017 Questions
When a foster child has been adopted by foster parents, do we submit 5017 & 5156 at that
time, or at relicensure
Please send a change adding the adopted children.
Is the 5017 required for re-licensing, or just initial licensing
Form 5017 is required at initial licensing. Form 5156 is required at relicensing. The supervising agency
should compare the 5156 and with the initial 5017 to determine if there have been changes. If changes
have occurred, provide an explanation concerning the changes.
Can a family submit a physical on another form from their physician within the 12 months
We prefer that our forms be used. If the family would have to pay for another physical you should check
the form they have and highlight where the questions on the DSS form have been answered. If all the
questions on the DSS form have been answered we may approve the form. Foster parent applicants
should be encouraged to take the physicals seriously. When possible they should have these done at
their regular physician’s office rather than going to a medical provider who is not familiar with the
applicant.
Sometimes it is hard to get the original form from the doctor but they will fax them to the
agency. Will this fax copy cause the Consultant to return the application to us
Try to get the original. We have to be able to read the information.
4. DSS-5156 Questions
Is it required to type the 5156
No.
If a foster parent has a TB test prior to 1 year mark of licensing, is that acceptable
The medical provider will need to make this determination.
When relicensing the parents do not need to have TB tests redone, correct
Correct. TB tests are not required for relicensing.
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 4

At initial licensure, are children required to get TB skin tests
Children are only required to get a TB test if someone in their home has tested positive.
We are having 5156's where the doctor is not putting the date of examination but has
signed the physical form. In most cases it is the actual date of the exam. What is
acceptable in that case
Have your foster parents request the physician write in the date of exam.
Do foster parents have to list all of their medications
No. Foster parents are not required to list their medications.
What specific types of diagnosis (medical or mental health) require a follow up letter from
the doctor/therapist, etc.
There is not a definitive answer for this question. Good social work judgment on the part of the licensing
worker is essential. Does the medical or mental health condition affect the safety and well being of a
child What is your agency’s liability if you do not have a complete understanding of the medical or
mental health condition
5. DSS-5016 Questions
For TFC, do both parents have to have a GED or high school diploma
North Carolina foster parents are not required to have a GED or high school diploma. North Carolina’s
licensing rule (10A NCAC 70E .1104 Criteria for the Family, Amended Eff. November 1, 2009 ) states:
“Foster parent applicants shall have graduated from high school or received a GED (Graduate
Equivalency Diploma) or shall have an ability to read and write as evidenced by their ability to
administer medications as prescribed by a licensed medical provider, maintain medication
administration logs and maintain progress notes.”
Doesn't DMA require that therapeutic foster parents have a high school degree
The proposed Therapeutic Family Services definition states that therapeutic foster families shall meet
the requirements of 10A NCAC 70E. This means the TFC family does not have to have a high school
degree or GED but has the ability to read and write as evidenced by their ability to administer
medications as prescribed by a licensed medical provider, maintain medication administration logs and
maintain progress notes. The final approval for the new definition has not been received from CMS;
however, most LME’s have accepted this criterion.
Can you clarify the rule on the safe guarding of swimming pools and ponds
We think the rule is clear. Rule 10A NACA 70E .1112 states access to such hazards shall be avoided by
either a fence at least 48 inches high with a locked gate around the hazard, or by a fence at least 48
inches high with a locked gate around the yard and exterior space of the home while still providing play
space for children. Access to water in above ground swimming pools shall be prevented by locking and
securing the ladder in place or storing the ladder in a place inaccessible to the children. The supervising
agency shall observe and document that the foster parents have taken measures to protect foster
children from having unsupervised access to swimming pools, beaches, rivers, lakes, streams, other
water sources, or other hazards.
If in the past foster parent applicants have had many traffic violations and we are unable to
list them all on the form—what do you do then
The form is interactive. You can list them all. If you have multiple offenses you need to take this into
consideration when deciding to recommend the family for licensing. Multiple traffic violations usually
demonstrate lack of judgment and a basic disregard for obeying laws, rules, and regulations.
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 5

When listing the criminal record, do we list everything, or only charges/convictions in the
past 10 years
List everything. Put dates of charges and convictions.
Must we justify why we are recommending someone for licensure if they have a conviction
for something in the distant past Even if the conviction is for something minor
Even long‐ago, “minor” convictions can be relevant to child safety and well‐being. The Licensing Office
needs sufficient information to be assured that issues in the past have been addressed and this person is
now a safe, appropriate person to care for a child.
Do new adults in the home need to be MAPP trained
New adults are not required by our Rules to have MAPP training unless they will be licensed as foster
parents. However, each adult in the home has the capacity to serve as a foster parent and you need to
make a careful determination regarding their care and supervision of foster children. If they have
responsibilities for the care and supervision of foster children they will need preservice training and will
need to be licensed as a foster parent.
If a person gets married after they are licensed, will the spouse have to be licensed
Yes, see 10A NCAC 70E.1104 (e). Whether married or not, when a new adult moves into the home
consideration needs to be given to whether they are going to be fostering. If it is a new spouse or
significant other it is assumed that they will be fostering. It is important to discuss this issue when
training foster families, especially single foster parents. They should be making plans prior to the
marriage for the future spouse to have criminal record checks and other eligibility requirements. Even
when other adults are spending significant amounts of time with the foster children such as when a
single foster parent is dating, the agency should know about this and should advise the family about
what processes need to occur. The risks of unknown backgrounds of people spending significant periods
of time with children are obvious and should be taken seriously by agencies. Often substantiated CPS
reports on foster parents involve someone in the home other than the foster parent who was the actual
perpetrator.
How long can an adult visit before background checks are needed and they are considered
a member of the household Do you count college-age children who visit on weekends and
summer What about medicals for them
The answer to this question depends on the situation and who the adult visitors are. There is not a rule
or policy that gives a definitive answer. Good social work judgment on the part of the licensing worker is
essential. Foster parents should be able to be like any other parent and have family members and
friends visit for periods of time. It is important to emphasize to foster parents that they are responsible
for the protection of foster children and they should be cautious about whom they allow in their homes.
Boyfriends, girlfriends, significant others who stay at the foster home on a regular basis should have
criminal record checks, fingerprint checks, medicals, etc. If this occurs with multiple people, perhaps this
is not the appropriate period of their life to be foster parents. College‐age children home for weekends
and summers should be listed on the 5015 under Other HH members 18 years of age or older and have
fingerprint checks, criminal record checks, medicals, etc.
If a family has an in-home daycare that is licensed for five, but do not take that many
children, can they still be licensed as a foster home
No, as long as they are licensed for day care the number of children stated on their day care license will
be counted in capacity. Therefore, if their license is for 5 day care children they are not eligible to be
foster parents.
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 6

A home cannot be licensed for TFC if they have an in-home daycare, correct
Correct.
Can a daycare home be approved for weekend respite care when they do not have daycare
children
No, it is the total number of children in the home that determines the capacity, not the period of time
that they are present. It is important to note that there are no specific rules or regulations relating to
respite care. Children receiving respite care are considered foster children and the foster home must
meet all the requirements for a licensed foster home.
Can you give some direction regarding previous agencies sharing information to the new
agency when a parent transfers What is their obligation What should the new agency do
if the old agency is not willing to share information
Rule 10A NCAC 70E .0805 requires all agencies to complete a biennial reassessment of the foster home.
This reassessment shall include a mutual assessment with the foster parents of their skills and abilities
to provide care for children, including ways in which they have been able to meet the needs of children
placed in their home and areas in which they need further development. The reassessment also
documents changes in physical set up as well as the foster parents' capacities for providing foster care
since the original home assessment or previous reassessments. The previous agency should provide the
latest reassessment to the new agency.
Is there anything that will let us know that the foster parent has been with five other
agencies if the family is not forthcoming
There is nothing automatic that would show that. You should be clear with the family that the
information exists. Encourage them to be up front about this because the Regulatory and Licensing
Services office will have that information. If you strongly suspect that they have been with multiple
agencies you can request this information from us. Please don’t request this unless you are seriously
considering the family for transfer and you suspect they are not forthcoming.
Is contact information available for other supervising agencies, so that if a foster parent has
been licensed before the previous agency can be contacted
You can find contact information for all private, licensed, child‐placing agencies in North Carolina at the
following URL: http://www.dhhs.state.nc.us/dss/licensing/docs/cpalistfostercare.pdf
Is it OK for providers to share drug screening results with each other if that foster parent
has been terminated by your agency for a positive drug screen
The family will need to sign a release that specifically gives authority to share information about drug
screens.
Can't we do some sort of web-based criminal record check as opposed to local criminal
record checks It is cost prohibitive for the agency to pay $25 for each local criminal record
check.
Local clerks of court records are required.
How do we get information from different States on child abuse and neglect
Go to this web site:
http://www.dfps.state.tx.us/child_care/other_child_care_information/abuse_registry.asp
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 7

Physical Restraints questions 1-4. Single parents cannot physically restrain children. Is the
answer to these questions N/A
Single foster parents can restrain children if there is a second trained adult available. See 10A NCAC 70E
.1103 (e)(6)(A) for waiver information. If a second trained adult is not available and the supervising
agency does not request a waiver, you will still check “Yes” to Item C (Physical Restraints), statement (3)
because you are stating foster parents understand they cannot use physical restraints unless there is a
second trained adult available or a waiver has been granted. Please remember that this answer applies
only to supervising agencies that utilize physical restraints. If your agency does not use physical
restraints the answer is “N/A”.
Can we do 3 visits in the home and one visit in the office, as opposed to 2 in the office and
one in the home
Yes. See 10A NCAC 70E .0802 for requirements related to office and home visits.
Can the agency make foster parents pay for their own criminal background checks
The supervising agency has the discretion to require foster parents to pay for criminal background
checks. However, if I was applying to be a foster parent I would find an agency that does not require me
to pay for criminal background checks.
If we are using an adoptive home assessment, do we include that instead of filling in the
MHA info on the 5016
The preplacement assessment (adoptive study) can only be substituted for the Family History. You must
address all 28 items that are required in a preplacement assessment (10A NCAC 70H .0405). Number
each of these items 1—28.
It says background checks need to be dated within 180 days of receiving the packet at the
Licensing Office. Is this referring to the Fingerprint letters
No. This does not refer to the fingerprint letter.
Do we do a complete Mutual Home Assessment for relicensure or just the 12 skills with
any updates
At relicensure please complete a two‐year summary and keep it in your files.
If a family lives in public housing and/or receives public assistance (unemployment, Work
First, Food Stamps, Medicaid and Section 8 vouchers), can they be foster parents
Yes. You need to make an assessment of all applicants regarding the amount of their income each
month as compared to their monthly expenses. Are they financially stable without the foster care
payment
Is there a rule number stating foster parents have to be working What if they are
therapeutic and this is their main source of income
Applicants have to show financial stability without the foster care payment. Foster care payments are
not guaranteed monthly income and therefore cannot be the family’s sole income. Be cautious that
foster parents do not sabotage reunification efforts in order not to lose their funding.
Can we find out if child support is owed if it's not reported by the applicant
The Child Support Enforcement Section within the Division of Social Services is researching this question.
Please clarify skills number 3 and 4. Number 3 says “identify” and 4 says to build on them.
See page 20 of A Supplemental Guide to Foster Home Licensing:
http://www.ncdhhs.gov/dss/licensing/docs/Guide‐03‐16‐09.pdf
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 8

Should we be asking how serious a dating relationship is so that we can do a criminal
background check
Yes. If the foster parent and/or foster children are spending significant amounts of time with someone
background checks should be done. Although we don’t want to be unnecessarily intrusive, it is
important to remember that our children are living in these homes and questions need to be asked that
will protect them. Foster parents should understand that up front. We have a right to know who is in
regular contact with foster children. If foster parents are uncomfortable with this, perhaps it is not a
good time for them to be foster parents.
Can you write in “no findings” if there were no findings under the criminal history
Yes, if there are no findings, write “no findings” for each adult in the home.
What are you looking for in the emotional stability and maturity question
How the individual has handled adversity in their lives, how they have handled conflicts, how long their
marriage has lasted, how long they remained employed in a job unless moves were upgrades, how they
deal with stress—all these are examples of issues that can be described behaviorally. There are many
others.
Is just a "yes" OK for the ability to give and receive affection
No. We want examples of how they give and receive affection.
For any of the 12 skills, is it acceptable for the needs to answer "none noted at this time"
We may not have noted any need at this time.
Yes, it is possible that you cannot professionally identify a need at a point in time. However, no one is
perfect, so they should have identified needs in some areas or there is no ability to grow, or someone
isn’t being completely honest.
Please clarify when we put a comment on Section X, Item A (under the grid).
Review the 5017 and 5156 to determine whether the foster parent or medical provider has indicated a
medical or mental health problem. All mental health issues need to be addressed in this section on the
5016. Major/significant medical problems will need to be addressed.
6. Waiver Questions
Have you seen any correlation between substantiations and waivers
No. We consider waivers carefully and ask for specific information. We put the supervising agency in the
position to do the same and to show how they will support the family. We have not seen waivers
adversely affecting children.
When are waivers necessary
Waivers should be viewed as rare and temporary. The vast majority of waivers are done to keep sibling
together or to place children with relatives. They will only be granted for non‐safety issues. Two rules
that cannot be waived are criminal record checks and training. These are in state statutes. We might
give a provisional license for training to occur within a certain period of time not to exceed 6 months,
but this would only be approved for a relative or kinship placement.
Please talk about waiver requests related to capacity for sibling groups.
The rule related to this is clear. See Item C of 10A NCAC 70E .1001.
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 9

7. Miscellaneous Questions
Where can I find NCDSS forms so I am sure to use the latest version
The NCDSS forms site URL is: http://info.dhhs.state.nc.us/olm/forms/forms.aspxdc=dss
Will child placement agencies ever be able to bill directly for Level II services without
going through the LME / having to get a Medicaid pass-through
LME’s need to answer this question.
Is there any way we can get around the fact that a foster parent is a relative of a DSS
employee In small counties, everyone is related!
DSS employees can be licensed by another agency. It is especially important to show that a conflict of
interest does not occur in situations such as your describe. We can consider this on a case‐by‐case basis
depending on the size of the agency and the position held by the employee. We advise that you contact
one of the licensing consultants to discuss specific situations.
Any word on when the new therapeutic foster care service definition goes into effect
No.
I have been told that Bloodborne Pathogens and Nonviolent Crisis Intervention are onetime
trainings, as long as ongoing training is continued in a child specific manner. Is that
your understanding as well
Please review 10A NCAC 70E.1117 (3) through (8) and 10A NCAC 70E.1103 regarding training for
physical restraints. North Carolina Interventions has requirements about how often this training should
be obtained and these must be followed. The following website should be helpful:
http://www.dhhs.state.nc.us/mhddsas/training/rscurricula/agencylist10‐18‐06web.pdf
The Administrative Rules do not require that Bloodborne Pathogens training be repeated, but
agencies should always continue to assess their foster parents’ retention of information and particularly
any information that can affect the foster children’s or their own health.
Keeping updated with CPR and First Aid training is challenging; is there a grace period
when this expires
Planning ahead is always important with training, relicensing, and other parts of the licensing process.
When agencies are monitored for compliance for training the spirit of the law is more important
than the letter of the law in relation to dates that these trainings have taken place. However, they
should be completed as closely as possible to the expiration dates.
When a therapeutic foster family goes on vacation with their foster child, how do we
handle the supervision requirement
Review 10 A NCAC 70G.0503(s) regarding supervision requirements. When there are extenuating
circumstances you may not be able to provide this supervision in the home. Case scenarios will be
different and agencies should plan how they will meet the supervision requirements while taking into
consideration the needs of the child and the foster family. There will not be any problems from a
licensure perspective as long as there is documentation in the child’s record that reflects the child was
on vacation with the family. You may want to check with your LME to see how they handle these
situations.
NC Division of Social Services: Follow‐up to June 15, 2010 Webinar 10