Successful Foster Home Licensing in NC - Training Matters

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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
Page 1 and 2: Handouts for the Webinar Successful
Page 3 and 4: Tips for Using the DSS-5015 Submit
Page 5: Tips for Using the Other Licensing
Page 9 and 10: III. LICENSE CHANGE REQUEST III. Li
Page 11 and 12: FAMILY FOSTER HOME RELICENSURE, TER
Page 13 and 14: Foster Home Environmental Condition
Page 15 and 16: NORTH CAROLINA DEPARTMENT OF HEALTH
Page 17 and 18: 2 V. Day Care Center Operation If t
Page 19 and 20: 4 understanding of the importance o
Page 21 and 22: Child Central Registry Check from a
Page 23 and 24: (19) assumes responsibility for her
Page 25 and 26: administration of a physical restra
Page 27 and 28: (5) Separate and accessible drawer
Page 29 and 30: Present Employment: Phone Number: I
Page 31 and 32: Skill 12: Making an informed decisi
Page 33 and 34: SIGNATURES I have reviewed and am i
Page 35 and 36: B. RACE CODES Race codes and possib
Page 37 and 38: June 15, 2010 Webinar Successful Fo
Page 39 and 40: June 15, 2010 Webinar DSS-5015 (con
Page 41 and 42: June 15, 2010 Webinar Perfect New A
Page 43 and 44: Follow-up Document from the Webinar
Page 45 and 46: If adding a new adult to the househ
Page 47 and 48: At initial licensure, are children
Page 49 and 50: A home cannot be licensed for TFC i
Page 51 and 52: Should we be asking how serious a d

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