Form Dss-5268 - Responsible Individuals List (Ril) Information Request - North Carolina Division Of Social Services

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NORTH CAROLINA DIVISION OF SOCIAL SERVICES
RESPONSIBLE INDIVIDUALS LIST (RIL) INFORMATION REQUEST
Instruction for completing DSS-5268 (please read carefully):
G.S. § 7B-311
authorizes the release of information regarding substantiated cases of abuse and serious neglect
from the Responsible Individuals List (RIL), for the sole purpose of determining current or prospective
employment in certain situations, or fitness to provide case for children. This includes applications to foster or
adopt a child. Requests for information may be submitted by:
Fax
(919) 715-6714, Attn: RIL
Mail (must include SASE)
N.C. Division of Social Services
325 N. Salisbury St.
Mail Service Center 2408
Raleigh, North Carolina 27699-2408
Attn: RIL
All sections of the DSS-5128 must be completed and signed by the agency and the prospective
employee/applicant/volunteer. Please print legibly or type all information. Incomplete or illegible forms will be
returned via fax without the RIL check completed.
Section 1: Requesting Agency Information
Agency Name: _______________________________________________________________________________
Mailing Address: _____________________________________________________________________________
City: ___________________________________________________ State: _______ Zip: ___________________
Phone: ______________________________________ Fax: _________________________________________
E-Mail Address: _____________________________________________________________________________
Type of Agency:
__ Child Care Provider
__ Child Caring Institution
(check one)
__ Child Placing Agency
__ County DSS
__ Group Home Facility
__ Guardian ad Litem
__ Other Provider of Adoption
__ Other Provider of Foster Care
__ Adoption Home Study
__ Foster Parent Applicant
Agency License Number (if available):____________________________________________________________
Agency Certification: I herby request information from the North Carolina Responsible Individuals List. I certify that I am a person
representing a child caring institution, child placing agency, group home facility, or a provider of foster care, child care or
adoption services that needs to determine the fitness of individuals to care for or adopt children. I either currently employ the
individual listed below, or am strongly considering the individual for an employment, contract, or volunteer position. I will only use
the information requested to determine whether to hire or retain the individual.
Name and Title (print): _________________________________________________________________________
Signature: ____________________________________________________________ Date: _________________
DSS-5268 (rev. 08/10)
Child Welfare Services
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