Form Dss-5268 - Responsible Individuals List (Ril) Information Request - North Carolina Division Of Social Services Page 2

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NORTH CAROLINA DIVISION OF SOCIAL SERVICES
RESPONSIBLE INDIVIDUALS LIST (RIL) INFORMATION REQUEST
Section II: Employee (E), Applicant (A), or Volunteer (V) Information
E, A, or V’s Full Name (Including MI):____________________________________________________________
E, A, or V’s Date of Birth (MM/DD/YYYY): __________/__________/__________
E, A, or V’s Social Security Number (last four digits only): ____ ____ ____ ____
E, A, or V’s Gender: ____ Male ____Female
Other names E, A, or V has used (maiden name, nicknames, former married names, etc.):__________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Employee (E), Applicant (A), or Volunteer (V) Acknowledgement: I acknowledge that I have been informed that the North Carolina
Division of Social Services will disclose to the above named agency whether my name appears on the Responsible Individuals
List, indicating that I am identified as being responsible for the abuse or serious neglect of a juvenile.
Name (print):_______________________________________________________________________________
Signature: ____________________________________________________________ Date: ________________
Section III: North Carolina Division of Social Services Office Use Only
Staff Initials
______
Form submitted incomplete and returned without the RIL check completed.
______
As of ___________________________ (date), E, A, or V’s name is NOT found on the RIL.
______
As of ___________________________ (date), A, A, or V’s name found on the RIL.
Finding: _______________________________________________________________________
Completed by:
Staff Name (print): ___________________________________________________________________________
Signature: ____________________________________________________________ Date: ________________
DSS-5268 (rev. 08/10)
Child Welfare Services
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