Form Dss-5282 - Notification Of Cps Involvement - Nc
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1
2NOTIFICATION OF CPS INVOLVEMENT
Division of Health Service Regulation
Division of Child Development
Division of Social Services
(DHSR)
(DCD)
(DSS)
Complaint Intake Unit
2201 Mail Service Center
Regulatory and Licensing Services
2711 Mail Service Center
Raleigh, North Carolina 27699
952 Old US Highway 70
Raleigh, North Carolina 27699
Courier # 56-20-17
Black Mountain, North Carolina 28711
1.800.624.3004 (P)
1.800.859.0829 (P)
Courier # 12-84-05
919.715.7724 (F)
919.662.4547 (P)
828.669.3388 (P)
919.661.4844 (F)
828.669.3365 (F)
Mental Health Facilities, Residential
Treatment Facilities - Level II and up
ral/home.asp
ngs.htm
Child Care Programs
Family and Therapeutic Foster Homes,
Level I Group Homes, Maternity Homes
Please indicate if this is:
Initial Notification
Case Decision Notification
This notice satisfies the requirement that DHSR/DCD/DSS receive notification of Child Protective Services (CPS)
involvement AND completion of a CPS assessment.
Administrative Code 10A N.C.A.C. 70A.0106 authorizes the release of the confidential information contained in this notice.
However, N.C.G.S. 7B-302 requires that the confidential information contained in this report shall remain confidential and
may only be re-disclosed if directly connected to the mandated responsibilities of the DHSR/DCD/DSS.
Name of Facility/Home: ____________________________________________________________
Location of Facility/Home (
): _____________________________________________
physical address
Licensing/Supervising Agency: _____________________________________________________
License ID#: __________________
Perpetrator (Name and Date of Birth): ________________________________________________
County Conducting the Investigative Assessment: _____________________________________
If the county responsible for the assessment is different from the county conducting the assessment, the county responsible
for the assessment submits this form. County responsible (if different from county investigating): ______________________
Name of Investigating Social Worker: ________________________________________________
Phone Number: ___________________________________________________________________
Social Work Supervisor: ___________________________________________________________
Phone Number: ___________________________________________________________________
Initial Notification:
Date: _______________________________________
Time: _____________________________
Name and age of child(ren): _________________________________________________________
_________________________________________________________________________________
DSS-5282 09/09
Page 1 of 2
CWS
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