Form Dss-5282 - Notification Of Cps Involvement - Nc Page 2
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1
2Information Needed:
Please provide sufficient information so that alleged victim child(ren) are not re-interviewed.
What happened (how, when, where, who was involved, were there any witnesses)? __________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Who was told about this and what did they do about it? _________________________________
_________________________________________________________________________________
Has this happened before? _________________________________________________________
Has the resident/patient/client experienced any negative outcome?
Yes
No
If so, How has the negative outcome affected the residents’/patients’/clients’ functioning? ____
_________________________________________________________________________________
_________________________________________________________________________________
Was the incident reported to staff? ___________________________________________________
Is anything being done to prevent it from happening again? _____________________________
_________________________________________________________________________________
What is the residents’/patients’/clients’ current location (room number)? ___________________
_________________________________________________________________________________
If this is a Case Decision Notification:
The completed North Carolina Case Decision Summary (DSS-5228) shall be attached to this notice and will
serve as notification of the case decision.
Assessments conducted on DSS and DHSR facilities require consultation with the assigned Children’s Program
Representative (CPR).
CPR Name: ______________________________________________________________________
Date case decision staffed with CPR: _________________________________________________
DSS-5282 09/09
Page 2 of 2
CWS
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