Form Dss-5278 - Request For Placement Evaluation For Infant Born To An Incarcerated Mother (Formerly Prison Baby Program) - Family Support And Child Welfare Services

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Request for Placement Evaluation
For Infant Born to an Incarcerated Mother
(formerly Prison Baby Program)
Date: _____________
OPUS Number: ___________________
Name of the Inmate: ______________________________DOB: ___________________
County of Residence:_________________ Expected Delivery Date:________________
Admission Date: _____________________ Length of Sentence:____________________
Placement Resource: ______________________________________________________
Address: _______________________________________________________________
City/State _________________________Telephone: _____________________________
Kinship: __________________________Employer: _____________________________
Alternate Contacts: ________________________________________________________
Please Note: A plan of care for the baby must be approved prior to the
child's release from the hospital after birth. If a plan of care has not been
approved, the DSS of the county of residence of the mother is responsible for
providing an appropriate placement.
Please complete your assessment within thirty (30) days unless the expected
delivery date noted above necessitates a quicker response. Upon completion,
fax the completed assessment to NC Correctional Institution for Women
at (919) 715-4335 or mail it to:
NC Correctional Institution for Women
Social Work Department
1034 Bragg Street
Raleigh NC 27610
In the event that the proposed caretaker is unwilling or unsuitable, please
contact the NCCIW Social Workers at (919)733-4340, extension 1601 or 1552,
in order that they may work with the mother to develop an alternate plan.
Please note that you must indicate on the assessment whether you approve
or disapprove the placement with the requested relative. It is important to
note that most of these placements are short term, depending upon the
length of the mother's sentence.
If you have any questions about this request, please contact the Foster Care
and Adoption Policy Team at (919)733-9465 or the NCCIW Social Workers at
(919)733-4340, extension 1601 or 1552.
DSS-5278 Rev. 10-07
Family Support and Child Welfare Services

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