Form Dss-5159 - Foster Home Change Request Application - North Carolina Division Of Social Services Page 2

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If you answered “NO” to (c) or (d) document how access to these objects, hazardous items, and/or
bodies of water are avoided: ___________________________________________________________
(e) Is the DSS-1515 Foster Home Fire Inspection Report attached? _____YES _____ NO
(f)
DSS-5150 Foster Home Environmental Conditions Report attached _____YES _____NO
6. When adding to the household complete the following:
Name: _____________________________________________________________________________
SSN: ______________________________________________________________________________
Relationship to foster parent(s): _________________________________________________________
(a) Complete Sleeping Arrangements Chart (III. 2.).
(b) Attach DSS-5017 Medical History Form.
(c) Attach DSS-5156 Medical Evaluation and TB tests results.
(d) New Household member 18 years of age or up? _____YES _____NO
If ‘YES’ Complete Background Checks, NC Child Abuse/Neglect History Table, and Child
Abuse/Neglect Central Registry Checks from other states if the new household member has not resided
in NC for the past five years. Attach Fingerprint Clearance Letter and RIL results.
Background Checks
{Must be completed on each new household member (18 years old and up)}
Name of New Adult Household Member: _______________________________________________
(Repeat this section as many times as needed)
Type of Background Check
Check
Date
Conducted
Conducted
Date :
Local Court Record Checked by Agency Staff
__YES
__NO
Findings & Dates:
Explanation of Findings:
Date:
NC Department of Corrections Offender Information
__YES
__NO
Findings & Dates:
Explanation of Findings:
Date:
NC Sex Offender and Public Protection Registry
__YES
__NO
Findings & Dates:
Explanation of Findings:
Health Care Personnel Registry
__YES
Date:
https://
__NO
Findings & Dates:
Explanation of Findings:
North Carolina Child Abuse Neglect History (new adult household members)
Child Abuse or Neglect Reported
__YES
__NO
Substantiation: __YES, Date of Substantiation:_________
__NO __ N/A
Explanation of Findings:
DSS-5159 (Rev 01/12)
2
Child Welfare Services

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