Get 5104 Nc Dss Form

Completing the 5104 NC DSS form online can streamline the process for individuals and professionals involved in child protective services assessments. This guide provides clear, step-by-step instructions on filling out each section of the form to ensure accurate and efficient submission.

Follow the steps to fill out the 5104 NC DSS form online

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Enter the county name in Field 1, using the two-digit code that represents the county conducting the assessment.
3. In Field 2, provide the county case number, which should consist of up to six numeric digits.
4. If applicable, add the case manager's name in Field 3. If a valid county worker ID is entered, this field is not required.
5. Input the case manager number in Field 4, which should be up to nine numeric digits.
6. Fill in Field 5 with the date of the initial report, following the MMDDCCYY format.
7. In Field 6, enter the date the CPS assessment was initiated, also in MMDDCCYY format.
8. Enter the date case decision was made in Field 7, using the MMDDCCYY format.
9. Complete Field 8 by entering the risk assessment rating, using the one-digit code that best represents the overall risk.
10. If applicable, in Field 9, enter the code for up to three counties that provided assistance during the assessment.
11. In Field 10, enter the Child ID from the SIS system for the alleged victim if they already exist in the system.
12. Fill Field 11 with the alleged victim's full name as it appears in the SIS system.
13. If the Social Security number of the child is known, enter it in Field 12; otherwise, leave it blank.
14. In Field 13, enter the child's date of birth, following the MMDDCCYY format if applicable.
15. Specify the child's gender in Field 14, using the appropriate one-digit code.
16. In Field 15, enter the child’s race/ethnicity using the correct two-digit code.
17. If applicable, fill in Fields 16-19 with information regarding the child's schooling, living arrangements, and any special areas of concern.
18. Complete Field 20 by entering the source of referral code for the report.
19. If a juvenile court petition has been filed, indicate this in Field 21 using the appropriate code.
20. Use Field 22 to report if criminal charges related to the case have been filed.
21. Input the perpetrator relationship code in Field 23, which is required for substantiated cases only.
22. Continue with Fields 24-39 to provide codes related to services provided, failure to report, contributory factors, and entries related to the perpetrator(s) as required.
23. Conclude the form by reviewing all entries for accuracy. Save your changes, then download, print, or share the completed form as required.

Start filling out the 5104 NC DSS form online now for a simplified and efficient process.