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Get NC DSS-5281 2010-2024

Division of Social Services, Regulatory and Licensing Services, via email to your NC Division of Social Services Program Consultant and copied to Cindy.Norton@dhhs.nc.gov within 72 hours of the incident. This form must be password protected before being emailed. GENERAL INFORMATION Agency Name: Agency Address: Please choose ONE of the following (A OR B): A. Name of residential facility or maternity home: Address of residential facility or maternity home: B. Name(s) of foster parent(s): Address.

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