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I. The Child Placement and Payment System Manual (CPPS)
A. PURPOSE OF THE CHILD PLACEMENT AND PAYMENT SYSTEM
1) To collect information about all children who are in the legal custody of county departments of social services or who are in
foster care pursuant to a Voluntary Placement Agreement (VPA), whether an assistance payment is being made via the
system.
2) To collect sufficient information regarding expenditures made by county departments of social services for foster care
assistance payments and to generate reimbursement of state and/or federal funds.
3) To collect information regarding children who are placed in North Carolina under an Interstate Compact Agreement.
4) To collect information about children who are receiving adoption assistance.
5) To collect sufficient information to enable cash payments to be made to adoptive parents.
6) To provide case management information about children in the system and provide a mechanism for updating information
about each child.
7) To collect and transmit information to meet federal reporting requirements.
8) To provide data for the purpose of measuring program performance.
B. INTERFACES WITH OTHER SERVICES SYSTEMS
The Client ID number is a common identifier, which links a child's record with other services systems. The Services Information
System (SIS) (https://policies.ncdhhs.gov/divisional/social-services/services-information-system-sis/policy-manuals) database serves
as a master file for all county child welfare agency service clients and maintains general client information which, therefore, does not
require duplicate entries in each of the systems. There is an edit on each of the systems that prohibits a client record being
established until a SIS record exists. The county can determine if a SIS record already exists by conducting a name search in the SIS
system. Consult the SIS menu screen and Data Entry Manual (https://policies.ncdhhs.gov/divisional/social-services/services-
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information-system-sis/policy-manuals/sis100-dss5027-de-instructions.pdf) for instructions. Counties should use this method of
verifying SIS records rather than using locally maintained indexes, which may not be identical to the SIS records and may not show
any possible duplicated numbers.
If a child has duplicate SIS numbers in a county, the county should determine if the numbers can be merged. Once counties have
identified the SIS number they wish to continue using (the target ID), they will be required to close out any open services on the
number to be merged (the source ID) before the system will allow a merge. In rare instances, the system may not be able to merge
the two IDs. In those cases, counties should continue to use only the number they have identified as the target ID. A note should be
placed in the child’s record noting that another ID was also used in the past, and that at the current time, the system will not allow a
merge. Any additional questions regarding SIS ID Merges may be directed to the Performance Management Section.
C. DSS-5094 FORM
County case managers may enter data directly into the CPPS if they have access to a data entry terminal. Edits are built into the
system to assure that all required fields are keyed.
Copies of the blank Child Placement and Payment Report (DSS-5094) may be found at: https://policies.ncdhhs.gov/divisional/social-
services/forms?b_start:int=90. Case managers will need to complete this DSS-5094 form and additional pages, in a manner that
assures that all the necessary and correct information is available for keying. DSS-5094 turnaround forms will be printed and sent to
the county for distribution each time the system is updated.
Establishing and maintaining a current record for each child is the responsibility of the county which has custody or placement
authority or supervision authority under an Interstate Compact Placement Agreement, regardless of the child's living arrangement. It
should be opened as soon as the county child welfare agency has obtained a type of authority as specified for Field 19 of the form
and closed when the county child welfare agency's authority no longer exists. In order for the case to be closed in the CPPS, it is not
sufficient to just close the service on the DSS-5027. An entry must be made in Fields 23, 24, 37, and 48 on the DSS-5094 in order to
close the case. If a child reenters care, their record can be reopened by completing a new DSS-5094 with the latest placement
authority information.
The DSS-5094 must be updated for any change with the exception of Fields 19, 20, 21 and Section IV (Fields 25-33) which are never
updated. Changes in Fields 1-4 and 6-13 must be made on the DSS-5027. Field 5 (SIS ID number) can only be changed if a SIS number
is part of a SIS ID merge. In this case, the system will change the number automatically as part of the merge process. The system will
update the SIS number during a batch process the night after the merge is keyed. Updates to fields 1-13 via the DSS-5027 or a SIS ID
merge will not automatically generate a new turnaround form. If an updated turnaround is needed, workers can open the record by
selecting option “3,” entering the Client ID on the menu screen, and pressing the “Enter” key. “Update” the record by pressing the
PF9 key and the message “PQA20- 5094 UPDATE SUCCESSFUL” will appear. Although no updates have been made directly into the
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CPPS system, by using the update function within CPPS, a turnaround will be generated that will include the new information
updated in the SIS. Note that some changes made in the DSS-5027 SIS system may require an overnight batch process to update.
Workers must wait until that process has occurred before attempting to generate a turnaround that displays the updated
information.
D. DSS-5095 FORM
County case managers may enter data directly into the Adoption Assistance Payment System if they have access to a data entry
terminal. Edits are built into the system to assure that all required fields are keyed.
If data is entered by another unit, the case manager will need to complete the Child Placement and Payment System | Adoption
Assistance (DSS-5095) form https://policies.ncdhhs.gov/divisional/social-services/forms?b_start:int=90 in order to assure that all the
necessary and correct information is available for keying. In either case, two turnaround forms will be printed and sent to the county
for distribution each time the system is updated.
E. REIMBURSEMENT REQUEST DEADLINES
1. DSS-5094 (Foster Care Assistance)
The first preliminary keying deadline for foster care reimbursement is 5:00 PM on the 5
th
workday of the month. A second
preliminary keying deadline is 5:00 PM on the 15
th
day of the month.
The final keying deadline for foster care assistance reimbursement is 5:00 PM the 19
th
of the month. If the 19
th
falls on a
weekend or State holiday, the deadline is 5:00 PM on the last workday prior to the 19
th
.
2. DSS-5095 (Adoption/ Extended Adoption Vendor Payments)
The keying deadline for adoption assistance vendor payments is 5:00 PM on the 19
th
of the month. If the 19
th
falls on a
weekend or State holiday, the deadline is 5:00 PM on the last workday prior to the 19
th
.
3. DSS-5095 (Adoption /Guardianship Assistance, Extended
Adoption/Guardianship Cash Payments)
The keying deadline for adoption assistance cash payments is 5:00 PM on the 3
rd
workday from the last workday of the
month.
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II. DSS-5094 FORM – DESIGN AND FUNCTION
All data on the DSS-5094 must be completed for all children in a county child welfare agency’s custody/placement responsibility regardless of
the child’s living arrangement. In addition, a DSS-5094 must be completed on children from other states who are placed in the county under
an Interstate Compact Agreement. The DSS-5094 is separated into multiple sections. Information sections for County, SIS and Child can be
captured using the DSS-5027 Services form and will automatically populate into the DSS-5094 form.
A. COUNTY INFORMATION AT THE TOP OF THE FORM (FIELDS 1 THROUGH 4)
Complete Fields 1 through 4 for every initial DSS-5094 submitted.
FIELD 1 - County Number (numeric, 2 digits)
No entry is required in this field if already printed on a DSS-5094. When using a blank DSS-5094, enter the standard two-digit county
ID code.
FIELD 2 - Case Manager's Name (alpha/numeric, 16 digits)
No entry is required in this field if already printed on the DSS-5094. If there is a change in case manager, update on the DSS-5027.
When using a blank DSS-5094, enter the case manager's last name, and first and middle initials.
FIELD 3 - Case Manager's Number (numeric, 9 digits)
No entry is required in this field if already printed on the DSS-5094. If there is a change in the case manager number, it must be
updated on the DSS-5027. When using a blank DSS-5094, enter the valid case manager number as obtained from the Services
Information System.
FIELD 4 - County Case Number (alpha/numeric, 6 digits)
This is an optional field available to assist the county in filing forms in case records. If a child has a SIS record, the County Case
Number from that system will be brought forward. The case number in this system must be the same as the case number in the SIS.
B. SIS INFORMATION (Fields 5 through 13)
Complete this section for all children.
This section contains information related to the SIS data fields on the DSS-5094. If there is a DSS-5027 already entered for this client
in the county, only Field 5 needs to be entered on the DSS-5094 (the system will automatically populate Fields 6 through 13 with
information already entered on the DSS-5027). Do not complete Fields 6 through 13 for that child. Submit the DSS-5027 to open the
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new service code(s) or update any fields. If SIS changes need to be made on a child already existing in SIS, use the child's DSS-5027
form.
If the child does not already have a DSS-5027 (SIS record) in the county, one will have to be established. A record should be opened
for this child via the DSS-5027 as is done for all service recipients. After the DSS-5027 is keyed, the child’s information will populate
into the CPPS system once the SIS number (Field 5) is keyed.
FIELD 5 - Client ID (numeric, 11 digits)
Enter the child's SIS ID number. An entry is required in this field for all children.
FIELD 6 - Client Name (alpha/numeric, 15 digits)
Enter the name of the child. An entry is required in this field for all children, however if the child has an existing SIS record, this field
will be brought over from that system.
FIELD 7 - Client's Social Security Number (numeric, 9 digits)
Enter the child’s social security number. An entry is required in this field for all children, however if the child has an existing SIS
record, this field will be brought over from that system.
When the child does not have a social security number, enter a zero in each of the spaces across the field and update this field via
the DSS-5027 when a Social Security Number has been obtained.
FIELD 8 - Date of Birth (numeric, 8 digits)
Record the month, day, and year of the child's birth. An entry is required in this field for all children, however if the child has an
existing SIS record, this field will be brought over from that system.
Use a leading zero for a month or day less than 10. If the child is abandoned or the date of birth is otherwise unknown, enter an
approximate month and year of birth, using the 15
th
as the day of birth.
FIELD 9 - Special Areas (numeric, 2 digits)
An entry is required in this field for all children, however if the child has an existing SIS record, this field will be brought over from
that system.
Enter the code(s), which reflects special characteristics of the client based on worker judgment, not necessarily legally or medically
established conditions. Up to six characteristics or circumstances may be entered for each individual. It is important to enter as
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many as appropriate because this information is useful for justifying funding needs to meet specific problems. It is also important to
update this information whenever there are changes or new special areas that are identified.
Code
Value
01
Developmental Disabilities
02
Blind or Visually Impaired
03
Deaf or Hard of Hearing
04
Physically Disabled
05
Emotionally Disturbed
06
Learning Disability
07
Medical Condition
08
HIV or AIDS
09
Substance Abuse
10
Do not use for new cases. Formerly Willie M. Class
11
Undisciplined Child
12
Delinquent Child
13
Homeless Person
FIELD 10 - Sex (numeric, I digit)
Enter the code, which identifies the sex of the child. An entry is required in this field for all children, however if the child has an
existing SIS record, this field will be brought over from that system.
Code
Value
1
Male
2
Female
FIELD 11 - Race (numeric, 2 digits)
Enter the code, which identifies the race of the child. An entry is required in this field for all children, however if the child has an
existing SIS record, this field will be brought over from that system.
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In general, a person's race is determined by how they define themselves. In the case of young children, parents define the race of
the child. If an “Unable to Determine” code (11 or 12) is used, this field must be updated immediately via the DSS-5027 when the
race/ethnicity is determined.
The race categories are:
• American Indian or Alaskan Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific Islander
• White
• Unable to Determine
Ethnicity
• Non-Hispanic or Latino
• Hispanic or Latino
Combinations of race codes that could be selected are:
Code
Value
01
White (Non-Hispanic or Latino)
02
White (Hispanic or Latino)
03
Black (Non-Hispanic or Latino)
04
Black (Hispanic or Latino)
05
American Indian or Alaskan Native (Non-Hispanic or Latino)
06
American Indian or Alaskan Native (Hispanic or Latino)
07
Asian (Non-Hispanic or Latino)
08
Asian (Hispanic or Latino)
09
Native Hawaiian or Other Pacific Islander (Non-Hispanic or Latino)
10
Native Hawaiian or Other Pacific Islander (Hispanic or Latino)
11
Unable to Determine (Non-Hispanic or Latino)
12
Unable to Determine (Hispanic or Latino)
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Code
Value
13
White/Black (Non-Hispanic or Latino)
14
White/Black (Hispanic or Latino)
15
White/American Indian or Alaskan Native (Non-Hispanic or Latino)
16
White/American Indian or Alaskan Native (Hispanic or Latino)
17
White/Asian (Non-Hispanic or Latino)
18
White/Asian (Hispanic or Latino)
19
White/Native Hawaiian or Other Pacific Islander (Non-Hispanic or Latino)
20
White/Native Hawaiian or Other Pacific Islander (Hispanic or Latino)
21
Black/American Indian or Alaskan Native (Non-Hispanic or Latino)
22
Black/American Indian or Alaskan Native (Hispanic or Latino)
23
Black/Asian (Non-Hispanic or Latino)
24
Black/Asian (Hispanic or Latino)
25
Black/Native Hawaiian or Other Pacific Islander (Non-Hispanic or Latino)
26
Black/Native Hawaiian or Other Pacific Islander (Hispanic or Latino)
27
American Indian or Alaskan Native/Asian (Non-Hispanic or Latino)
28
American Indian or Alaskan Native/Asian (Hispanic or Latino)
29
American Indian or Alaskan Native/Native Hawaiian or Other Pacific Islander (Non-
Hispanic or Latino)
30
American Indian or Alaskan Native/Native Hawaiian or Other Pacific Islander
(Hispanic or Latino)
31
Asian/Native Hawaiian or Other Pacific Islander (Non-Hispanic or Latino)
32
Asian/Native Hawaiian or Other Pacific Islander (Hispanic or Latino)
33
White/Black/American Indian or Alaskan Native (Non-Hispanic or Latino)
34
White/Black/American Indian or Alaskan Native (Hispanic or Latino)
35
White/Black/Asian (Non-Hispanic or Latino)
36
White/Black/Asian (Hispanic or Latino)
37
White/Black/Native Hawaiian or Other Pacific Islander (Non-Hispanic or Latino)
38
White/Black/Native Hawaiian or Other Pacific Islander (Hispanic or Latino)
39
White/American Indian or Alaskan Native/Asian (Non-Hispanic or Latino)
40
White/American Indian or Alaskan Native/Asian (Hispanic or Latino)
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Code
Value
41
American Indian or Alaskan Native/Native Hawaiian or Other Pacific Islander (Non-
Hispanic or Latino)
42
American Indian or Alaskan Native/Native Hawaiian or Other Pacific Islander
(Hispanic or Latino)
43
White/Asian/Native Hawaiian or Other Pacific Islander (Non-Hispanic or Latino)
44
White/Asian/Native Hawaiian or Other Pacific Islander (Hispanic or Latino)
45
Black/American Ind. or Alaskan/Asian (Non-Hispanic or Latino)
46
Black/American Ind. or Alaskan/Asian (Hispanic or Latino)
47
Black/American Ind. or Alaskan/Native/Hawaiian (Non-Hispanic or Latino)
48
Black/American Ind. or Alaskan Native/Hawaiian (Hispanic or Latino)
49
Black/Asian/Native Hawaiian or Other Pacific Islander (Non-Hispanic or Latino)
50
Black/Asian/Native Hawaiian or Other Pacific Islander (Hispanic or Latino)
51
American Indian/Asian/Native Hawaiian (Non-Hispanic or Latino)
52
American Indian/Asian/Native Hawaiian (Hispanic or Latino)
53
White/Black/American Indian/Asian (Non-Hispanic or Latino)
54
White/Black/American Indian/Asian (Hispanic or Latino)
55
White/Black/American Indian/Native Hawaiian (Non-Hispanic or Latino)
56
White/Black/American Indian/Native Hawaiian (Hispanic or Latino)
57
White/Black/Asian/Native Hawaiian (Non-Hispanic or Latino)
58
White/Black/Asian/Native Hawaiian (Hispanic or Latino)
59
White/American Indian/Asian/Native Hawaiian (Non-Hispanic or Latino)
60
White/American Indian/Asian/Native Hawaiian (Hispanic or Latino)
61
Black/American Indian/Asian/Native Hawaiian (Non-Hispanic or Latino)
62
Black/American Indian/Asian/Native Hawaiian (Hispanic or Latino)
63
White/Black/American Indian/Asian/Native Hawaiian (Non-Hispanic or Latino)
64
White/Black/American Indian/Asian/Native Hawaiian (Hispanic or Latino)
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FIELD 12 – School (numeric, 1 digit)
Enter the appropriate code to indicate if the child is attending school on a scheduled basis. Do not take holidays, breaks or summer
vacations into consideration. An entry is required in this field for all children, however if the child has an existing SIS record, this field
will be brought over from that system. This field should be updated annually on the DSS-5027.
Code
Value
1
Yes, in school
2
No, not in school
FIELD 13 - Grade (alpha, numeric, 2 digits)
For children who are in school, enter the grade associated with their current or most recent attendance. If no longer in school, enter
the last grade completed. An entry is required in this field for all children, however if the child has an existing SIS record, this field
will be brought over from that system. This field should be updated annually on the DSS-5027.
Code
Value
P
Preschool (including Kindergarten)
1-20
Current or Highest Grade
98
GED
99
Unknown (show special education here if not certain of grade equivalent)
C. CHILD INFORMATION (Fields 14 through 18)
Complete this section for all children.
This section of the form pertains to the child's situation at the time he/she was placed in county child welfare agency
custody/placement responsibility and must be completed every time a DSS-5094 is opened to show the child has come into the
custody/placement responsibility of the county child welfare agency (new cases and reopening of terminated cases). Information in
this section must be completed for all cases. Fields 14, 15, 16, and 17 must be updated immediately at any time there is a change or
when new information becomes available.
FIELD 14 - Disability (numeric, 1 digit)
Complete for each of the disabilities listed. This field differs from the SIS Special Areas field in that it requires the opinion of a
qualified professional.
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A qualified professional, as defined by Adoption and Foster Care Analysis and Reporting System (AFCARS), is a person employed by a
medical facility or practice, including physicians, physician assistants, nurses, emergency medical technicians, dentists, dental
assistants and technicians, chiropractors or a person employed by a mental health facility or practice, including psychologists,
psychiatrists, therapists, etc... Any condition found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) or any
medically diagnosed physical disability should be reflected in Field 14. Attention Deficit Hyperactivity Disorder (ADHD) is entered as
"EMOTIONALLY DISTURBED".
• If there has been a diagnosis of a disability(ies) by a qualified professional, enter a "1" in the block beside "DISABILITY".
• If there is no disability, (whether the child was assessed or not) enter a "2" in the block beside "DISABILITY".
• If there appears to be a disability(ies) but a diagnosis by a qualified professional has not yet been conducted, enter a "3" in the
block beside "DISABILITY". It is important to change this code as soon as a diagnosis is obtained.
• If a "1" is entered in the "DISABILITY" block, a "1" must also be entered in the block beside the disability(ies) diagnosed by a
qualified professional.
• If a “2” or "3" is entered in the "DISABILITY" block, leave all blocks beside the disabilities listed on the form blank.
Code
Value
1
Yes, a qualified professional has clinically diagnosed the disability. Requires that
“1” be entered for all the disability(ies) diagnosed.
2
No, there is no disability.
3
Not yet determined. It is important to change this code as soon as a diagnosis is
obtained.
FIELD 15 - Adoption Status (multi-part data element numeric) a. Currently Free?
Code
Value
1
If the child is currently free for adoption, enter "1" in this box. If Code “1” is used,
Fields 38 and 39 must be completed. “Currently Free” means that the court has
ordered Termination of Parental Rights (TPR) and the 10-day waiting period has
passed with no notice of appeal (or relinquishment for adoption has been
obtained) on both parents or the case on appeal is resolved.
2
If the child is not currently free for adoption, enter "2".
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3
If the child's status is unknown, enter "3". If the child’s status is later determined,
change to the correct code.
4
If TPR is pending, enter "4". This includes if a TPR petition has been filed on at
least one parent or for cases under appeal. Once the court orders Termination of
Parental Rights and the 10-day waiting period has passed with no notice of appeal
(or relinquishment for adoption has been obtained) on both parents or the case
on appeal is resolved, change to the correct code.
b. Previously Adopted?
Code
Value
1
If the child has ever been legally adopted domestically, enter "1".
2
If the child has never been legally adopted, enter "2".
3
Enter "3" if the information is not available. If this information is later
determined, change to the correct code.
4
If the child has ever been legally adopted internationally, enter “4”.
c. Age at Previous Adoption, Value
If the answer to Previously Adopted is yes (Code 1 or 4), enter the age when the adoption was finalized. If uncertain,
estimate age.
If the answer to Previously Adopted is no (Code 2), or unavailable (Code 3), leave age blank.
d. Adoption Dissolved—A child who was previously adopted, including international
adoptions, and enters Foster Care as a result of the court terminating the parents’ rights or the parents’ relinquishing their
rights to the child.
Value
If the answer to Previously Adopted is yes (Code 1 or 4) enter Y (“yes”) or N (“no”) if previous adoption was dissolved.
FIELD 16 - HIV Status (alpha, 1 digit)
This field identifies the basis for Human Immunodeficiency Virus (HIV) Foster Care Assistance. Complete if the child meets one of the
HIV categories as diagnosed by a qualified professional. Otherwise, leave blank.
If a county child welfare agency is requesting HIV payment, the request must continue to be made manually. Instructions for
requesting payment can be found in the payment section of this manual – Fields 50 and 51.
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Code
Value
E
Perinatally exposed infant 0-24 months who cannot be classified as definitely
infected, but who has antibodies to HIV, indicating exposure to an infected
mother.
N
Infant, child or youth who meets one of the Center for Disease Control (CDC)
definitions for infection but who has no previous signs or symptoms of HIV.
A
Infant, child or youth who shows mild signs or symptoms of HIV.
B
Infant, child or youth who shows moderate signs or symptoms of HIV.
C
Infant, child or youth who shows severe signs or symptoms of HIV.
T
Child aged 0-21 with laboratory evidence of HIV infection who has a resulting
terminal diagnosis with a life expectancy of less than six months.
FIELD 17 - Is Client A Parent/Pregnant? (multi-part alpha/numeric)
Enter a "Y" or "N" in the correct block to indicate "yes" or "no" to identify if the client is a teenage parent under the age of 18, male
or female, who has had a child and whose rights to that child have not been terminated either through court action, consent, or
relinquishment. Field should be updated appropriately if county is seeking an Adolescent Parenting exception under the Families
First Prevention Service Act.
a. Parent
Code
Value
Y
Yes, the client has a child(ren). Requires entry for “Number of Children”
N
No, the client has not previously had a child; or, the client has previously had a
child, but client's rights have been terminated either through court action,
consent, or relinquishment
If client is a parent whose rights to that child have not been terminated, enter in the number of children in the home. If none, enter
in “00 (a two-digit number should always be entered in the second part of this field).
When the client is no longer considered to be a parent, due to court action, consent or relinquishment, the field should be changed
to “N”. This field is required for both male and female clients.
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b. Pregnant
Code
Value
Y
Yes, the client is pregnant. May only be selected if the client is female.
N
No, the client is not pregnant. If the client was previously pregnant, when she
is no longer pregnant, the field should be changed to “N”.
FIELD 18 - Special Population (numeric, 1 digit) Enter the appropriate code as it applies to
the child.
Code
Value
1
Indian (Bureau of Indian Affairs Federally recognized tribe)
3
Unaccompanied Refugee Minor
5
Not Applicable
D. PLACEMENT AUTHORITY (Fields 19 through 24)
Complete this section for all children.
This section of the form contains the reason that the county child welfare agency obtained custody and placement responsibility of a
child. Information in this section must be completed for all cases. Fields 19, 20, and 21 reflect the initial placement authority reason
and date. If the agency's custody and/or placement authority ends, Fields 23 and 24 must completed. If the child re-enters care, a
new DSS-5094 must be completed with the reasons for the re-entry into care.
FIELD 19 - Type of Authority (numeric, 2 digits)
Enter the two-digit code, which describes the statutory, or policy basis, which mandates county child welfare agency supervision,
care and/or placement of a child.
Once this field is completed, it may not be updated or changed. If custody and/or placement responsibility is terminated and the
child(ren) subsequently re-enters custody and/or placement responsibility, a new DSS-5094 must be completed and entered in the
CPPS.
If a client enters a Contractual Agreement for Residential Services (CARS), then Field 19 must be coded as “09”.
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If a client turns 18 years old while in the custody or placement authority of the county child welfare agency and enters into a CARS
upon his or her 18
th
birthday, then the DSS-5094 must be terminated and a new DSS-5094 opened the next calendar day.
FIELD 19A – CDJJ [ENTRY REQUIRED IF APPLICABLE]
Enter “X” only if the County Child Welfare Agency has been ordered to assume responsibility of non-secure custody by a Juvenile
Delinquency Court Judge. NOTE: Field 19 must have an entry of “03.”
FIELD 20 - Reason (Alpha, 1 digit)
Enter "X" for all the actions or conditions associated with the child's entry into the county child welfare agency’s custody/placement
responsibility with the exception of Human Trafficking. If a child came into custody as a result of sexual trafficking “S” should be
entered, as a result of labor trafficking “L” should be entered If a child came into custody as a result of both sexual and labor
trafficking, a “B” should be entered. At least one condition must be associated with the child's entry into the county child welfare
agency’s custody/placement responsibility.
"Child's behavior" includes delinquency and undisciplined behaviors. "Coping" is used for dependent children. Emotional Abuse is
coded as "Neglect". This is to satisfy Federal reporting requirements and does not reflect a change in the North Carolina General
Statutes.
Code
Value
01
County child welfare agency ordered to assume responsibility for nonsecure custody by
a court of competent jurisdiction (G.S. § 7B-502).
02
Court ordered legal custody, but the county child welfare agency does not have
placement authority.
03
Court ordered legal custody with the county child welfare agency having placement
authority.
04
Relinquishment for adoption by parent(s) or guardian of the child.
05
(Reserved for later use.) Do not use this code
06
(Reserved for later use.) Do not use this code
07
Voluntary Placement Agreement with parent(s) or legal guardian(s).
08
Interstate Compact Placement Agreement into North Carolina.
10
Transfer in from another North Carolina county
11
Transfer in from another North Carolina county (placement was originally a VPA) This
code is no longer valid for new placements after February 2017.
12
Voluntary Placement Agreement for Extended Foster Care Services (FC 18 to 21)
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Once this field is completed, it may not be updated or changed. If custody and/or placement responsibility is terminated and the
child(ren) subsequently re-enters custody and/or placement responsibility, a new DSS-5094 must be completed and entered into the
CPPS.
If “Domestic Violence” is entered with no other reason code, the system displays the error message: “At least one more authority
reason must be entered.” One other placement authority reason code is required when using “Domestic Violence”.
If Human Trafficking is entered, Field 67 “Trafficking Victim” must have a code of 2, if “S” is entered, 3 if “L” is entered, or 4 if “B” is
entered.
FIELD 21 - Beginning Date (numeric, 6 digits, MMDDYY format)
Enter the date that the agency obtained the initial type of authority, which sanctions county child welfare agency supervision, care
and/or placement of the child.
Once this field is completed, it may not be updated or changed. If custody and/or placement responsibility is terminated and the
child(ren) subsequently re-enters custody and/or placement responsibility, a new DSS-5094 must be completed and entered into the
Child Placement and Payment System.
FIELD 22 - Out of State Placement (alpha, 1 digit)
Enter a “Y” if the child's current placement is in a state other than North Carolina. If the child is placed in North Carolina, leave
blank.
FIELD 23 - Termination Reason (numeric, 2 digits)
Enter the code, which reflects the reason why the county child welfare agency’s placement authority is terminated and the foster
care service is being closed. This is the reason why the county child welfare agency no longer has custody or placement
responsibility. Otherwise, leave blank.
If an entry is made in this Field 23, an entry must also be made in Fields 24, 37, and 48.
If a client turns 18 years old while in the custody or placement responsibility of the county child welfare agency, then the
Termination Reason must be coded as “07.”
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Code
Value
01
Reunification with Parents or Primary Caretakers – Custody/Placement responsibility
of the child was returned to his or her principal caretaker(s) from whom the
child(ren) was removed.
02
Guardianship with a Relative – Legal Guardianship of the child was awarded to an
individual by the court.
03
Adoption – The child was legally adopted. If Adoption is the Termination Reason,
Parental Rights Termination Dates (Fields 38 and 39) must have been completed.
04
Guardianship with other court-approved caretaker – Legal Guardianship of the child
was awarded to an individual.
05
Custody with non-removal Parent or Relative.
06
Custody with other court approved caretaker.
07
Emancipation – The child reached age 18 or older and is no longer subject to county
child welfare agency supervision, or the child was legally emancipated pursuant to
Article 35 of Chapter 7B of the North Carolina General Statutes.
08
Transfer to Another Agency – Responsibility for the care of the child was awarded to
another agency - either in or outside of the State.
09
Runaway – The child ran away from the foster care placement and the county child
welfare agency is relieved of custody or placement responsibility.
10
Death of Child – The child died while in foster care.
11
Interstate Compact Placement Agreement with another State was terminated. Use
this code only if Placement Authority Reason Code in Field 19 is “08” (Interstate
Compact Placement Agreement Into North Carolina).
12
Authority Revoked for reasons other than above.
13
Other (reserved for state staff use only - this code is to be used when a case has been
opened erroneously and needs to be closed). To use this code, the agency must send
a letter on Department letterhead with an explanation and request that the case be
closed with another code and sent to:
NC Division of Social Services
Child Welfare Services
ATTN: 5094 Corrections
Mail Service Center 2408
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Raleigh, NC 27599-2408
14
Termination of CARS agreement – The child chose to terminate their CARS
agreement.
15
Termination of Voluntary Placement Agreement for Extended Foster Care Services (FC
18 to 21)
FIELD 24 - Termination Date (numeric, 6 digits, MMDDYY format)
Enter the date upon which the authority to supervise, care for and/or place the child terminated and the foster care service is being
closed. Otherwise, leave blank.
If an entry is made in Field 24, an entry must be made in Fields 23, 37, and 48.
E. PRINCIPAL CARETAKER(S) INFORMATION (Fields 25 through 33)
Complete this section for all children.
This section contains information, which pertains to primary adult caretaker(s) from whom the child was removed at the time the
county child welfare agency was given custody or placement responsibility for the child. Once an entry is made in these fields, it
may not be updated or changed.
FIELD 25 - Family Structure (numeric, 1 digit)
Enter the appropriate code to describe the child's family structure at the time the child was removed.
An entry is required for all cases.
Code
Value
1
Married Couple - Requires entry in fields 28-33.
2
Unmarried Couple - Requires entry in fields 28-33.
3
Single Female - Requires entry in fields 28-30.
4
Single Male - Requires entry in fields 28-30.
5
Unable to Determine (if the child was abandoned or the child's caretakers are
otherwise unknown.)
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FIELD 26 - Intensive Family Preservation (numeric, 4 digits)
The Intensive Family Preservation Services (IFPS) model provides in-home crisis intervention services designed to help families at
imminent risk of having a child removed from the home. These services help to maintain children safely in their homes (whenever
possible) and prevent unnecessary separation of families. This model is characterized by very small caseloads for workers, 24-hour
availability of staff, the provision of services primarily in the child's home or in another environment, and intensive, time-limited
services lasting no more than 4-6 weeks.
Enter the code to signify if IFPS were provided to the family within the 12 months prior to the child entering the county child welfare
agency’s custody/placement responsibility.
Code
Value
1000
Yes, IFPS provided by the county child welfare agency.
2000
Yes, IFPS provided by MH/DD/SAS.
3000
Yes, IFPS provided by private non-profit organization.
4000
No, IFPS services not provided.
5000
N/A - No IFPS in county.
6000
N/A - IFPS full.
FIELD 27 - Number of Children in the Home (numeric, 2 digits)
Enter the total number of children, related or not, residing in the home where the child was residing at the time the county child
welfare agency received custody or placement responsibility for the child. Include the child for whom this data is being entered.
Field 28 – Year of Birth of First Caretaker (numeric, 2 digits)
Enter the year of birth of one of the child’s caretakers. If this is not known, estimate. Only the YOB needs to be entered, the system
will calculate the age.
An entry is required in this field if Field 25 is coded 1 through 4.
FIELD 29 - Race of First Caretaker (numeric, 2 digits) Enter the code, which describes the race of
the caretaker.
The race categories can be found under Field 11.
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An entry is required in this field if Field 25 is coded 1 through 4.
FIELD 30 - Relationship of First Caretaker (numeric, 1 digit)
Enter the code, which identifies the relationship of the caretaker to the child.
Code
Value
1
Biological Parent
2
Adoptive Parent
3
Step Parent
4
Other Relative
5
Guardian
6
Other
An entry is required in this field if Field 25 is 1 through 4.
Field 31 – Year of Birth of Second Caretaker (numeric, 2 digits)
Enter the year of birth of a second caretaker, if any. If this is not known, estimate. Only one of YOB needs to be entered, the system
will calculate the age. Leave blank if there is only one caretaker.
An entry is required in this field if Field 25 is coded 1 through 4.
FIELD 32 - Race of Second Caretaker (numeric, 2 digits)
Enter the code, which describes the race of this caretaker. Leave blank if there is only one caretaker.
The race categories are can be found under Field 11.
An entry is required in this field if Field 25 is coded 1 or 2.
FIELD 33 - Relationship of Second Caretaker (numeric, 1 digit)
Enter the code, which identifies the relationship of this caretaker to the child. Leave blank if there is only one caretaker.
Code
Value
1
Biological Parent
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2
Adoptive Parent
3
Step Parent
4
Other Relative
5
Guardian
6
Other
An entry is required in this field if Field 25 is coded 1 or 2.
F. PERMANENT PLAN (Fields 34 through 37)
Complete this section for all children and update whenever the plan changes.
This section pertains to the plan goal of the child and any barriers to that plan.
FIELD 34 - Plan Goal (numeric, 2 digits)
Enter the code which best identifies the most recent Permanent Plan Goal based on the latest review of the child’s case plan, either
agency or court review. The Plan Goal describes the desired permanency outcome, which is most appropriate based on current case
circumstances.
Code
Value
01
Prevention of out-of-home placement services are being provided to prevent
placements in out of home care. The county child welfare agency has custody, but the
child remains in the home and has not been in out-of-home placement. Do not use
this code for Trial Home Visits. Use Code 02 for Trial Home Visits (or 06 for trial visits
with the non-removal parent).
02
Family reunification with parent(s)\caretaker(s) from whom the child was removed.
This Code is also to be used when the child returns home for a Trial Home Visit and the
county child welfare agency retains custody.
03
Adoption
04
Guardianship with Relative
05
Guardianship with other court approved caretaker
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Code
Value
06
Custody with non-removal Parent or Relative. This Code is also to be used when the
child is placed for a Trial Visit with a non-removal Parent and the county child welfare
agency retains custody.
07
Custody with other court approved caretaker
08
Plan Goal not yet established. (Not appropriate after 30 days – update to another Plan
Goal at least by the 30
th
day hearing. Code 08 should only be used in exceptional
circumstances, as the Plan Goal should be known at the time the agency receives
custody or placement responsibility in most cases.)
09
Emancipation – A youth who will be emancipated, or who is 18 years or older who has
signed a Contractual Agreement for Residential Services (CARS).
10
Another Planned Permanent Living Arrangement (APPLA) - A permanent living
arrangement for a youth age 14 or over who resides in a family setting which has been
maintained for at least the previous six concurrent months; and in which the youth and
caregiver have made a mutual commitment of emotional support and the youth has
been integrated into the family; and the youth and caregiver are requesting that the
placement be made permanent. Other permanency options must have been ruled out.
11
Reinstatement of Parental Rights - Circumstances that allow this option as a permanent
plan are outlined in G.S. § 7B-1114
(http://www.ncleg.net/gascripts/statutes/statutelookup.pl?statute=7b-
1114).%20%20). These circumstances are very narrow and require the court’s
determination and an order.
12
Completing secondary education or a program leading to an equivalent credential
13
Enrolled in an institution that provides postsecondary or vocational education
14
Participating in a program or activity designed to promote, or remove barriers to
employment
15
Employed for at least 80 hours per month
16
Incapable of completing the education or employment requirements due to a medical
condition or disability
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Custody and Guardianship are judicial decisions.
Long Term Foster Care and Independent Living are not permanent plans.
As long as a minor child is in an agency's custody, the agency must work toward a permanent plan, even if the child's present status
is extended foster care. If return to parents or custody or guardianship with a relative or other suitable person have been eliminated
as possibilities, and the child has indicated that he or she will not cooperate with adoptive placement, the plan will be custody with
other court approved caretaker, code 07 or guardianship with other approved caretaker, code 05.
Code 08 is to be used when the child initially enters care and it is not yet clear what the plan is for that child. Code 08 should only be
used in exceptional circumstances, as the Plan Goal should be known at the time that the agency receives custody or placement
responsibility in most cases. Code 08 shall not continue past 30 days at which time the Family Services Case Plan, Part B, Case Plan,
for the child should be completed. At that time, another appropriate code should be entered.
Code 10 is only valid for a case that includes children ages 14 thru 17. The system will display an error message if a child on the case
is age 0 thru 13 and Code 10 is entered in this field.
Codes 12 through 16 may only be used for youth who have signed a Voluntary Placement Agreement for Extended Foster Care
Services (FC 18 to 21).
FIELD 35 - Date Plan Made (numeric, 6 digits, MMDDYY format) Enter the effective date, which corresponds to
the current Plan Goal.
FIELD 36 - Barriers to Plan (numeric, 2 digits per barrier)
Enter the code, which describes the negative constraints that must be addressed by agency intervention in order to realize the
Planned Goal for the child.
a. At least a primary barrier must be entered in the first two spaces of this field.
b. A secondary barrier may be entered in the last two spaces of the field.
c. Barriers to goal achievement may change as case circumstances and goals change. They should be evaluated at each case
review.
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Code
Value
01
Inadequate Placement - Current placement resource does not facilitate the goal.
02
Mental Health Treatment - Adequate mental health treatment is not available or in
place.
03
Educational Resources - Alternative educational resources are not available to meet
the special learning needs of the child.
04
Adoptive Family - An adoptive family has not been identified.
05
Acceptable Housing - Acceptable housing for the child's family is not available.
06
Child's Medical Needs - Child requires special medical or psychological care.
07
Family Health Needs - One or more of the child's family members require special
medical or psychological care.
08
Inadequate income of parents.
09
Conduct of parents (alcohol, drug, violence, etc.).
10
Not legally free for adoption.
11
Court not in agreement with permanent plan.
12
Agency cannot assure child's safety if plan achieved.
13
Incomplete Assessment/Evaluation - Need more comprehensive assessment of the
child's and/or family problems and needs; or the appropriateness of the current plan
needs more evaluation.
14
Unstable living arrangement.
15
Geographic Distance - Work with parent(s), or relative(s) is constrained by geographic
distance.
16
Limited Functioning - Family functioning is too limited to assume childcare and
nurturing role.
17
Child's conduct/behavior.
18
Child’s Readiness – The child is not ready to participate in, accept, and/or support the
plan goal.
19
No barriers identified at this time and child is in permanent living arrangement.
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When two barriers have been entered and one needs to be deleted, draw a line through the code that no longer applies for data
entry person to delete. If two codes are entered in Field 36 and later they are no longer applicable, line through both for data entry
person to delete and enter at least one new code.
FIELD 37 - Date Plan Realized (numeric, 6 digits, MMDDYY format)
Enter the date upon which the desired permanency outcome has been reached. This date should not relate to dates upon which the
Planned Goal may have been changed but rather, the date upon which a goal has been achieved and no further goals are being
planned and the agency no longer has custody or placement responsibility.
If an entry is made in Field 37, there must be an entry in Fields 23, 24, and 48.
G. PARENTAL RIGHTS TERMINATION (Fields 38 through 39)
Complete this section when relinquishment has been signed or when parental rights are terminated.
This section pertains to the Termination of Parental Rights (TPR) either by court action or relinquishment. The date that parental
rights are terminated by court action is the date that the court actually orders the TPR either from the bench or the date recorded in
the written court order as having been entered by the court. These dates need to be entered immediately as soon as termination is
obtained for each parent.
FIELD 38 - Mother TPR Date (numeric, 6 digits, MMDDYY format)
Enter the date of relinquishment to the agency or the date that the court terminated the mother’s parental rights. If the mother is
known to be deceased, enter the date of death.
FIELD 39 - Father TPR Date (numeric, 6 digits, MMDDYY format)
Enter the date relinquishment to the agency or the date that the court terminated the father’s (or putative father’s if there is no
legal father) parental rights. If the father is known to be deceased, enter the date of death.
If relinquishment is revoked, submit DSS-5094 deleting date(s) from Fields 38 and/or 39. If the Termination of Parental Rights is
overturned on appeal, submit DSS-5094 deleting date(s) from Fields 38 and/or 39. If dates are entered in both fields and the child is
legally free for adoption, enter a “1” in Field 15 (Adoption Status). If the Termination Reason in Field 23 is Code “03” (Adoption),
Fields 38 and 39 are required.
H. CASE REVIEWS (Fields 40 through 44)
Complete this section for all children.
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This section pertains to the Permanency Planning Action Team (PPAT) review and Court Review information for a particular case and
is updated immediately as appropriate and necessary. Updates must be made in these fields in accordance with State Standards.
Please refer to Permanency Planning in the NC Child Welfare Manual (https://www2.ncdhhs.gov/info/olm/manuals/dss/) for specific
policy requirements.
FIELD 40 - Date of Last Agency Team Review (numeric, 6 digits, MMDDYY format)
a. Enter the date of the most current review completed by the agency review team (leave blank if initial review has not yet
occurred), or
b. For children being supervised in North Carolina under the provisions of an Interstate Compact Agreement with another
state, enter the date a progress report was provided to the state, which has responsibility for the child.
FIELD 41 - Next Agency Team Review Due (numeric, 6 digits, MMDDYY format)
a. Enter the date that the next review by the agency team is scheduled, or
b. For a child being supervised in North Carolina under the provisions of an Interstate Compact Agreement with another state,
enter the date that a progress report is due to be sent to the state which has responsibility for the child.
FIELD 42 - Review Not Required (Court) (alpha, 1 digit)
Enter an “X” in this field if the county child welfare agency’s authority to supervise, care for and/or place the child is not subject to
review requirements, either statutory review or court ordered review.
There are two occasions when a review would not be required for a child in a county child welfare agency’s custody or placement
responsibility.
a. A youth who has been emancipated, or an 18-year-old who has signed a voluntary placement agreement.
b. When the court has waived the holding of subsequent review hearings as provided in G.S. § 7B-906.1
http://www.ncleg.net/EnactedLegislation/Statutes/PDF/BySection/Chapter_7B/GS_7 B-906.1.pdf.
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When an entry is made in this field, Fields 43 and 44 must be left blank.
If the child’s situation changes and the court reinstates the required reviews, data entry should delete the “X” in Field 42 and new
dates should be entered in Fields 43 and 44.
FIELD 43 - Date of Last Review (Court) (numeric, 6 digits, MMDDYY)
Leave blank until adjudication or the court review of a VPA. The first entry will be either the adjudication date or the date of the
court review of the VPA. Subsequent entries will reflect the date the case was last reviewed, including reviews, Permanency
Planning Hearings, TPR hearings, etc., by a court of competent jurisdiction.
When an entry is made in this field, do not complete Field 42.
FIELD 44 - Next Review Due (Court) (numeric, 6 digits, MMDDYY)
a. Enter the date that the next court review is scheduled.
b. Once the date is entered in Field 43, a date must be entered in Field 44. If a date is not entered in this field by the county, or
if a date is entered which is greater than the mandated court review requirements, the system will not accept the form.
When a minor child is placed by authority of a voluntary placement agreement, leave Field
42 blank and enter a date not to exceed 90 days from the date of the agreement in this field.
I. LIVING ARRANGEMENT (Fields 45 through 49)
Complete this section for all children and update when there is a change in living arrangement, whether reimbursement is being
requested or not.
This section pertains to the living arrangement status of the child. New data must be entered every time a living arrangement,
progress towards permanence, beginning date, ending date, or facility ID changes. There must always be an open living arrangement
as long as the county child welfare agency has custody/placement responsibility.
Because it is recognized that multiple changes in a child’s living arrangement or placement can occur during a relatively short period
of time, space has been allowed to record up to three moves on one form. However, please note that additional living arrangements
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cannot be opened until the previous living arrangement is closed (Field 48) If additional lines are needed, use a blank form and write
“1 of 2” on the side margin of the 1
st
form and “2 of 2” on the side margin of the second form. This will let data entry workers know
it is a two-page entry. Omissions in required fields of this section may affect reimbursement.
Do not include the living arrangement from which the child was removed unless the child remained in the living arrangement after
the agency received custody/placement responsibility.
1. Each time a child moves from one placement to another, a new line of data must be entered, regardless if there is an associated
change in the assistance payment. Federal reporting regulations require that county child welfare agencies be able to track every
move a child makes while in a county child welfare agency’s custody/placement responsibility.
2. When a child moves from one placement setting to another, even if the type of Living Arrangement does not change, the current
line of data must be closed out and the new information must be opened on a blank line.
Example: A child's facility ID changes from A00001 to A99999 but the type living arrangement remains a Code 56 in Field 45.
Close out the line of data, which contains the facility ID A00001 and complete a new line of data using the facility ID A99999.
Be sure that the end date of the facility ID A00001 and the begin date of the facility ID A99999 differ by one day. Then
Update the Placement Provider information in Fields 62 through 66. For financial and payment information to be entered
correctly, it may be necessary to close the previous service period and create a new line for the current service period
placement and payment information.
3. When the living arrangement type changes, regardless if the facility ID changes, the current line of data must be closed out and
the new information must be entered on a blank line.
Example: A child's living arrangement type changes from 56 (family foster home) to 67 (adoptive family foster home), but
the facility ID remains the same. Close out the line of data, which contains the living arrangement 56 and complete a new
line of data using the living arrangement 67. Be sure that the end date of the living arrangement 56 and the begin date of
the living arrangement 67 differ by one day.
4. When a child moves from one relative living arrangement to another relative living arrangement, the current line of data must
be closed and the information pertaining to the new relative living arrangement must be entered on a blank line.
Example: A child moves from 52 (Grandmother) to 52 (Aunt). Close out the line of data which contains the living
arrangement 52 (Grandmother's data) and complete a new line of data using the living arrangement 52 (Aunt's data). Be
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sure that the end date of the living arrangement 52 (Grandmother) and the begin date of the living arrangement 52 (Aunt)
differ by one day. Then update the Placement Provider information in Fields 62 through 66
When the Placement Authority is terminated, and the case is closed for Child Placement Services (termination reason should be
entered in Fields 23 and 24), enter an end date for the last living arrangement code in Field 48. This date should be the same as the
Placement Authority termination date (Field 24). Also, the Date Plan Realized should be entered in Field 37 and should be consistent
with the dates in Fields 24 and 48.
Corrections/changes can only be made to data that is within the current reporting period.
If the date in Field 47 of the current placement is not within the current processing month (in the example below, the current
processing month is September), only Field 48 can be entered on the same line as the current living arrangement
Example: In this example, the worker wants to make a change to the placement or payment information for September. The date
printed in Field 47 for this child’s DSS-5094 is August 1. In order for the worker to enter a change for the month of September, the
worker must enter August 31 in Field 48 and then enter a new Living Arrangement line of data in Fields 45 through 47 and 49
through 51 if applicable. For the September month of service, the cutoff for data entry is October 19.
FIELD 45 - Type (numeric, 2 digits)
Enter the appropriate code to describe the living arrangement that the child entered at the time the county child welfare agency
became responsible. Wherever a child spends the night of the day the agency receives custody and/or placement responsibility is
considered the first placement, and therefore the first living arrangement. Therefore, the begin date of the very first living
arrangement should be the same date as the Placement Authority Begin Date in Field 21.
Code
Value
50
Home of Parent(s) – The home of a child in which he resides with at least one biological or adopted
parent. This code is to be used for children who enter a county child welfare agency’s
custody/placement responsibility and are not physically removed from the home of the Parent. Do not
use this code for Trial Home Visits or Trial Visits with a non-removal parent (See Code 75)
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Code
Value
51
Home of Legal Guardian – The home of a child in which he resides with a person who has been given
legal guardianship of the child in accordance G.S. § 7B-600. This code is to be used for children who
enter a county child welfare agency’s custody/placement responsibility and are not physically removed
from the home of the Legal Guardian. Do not use this code for Trial Home Visits or Trial Visits with a
non-removal parent (see Code 75).
52
Home of Relative – The unlicensed home of a child in which he resides with a person who is a relative
within the following degrees of kinship: brother, sister, aunt, uncle, first cousin, nephew, niece, and
persons designated as grand, great, or great-great; step relatives limited to stepfather, stepmother,
stepbrother, or stepsister; any adoptive relatives designated above; spouses of any person named
above, even after the marriage is terminated by death or divorce; or an alleged father or alleged
paternal relative of the degree of kinship specified above.
53
Therapeutic Home (MH/DD/SAS) - A foster family home licensed under the program standards of the
Division of Mental Health, Developmental
Disabilities, and Substance Abuse in which the foster parents are trained and have the knowledge to
provide services for the care, treatment, habilitation or rehabilitation of the mentally ill, the mentally
retarded or substance abusers.
54
Division of Adult Correction and Juvenile Justice - A facility for delinquent juveniles who have been
committed to the Department of Public Safety’s Division of Adult Correction and Juvenile Justice
(Formally the Division of Juvenile Justice and Delinquency Prevention).
55
Residential School – A residential educational facility where children reside for up to 7 days a week.
This includes boarding schools operating for the emotionally disturbed and children with similar
conditions who cannot participate in the regular public-school system.
56
Family Foster Care Home – A foster family home is a home licensed in accordance with standards of
the Division of Social Services to provide 24-hour care for as many as 5 children in a substitute family
setting under the supervision of a public or private agency. Do not use this code for a relative
placement that is licensed as a Family Foster Care Home. Use Code 71 for Family Foster Home –
Relative
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Code
Value
57
Small Group Home (Residential) – A small group home is a 24-hour residential facility for nine or fewer
individuals which is licensed or approved to provide care and services to individuals in a small group
living arrangement. Exclude treatment programs administered by psychiatric units of hospitals or which
operate under the administration and program standards of the Division of
Mental Health, Developmental Disabilities, and Substance Abuse Services.
58
Small Group Home (Treatment) – A small group home (treatment) is a 24-hour residential facility for
nine or fewer individuals which is licensed or approved to provide residential treatment in a group
setting under the administration and program direction of the psychiatric unit of a hospital or the
administration and
program standards of the Division of Mental Health, Developmental Disabilities, and Substance Abuse
Services.
59
Children’s Camp – A residential child care facility which is licensed by the Department of Health and
Human Services to provide foster care and related services at a either a permanent camp site or in a
wilderness setting in accordance with administration and program standards adopted by the Social
Services Commission and which are administered by the Division of Adult Correction and Juvenile
Justice.
60
Specialized Family Foster Care Home (county child welfare agency) – A foster family home licensed by
the DHHS under the program standards administered by the Division of Social Services and supervised
by a county child welfare agency or a private child placement agency, in which the foster parents are
trained and have knowledge to provide specialized social services in addition to basic foster family
care. Do not use this code for a relative placement that is
licensed as a Specialized Family Foster Care Home. Use Code 73 for Specialized Family Foster Home –
Relative.
61
Large Group facility (Residential) - A staffed premises with paid and/or volunteer staff where 10 or
more children receive continuing full-time foster care. Such facilities are licensed or approved under
standards administered by the Division of Social Services
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Code
Value
62
Large Group Facility (Treatment) - A 24-hour residential treatment facility (public or private) unitizing
permanent buildings located on one site for 10 or more persons who need care, treatment, habilitation
or rehabilitation because they are mentally ill, mentally retarded or substance abusers. Such facilities
may operate as a psychiatric hospital or unit of a hospital.
63
Hospital - An institution for the medical treatment and care of the sick.
64
Supervised Independent Living Arrangement – A transitional living arrangement where the child is
under the supervision of the agency but without 24-hour adult supervision, is receiving financial
support from the child welfare agency, and is in a setting which provides an opportunity for increased
responsibility for self-care. Such arrangements must be approved by the court if the youth is in county
a county child welfare agency’s custody.
65
Adoptive Home (Non-relative) - An adoptive home is a family home of a nonrelative in which a child has
been placed for adoption and is living prior to the court's issuance of a final decree of adoption. This
may include adoptive homes which are licensed as foster family homes only for the time period
between the filing of the petition to adopt and the court's issuance of the final decree of adoption. Do
not use this code for the living arrangement of a child being adopted by his former foster parents, use
Code 67. Do not use this code for a relative adoptive home placement. Use Code 66, Adoptive Home
(Relative).
66
Adoptive Home (Relative) - The home of a child who is in the process of being adopted by relative(s)
when the relative is identified as the child’s adoptive placement and prior to the court’s issuance of the
Decree of Adoption, whether or not the home is licensed as a foster home.
67
Adoptive Home (Foster Home) - The home of a child who is in the process of being adopted by his
former foster parents, whether or not the home continues to be licensed as a foster home. If the
child's foster parents are adopting and will continue to receive a foster care payment, Code 67 will
require an entry in Field 49 in order for the Agency to get reimbursement. Change to Code 67 when
the Agency Adoption Committee decides that this will be the child's adoptive family. The beginning
date for Code 67 will be one day later.
68
Maternity Home - A 24-hour residential program whose primary purpose is to provide care and related
services to pregnant females
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Code
Value
69
Jail, Lock-up, Detention Facility or Facility Administered by the North Carolina State Department of
Corrections - A 24-hour residential facility for persons involuntarily detained because of their alleged or
adjudicated illegal activity.
70
Emergency Shelter - a residential facility which provides emergency and temporary care with a
minimum length of stay of no more than ninety (90) days. Exclude treatment programs administered by
psychiatric units of hospitals or by the Division of Mental Health, Developmental Disabilities, and
Substance Abuse Services.
71
Family Foster Home, Relative - The licensed home of a child in which he resides with a person who is a
relative within the following degrees of kinship: brother, sister, aunt, uncle, first cousin, nephew, niece,
and persons designated as grand, great, or great-great; step relatives limited to stepfather, stepmother,
stepbrother, or stepsister; any adoptive relatives designated above; spouses of any person named
above, even after the marriage is terminated by death or divorce; or an alleged father or alleged
paternal relative of the degree of kinship specified above.
73
Specialized Family Foster Home, Relative - The licensed home of a child in which he resides with a
person who is a relative within the following degrees of kinship: brother, sister, aunt, uncle, first cousin,
nephew, niece, and persons designated as grand, great, or great-great; step relatives limited to
stepfather, stepmother, stepbrother, or stepsister; any adoptive relatives designated above; spouses of
any person named above, even after the marriage is terminated by death or divorce; or an alleged
father or alleged paternal relative of the degree of kinship specified above; AND the relative foster
parents must be trained and have knowledge to provide specialized social services in addition to basic
foster family care.
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Code
Value
75
Trial Home Visit - The child, has been in a foster care (Out-of-Home) placement and remains in the
custody and placement authority of a county child welfare agency, but has been returned to the home
of the parent (either removal parent or non-removal parent) for a limited and specified time period,
prior to return of custody and case closure. Trial Home Visits should not last longer than six months,
unless the court specifies a longer period of time in the first order that approves the Trial Home Visit.
The agency should return to court prior to the six months (or the time specified by the judge) to
request that custody be given to the parent and the case closed or, if the child is not safe to remain in
the home, to return the child to Out-of-Home placement. Under any circumstances, do not change the
Living Arrangement Code from 75 to 50 or 51. The only time that the Living Arrangement Code should
be changed from 75 is when the child returns to Out-of-Home placement.
76
Runaway - The child has run away and the Agency still retains custody or placement responsibility.
77
College/University Dormitory – may only be used with Extended Foster Care (FC 18 to 21)
78
Semi-Supervised Independent Living Arrangement – may only be used with Extended Foster Care (FC 18
to 21)
98
Respite - The temporary placement of a child, not to exceed 14 consecutive days, to allow time for the
child's caregiver (family foster home, kinship home, etc.) to have a break from heavy childcare
demands.
99
Other - Placement Approved by the Court.
For youth who have signed a Voluntary Placement Agreement for Extended Foster Care Services (FC 18 to 21) only the following
codes are valid: 53, 56, 57, 58, 60, 61, 62, 77, and 78.
FIELD 46 - Progress towards Permanence (numeric, 1 digit)
Enter the appropriate code in Field 46 for the placement identified in Field 45. It is critical that this field accurately reflects the child’s
current placement’s status and type of change.
The placement is not considered to have achieved permanence if the county child welfare agency retains legal custody/placement
responsibility. Permanence, the ultimate goal, is defined by the placement being legally secure and the Agency no longer having
custody or placement responsibility. "Progress Towards Permanence" exists when everything is in place for permanence except that
the placement is not yet legally secure.
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Example: A child’s living arrangement is 56. The permanent plan for this child is now adoption, but TPR has not yet been filed. The
foster family has indicated their willingness to adopt this child, therefore the Progress towards Permanence needs to be completed.
Close out the current line of data which contains the living arrangement 56 and complete a new line of data using the living
arrangement 56 with the begin date as the date that permanence was achieved. Place a 3 in Field 46. Be sure that the end date of
the current living arrangement and the begin date of the new living arrangement differ by one day.
Code
Value
1
Move: progress towards permanency. Current living arrangement is considered a
move from previous living arrangement. The child is currently in a placement where
there is a mutual commitment to a lasting relationship between the child and at least
one adult AND the placement is expected to endure until the child reaches adulthood.
Everything is in place for permanency except that the placement is not yet legally
secure.
2
Move: no progress towards permanency. Current living arrangement is considered a
move from previous living arrangement. This move is not progress towards a
permanent placement.
3
Not a move: progress towards permanency. Living arrangement code may change, but
child is still in the same home; or child may actually go into a temporary living
arrangement (i.e., respite care) and child will return to the same placement where
there is a mutual commitment to a lasting relationship between the child and at least
one adult AND the placement is expected to endure until the child reaches adulthood.
Everything is still in place for permanency except that the placement is not yet legally
secure.
4
Not a move: no progress towards permanency. Current living arrangement is not
considered a move from previous living arrangement. This move is not progress
towards a permanent placement. This code should also be used for the initial entry of
the DSS-5094 form.
This field is used to calculate the percent of children who are legally free for adoption and who are not yet in their identified
adoptive families (Available for Adoption). It is critical for analysis of this data that this field is kept current.
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FIELD 47 - Beginning Date (numeric, 6 digits, MMDDYY format)
Enter the date that the child first entered the placement. This is the first day that the child is in the placement (spends the night).
Example: Child leaves facility AAAAAA on the afternoon of July 10
th
and goes to facility ZZZZZZ. The end date for facility
AAAAAA is July 9
th
. The beginning date for facility ZZZZZZ is July 10
th
.
FIELD 48 - Ending Date (numeric, 6 digits, MMDDYY format)
Enter the date that the child moved from the placement. This is the last day that the child is in the placement (spent the night).
Example: Child leaves facility AAAAAA on the afternoon of July 10
th
and goes to facility ZZZZZZ. The ending date for facility
AAAAAA is July 9
th
.
If the line for living arrangement data is being changed to add another line, the ending date the old line of living arrangement data
(Field 48) and the begin date of the new line of living arrangement data (Field 47) must differ by one day. When the Placement
Authority is terminated, the last Living Arrangement ending date (Field 48) should be the same date as the Placement Authority
termination date (Field 24).
FIELD 49 - Facility ID Number (alpha/numeric, 6 digits)
If the living arrangement identified in Field 45 is a foster care facility licensed by the Division of Social Services, the Division of Mental
Health, Developmental Disabilities and Substance Abuse Services, or by the Division of Health Service Regulation (DHSR), enter the
6-digit identification number assigned to the facility.
Mental Health Therapeutic Homes and Residential Treatment Group Homes must have a valid ID assigned in the Foster Care Facility
License System. These IDs begin with an “H” or “R”. If the facility does not already have a valid number, the county child welfare
agency or the facility must submit an application, along with a copy of the current DHSR license to the Child Welfare Services Section
for review and approval. This should be mailed to:
Division of Social Services
Regulatory and Licensing Services
952 Old Highway West 70
Black Mountain, NC 28711
A list of all “H” numbers is available in NCXPTR under the title: DHRFCF Mental Health Facilities.
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For youth who have signed a Voluntary Placement Agreement for Extended Foster Care Services (FC 18 to 21 ) and are not living in
an otherwise licensed placement the following Facility ID codes shall be used.
Facility ID
Description
Z00001
Payment is made to the youth who has signed the Voluntary Placement Agreement
for Extended Foster Care Services (FC 18 to 21 ).
Z00002
Payment is made to the landlord of the youth who has signed the Voluntary
Placement Agreement for Extended Foster Care Services (FC 18 to 21).
Z00003
Payment is made to an unlicensed person that the youth who has signed the
Voluntary Placement Agreement for Extended Foster Care Services (FC 18 to 21) is
residing with.
Z00004
Payment is made to the school or university that the youth who has signed the
Voluntary Placement Agreement for Extended Foster Care Services (FC 18 to 21) is
attending.
Z00005
Payment is made to another living arrangement of the youth who has signed the
Voluntary Placement Agreement for Extended Foster Care Services (FC 18 to 21 ).
J. PAYMENT INFORMATION (Fields 50 through 51)
Complete this section for children for whom payment will be claimed by the county child welfare agency. Complete only if
requesting reimbursement and update as needed.
Three lines are provided which relate to the lines in Part VIII, Living Arrangement. This means that each living arrangement for the
child must be shown in Section VIII, and if any reimbursement is being claimed by the county child welfare agency for any of these
arrangements, it must be shown in this Section on the same line that describes the type of living arrangement. Omissions in required
fields of this section may affect reimbursement. When a child moves from one facility to another within the same month, the
monthly rate entered in Field 51 must be the prorated amount for the time spent in that setting. Only use Field 50 to report for a
full month of care.
Example: The child is in facility AAAAAA from August 10
th
through September 4
th
, moves to facility ZZZZZZ beginning September 5
th
and remains through the end of the month. The reporting deadline for August data is Friday, September 19
th
. The amount entered in
Field 51 must be the prorated amount to cover the cost of care from August 10
th
through August 31
st
. Prior to the next reporting
deadline for September data, the amount entered in Field 51 must be the prorated amount to cover the cost of care from
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September 1
st
through September 4
th
. Enter an ending date of September 4
th
in Field 48. Complete a new line of data, entering the
Living Arrangement type in Field 45, the Begin Date of September 5
th
in Field 47, and leaving Field 48 (End Date) blank. This is
assuming that the child will remain for the rest of the month. Enter the monthly rate in Field 50 and enter the prorated amount to
cover the cost of care from September 5
th
through September 30
th
in Field 51.
FIELD 50 - Monthly Rate (numeric, 6 digits, 0000.00 format)
a. Enter the dollar and cents amount to show the amount of money the county child welfare agency pays to the facility for a
full month of care. This is the cost of care less any resources that are used on an ongoing basis to pay for care. The amount
entered is not limited to the maximum rate eligible for Federal or State reimbursement.
b. Each line must correspond with the line in Section VIII, which identifies the placement for which payment is being requested.
FIELD 51 - Payment Amount (numeric, 6 digits, 0000.00 format)
a. Enter the dollar and cents amount to show the actual payment to the facility when the amount that a county paid was
different from the monthly rate. This could be when the county is paying for a partial month of care (child enters or leaves
care during a month), the county uses the child’s resources towards the cost of care, or the county adds a clothing allowance
to the monthly rate.
b. The amount entered in this field will be reimbursed only one time and will then be deleted from the form. On-going monthly
payments to the county will be made in the amount, which is entered in the Monthly Rate field (Field 50) until an amount is
entered in this field or until the placement is terminated.
c. Reimbursements to counties for payments made during the previous month are made to the counties on the next working
day after the 19
th
of the month. The amount must be entered by the deadline in order to be reimbursed by the state. See
Reimbursement Request Deadlines (Under Section I; Letter E).
The system will not automatically increase foster care payments for children as they "age up" into a higher monthly payment
category. All counties are not paying a standard graduated payment. Therefore, the system cannot change the payment since the
amount is not uniform across the State.
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Field 50 and 51 should not reflect HIV supplemental payments. Requests for supplemental
HIV payments should continue to be made manually using the DSS-5758
(https://policies.ncdhhs.gov/divisional/social-services/forms) form. This form should be mailed to the Division of Social Services
at:
NC Division of Social Services
ATTN: HIV Supplemental
Child Welfare Services
Mail Service Center 2408
Raleigh, NC 27599-2408
K. ELIGIBILITY INFORMATION (fields 52 through 56)
Completion of this section is required for all children for whom foster care assistance payments are being requested.
This includes all children placed in foster care homes supervised by the county child welfare agency, as well as children in the Child
Caring Institutions, Children's Camps and facilities licensed under the standards of DMH/DD/SAS that have been assigned a county
child welfare agency facility ID number. This section includes information regarding the eligibility review period, funding source and
child’s resources for a case. This information must be updated immediately upon any change in eligibility. Failure to update fields or
omissions in required fields will affect reimbursement.
FIELD 52 - Eligibility Review Period from Date (numeric, 6 digits, MMDDYY format) Enter the effective begin date of the child's
current period of eligibility for foster care assistance.
An entry is required in this field, when an entry is made in Field 53.
FIELD 53 - Eligibility Review Period through Date (numeric, 6 digits, MMDDYY format) Enter the last date upon which the child is
eligible for foster care assistance for the current eligibility period.
An entry is required in this field when an entry is made in Field 52. The date entered in this field cannot be greater than 12 months
from the date entered in Field 52.
FIELD 54 - TEA Eligibility (numeric, 6 digits, MMDDYY format) Enter the effective date of TEA eligibility when
it has been established.
If a date exists in this field and a new date is entered, it must be 365 days greater than what already exists.
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FIELD 55 - Funding Source (alpha, 1 digit)
Field 55 is comprised of 4 boxes:
The three boxes arranged vertically underneath the heading “55. Funding Source” (IV-E, TEA and STATE) are to indicate the funding
source for the foster care maintenance payment.
The IV-E Admin Eligible Indicator box to the right of the STATE box is to identify children eligible for IV-E administrative payments
during the month even though the IV-E box in field 55 is left blank.
Funding Source for Maintenance Payment Boxes:
Enter a code in one box to indicate the funding source to be used to reimburse the county for foster care assistance (maintenance)
payments in Field 50. Enter a code in only one box. Leave all three boxes empty when no county foster care assistance payments
are being claimed for reimbursement.
Here are the codes.
Code
Value
X
Used for children under 18 eligible for IV-E, TEA, or SFHF funding
E
Used for young adults in Extended Foster Care (FC 18 to 21) eligible for IV-E or SFHF funding
• Instructions for Children Under 18 Eligible for IV-E, TEA or State Foster Home Funding:
1. Enter X in the IV-E box if an assistance payment is being made for a IV-E eligible child in an approved placement with a license
number issued by NC DSS unless a child’s SSI funds are being used for all or part of the maintenance payment, in which case the
IV-E box should be left blank. (Note—Enter X in the IV-E box if an assistance payment is being made for a IV-E eligible child
placed in a NC DSS licensed group facility irrespective of when the child was placed in the facility. For congregate care, under the
Families First Prevention Services Act, the system will calculate the two-week limit on IV-E reimbursements of new placements
made after September 30, 2021 and will make appropriate adjustments.
2. Enter X in the TEA box if an assistance payment is made for a TEA eligible child who is not eligible for IV-E and does not have SSI.
If TEA is the funding source, a date must be entered in Field 54. If TEA is coded and the begin date is not the first day of the
month, the system will reimburse from State (SFHF) only for that month and from TEA for subsequent months.
3. Enter X in the STATE box if an assistance payment is made for a child who is not eligible for IV-E or TEA. Also enter X in the State
box for a IV-E eligible child whose SSI funds are being used for the foster care assistance payment.
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• Instructions for Young Adults in Extended Foster Care (FC 18 to 21)
1. Enter E in the IV-E box if an assistance payment is being made for a young adult who is IV-E eligible even if the young adult is
concurrently eligible for SSI.
2. Enter E in the STATE box if an assistance payment is being made for a young adult who is not IV-E eligible.
Note: TEA is not a valid funding source for Young Adults in the Extended Foster Care program.
IV-E Admin Eligible Indicator Box:
The IV-E Admin Eligible Indicator is the fourth box in field 55 and is located immediately to the right of the box labeled “State.”
This box is used to identify otherwise IV-E eligible children or young adults who are eligible for administrative payments during the
month even though IV-E was not used to reimburse the county for a maintenance payment (i.e., the IV-E box in field 55 is left
blank). The IV-E Admin Eligible Indicator box captures situations in which children should be included in the calculation of the IV-E
penetration rate used to reimburse counties for administrative costs. Place an X in the IV-E Admin Eligible Indicator if the IV-E
eligibility box is blank and any of the following situations is true:
• A IV-E eligible child’s SSI is being used for foster care assistance payments
• A IV-E eligible child was on runaway status from a reimbursable placement at least one day in the month
• A IV-E eligible child was placed in an unlicensed relative home at least one day in the month for which an application for
licensure or approval of the home as a family foster home is pending. Application or approval of licensure should be considered
pending once the relative has requested to begin the licensure process or has signed up for foster care licensure classes.
Eligibility for administrative payments under this exception can last no longer than 12 months or the average time it takes to
license or approve a foster home.
• A IV-E eligible child was in a court-ordered trial home placement every day of a federal fiscal quarter. (January-March, April-
June, July-September or October-December.) This box can only be checked on 5094s that are completed after the months of
March, June, September, and December.)
• A IV-E eligible young adult in FC 18-21 is eligible for administrative payments even though the IV-E maintenance funding box is
blank because the young adult was not in an approved placement that month.
FIELD 56 - Child's Resources (numeric, 6 digits, 0000.00 format)
Enter the actual dollars and cents amount of the child's income, which is available on an ongoing basis to pay all or part of the cost of
care.
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L. FEDERAL ASSISTANCE INFORMATION (Fields 57 through 61)
Complete this section for all children who are in an out-of-home placement, including the home of relatives.
This section pertains to the type of other financial assistance a child is receiving. Information in this section must be completed for
all cases. Check all that apply. This information must be updated immediately upon any change in federal assistance for the child.
FIELD 57 - TANF/WFFA - Temporary Assistance for Needy Families/Work First Family
Assistance (formerly IV-A, AFDC)
Check this item if the child is living with relative(s) whose source of support is a TANF/WFFA payment for the child.
FIELD 58 - IV-D (Child Support)
Check this item if child support funds are being paid to the state agency on behalf of the child by assignment from the receiving
parent.
FIELD 59 - XIX (Medicaid)
Check this item if the child is eligible for and may be receiving assistance under Title XIX.
FIELD 60 - SSI or Other Social Security Act Benefits
Check this item if the child is receiving support under Title XVI or other Social Security Act Titles not included above.
FIELD 61 - IV-E Adoption Assistance
Check this box if Title IV-E Non-recurring Costs are being paid on behalf of the child.
M. SUBSTITUTE PARENT INFORMATION (Fields 62 through 66)
Complete this section for all children who are residing in a family-type setting, whether licensed or not (Living Arrangement Codes
56, 60, 65, 66, 67, 71, 73).
This section pertains to the substitute family structure where a child is placed by the county child welfare agency, regardless of
whether or not these homes are licensed or if reimbursement is being requested. Do not complete unless the child is in one of the
above described living arrangements. If completing a form that includes more than one placement for the same reporting period,
enter the most current information in this field if applicable. Update each time that the child moves to one of the above settings.
Do not complete if the child remains with the parent or relative from whom custody was removed.
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Do not complete if child is in living arrangement type "Runaway," code 76 in Field 45.
FIELD 62 - Family Structure (numeric, 1 digit)
Enter the code which best describes the nature of the substitute family structure with whom the child is living.
Code
Value
1
Married Couple - Requires entry in fields 63-66.
2
Unmarried Couple - Requires entry in fields 63-66.
3
Single Female - Requires entry in fields 63-64.
4
Single Male - Requires entry in fields 63-64.
FIELD 63 - Year of Birth of First Substitute Parent (numeric, 2 digits) Enter the year of birth of one substitute parent.
An entry is required in this field if Field 62 is 1 through 4.
FIELD 64 - Race of First Substitute Parent (numeric, 2 digits)
Enter the code (found under Field 11) which describes the race of the first substitute parent.
An entry is required in this field if Field 62 is 1 through 4.
FIELD 65 - Year of Birth of Second Substitute Parent (numeric, 2 digits)
Enter the year of birth of the second substitute parent. If there is only one substitute parent, leave this field blank.
An entry is required in this field if Field 62 is 1 or 2.
FIELD 66 - Race of Second Substitute Parent (numeric, 2 digits)
Enter the code (found under Field 11) which describes the race of the second substitute parent. If there is only one substitute
parent, leave this field blank.
An entry is required in this field if Field 62 is 1 or 2.
N. FIELD 67 – Trafficking Victim (numeric, 1 digit)
Enter the code which indicates if the client is a victim of Human Trafficking, and if so, what type of trafficking.
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Code
Value
1
The client is not a victim of Human Trafficking of any sort
2
The client is a victim of Sexual Trafficking. Required if Field 20 “Human Trafficking”
is equal to S.
3
The client is a victim of Labor Trafficking. Required if Field 20 “Human Trafficking” is
equal to L.
4
The client is a victim of both Sexual and Labor Trafficking. Required if Field 20
“Human Trafficking” is equal to B.
An entry or 2, 3 or 4 will require entry in Fields 72-76.
O. NON-FAMILY PLACEMENT SERVICES (Fields 68 through 71)
Complete this section for all children who are residing in a non-family foster care setting.
Entry in this section is required if there is a Living Arrangement Type Code of 54,55,57,58,59,61, 62,63,64,68,69,70,98 or 99 in Field
45.
FIELD 68 – Service Type (numeric, 1 digit)
Enter the code which indicates the type(s) of services provided by the non-family foster care setting.
Code
Value
1
Specialized Education
2
Treatment
3
Counseling
4
Other Services
5
No services provided in facility
6
Pre-Natal, Pregnancy or Adolescent Parent
FIELD 69 – Service Frequency (numeric, 1 digit)
Enter the code which indicates the frequency of services provided in the non-family foster care setting (Field 68).
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Code
Value
1
Daily
2
Weekly
3
Monthly
4
As Needed (no regular frequency)
An entry is required in this field if the value in Field 68 is 1, 2, 3, or 4.
FIELD 70 – Begin Date (numeric, 6 digits, MMDDYY format)
Enter the date that the services indicated in Field 68 began. This date must be greater than or equal to the Begin Date (Field 47) of
the non-family foster care setting indicated in Field 45.
An entry is required in this field if Field 68 is 1, 2, 3, or 4.
FIELD 71 – End Date (numeric, 6 digits, MMDDYY format)
Enter the date that the services indicated in Field 68 ended.
An entry is required if there is an entry in Field 70, and an entry in Field 48 for the nonfamily foster care setting indicated in Field 45.
The date in this field must be less than or equal to the end date (Field 48) of the non-family foster care setting indicated in Field 45.
P. TRAFFICKING (Fields 72 through 76)
Complete this section for children identified as trafficking victims (Field 67).
Entry in this section is required if Field 67 is 2, 3, or 4.
FIELD 72 – Trafficking Begin Date (numeric, 6 digits, MMDDYY format)
Enter the date that the child first became a victim of human trafficking. If exact date is unknown, an approximate date may be
entered.
An entry is required in this field if the value in Field 67 is 2, 3, or 4.
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FIELD 73 – Trafficking End Date (numeric, 6 digits, MMDDYY format)
Enter the date that the child ceased to be a victim of human trafficking. If exact date is unknown, an approximate date may be
entered.
An entry is required if there is an entry in Field 72 and the child has any Living Arrangement Type other than Runaway (76).
FIELD 74 – Reported to Law Enforcement (numeric, 1 digit)
Enter the code that indicates whether the child victim of human trafficking (Field 67) was reported as a victim to Law Enforcement.
Code
Value
1
Yes
2
No, was reported to DSS by Law Enforcement
3
No, other reason
An entry is required in this field if the value in Field 67 is 2, 3, or 4.
FIELD 75 – Date Reported to Law Enforcement (numeric, 6 digits, MMDDYY format) Enter the date that the child victim of human
trafficking was reported to Law Enforcement (Field 74).
An entry is required in this field if the value in Field 74 is 1.
FIELD 76 – Custody Status (numeric, 1 digit)
Enter the code which indicates the child’s custody status when he/she was a victim of human trafficking (Field 67).
Code
Value
1
In DSS Custody (Foster Care) when Trafficking Victim
2
Not in DSS Custody (Foster Care) when Trafficking Victim
An entry is required in this field if the value in Field 67 is 2, 3, or 4.
Q. RUNAWAY (Fields 77 through 90)
Complete this section for all children who have a Living Arrangement Type (Field 45) equal to Runaway (Code 76).
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Fields 77-90 may be updated (additional items selected) after initial entry as more information may be disclosed/discovered. If items
are incorrectly selected and needed to be deleted, a written request may be faxed to the Performance Management Section at
919334-1052 detailing the specific item(s) to be deleted and the reason(s).
Runaway Contributory Factors (Fields 77-82)
If the child has a Living Arrangement Type (Field 45) equal to Runaway (Code 76), at least one item in Fields 77-82 must be selected.
FIELD 77 – CPS History (>3 previous assessments) - Enter “X” in this field if the child’s entire CPS history includes more than 3
assessments, including the assessment that led to the foster care placement, and any assessments while in Foster Care. Otherwise,
leave this field blank.
FIELD 78 – Separation from Siblings - Enter “X” in this field if the child has siblings who are not in the identical foster care
placement. This may include siblings who remain in the home and were not taken into foster care, as well as siblings who were
taken into care but are in a different placement. Otherwise, leave this field blank.
FIELD 79 – Multiple FC Moves (>3 during the current FC episode) – Enter an “X” in this field if the child has had more than 3 moves
during the current episode of foster care.
Remember that Respite does not count as a move.
Otherwise, leave this field blank.
FIELD 80 – Running to Someone – Enter an “X” in this field if the child ran away from foster care in order to be with someone
(including but not limited to: a friend, family, etc.) Otherwise, leave this field blank.
FIELD 81 – Running from Foster Care Placement – Enter an “X” in this field if the child ran away from their specific Foster Care
Placement.
Otherwise, leave this field blank.
FIELD 82 – Other – Enter an “X” in this field if the child ran away from foster care for any other reason.
Otherwise, leave this field blank.
Runaway Experiences (Fields 83-90)
If the child has a Living Arrangement Type (Field 45) equal to Runaway (Code 76), at least one item in Fields 83-90 must be selected.
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FIELD 83 – Alcohol and/or Illegal Drug Use - Enter “X” in this field if the child’s experiences during this runaway episode included
alcohol and/or illegal drug use. Otherwise, leave this field blank.
FIELD 84 – Voluntary Sexual Activity - Enter “X” in this field if the child’s experiences during this runaway episode included
voluntary sexual activity. Otherwise, leave this field blank.
FIELD 85 – Involuntary Sexual Activity - Enter “X” in this field if the child’s experiences during this runaway episode included
involuntary sexual activity. Otherwise, leave this field blank.
FIELD 86 – Lived with Friends - Enter “X” in this field if the child’s experiences during this runaway episode included living with
friends.
Otherwise, leave this field blank.
FIELD 87 – Lived with Family - Enter “X” in this field if the child’s experiences during this runaway episode included living with family.
Otherwise, leave this field blank.
FIELD 88 – Lived in Homeless Shelter - Enter “X” in this field if the child’s experiences during this runaway episode included
living in a homeless shelter. Otherwise, leave this field blank.
FIELD 89 – Lived on the Street - Enter “X” in this field if the child’s experiences during this runaway episode included living on the
street.
Otherwise, leave this field blank.
FIELD 90 – Other - Enter “X” in this field if the child’s experiences during this runaway episode including experiences not listed
above.
Otherwise, leave this field blank.
V. DSS-5094-A FORM – DESIGN AND FUNCTION
The DSS-5094-A is designed to capture information regarding face to face visits made with children in Foster Care. The DSS-5094-A is
separated into two sections.
A. COUNTY AND SIS INFORMATION (Fields 1 through 7)
Complete Fields 1 through 4 for every initial DSS-5094-A submitted.
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FIELD 1 - County Number (numeric, 2 digits)
No entry is required in this field if already printed on a DSS-5094-A. When using a blank DSS-5094-A, enter the standard two-digit
county ID code.
FIELD 2 - Case Manager's Name (alpha/numeric, 16 digits)
No entry is required in this field if already printed on the DSS-5094-A. If there is a change in case manager, update on the DSS-5027.
When using a blank DSS-5094-A, enter the case manager's last name, and first and middle initials.
FIELD 3 - Case Manager's Number (numeric, 9 digits)
No entry is required in this field if already printed on the DSS-5094-A. If there is a change in the case manager number, it must be
updated on the DSS-5027. When using a blank DSS-5094-A, enter the valid case manager number as obtained from the Services
Information System. Please refer to PM-REM-AL-0407 dated May 23, 2007:
(http://info.dhhs.state.nc.us/olm/manuals/dss/rim-05/adm/PM-REM-AL-0407.htm)
FIELD 4 - County Case Number (alpha/numeric, 6 digits)
No entry is required in this field if already printed on the DSS-5094-A. If a child has a SIS record, the County Case Number from that
system will be brought forward.
FIELD 5 - Client ID (numeric, 11 digits)
Enter the child's SIS ID number. An entry is required in this field for all children.
FIELD 6 - Client Name (alpha/numeric, 15 digits)
Enter the name of the child. An entry is required in this field for all children, however if the child has an existing SIS record, this field
will be brought over from that system.
FIELD 7 - Date of Birth (numeric, 8 digits)
Record the month, day, and year of the child's birth. An entry is required in this field for all children, however if the child has an
existing SIS record, this field will be brought over from that system.
Use a leading zero for a month or day less than 10. If the child is abandoned or the date of birth is otherwise unknown, enter an
approximate month and year of birth.
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B. VISIT INFORMATION (Fields 8 and 9)
This section of the form contains information about face to face visits made with children in Foster Care. Each time a child in care is
visited, the DSS-5094-A should be updated to capture information regarding the visit.
FIELD 8 - Visit Date (numeric, 6 digits, MMDDYY format)
Enter the date that the social worker had a face to face visit with the child.
Once a visit date has been entered it cannot be changed, however visits may be deleted if they were entered in error or the wrong
date was keyed. Select the row to be deleted, then delete. If appropriate, then add the correct visit date.
FIELD 9 – Home Visit Indicator (alpha, Y or blank)
Enter “Y’ if the visit occurred in the home of child (home is defined as the place the child is residing while in care).
Leave the field blank if the visit did not occur in the home of the child.
Code
Value
Y
Yes, the visit occurred in the child’s home.
(blank)
The visit did not occur in the child’s home (note that any entry in this field
other than “Y” will revert to blank once the record is saved).
The Home Visit Indicator field can be updated after entry. Select the row to be updated, then update and change the home visit
indicator as needed.
VI. DESIGN OF THE DSS-5095 form
(DSS-5095 form is separated into multiple sections)
A. County Information at the top of the Form (Fields 1 through 4) Complete Fields 1 through 4 for every DSS-5095 submitted.
B. SECTION I – Services Information System (SIS) Information (Fields 5 through 14) This section contains information needed to open
a SIS case via the DSS-5095 form. Complete Fields 7 through 13 for an adoption assistance child who is being assigned a new SIS ID
number and a DSS-5027 form has not been submitted.
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To save time, the new form DSS-5095 can be used to open both the service case in SIS and the Adoption Assistance case in CPPS.
a) When this method is selected, Adoption Assistance Services for Children (service code 010) will automatically be opened in
the Service Plan portion of the SIS. A begin date for this service must be entered by the data entry staff on the DSS-5027.
b) When this method is used, it is imperative that the correct SIS Client ID is used. A name search must be conducted to
determine if the child has an existing Client ID or active record (DSS-5027) in the Services Information System (SIS) before
assigning a Client ID. Only after a thorough search has been conducted, and all possible matches have been ruled out,
should a new Client ID be assigned using this method. Failure to conduct a name search prior to assigning a Client ID can
result in multiple IDs being created for a single client.
c) A turnaround DSS-5027 will also be created to enable the worker to make SIS updates.
C. SECTION II – Adoption/Guardianship Assistance (Fields 15 through 24)
D. SECTION III - Cash Payment Request (Field 28)
E. SECTION IV - Payee Information (Fields Not Labeled)
VI. DSS-5095 FORM – DESIGN AND FUNCTION
A. County Information (Fields 1 through 4)
Entries in this section are only required when a new SIS record is being opened via this form. If the child has an existing SIS record,
the information from that record will be brought into this record. If SIS changes need to be made, use the child's DSS-5027 form.
Field 1 - County (numeric, 2 digits)
No entry is required in this field if already printed on the DSS-5095. When using a blank DSS-5095, enter the standard two-digit
county ID code.
Field 2 - Case Manager's Name (alpha/numeric, 16 digits)
No entry is required in this field if already printed on the DSS-5095. When using a blank DSS-5095, enter the case manager's last
name, and first and middle initials.
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Field 3 - Case Manager's Number (numeric, 9 digits)
No entry is required in this field if already printed on the DSS-5095. When using a blank
DSS-5095, enter the valid case manager's number as obtained from the Services
Information System. See PM-REM-AL-0407
(http://info.dhhs.state.nc.us/olm/manuals/dss/rim-05/adm/PM-REM-AL-0407.htm).
Field 4 - County Case Number (numeric, 6 digits)
This is an optional field available to assist the county in filing forms in case records. If a child has a SIS record, the County Case
Number from that system will be brought forward. The case number in this system must be the same as the case number in the SIS.
B. SIS Information (Fields 5 through 14)
Complete this section for all children receiving adoption assistance payments.
Field 5 - Client ID (Numeric, 11 Digits)
Enter the child's SIS ID number. An entry is required in this field for all children.
Field 6 - Client Name (alpha/numeric, 15 digits)
Enter the name of the child. An entry is required in this field for all children.
As part of the Common Name Data Service (SIS ID merge) a new SIS identification number shall NOT be assigned to children who are
adopted from foster care. The name change should be done on the DSS-5027.
Complete only Fields 5 and 6 for a child who has an existing SIS record.
For a child in an adoptive placement, the same SIS ID used in foster care continues to be used following the entry of the Decree of
Adoption.
Complete Fields 5 through 14 according to instructions for an adoption assistance child who is being assigned a new SIS ID number
and a DSS-5027 form has not been submitted.
Field 7 - Client Social Security Number (numeric, 9 digits)
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If the child has an existing SIS record, this number will be automatically brought over from the SIS. If a new SIS record is being
opened via this form, complete the child's Social Security Number. When the child does not have a Social Security Number, enter a
zero in each of the spaces across the field and update this field via the DSS-5027 when a social security number has been obtained.
Field 8 - Date of Birth (numeric, 8 digits)
Record the month, day, and year of the child's birth. Use a leading zero for a month or day less than 10. If the child is abandoned or
the date of birth is otherwise unknown, enter an approximate month and year of birth using the 15
th
as the day of birth.
Field 9 - Special Areas (numeric, 12 digits)
Enter the code(s), which reflects special characteristics of the client based on worker judgment, not necessarily legally or medically
established conditions. Up to six characteristics or circumstances may be entered for each individual. It is important to enter as
many as appropriate because this information is useful for justifying funding for special needs.
Code
Value
01
Developmental Disabilities
02
Blind or Visually Impaired
03
Deaf or Hard of Hearing
04
Physically Disabled
05
Emotionally Disturbed
06
Learning Disability
07
Medical Condition
08
HIV or AIDS
09
Substance Abuse
10
Do not use for new cases. Formerly Willie M. Class.
11
Undisciplined Child
12
Delinquent Child
13
Homeless Person
Field 10 - Sex (numeric, 1 digit)
Enter the code, which identifies the sex of the child.
Code
Value
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1
Male
2
Female
Field 11 - Race (numeric, 2 digits)
Enter the code, found under Field 11 of the DSS-5094, which identifies the race of the child.
Field 12 - School (numeric, 1 digit)
Enter the appropriate code to determine if the child is attending school on a scheduled basis. Do not take holidays, breaks or
summer vacations into consideration. This field should be updated annually on the DSS-5027.
Code
Value
1
Yes, in school
2
No, not in school
Field 13 - Grade (Alpha, numeric, 2 digits)
For children who are in school, enter the grade associated with their current or most recent attendance. This field should be updated
annually on the DSS-5027.
Code
Value
P
Preschool (including Kindergarten)
1-20
Current or Highest Grade
98
GED
99
Unknown (show special education here if not certain of grade equivalent)
Field 14 - HIV Status (alpha, 1 digit)
This field identifies the basis for HIV Adoption Assistance. Complete if the child meets one of the HIV categories as diagnosed by a
qualified professional. Otherwise, leave blank.
Code
Value
E
Perinatally exposed infant 0-24 months who cannot be classified as definitely
infected, but who has antibodies to HIV, indicating exposure to an infected mother.
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N
Infant, child or youth who meets one of the CDC definitions for infection but who has
no previous signs or symptoms of HIV.
A
Infant, child or youth who shows mild signs or symptoms of HIV.
B
Infant, child or youth who shows moderate signs or symptoms of HIV.
C
Infant, child or youth who shows severe signs or symptoms of HIV.
T
Child aged 0-21 with laboratory evidence of HIV infection who has a resulting terminal
diagnosis with a life expectancy of less than six months.
C. Payment Information (Fields 15 through 29)
Field 15 - Date of Petition/Sanctioned Guardianship (numeric, 6 digits, MMDDYY format)
Enter the date that the Petition for Adoption was filed with the court, or that Guardianship was sanctioned by the court.
Once a date has been entered, a new date cannot be entered unless Field 16 is completed.
Field 16 - Date of Final Order (numeric, 6 digits, MMDDYY format) Enter the date the Decree of Adoption or
Guardianship was entered.
Field 17 - Special Population (numeric, 1 digit) Enter a valid code in this field as applicable to
the child.
Code
Value
1
Indian (Bureau of Indian Affairs, Federally recognized tribe)
3
Unaccompanied Refugee Minor
5
Not Applicable
Field 18 - From (Adoption/Guardianship Assistance Agreement) (numeric, 6 digits, MMDDYY format)
Enter the date the adoptive parents signed the original Adoption Assistance Agreement or the guardian signed the original
Guardianship Assistance Agreement. This field is not updated.
Field 19 - Through (Adoption/Guardianship Assistance Agreement) (numeric, 6 digits, MMDDYY format)
Since the Adoption/Guardianship Assistance Agreement remains in effect until the child reaches his 18
th
birthday, enter the date of
the last day of the month in which the child will turn 18. If the child will qualify for extended benefits due to adoption/guardianship
occurring at 16 or 17, enter the last day of the month in which the child will turn 21.
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An entry will only be accepted if an entry exists in Fields 16 and 18.
Field 20 - Non-Recurring Adoption/Guardianship Costs (numeric, 6 digits, 0000.00 format)
Enter the actual amount the Agency paid to the adoptive parents, guardian or provider for eligible non-recurring
adoption/guardianship costs. Do not enter a funding source.
An entry will only be accepted if there is a date in Field 15 and it is earlier than or the same date the costs are entered into the
system. The amount entered cannot be greater than the "Balance Available."
REIMBURSEMENT REQUEST DEADLINES
1. DSS-5095 (Adoption Assistance, Extended Adoption Assistance Vendor
Payments)
The keying deadline for adoption assistance vendor payments is the 19
th
of the month. If the 19
th
falls on a weekend
or State holiday, the deadline is the last workday prior to the 19
th
.
2. DSS-5095 (Adoption Guardianship Assistance, Extended
Adoption/Guardianship Assistance Cash Payments)
The keying deadline for adoption assistance cash payments is the 3
rd
working day from the last working day of the
month.
Field 21 – Medical Vendor (numeric, 6 digits, 0000.00 format)
Enter the actual amount, which was paid to the provider(s) for medical services or treatment of the child. If more than one
reimbursement is being claimed during the same reporting period, add the payments together and enter the total amount in this
field. The system will reimburse the amount that is showing on the screen on the date that the payments are made, up to the
maximum allowable for this item.
An entry will only be accepted if an entry exists in Fields 16, 18, and 19.
Field 22 – Therapeutic Vendor (numeric, 6 digits, 0000.00 format)
Enter the actual amount, which was paid to the provider(s) for therapeutic services or treatment rendered to the child. If more than
one reimbursement is being claimed during the same reporting period, add the payments together and enter the total amount in
this field. The system will reimburse the amount that is showing on the screen on the date that the payments are made, up to the
maximum allowable for this item.
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An entry will only be accepted if an entry exists in Fields 16, 18, and 19.
Field 23 - Funding Source (alpha, 1 digit)
This signifies the type of funding source for the medical or therapeutic vendor payment.
a. For children placed by private agencies, enter an “X" in the "STATE funding source box.
b. For all other children, enter an "X" in the IV-B funding source box.
c. No entry is required in this field for Non-Recurring Adoption/Guardianship Costs in Field 20.
d. Once completed, this field cannot be changed. If information is entered incorrectly, a letter must be sent to the Child
Welfare Services Section requesting that the correction be made. Mail to:
NC Division of Social Services
ATTN: Adoptions/Guardianship Program Coordinator
Child Welfare Services
Mail Service Center 2408
Raleigh, NC 27699-2408
Balance Available -This amount will be calculated by the system based on each request and the maximum allowed per year for the
medical and therapeutic vendor payments, and for the Non-Recurring Adoption Costs.
Field 24 - Monthly Amount (numeric, 6 digits, 0000.00 format)
a. Enter the dollar amount that is shown in Item A.2. of the DSS-5013 Adoption
Assistance Agreement (http://info.dhhs.state.nc.us/olm/forms/dss/dss-5013-ia.pdf). The amount entered is limited to the
maximum rate eligible for state and/or federal participation.
The system will automatically increase adoption assistance payments for children as they "age up" into a higher monthly payment
category.
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b. If an initial retroactive payment is to be made, the system will compute the number of retroactive payments due based on
the Beginning Payment Date in Field 25. This is only applicable for retroactive payments up to six months from the
Beginning
Payment Date. Any request beyond six months must be submitted to the Child Welfare Services Section:
NC Division of Social Services
ATTN: Adoptions/Guardianship Program Coordinator
Child Welfare Services
Mail Service Center 2408
Raleigh, NC 27699-2408
Field 25 - Beginning Payment Date (numeric, 4 digits, MMYY format)
Enter the date that the adoption/guardianship assistance cash payment is to begin. This may be retroactive up to six months
following the month in which the Final Decree for Adoption/Guardianship was entered. The field can not be updated or changed
after payment begins.
An entry in this field must be one month greater than the date entered in Field 16.
Field 26 - Funding Source (alpha, 1 digit)
Enter the appropriate funding code box to indicate the funding source from which the cash payment is to be reimbursed.
Code
Value
X
Adoption Assistance
E
Extended Adoption Assistance (18-20)
R
Guardianship Assistance
P
Extended Guardianship Assistance (18-20)
Field 27 - Reason (Cash Payment Termination) (numeric, 1 digit)
Enter the code to indicate the reason the cash payment for the child is being terminated.
If an entry is made in this field an entry must also be made in Field 28.
Code
Value
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1
Child 18
2
Adoptive Parents/Guardian Not Legally Responsible
3
Adoptive Parents/Guardian Deceased
4
Adoptive Parents/Guardian Not Financially Responsible
5
Child Died
7
Other
8
Child 21
Field 28 - Date (Cash Payment Terminated) (numeric, 6 digits, MMDDYY format) Enter the date that the cash payment for the
child is to be terminated.
If an entry is made in this field an entry must also be made in Field 27.
Field 29 - Criminal Records Check (numeric, 6 digits, MMDDYY format)
Please enter a date for the most recent Criminal Records Check that you have on all adult members of the adoptive/guardianship
applicant’s household during the pre-placement assessment.
D. Payee Information
1. First name
Enter the payee's first name in this field. Do not abbreviate, punctuate, or space between letters within the field. Enter
letters only in the spaces provided. 2. Middle Initial
Enter if there is one. Otherwise leave blank.
3. Last Name
Enter the payee's last name. Do not abbreviate, punctuate, or space between letters within the field. Enter letters only in the
spaces provided.
4. JR/SR/ETC
Enter only if part of the legal name.
5. Address line 1
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Enter the street, rural route or general delivery. Use the abbreviations, which are accepted by the U.S. postal service.
(https://pe.usps.com/text/pub28/28apc_002.htm).
6. Address Line 2
If an additional line of address is needed, enter it in the space provided. If Address Line 1 was used to show that mail is to be
sent in care of another individual, use Address Line 2 for the street address.
7. City
Enter the name of the city or town. Use standard abbreviations, which are accepted by the U. S. postal service.
8. State
Enter the two-letter state abbreviation.
9. Zip Code
Enter the five-digit zip code in the first five spaces. If the 9-digit code is known, enter the remaining digits.
