Dss 5283 Form PDF Details

The North Carolina Division of Social Services plays a crucial role in ensuring that agencies and facilities operating under its jurisdiction adhere to state licensing rules and regulations. Among the tools available for maintaining these standards is the DSS 5283 form, a regulatory and licensing services complaint form designed specifically for grievances against child placing agencies for adoption and foster care, residential maternity homes, and residential child-care facilities. This form facilitates the filing of official complaints by individuals who believe that one of these licensed entities has violated North Carolina's licensing rules. It is critical to note that the DSS 5283 form is not applicable for issues concerning county departments of social services, child support services, or adult services. Once filled out, the form becomes a public document and is used by the Regulatory and Licensing Services to investigate the complaint. Information required includes personal details of the complainant, details about the agency or facility in question, and a comprehensive account of the incident(s) leading to the complaint. It's important for complainants to understand that while the Division of Social Services can investigate violations, it does not have the authority to compel agencies to return fees or provide any form of compensation. The procedure for complaint submission is streamlined, allowing for mailing or faxing the completed form directly to the Division of Social Services, thereby initiating the investigation process.

QuestionAnswer
Form NameDss 5283 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdss complaint, dss complaints, dss complaint nc, how to fight dss in nc

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North Carolina Division of Social Services

Regulatory and Licensing Services Complaint Form

This form is for complaints against agencies/facilities licensed by the North Carolina Division of Social Services (i.e. Child Placing Agencies for Adoption and Foster Care, Residential Maternity Homes, and Residential Child-Care Facilities). In order for Regulatory and Licensing Services to investigate your complaint it must be made against one of the agencies listed on this website (http://www.ncdhhs.gov/dss/licensing/listings.htm). Please note that this form does NOT pertain to complaints related to county departments of social services, child support services or adult services.

I wish to file an official complaint against the agency/facility named below. I am submitting this information so that it may be determined if the agency/facility has violated North Carolina licensing rules. This is a PUBLIC DOCUMENT. As part of the investigative process this document will be shared with the agency/facility that the complaint is made against. Please note that the Division of Social Services cannot force agencies to return fees, money or any form of compensation to you. The Division of Social Services will determine if the agency has violated administrative rules.

Information About You

Name:

 

 

Relationship to Agency:

 

Address:

 

City:

State:

Zip:

County:

Phone:

 

Email:

 

Complaint Filed Against One of the Agencies Listed at this Website:

http://www.ncdhhs.gov/dss/licensing/listings.htm

Name of Agency/Facility:

Agency Address:

City:

State:

Zip:

Agency Phone:

 

Date of Incident:

 

Give details of your concerns (Who, What, When, Where, How, etc.) Use additional sheets if necessary.

Date:

Completed form must be returned to:

 

Mail:

Division of Social Services, Regulatory and Licensing Services, 952 Old US Highway 70, Black Mountain, North Carolina 28711

OR

Fax:

828-669-3365

DSS-5283 (Rev. 1/14) DSS/Regulatory and Licensing Services

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