Form Dss 5102 PDF Details

The DSS-5102 form, developed by the North Carolina Department of Health and Human Services Division of Social Services, serves a crucial role in the adoption process by ensuring that adoptive parents receive comprehensive non-identifying background information about the child they plan to adopt. This document, meticulously filled out by biological parents, contains essential details concerning the child’s birth history, including date of birth, physical characteristics at birth, and racial and national backgrounds. Moreover, it extends to provide an in-depth account of the biological parents' characteristics, such as their physical attributes, health history, allergies, hobbies, educational background, occupation, and family medical history, among others. The information shared aims to preserve the child's connection to their genetic roots, offering a deeper understanding of inherited traits and potential health issues. The form also touches upon the desires of biological parents regarding future contact, and encapsulates data on the extended family's characteristics, which may include grandparents, aunts, and uncles, thus providing a fuller picture of the biological family's background. With stipulations on how the form should be disseminated among the involved parties and instructions for certification, the DSS-5102 underscores a vital part of the adoption process, balancing the privacy concerns of biological parents with the adoptive family's right to access pertinent heritage and health-related information about the child.

QuestionAnswer
Form NameForm Dss 5102
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesdss5102 form, dss form 8191, dds 5102, dss 8551 form

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NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

Division of Social Services

NON-IDENTIFYING BACKGROUND INFORMATION

To Biological Parent: Please complete the blanks below as thoroughly as you can. This information will be given to the adoptive parents to be shared with your child at an appropriate time and/or may be released pursuant to North Carolina General Statutes §48-9-103, 48-9-104 and 48-9-109. This, along with the medical information, will be of utmost value to your child in learning about his/her genetic roots.

CHILD’S BIRTH HISTORY

Date of Birth:

____________________

Weight:____________________

Length: _________________

Time of Birth:

____________________

Day of Birth: ______________

Race: ___________________

Nationality:

____________________

General Physical Appearance: _________________________________

__________________________________________________________________________________________________

CHARACTERISTICS OF BIRTH/PRIOR ADOPTIVE PARENT

INDICATE:

MOTHER

 

FATHER

 

Biological Parent? ____________ (yes or no)

Prior Adoptive Parent? ____________ (yes or no)

1.

Age (in years): __________

Race: ________________________

Nationality: _______________________

2.Ethnic Background: ________________________________________________________________________

3.

Height? _____________

Average weight? _________________ Eye Color? ___________________________

4.

Complexion:

Fair

 

Medium

Olive

Dark

 

Have you ever had a complexion problem?

Yes

No If so, what? ____________________________

5.

Build:

Small-Boned

Medium-Boned

Large-Boned

6.

Are you:

 

Right-handed

 

Left-Handed

Ambidextrous

7.What is the natural color of your hair? ____________________________________________________________

 

Is your hair:

Naturally Curly

 

Straight

Wavy

Thick

Thin

 

Do you like to wear it long or short? ______________________________________________________________

8.

Do you wear eye correction?

Yes (

Glasses

 

Contacts)

No

 

If you wear eye correction, at what age did you start wearing it? ______________________________________

 

Reason for eye correction?

Near-Sighted

Far-Sighted

Other: ________________

9.

Did you ever wear orthodontic braces?

Yes

No

 

 

 

If so, why did you need them? __________________________________________________________________

10.

Are you allergic to anything?

Yes

No

If yes, what are you allergic to and what is your

 

reaction?

_______________________________________________________________________________

1

 

 

 

 

 

 

 

DSS-5102 (Rev. 11/2014) Child Welfare Services

11.What are your hobbies and interests? ___________________________________________________________

____________________________________________________________________________________________

12.What are your favorite foods and drinks? __________________________________________________________

13.

What is your favorite color?

_____________________Your favorite season? __________________________

 

Your favorite holiday? ____________________________________

14.

Education (highest grade completed): ________ Scholastic Performance: ____________________________

 

Favorite subjects in school?

_________________________________________________________________

 

Any extracurricular activities?

_________________________________________________________________

15.Special Talents: ______________________________________________________________________________

16.Religious Preference: ________________________________________________________________________

17.Usual Occupation: ____________________________________________________________________________

18.

Military Service:

Yes

No

If yes, what branch?

________________________________

19.Marital Status: ______________________________

20.Age and sex of other children: _________________________________________________________________

21.

Were you or anyone in your family adopted?

Yes

No If yes, who? ___________________________

22.Why are you placing child for adoption? ___________________________________________________________

____________________________________________________________________________________________

23.

Are you interested in future contact with the child?

Yes

No

24.If you are deceased when the child reaches age 18, would you have any objection to the child contacting birth

family?

Yes

No

If so, what are your concerns? ________________________________

___________________________________________________________________________________________

25.What was your relationship with the child’s other biological parent?

Friends

Dating Steadily

Engaged

Married

None

Other: ___________________________________________

26.Other reasonably available information such as scars/birth marks/tattoos, etc.? ____________________________

____________________________________________________________________________________________

PERSONALITY DESCRIPTION:

Please check all that apply.

Aggressive

Friendly

Calm

Happy

Emotional

Irresponsible

Easygoing

Independent

Other: ____________________________

2

DSS-5102 (Rev. 11/2014)

Child Welfare Services

Nervous

Outgoing

Rebellious

Worrisome

Self-Confident

Serious

Shy

Stubborn

Temperamental

Unhappy

CHARACTERISTICS OF EXTENDED FAMILY MEMBERS

CHILD’S GRANDPARENT 1

CHILD’S GRANDPARENT 2

Age: (If Deceased, State Age and

Cause of Death

Sex (male, female)

Race (Black, White, etc.)

Ethnicity (Hispanic, etc.)

Nationality (American, etc.)

Height/Weight

Hair/Eye Color

Build/Complexion

Right/Left Handed

Hobbies/Talents/Interests

Education

Occupation

Military Service

Religious Preference

CHILD’S AUNTS AND UNCLES

Brother

Sister

Brother

Sister

Brother

Sister

Age: (If Deceased, State

Age and Cause of Death

Race (Black, White, etc.)

Ethnicity (Hispanic, etc.)

Nationality (American, etc.)

Height/Weight

Hair/Eye Color

Build/Complexion

Right/Left Handed

Hobbies/Talents/Interests

Education

Occupation

Military Service

Religious Preference

Special Comments to Child: ________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

INSTRUCTIONS: This form should be completed to collect birth parent and prior adoptive parent information. Both forms should clearly indicate whether the information is related to a birth parent or a prior adoptive parent. One copy of this form is to be given to the adoptive parents prior to placement of a minor child for adoption; one copy is to be filed with the Petition for Adoption to be forwarded by the Clerk of Superior Court to the Division of Social Services, State Department of Health and Human Services; and one copy is to be retained in the agency's file. In agency adoptions, the certification page shall not be provided to the adoptive parent(s) if it contains the name of a birth parent or birth parent’s relative.

3

DSS-5102 (Rev. 11/2014) Child Welfare Services

CERTIFICATION

This document should be certified by the person who prepared it. (In agency adoptions, this certification page shall not be provided to the adoptive parent(s) if it contains the name of a birth parent or birth parent's relative.)

I hereby certify that I prepared this Non-Identifying Background Information.

_______________________________________________

Signature of (Parent) (Relative) (Agency Representative)

________________________

Date:

STATE OF NORTH CAROLINA

__________________________COUNTY

Sworn to and subscribed before me this _______day of __________________I __________________________________.

(S E A L)

_______________________________________

Signature of Notary Public

My Commission Expires: _______________________

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DSS-5102 (Rev. 11/2014)

Child Welfare Services

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1. Fill out the dss 8551 form with a selection of major blank fields. Note all the required information and make sure not a single thing left out!

Tips on how to fill in form dss 5102 portion 1

2. After the last part is completed, you're ready to include the necessary details in What is the natural color of your, Is your hair, Naturally Curly, Straight, Wavy, Thick, Thin, Do you like to wear it long or, Do you wear eye correction, Yes, Glasses, Contacts, If you wear eye correction at what, Reason for eye correction, and NearSighted so that you can move forward further.

Stage number 2 in submitting form dss 5102

3. This stage is going to be easy - complete all of the form fields in What are your hobbies and, What are your favorite foods and, What is your favorite color, Your favorite season, Your favorite holiday, Education highest grade completed, Favorite subjects in school, Any extracurricular activities, Special Talents, Religious Preference, Usual Occupation, Military Service, Yes, If yes what branch, and Marital Status to conclude this part.

Filling out part 3 in form dss 5102

4. Filling out Marital Status, Age and sex of other children, Were you or anyone in your family, Yes, No If yes who, Why are you placing child for, Are you interested in future, Yes, If you are deceased when the child, family, Yes, If so what are your concerns, What was your relationship with, Friends, and Dating Steadily is vital in the fourth part - you'll want to don't hurry and fill out each and every field!

Filling out section 4 in form dss 5102

You can certainly get it wrong when completing the Are you interested in future, and so make sure that you look again before you submit it.

5. This document must be finalized with this particular segment. Below you can find a detailed list of form fields that need accurate information in order for your form usage to be complete: PERSONALITY DESCRIPTION, Please check all that apply, Aggressive Calm Emotional Easygoing, Friendly Happy Irresponsible, Nervous Outgoing Rebellious, SelfConfident Serious Shy, Stubborn Temperamental Unhappy, Other, and DSS Rev Child Welfare Services.

Filling in segment 5 in form dss 5102

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