NC DSS-5295 Monthly Permanency Planning Contact Record: Sections and Filing

The North Carolina DSS-5295 Monthly Permanency Planning Contact Record is the standardized form a county child welfare worker completes every month, during a face-to-face visit, for each child in an out-of-home placement such as foster care, kinship care, or a residential facility. The entire form must be filled out each month, signed by the worker, reviewed and signed by a supervisor, and distributed to the licensing worker, the assigned child welfare worker, and the foster or kinship parents.¹

One quick boundary before the walkthrough: DSS-5295 is not a child support application. That is a separate form, DSS-4451.

Who Completes It and How Often

County permanency planning workers complete DSS-5295 during their monthly face-to-face contact with the child. If the worker visits the placement home more than once in a month, the form can be filled out across those visits rather than all at once. At least four out of every six visits must happen where the child actually lives, not at a county office or other location.¹

The form stays in use until the child achieves permanency. Even after a child goes back to a parent’s home, the worker keeps completing DSS-5295 each month for as long as the county agency retains legal custody.²

Demographics and Placement Type

Start at the top. Enter the agency name, the visit date, and whether the visit took place where the child lives or somewhere else. List each child or sibling group being visited with first name, last name, age, and current permanent plan (reunification, adoption, guardianship, custody, or another planned permanent living arrangement).³

Identify the placement type. The categories are foster care, therapeutic foster care, specialized foster care, kinship care, and residential. Then record the provider type (family foster home, group home, out-of-state placement, residential treatment, or other), the names of the foster or kinship parents, any direct care providers in group or residential settings, and all other adults and children living in the home.³ Picking the correct placement type matters because some later sections shift depending on the setting.

Section 1: The Placement Environment

Document any household changes since the last visit. That includes new childcare arrangements, pets, home remodeling, shifts in the family’s financial situation, and anyone moving in or out. For group home and residential placements, focus on staff changes and how those changes affect the children.³

Then assess the relationships inside the home: between the placement provider and the child, between the child and other adults in the home, and between the providers themselves. If there is conflict, describe both its source and how it is being resolved. Small observations belong here. A child who seems withdrawn around a new household member, or a provider who looks overwhelmed, should be documented plainly.

Section 2: Placement Provider Well-Being

This section turns the lens on the foster or kinship parents. Document the following for each one:

Social support network and respite plan for breaks from caregiving.
Any services, referrals, or training the provider needs.
Whether the provider is participating in shared parenting with the birth family, and what support that requires.
Physical and mental health needs of any household member that could affect the placement.
Whether the provider has the information they need about the court process, the child’s plan, and upcoming hearings or team meetings.

Placement stability depends heavily on whether providers feel supported. A foster parent without respite or shut out of case planning is more likely to request that the child be moved.³

Section 3: Safety and Supervision

Address each of the following: whether the child feels safe, sleeping arrangements, privacy and personal boundaries, how the provider handles discipline, and the level of supervision the child receives. How each area is assessed is left to the worker’s professional judgment on a case-by-case basis, but each must be addressed.¹

The instructions expect two components during the visit: time speaking privately with the child, and direct observation of the child interacting with the provider. When and how to do each is a judgment call, but both need to happen.

Section 4: Child Status

This is the longest part of the form. It covers behavior, education, health, activities, and connections.

Behavior and Education

Document behavioral successes, any challenging behaviors, how well the provider manages those behaviors, and how the child interacts with peers. For education, record academic and social performance, what the child needs to succeed in school, and any afterschool or childcare arrangements. If the child has changed schools or a school change is being considered, note whether a Best Interest Determination (BID) meeting has been held, as required under the Every Student Succeeds Act for children in foster care.³

Physical, Dental, and Mental Health

Record current health status, any unmet medical or dental needs, changes in mood or behavior, the quality and frequency of mental health services, and any sexual health concerns. The medication table requires each prescribed medication, dosage, prescriber, and whether side effects have been observed.

Pay attention to the 72-hour rule. If you note side effect concerns for any psychotropic medication, you must request a referral to care management, or follow up with the current care manager for a medication reconciliation, within 72 hours. Urgent concerns go straight to the prescriber.³

Activities and Connections

Document whether the child has access to age-appropriate or developmentally appropriate activities, and whether the provider is applying the Reasonable and Prudent Parent Standard when deciding which activities the child can participate in. Track efforts to maintain the child’s connections with birth family, siblings, extended relatives, and the broader community. The final subsection asks about the child’s Lifebook, the personal record of the child’s history, milestones, and memories, and whether the child needs help maintaining it.³

Private Conversation With the Child

Near the end of the form, confirm yes or no whether you spent time speaking privately with the child during the visit. A private conversation gives the child space to raise concerns they would not voice in front of the provider. Consistently skipping this creates a gap supervisors and courts will notice.

Narrative, Follow-Up, and Signatures

Use the narrative space for a general summary of the visit. Then complete the structured follow-up table, which lists specific activities identified during the visit, the person responsible for each one, and a target date for completion. This is where the visit translates into action, whether that is a referral, a school meeting, or a medical appointment.¹

Sign the completed form. Route it to your supervisor for review and a second signature. Once approved, distribute copies to the agency’s licensing worker, the assigned child welfare worker (if different from you), and the foster or kinship parents caring for the child.¹

Timeliness and Why It Matters

North Carolina policy requires case documentation to be current within seven days of any case activity. The record must reflect the dates and content of face-to-face and telephone contacts with the child, parents, foster parents, and other involved parties, and it should show progress toward the services in the Permanency Planning Family Services Agreement. When reunification is the plan, it should also show the parent’s progress toward the agreement’s goals.⁴

Falling behind creates real problems. The DSS-5295 record feeds directly into the reports filed with the court at each permanency planning hearing, which under G.S. 7B-906.1 happen within 90 days of the initial dispositional hearing and at least every six months after that.⁵ If documentation does not reflect that monthly contacts occurred and that safety and well-being were assessed, the court may question whether those things happened at all, and the agency’s ability to demonstrate reasonable efforts suffers.

Where to Get the Form

The current version of DSS-5295 (Rev. 05/2021) is published as a PDF on the North Carolina Department of Health and Human Services policies portal.⁶ County agencies may also generate it through NC FAST, the state’s integrated case management system. The companion instructions are published alongside the form as a separate PDF covering each section in detail.

1
North Carolina Pediatric Society. Instructions for DSS-5295 Monthly Permanency Planning Contact Record
2
North Carolina Department of Health and Human Services. Permanency Planning Services Policy, Protocol, and Guidance
3
North Carolina Department of Health and Human Services. DSS-5295 Monthly Permanency Planning Contact Record
4
North Carolina Department of Health and Human Services. Permanency Planning Services Policy, Protocol, and Guidance
5
North Carolina General Assembly. North Carolina General Statutes Chapter 7B Article 9
6
North Carolina Department of Health and Human Services. DSS-5295 Monthly Permanency Planning Contact Record