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Table of County Codes Used for the Services Information System.
SERVICES INFORMATION SYSTEM CLIENT ENTRY FORM DSS-5027
SERVICES INFORMATION SYSTEM CLIENT ENTRY FORM DSS-5027
01 |
Alamance |
51 |
Johnston |
02 |
Alexander |
52 |
Jones |
03 |
Alleghany |
53 |
Lee |
04 |
Anson |
54 |
Lenoir |
05 |
Ashe |
55 |
Lincoln |
06 |
Avery |
56 |
Macon |
07 |
Beaufort |
57 |
Madison |
08 |
Bertie |
58 |
Martin |
09 |
Bladen |
59 |
McDowell |
10 |
Brunswick |
60 |
Mecklenburg |
11 |
Buncombe |
61 |
Mitchell |
12 |
Burke |
62 |
Montgomery |
13 |
Cabarrus |
63 |
Moore |
14 |
Caldwell |
64 |
Nash |
15 |
Camden |
65 |
New Hanover |
16 |
Carteret |
66 |
Northampton |
17 |
Caswell |
67 |
Onslow |
18 |
Catawba |
68 |
Orange |
19 |
Chatham |
69 |
Pamlico |
20 |
Cherokee |
70 |
Pasquotank |
21 |
Chowan |
71 |
Pender |
22 |
Clay |
72 |
Perquimans |
23 |
Cleveland |
73 |
Person |
24 |
Columbus |
74 |
Pitt |
25 |
Craven |
75 |
Polk |
26 |
Cumberland |
76 |
Randolph |
27 |
Currituck |
77 |
Richmond |
28 |
Dare |
78 |
Robeson |
29 |
Davidson |
79 |
Rockingham |
30 |
Davie |
80 |
Rowan |
31 |
Duplin |
81 |
Rutherford |
32 |
Durham |
82 |
Sampson |
33 |
Edgecombe |
83 |
Scotland |
34 |
Forsyth |
84 |
Stanly |
35 |
Franklin |
85 |
Stokes |
36 |
Gaston |
86 |
Surry |
37 |
Gates |
87 |
Swain |
38 |
Graham |
88 |
Transylvania |
39 |
Granville |
89 |
Tyrrell |
40 |
Greene |
90 |
Union |
41 |
Guilford |
91 |
Vance |
42 |
Halifax |
92 |
Wake |
43 |
Harnett |
93 |
Warren |
44 |
Haywood |
94 |
Washington |
45 |
Henderson |
95 |
Watauga |
46 |
Hertford |
96 |
Wayne |
47 |
Hoke |
97 |
Wilkes |
48 |
Hyde |
98 |
Wilson |
49 |
Iredell |
99 |
Yadkin |
50 |
Jackson |
00 |
Yancey |
01 Service no longer needed or wanted
02 Client not eligible
03 Death of client
04 Service not available
09 Other
This field is used to collect information which is needed for a special purpose and will not be used except under special circumstances. Refer to Section II: "Table Values for Reserved Fields" of this Appendix for the individualized instructions regarding the use of this field.
1 Indigent Recipient
01 Developmental Disabilities
Having a severe, chronic mental or physical disability resulting in substantial limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, capacity for independent living, learning, mobility, self direction, and economic self-sufficiency and reflecting the person's need for a combination of special inter-disciplinary care or treatment of a lifelong or extended duration, manifested before age 22, unless caused by a head injury.
02 Blind or Visually Impaired
Having visual impairment that, in the worker's judgment, may significantly affect day-to-day functioning.
03 Deaf or Hard of Hearing
Having a hearing impairment, whether permanent or fluctuating, that may in the worker's judgment, adversely affect day-to-day functioning; a communication disorder such as stuttering, impaired articulator; or a language impairment that adversely affects functioning.
04 Physically Disabled
Having a physical condition that may, in the worker's judgment, adversely affects the individual's day-to-day or intermittent functioning.
05 Emotionally Disturbed
Having mental or emotional problems exhibited in a wide range of important social and personal contexts and causing significant impairment in social, educational, or occupational functioning.
06 Learning Disability
Having a disorder in one or more of the basic psychological processes involved in understanding or using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or to use mathematical calculations. An example of a learning disability would be dyslexia.
07 Medical Condition
Having any apparently disabling physical condition other than those listed above, which has been diagnosed by a licensed physician and that needs medical attention.
08 HIV and AIDS
Having a syndrome, or a disease complex in which the natural immune system is suppressed so significantly that individuals gradually die from vulnerability to a variety of unusual infections and concerns (opportunistic infections) that would not ordinarily pose a threat to an immunologically healthy person.
09 Substance Abuse
Using alcohol or other drugs to a degree which creates a risk of harm to self or others, or impairs social, educational or occupational functioning.
11 Undisciplined Child
A child who is an adjudicated undisciplined child under NCGS 7A-517(28).
12 Delinquent Child
A child who is an adjudicated delinquent child under NCGS 7A-517(12).
13 Homeless Person
A person who does not have what society defines as a normal place of his/her own to live.
14 Alzheimer's Disease and Related Dementia’s
Having an organic mental disorder, in which intellectual function is progressively impaired in a previously well adult, usually accompanied by memory loss, disorientation, impaired judgment, and personality change.
01 Out-of-Home Placement
A need to move a child from the home of parents or other responsible adult(s); or a need for an adult to leave own home (or home maintained for him/her by caretakers) and be placed in substitute care.
02 Prevention of Placement
A need for services to keep a child or adult in his/her own home (or home maintained for him/her by caretakers).
03 Family Reunification
A need for services to improve conditions which led to family separation so that family may be reunited
04 Family Disruption
A need for services to strengthen and maintain the family.
05 Protective Services
A need for services as a result of a report of child abuse or neglect or adult abuse, neglect or exploitation. Use this designation even for those cases where the report was not substantiated after assessment.
09 Other
A need for services for reasons other than those defined above.
01 Minor
Any individual under the age of 18, unless emancipated.
02 Emancipated Minor
A child who has been adjudicated an "emancipated minor", or who is currently married, or who is a member of the armed forces.
03 Adult
Any individual who is age 18 or over, unless incompetent.
04 Incompetent Adult
An adult who has been adjudicated incompetent.
01 Living Alone
An independent living arrangement where the individual resides either alone, or with others where the relationship is not characterized by intimacy, continuity or commitment, as in a rooming house or shared housing.
02 Living With Family or Other Significant Individual(s)
A home occupied by two or more people who are related by blood, marriage, adoption or who have a commitment to care for one another.
03 Family Care Home
A licensed domiciliary home having a capacity of two to six residents.
04 Home for the Aged
A licensed domiciliary home has a capacity of seven or more residents.
05 Group Home for Developmentally Disabled Adults
A licensed DDS group home housing residents with developmental disability, regardless of which local/state agency has licensing monitoring or certification responsibilities.
06 Nursing/Combination Home
A licensed facility which provides nursing or convalescent care for three or more persons.
07 Treatment/Rehabilitation Facility/Home
A 24-hour facility/home, which provides treatment or rehabilitation, services for medical, psychosocial, or psychiatric needs (e.g. medical or psychiatric hospital, State Mental Retardation Center, mental health group home for persons with mental illness). Not included in this definition are nursing homes, maternity homes, and group homes for developmentally disabled adults.
08 Maternity Home
A 24-hour residential program whose primary purpose is to provide care, support and other services for pregnant females.
09 Jail, Lockup, Detention
A local jail or a facility administered by the Department of Corrections or Division of Youth Services.
10 Battered Women's Shelter
A 24-hour residential program whose primary purpose is to offer protection, food, shelter, support and other services to battered women and their children.
11 Shelter for the Homeless
An overnight shelter for people without homes.
97 Child Placement System (DSS-5094)
When the client is a child for whom the DSS has custody or placement authority, the living arrangement will be tracked through the Child Placement and Payment System. This code should remain unchanged in this system for as long as the DSS-5094 record remains open. If the client remains a service client after the DSS-5094 record is closed, this field will have to be updated to reflect the actual living arrangement.
98 Other
A living arrangement which is known to the agency but does not fit the above definitions.
99 Unknown
1 Male
2 Female
The 6 races are:
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Unable to Determine
Race codes and possible combinations that could be selected are:
01 =White Native (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)
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)
41 = White/American Indian or Alaska. Native/Native Hawaiian or Other Pac. Islander (Non Hispanic or Latino)
42 = White/American Indian or Alaskan. Native/Native Hawaiian or Other Pac. 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)
P Yes – individual is enrolled in a public school
R Yes – individual is enrolled in a private school
H Yes – individual is enrolled in home school
N No – individual is not enrolled in school
P Preschool
00 No grade completed.
01 - 20 Enter the highest grade attained whether the individual is currently enrolled or no longer in school. Entry is required if the age of the individual is between 4 and 21 years of age (inclusive), based on the date of birth entered in Field 4.
98 GED status
99 Unknown Not allowed if individual is between 4 and 21 years of age (inclusive).
EN English |
KO Korean |
SP Spanish |
LA Laotian |
AR Arabic |
MI Miao |
CA Cambodian |
MK Mon-Khmer |
CH Chinese |
PE Persian |
FR French |
PO Polish |
FC French Creole |
PG Portuguese |
GE German |
PC Portuguese Creole |
GR Greek |
RU Russian |
GU Gujarati |
SC Serbo-Croatian |
HI Hindi |
TA Tagalog |
HM Hmong |
TH Thai |
HU Hungarian |
UR Urdu |
IT Italian |
VI Vietnamese |
JA Japanese |
OT Other |
FIELD 28: SPECIAL EDUCATION STATUS
Y Yes - the youth is receiving special education at no cost to the parent.
N No - the youth is not receiving special education.
FIELD 29: RACE DECLINED
Y Yes - the youth or parent has declined to identify a race; ‘Y’ is valid only when the Race Code in Field 24 is ‘11’ or ‘12’.
N No - the youth or parent has not declined to identify a race; ‘N’ is valid with any Race Code in Field 24 (including ‘11’ or ‘12’).
NOTE: Complete both fields 7 and 14 for HCCBG.
It is essential that the Home and Community Care Block Grant codes be keyed into the system by the 10th of each month or the last working day prior to the 10th when the 10th falls on a weekend or holiday. Payment may be denied by the Division of Aging if this deadline is not met.
All five spaces must be completed or the client will not be registered and payment from the Division of Aging will not be made except as noted for the Fifth Space, which is required only for clients receiving Preparation and Delivery of Meals. The Division of Aging policy regarding the definitions and use of these codes is to be followed. This can be found in the Home and Community Care Block Grant Procedures Manual for Community Service Providers, Sections 3 and 4.
First Space - Enter A in the first space of the Other field to identify that the data to follow applies to the Home and Community Care Block Grant (HCCBG) administered by the Division of Aging.
Second Space - Is client oriented?
1 No Referral source or agency's professional assessment indicates client has a problem with or has suffered a significant decline in short term memory, thinking, or decision making.
2 Yes Referral source or agency's professional assessment indicate no indication of a significant memory problem.
Third Space - Number of IADL impairments client experiences.
0 None
1 One impairment
2 Two impairments
3 Three or more impairments
Fourth Space - Number of ADL impairments client experiences.
0 None
1 One impairment
2 Two impairments
3 Three or more impairments
Fifth Space - Is client at nutritional risk?
Note: Entry required only for clients receiving Preparation and Delivery of Meals
1 No nutritional risk
2 Moderate nutritional risk
3 High nutritional risk
First Space - Enter A in the first space of the Special Use field to identify that the data to follow applies to the Home and Community Care Block Grant (HCCBG) administered by the Division of Aging.
For each service to be provided under the Home and Community Care Block Grant, complete the next five spaces of this field to answer the following questions. All five spaces must be completed or the client will not be registered and payment from the Division of Aging will not be made except as noted for the Sixth Space, which is required only for clients receiving Preparation and Delivery of Meals. The Division of Aging policy regarding the definitions and use of these codes is to be followed. This can be found in the Home and Community Care Block Grant Procedures Manual for Community Service Providers, Sections 3 and 4.
Second Space - What is the functional status of the individual?
Note: DSS-5027 entry will be rejected if the functional status is coded “1 Well” and the client is being registered for In-Home Aide Services, Adult Day Care or Adult Day Health unless the client is the caregiver as indicated in the Fourth Space, below.
1 Well
2 At Risk
3 High Risk
Third Space - Is the service being provided to relieve the caregiver?
(When the answer is Yes and the service being provided is In Home Aide Services, the system will automatically convert to the DOA Respite code for the same level of In Home Aide Services).
1 Yes
2 No
Fourth Space - Is the client the caregiver?
1 Yes
2 No
Fifth Space - Is the client economically needy?
1 Yes
2 No
Sixth Space - Are Nutrition Services (as defined by the Division of Aging) being provided under the Division of Aging definition of Special Eligibility Criteria? Note: Entry required only for clients receiving Preparation and Delivery of Meals. DSS-5027 entry will be rejected if incorrect age entry is made here for clients being registered for Preparation and Delivery of Meals.
1 Yes (Client is age 59 or under)
2 No (Client is age 60 or older)
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For questions or clarification on any of the policy contained in these manuals, please contact your local county office. |
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