DSB-1010: Registrant Data Form may be prepared by any referral source from information on the DSB-2202: Report of Eye Examination. This form is also used by Social Workers for the Blind to notify the Register Clerk of changes in registrants’ situations such as name changes, address changes, county transfers and deletions.
The form is now available on line and information should be entered and then forwarded electronically to the Register Clerk (see Email option in lower right hand corner). The only exception to this is when a person is being added to the Register and then the form should be printed after information has been entered (see print option in lower right corner of form) and medical information should be attached. The DSB-1010 and the medical information should then be mailed to the Register Clerk at Division of Services for the Blind, 2601 MSC, Fisher Building, Raleigh, NC 27699-2601.
Enter the date the form is being prepared and the name of the person submitting the data. Enter in the appropriate block to indicate if the registrant is new, a change of information on an existing registrant, a removal of a registrant or a transfer from one county to another.
Register Number: If this number is known by the person submitting the data, then the number should be entered.
Social Security Number: This is a required entry and it is very important that the number is entered correctly.
Registrant Name: Enter the registrant’s last name, first name and middle initial.
Sex: Enter code M for male or code F for female.
Maiden Name: Enter registrant’s maiden name. Leave blank if not applicable or if this information is not available.
Date of Birth: Enter a two-digit month, two-digit day and four-digit year for the registrant. It is critical that the worker verify the birth date. If the birth date is unknown, leave the field blank until birth date is obtained and update it at that time.
Area: Enter a one-digit code to indicate that registrant is being served in Area 1,2,3 or 4.
Code 1: Counties served by Asheville and Charlotte District Office
Code 2: Counties served by Winston-Salem District Office
Code 3: Counties served by Fayetteville and Raleigh District Office
Code 4: Counties served by Greenville and Wilmington District Office
County: Enter a two-digit code for the county using county codes from Appendix A.
Address: Enter the registrant’s current street address, city, two-digit state code and the zip code.
Telephone: Enter the registrant’s telephone number including the three-digit area code and seven digit number.
In Institution: Enter a one-digit number code to indicate if registrant is currently in a public or private licensed home or institution.
Code 1: In public or private licensed home or institution
Code 2: Not in an institution
Race/Ethnicity: Enter “X” in all boxes that apply.
Language Preference: Enter the two-character code. Default is English.
EN=English SP=Spanish AR=Arabic CA=Cambodian CH=Chinese FR=French FC=French Creole GE=German GR=Greek GU=Gujarati HI=Hindi HM=Hmong HU=Hungarian IT=Italian JA=Japanese KO=Korean LA=Laotian MI=Miao MK=Mon-Khmer OT=Other PE=Persian PO=Polish PG=Portugese PC=Portugese Creole RU=Russian SC=Serbo-Croation TA=Tagalog TH=Thai UR=Urdu VI=Vietnamese
Vision Group: Coded by Register Clerk in State Office. See Appendix C in Register Manual.
Hearing Impairment Code: Complete with one of the following codes.
Blank: Hearing status not known
0: No hearing loss
B/VI Due to Retinitis Pigmentosa with:
1 Mild hearing loss
2 Moderate to severe loss
3 Profound hearing loss
B/VI Due to other causes with:
4 Profound prelingual hearing loss (occurring before 3rd birthday)
5 Profound hearing loss occurring between ages 3-21
6 Profound hearing loss occurring after age 21
7 Moderate to severe hearing loss occurring prior to age 21
8 Moderate to severe hearing loss after age 21
9 Mild hearing loss
Diagnosis: Coded by Register Clerk in State Office. See Appendix D in Register Manual.
Etiology: Coded by Register Clerk in State Office. See Appendix E in Register Manual.
Deceased: Enter code “Y” if deceased or leave blank.
Remove from Register: Enter code “Y” if registrant is to be removed.
Reason: Enter a code indicating the reason for removal from the Register.
Code 1: Death
Code 2: Left North Carolina
Code 3: Vision restored. Attach eye report verifying the improved vision.
Code 6: Unable to locate. This code accepted only if all of the following data are reported on the back of the DSB-1010. If sending the DSB-1010 electronically to the Register Clerk, send an email that includes the following data:
(1.) Attempt to contact registrant by telephone, and
(2.) Letter to registrant has been returned undeliverable and
(3.) DSS records have been searched (ex. Medicaid and/or Food Stamps and no record of registrant is available
Code 7: Administrative error; duplicate
Re-add to Register: If the registrant has previously been on the register but was removed (examples: moved out of state or vision improved) but later needs to be added to the register again, please enter “Y” in the field.
For questions or clarification on any of the policy contained in these
manuals, please contact the local district office.