Lds2221a Form

STAPLE TO LDSS-2221A IF NEEDED Use only if the space on the LDSS-2221A under Reasons for Suspicion is not enough to accommodate your information PERSON MAKING THIS REPORT Print clearly if filling out hard copy. Residential Institutional Abuse Reports Submit a paper copy of form LDSS 2221A originally signed. It must be submitted directly to the Office of Children and Family Services OCFS Regional Office associated with the county in which the abused/maltreated child is in care. Report Date Case ID Time LDSS-2221A Rev. 9/2007 FRONT Call ID AM Local Case PM NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES REPORT OF SUSPECTED CHILD ABUSE OR MALTREATMENT Local Dist/Agency SUBJECTS OF REPORT List all children in household adults responsible and alleged subjects. Line Last Name First Name Sex Birthday or Age M F Unk Mo/Day/ Yr Aliases Race Code Ethnicity Ck Only If Hispanic/Latino Relation Role Lang. MORE List Addresses and Telephone Numbers Using Line Numbers From Above Area Code Telephone No* BASIS OF SUSPICIONS Alleged suspicions of abuse or maltreatment. Give child ren s line number s. If all children write ALL. DOA/Fatality Swelling/Dislocation/Sprains Fractures Child s Drug/Alcohol Use Poisoning/Noxious Substances Internal Injuries e*g* Subdural Hematoma Choking/Twisting/Shaking Emotional Neglect Lacerations/Bruises/Welts Lack of Medical Care Inadequate Food/Clothing/Shelter Burns/Scalding Malnutrition/Failure to Thrive Lack of Supervision Excessive Corporal Punishment Sexual Abuse Abandonment Inappropriate Isolation/Restraint Institutional Abuse Only Inadequate Guardianship Parent s Drug/Alcohol Misuse Other specify Educational Neglect If known give time/date of alleged incident State reasons for suspicion including the nature and extent of each child s injuries abuse or maltreatment past and present and any evidence or suspicions of Parental behavior contributing to the problem* MO DAY YR Additional sheet attached with more explanation* CONFIDENTIAL AM The Mandated Reporter Requests Finding of Investigation Area Code TELEPHONE YES NO SOURCE S OF REPORT NAME ADDRESS AGENCY/INSTITUTION RELATIONSHIP Med* Exam/Coroner Social Services For Use By Physicians Only Public Health Hosp* Staff Law Enforcement Mental Health Medical Diagnosis on Child School Staff Neighbor Relative Instit. Staff Signature of Physician who examined/treated child X Hospitalization Required None Under 1 week 1-2 weeks Over 2 weeks Actions Taken Or Medical Exam X-Ray Removal/Keeping Not. Med Exam/Coroner About To Be Taken Photographs Returning Home Notified DA Title Date Submitted Mo. Day Yr. TO ACCESS THE LDSS-2221-A FORMS Via Internet http //www. ocfs. state. ny. us/main/forms/cps/ Via Intranet http //ocfs. state. nyenet/admin/forms/SCR/ or TO ORDER A SUPPLY OF FORMS access OCFS-4627 Request for Forms and Publications from either site above fill it out and send to Office of Children and Family Services Resource Distribution Center 11 Fourth Ave Rensselaer NY 12144. If you have difficulty accessing this form from either site you can call The Forms Hot Line at 518-473-0971.