Free Ldss 3370 Form in PDF

Free Ldss 3370 Form in PDF

The LDSS-3370 form, revised as of April 2011, serves as a comprehensive document for conducting checks against the Statewide Central Register Database. It is crucial for ensuring the accuracy of information provided to facilitate precise data entry and results, concerning the background of individuals and other household members for various purposes, including employment and caregiving positions. Detailed instructions on the form guide applicants through the process of filling it out correctly, including sections on agency information, applicant and household member information, and address history.

For those looking to complete the Statewide Central Register Database Check, it is essential to provide clear, accurate information and review the form for completeness and legibility. Click the button below to learn more about filling out the LDSS-3370 form.

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In a world where safeguarding children and vulnerable populations is paramount, the significance of thorough vetting processes cannot be overstressed. The LDSS-3370 form, revised in April 2011, plays a crucial role by establishing a protocol for entities to follow when requesting checks from the Statewide Central Register Database. This form is an essential tool in identifying individuals with histories of child abuse or maltreatment, crucial for positions in adoption, foster care, and various childcare provisions. Its comprehensive design ensures all household members, adults and children alike, are accounted for, reflecting a commitment to thoroughness. The detailed instructions dictate the proper completion of the form, requiring applicants to list all names, including maiden and aliases, and provide a robust 28-year address history, emphasizing the rigorous scrutiny applicants undergo. For certain categories, collecting a fee accompanies the submission, underscoring the procedural formalities embedded in its usage. By mandating signatures from applicants and relevant household members, the form also enshrines a declaration of accuracy and honesty, underpinning the serious nature of the check. Moreover, the distribution and request instructions for obtaining the LDSS-3370 underscore the systematic approach adopted by the New York State Office of Children and Family Services to streamline this critical vetting process.

Preview - Ldss 3370 Form

LDSS-3370 (Rev. 12/2019) DCCS version

Instructions for Completing the Statewide Central Register

Database Check Form LDSS-3370, DCCS version

ALL information on the LDSS-3370, DCCS version must be easily read so that data entry and results are accurate. Each Statewide Central Register Database Check form LDSS-3370, DCCS version submitted should be reviewed for completeness and legibility by the program/agency liaison. If the form is incomplete or illegible, it will be returned to the agency for corrections.

HOW TO COMPLETE THE FORM:

AGENCY INFORMATION

TOP LINE OF FORM

The three-digit agency code must be placed in the top left-hand box, followed by the Resource I.D. (RID) in the next box to the right. (Contact the licensing agency if there are any questions about these.)

Day Care providers must place their Child Care Facility System (CCFS) Number in the box next to Resource ID (RID), in lieu of RID number. (Contact your licensing agency/regional office if you have any questions).

Clearance Category letter code (see the back of form LDSS-3370, DCCS version) must be placed in the middle box.

Phone number (with area code) enables the SCR to contact the agency liaison if this becomes necessary.

The Request ID Box is for SCR use only.

AGENCY ADDRESS AREA

Agency Name: Please use full name, no abbreviations

Agency Liaison is the contact person at the inquiring agency. (The SCR response will be addressed to the liaison.) The liaison cannot be the applicant or a relative of the applicant.

Agency Address: Must include street and city

APPLICANT INFORMATION

APPLICANT/HOUSEHOLD MEMBER AREA

ALL HOUSEHOLD MEMBERS, ADULTS AND CHILDREN, WHETHER RELATED TO THE APPLICANT OR NOT, ARE TO BE LISTED IN THIS AREA OF THE FORM.

Remember to write clearly or type all information to assist in obtaining an accurate response. Record all names with the last name first, then the first name, and middle name.

First line: Applicant’s name. If there is more than one applicant place the additional name(s) on the lines below the maiden name line.

Second line: Any maiden names, previous married names, or aliases by which the applicant is or has been known. Use additional lines if there is more than one maiden/married/alias name to be listed.

Remaining lines: Names of all other household members. (Attach an additional page if needed.)

IF THERE ARE NO OTHER HOUSEHOLD MEMBERS, PLEASE CHECK BOX FOR NO OTHER HOUSEHOLD MEMBERS.

First column: indicate the relationship to the applicant of each person listed. (Spouse, son, daughter, mother, father, friend, etc.)

Sex M/F column: check either M (Male) or F (Female) for every person listed.

Date of Birth column: fill in complete date of birth (mm/dd/yyyy) for everyone listed on the form.

ADDRESS AREA

The information required varies depending on the category (see the back of the form for categories).

For Adoption, Foster Care and Family and Group Family Day Care, provide addresses for the applicant and any household member who is 18 years of age or older. For legally-exempt Family Child Care provide addresses for the applicant and any household member who is 18 years of age or older, unless the household member is related in any way to all children in care. This information must date back to the last 28-years. Attach supplemental pages if necessary, but do not use another LDSS-3370, DCCS version form to list this additional information. Be sure to associate address histories with individuals (i.e., indicate which addresses are for which household member).

For all other categories, only the applicant’s address history is required – for the last 28-years.

Complete addresses are required. Include street name, street number, apartment number and city/town/village. Post Office Box numbers are not acceptable. If the applicant has lived abroad, indicate country and dates (months/years) of residence. If the applicant has spent time in the military, list base names and locations along with dates (months/years).

Be sure that there are no periods of time unaccounted for.

The top line is for the current address. The previous address should be listed on the second line downward, and so on, to the back of the form for the last 28-years. Staple the attached supplemental page to the form if more space is needed, but do not use another copy of the LDSS-3370, DCCS version for this additional information.

SIGNATURE AREA

Signatures required depend upon the category (see the back of the form for categories).

For Adoption, Foster Care and Family and Group Family Day Care, signatures are needed from the applicant and any household member who is 18 years of age or older. For legally-exempt Family Child Care, signatures are needed from the applicant and any household member who is 18 years of age or older unless the household member is related in any way to all children in care.

For all other categories, only the applicant’s signature is required.

All signatures must correspond to the names recorded in the Applicant/Household Member Area. For example: Mary Smith should not sign Mary Ann Smith. Victoria Smith should not sign Vicki.

Applicants must sign in the boxes marked Applicant’s Signature; household members over 18 years of age who are not applicants must sign in the boxes at the extreme bottom of the page marked Signature.

All signatures must be dated (mm/dd/yyyy). The SCR will not accept a form with a signature date more than six-months old.

If you have questions regarding completion of this form, please call the SCR at 518-474-5297.

SUBMIT YOUR COMPLETED LDSS-3370, DCCS VERSION TO THE PERSON REFERENCED IN OCFS-6000

INCLUDE THE REQUIRED FEE FOR EACH APPLICANT FOR EMPLOYMENT/TO BE A CHILD CARE PROVIDER

TO ORDER A SUPPLY OF FORM, LDSS-3370, DCCS version:

Please access the OCFS-4627, Request for Forms and Publications, from the Intranet: http://ocfs.state.nyenet/admin/forms/Management_Services/

Internet http://ocfs.ny.gov/main/documents/forms_keyword.asp and mail the completed OCFS-4627, Request for Forms and Publications to: THE NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES, FORMS AND PUBLICATIONS UNIT, 52 WASHINGTON ST. ROOM 116 SOUTH BLDG., RENSSELAER, NY 12144.

LDSS-3370 (Rev. 12/2019) DCCS version FRONT

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

STATEWIDE CENTRAL REGISTER DATABASE CHECK

Agency Use Only

SCR USE ONLY

REQUEST I.D.:

ALL INFORMATION MUST BE COMPLETE. PLEASE PRINT OR TYPE

AGENCY CODE:

RESOURCE I.D. (RID)

CHILD CARE FACILITY SYSTEM (CCFS) NUMBER:

CATEGORY (Use alpha codes on reverse):

PHONE NUMBER (Area Code):

 

 

 

 

 

 

 

( )

-

 

 

 

 

 

 

 

 

PRINT BELOW THE ADDRESS ASSOCIATED WITH YOUR RID/CCFS NUMBER:

The particular classifications of persons who must or may be screened

AGENCY

 

 

 

 

are set forth on the reverse side of this document. The alpha codes to

 

 

 

 

complete the “Category” box above, are also on the reverse side of this

NAME:

 

 

 

 

 

 

 

 

form.

 

 

 

 

 

 

 

 

AGENCY

 

 

 

 

 

 

 

 

 

FOR ALL CATEGORIES: Complete the following for yourself, your

LIAISON:

 

 

 

 

 

 

 

 

spouse, your children and any other person(s) in your home at the

 

 

 

 

 

 

STREET

 

 

 

 

present time. MAKE SURE YOU COMPLETE ALL MAIDEN

ADDRESS:

 

 

 

 

NAME/ALIAS/MARRIAGE SECTIONS THAT APPLY. IF NONE,

 

 

 

 

 

 

STATE “NONE” List RELATIONSHIP in the fields below.

CITY:

 

STATE:

ZIP CODE:

 

(see reverse side for instructions) Attach additional page if necessary.

 

 

 

 

 

 

The purpose of collecting the demographic data on other persons in your household who are not screened pursuant to Section 424-a of the Social Services Law is to enable the NYS Office of Children and Family Services to identify with the greatest degree of certainty whether the person(s) being screened is the subject of an indicated child abuse or maltreatment report. The utilization of this information in a discriminatory manner is contrary to the Human Rights Law.

APPLICANT/HOUSEHOLD MEMBER AREA

PLEASE TYPE OR PRINT CLEARLY

 

 

 

IF THERE ARE NO OTHER HOUSEHOLD MEMBERS, PLEASE CHECK THIS BOX.

 

 

 

 

 

 

 

 

 

 

 

 

 

RELATIONSHIP TO

LAST NAME

 

FIRST NAME

SEX

DATE OF BIRTH

APPLICANT

 

M/F

mm

dd

yyyy

 

 

 

APPLICANT

 

 

 

M

 

 

 

 

 

 

F

 

 

 

APPLICANT MAIDEN/ALIAS/

 

 

 

M

 

 

 

MARRIED NAME

 

 

 

F

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

Please provide your current address and any other addresses at which you have resided for the last 28-years, including street, street number, city and state. For Adoption, Foster Care, Family and Group Family Day Care and legally-exempt Family Child Care, also include the same address history for household members 18 years of age or older.

CURRENT STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM (Mo/Yr)

TO (Mo/Yr)

 

 

 

 

 

/

/

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM (Mo/Yr)

TO (Mo/Yr)

 

 

 

 

 

/

/

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM (Mo/Yr)

TO (Mo/Yr)

 

 

 

 

 

/

/

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM (Mo/Yr)

TO (Mo/Yr)

 

 

 

 

 

/

/

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM (Mo/Yr)

TO (Mo/Yr)

 

 

 

 

 

/

/

 

 

 

 

 

 

 

I affirm that all the information provided on this form is true to the best of my knowledge. I understand that if I knowingly give false statements, such action could be grounds for denial or dismissal from employment or denial or revocation of a license, certificate, permit, registration or approval.

APPLICANT’S SIGNATURE

DATE (mm/dd/yyyy)

 

/

/

EIGHTEEN-YEARS OF AGE OR OLDER:

APPLICANT’S SIGNATURE

DATE (mm/dd/yyyy)

/ /

I understand that as a person 18 years of age or older in a home of an applicant to become an Adoptive or a Foster Parent or a Family or Group Family Day Care provider or a legally-exempt family child care provider, the information I have provided will be used to inquire of the Statewide Central Register to determine if I am the subject of an indicated report of child abuse or maltreatment.

SIGNATURE

DATE (mm/dd/yyyy)

/ /

SIGNATURE

DATE (mm/dd/yyyy)

/ /

LDSS-3370 (Rev. 12/2019) DCCS version REVERSE

AGENCY LIAISON INSTRUCTIONS

Please verify that each form is completed. Incomplete forms will be returned to the sender. For ADOPTION, FOSTER CARE, and FAMILY and GROUP FAMILY DAY CARE, if both spouses are applicants, both are to sign. Persons 18 years of age or older residing in the home of applicants for ADOPTION, FOSTER CARE and FAMILY AND GROUP FAMILY DAY CARE also must sign the form.

AGENCY CODE: Record your three-digit agency code. NOTE: Day Care, Family and Group Family Day Care and Camps must provide the agency code of the agency or office which issues your license or certificate. Verify your Alpha or Alpha/Numeric three-digit code with your licensing agency.

DAYCARE PROVIDERS: Must place their Child Care Facility System (CCFS) Number in the box next to Resource ID (RID), in lieu of RID number. (Contact your licensing agency/regional office if you have any questions).

RESOURCE I.D. (RID): Record your RID in this field. OCFS, OMH, OMRDD, DOH, OASAS and SED licensed agencies and programs and local departments of social services, have RIDs as of 9/2001. Verify your RID with your licensing agency. If you need assistance, email: ocfs.sm.conn_app@ocfs.ny.gov

CLEARANCE CATEGORIES: Record the appropriate alpha code in the category box.

A–Adult Services/Family Type Home for Adults

L–This is a director or employee at legally exempt group child

care. (This category is only to be used by Enrollment Agencies).

 

CCE–Child Care Current Employee

(fee required - see below) *

CCZ–Child Care Prospective Volunteer/Consultant

 

M–Director of a summer camp, overnight camp, day camp or

CCS–Child Care Provider of Goods/Services

traveling day camp.

 

D–Prospective employee (Local DSS district - bill against

N–Applying for a license to operate a day care center. (To be

reimbursement) **

submitted by authorized licensing agency only.)

 

(fee required - see below) *

F–Prospective/new employee other than day care employees.

P–Applying to be a family day care provider. (fee required - see

(fee required - see below) *

below) * Provide address history for all household members 18-

G–This is a provider or employee, at legally-exempt in-home child

years old or over.

 

care who does not reside in the home. No checks required

Q–Applying to be group family day care provider.

when provider is a legally-exempt relative-only in-home child

(fee required - see below) * Provide address history for all

care provider.

household members 18 years old or over.

 

(This category is only to be used by Enrollment Agencies) (fee

R–Applying to be kinship foster parents.

required - see below) *

 

 

U–Universal Pre-K Teacher (fee required - see below)*

I–This is a provider, at legally-exempt family child care. No checks

W–Applying to be foster parents or family care home providers.

required when provider is a legally-exempt relative-only family

 

child care provider. (This category is only to be used by

X–Applying to be adoptive parents pursuant to an application

Enrollment Agencies) (fee required - see below) * For providers,

pending before the inquiring agency.

include address history for all household members 18-years old

Y–Prospective Day Care employee (fee required - see below) *

or over who are not related in any way to all children in care.

–Applying to be a Group Family Day Care Assistant.

 

 

(fee required - see below) *

J–Age 18 or Older Household Member (with no child care role)

Prospective employee of legally-exempt family child care (fee

 

 

required-see below)*

 

 

AGENCY LIAISON: Record the name of the person to whom the response should be sent (cannot be the same as applicant or related to the applicant).

APPLICANT/HOUSEHOLD MEMBER AREA INSTRUCTIONS: This information is to be provided by the applicant/employee/ provider. (See front of form).

APPLICANT(S): -USE FIRST LINE (at least one person must be so designated)

MAIDEN NAME/ALTERNATIVE/AKA: MUST be completed for every applicant. Record ALL previous names used. Start with second line. Use as many lines as needed (one last name per line)

OTHER HOUSEHOLD MEMBERS: describe relationship to applicant, e.g., son, daughter, father, mother, friend, etc. on remaining lines

(ATTACH ADDITIONAL PAGE IF NECESSARY)

IF THERE ARE NO OTHER HOUSEHOLD MEMBERS, PLEASE CHECK BOX FOR NO OTHER HOUSEHOLD MEMBERS.

*Social Services Law 424-a(1)(f) requires the collection of a $25.00 fee for applicants for employment and applicants to be a child care provider. A certified check, postal or bank money order, teller's check, cashier's check or agency check made payable to "New York State Office of Children and Family Services" in the amount of twenty-five dollars, is to accompany the form. The check must also include the applicant's name and the agency code.

N.B.: a separate check must accompany each form.

**Social Services Law 424-a, allows local DSS to bill against their reimbursement the charge collected for screening prospective employees.

If you have questions, please call the SCR at 518-474-5297.

SUBMIT YOUR COMPLETED FORM, LDSS-3370, DCCS VERSION TO THE PERSON REFERENCED IN OCFS-6000 INCLUDE THE REQUIRED FEE FOR EACH APPLICANT FOR EMPLOYMENT/TO BE A CHILD CARE PROVIDER

LDSS-3370 (Rev. 12/2019) DCCS version

STAPLE TO LDSS-3370, DCCS version (IF NEEDED)

STATEWIDE CENTRAL REGISTER DATABASE CHECK FORM

ADDITIONAL PAGE

(Use only if the space on the form, LDSS-3370, DCCS version is not sufficient)

APPLICANT NAME:

Print clearly, all dates must be consecutive (month/year). Be sure to associate address histories with particular individuals.

 

PREVIOUS STREET ADDRESS

 

 

CITY

 

 

STATE

 

 

ZIP

 

 

FROM

 

 

TO

 

 

 

 

 

 

 

 

 

 

(Mo/Yr)

 

 

(Mo/Yr)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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LDSS-3370 (Rev. 12/2019) DCCS version

STAPLE TO LDSS-3370, DCCS version (IF NEEDED)

STATEWIDE CENTRAL REGISTER DATABASE CHECK FORM

ADDITIONAL PAGE

(Use only if the space on the form, LDSS-3370, DCCS version is not sufficient)

APPLICANT NAME:

Other Household Members are: (please print clearly):

IF THERE ARE NO OTHER HOUSEHOLD MEMBERS, PLEASE CHECK THIS BOX.

SCR USE

RELATIONSHIP

LAST NAME

FIRST NAME

SEX

DATE OF BIRTH

ONLY

TO APPLICANT

 

 

M/F

mm

dd

yyyy

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

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Document Specs

Fact Name Description
Form Number and Revision Date LDSS-3370, revised in April 2011
Purpose To complete a Statewide Central Register Database Check
Accuracy Importance All information must be easily read to ensure accurate data entry and results
Agency Information Requires the inclusion of a three-digit agency code, Resource I.D. (RID), and additional identifiers depending on the provider type
Applicant Information All household members, adults and children, must be listed with detailed demographic information
Address Requirements Address histories for the last 28 years are required, with specifics varying by the application category
Signature Requirements Varies by category but all signatures must be current (not older than 6 months)
Submission Address Completed forms are to be mailed to Statewide Central Register P.O. Box 4480, Albany, N.Y. 12204-0480
Form Ordering Information LDSS-3370 forms can be ordered from the website of the Office of Children and Family Services or by mail using the OCFS-4627 form
Governing Law Section 424-a of the Social Services Law in New York State

Instructions on Writing Ldss 3370

Filling out the LDSS-3370 form is an important process that requires attention to detail to ensure all information submitted is accurate and complete. This form is essential for those needing to complete the Statewide Central Register Database Check. Before starting the form, gather all necessary personal and household information to ensure the process is smooth and efficient. Plan to review each section carefully, providing clear and legible details to prevent any delays. Following is a step-by-step guide for completing the LDSS-3370 form.

  1. At the top left-hand box, enter the three-digit agency code. Contact your licensing agency if you have questions about this code.
  2. In the box to the right of the agency code, write the Resource ID (RID) or, for daycare providers, the Child Care Facility System (CCFS) Number. If unsure, contact your licensing agency or Regional Office.
  3. In the middle box, place the clearance category letter code. You can find this code on the back of the form.
  4. Enter the phone number, including the area code, to allow the Statewide Central Register (SCR) to contact your agency liaison if necessary.
  5. Under AGENCY ADDRESS AREA:
    • Write the full name of the agency without abbreviations in the designated space.
    • List the agency liaison's name. Remember, the liaison cannot be the applicant or a relative of the applicant.
    • Provide the complete agency address, including street, city, state, and zip code. Make sure the address matches the one associated with your RID/CCFS number.
  6. For the APPLICANT/HOUSEHOLD MEMBER AREA:
    • Write or type all names clearly, starting with the applicant’s last name, first name, and middle name. Use additional lines for maiden names, previous married names, or aliases.
    • List all household members, adults and children, indicating their relationship to the applicant, sex, and date of birth. If there are no other household members, write “NONE”.
  7. In the ADDRESS AREA, provide the current address and address history for the last 28 years for the applicant and household members (if required by the specific category). Include complete streets, cities, and states. For periods spent abroad or in military service, include countries or bases and dates of residence. Attach additional pages if more room is needed.
  8. In the SIGNATURE AREA, make sure the applicant and any required household members sign and date the form in the appropriate boxes. All signatures must match the names provided in the Applicant/Household Member Area.
  9. Mail the completed form to the Statewide Central Register at the address provided on the form.

Once the LDSS-3370 form has been accurately filled out and sent, the next step is to await feedback from the Statewide Central Register. They will process the information to determine if the individual(s) in question is the subject of an indicated report of child abuse or maltreatment. During this waiting period, it's essential to ensure all contact information provided is up-to-date to receive the SCR's response promptly. If additional information or clarification is needed, the SCR or your agency liaison will reach out using the contact details provided on the form.

Understanding Ldss 3370

What is the LDSS-3370 form used for?

The LDSS-3370 form is utilized for conducting a Statewide Central Register (SCR) Database Check. It's primarily designed to screen individuals applying for positions or roles that place them in close proximity with children, such as foster care, adoption, family and group family day care, among others. The purpose of the form is to identify any individuals who may have a history of child abuse or maltreatment.

Who needs to complete the LDSS-3370 form?

Individuals applying to become adoptive parents, foster parents, family or group family day care providers, and other specific roles that require a background check for child abuse or maltreatment must complete this form. Additionally, any household members over the age of 18 residing in the home of the applicant also need to fill out their portion of the LDSS-3370 form. Certain categories of employment that involve working with children may also require completion of this form.

What information do you need to provide on the LDSS-3370 form?

The form requires detailed information about the applicant, including current and past addresses for the last 28 years, full name (including any maiden names, previous married names, or aliases), date of birth, and sex. Household members, both adults and children, related or not to the applicant, should also be listed with their details. For specific categories like adoption or foster care, address history of household members above 18 years old is also needed.

How do you submit the completed LDSS-3370 form?

Once the LDSS-3370 form is filled out completely and accurately, it should be mailed to the Statewide Central Register (SCR) at P.O. BOX 4480, Albany, N.Y. 12204-0480. It is crucial to ensure that the form is legible and all sections are completed to avoid delays in the screening process. Incomplete or illegible forms will be returned for corrections.

Is there a fee associated with the LDSS-3370 form?

Yes, for certain categories, a $25.00 fee is required when submitting the LDSS-3370 form. This fee applies to prospective/new day care employees, group family day care assistants, and providers, among others. The payment should be made via a certified check, postal or bank money order, teller's check, cashier's check, or agency check made payable to "New York State Office of Children and Family Services". The check should include the applicant's name and the agency code.

What happens if information provided in the LDSS-3370 form is found to be false?

If an applicant knowingly provides false information on the LDSS-3370 form, such action could lead to denial or dismissal from employment, or denial or revocation of a license, certificate, permit, registration, or approval. It is imperative that all information provided is true and accurate to the best of the applicant's knowledge.

Where can one obtain the LDSS-3370 form or order additional supplies?

The LDSS-3370 form can be accessed and ordered through the New York State Office of Children and Family Services (OCFS) website. For direct access or to order a supply of LDSS-3370 forms, use the OCFS-4627 Request for Forms and Publications. These forms can also be obtained by contacting the automated forms hotline at 518-473-0971.

Common mistakes

Filling out the LDSS-3370 form can be challenging, and errors can lead to delays or inaccuracies in processing. One common mistake is not providing complete agency information, including the three-digit agency code, Resource ID (RID), or Child Care Facility System (CCFS) Number where required. This critical information aids in identifying the agency requesting the database check, and neglecting to include it can result in the form being returned for corrections.

Another frequent error involves the agency address area. Often, individuals forget to use the full name of their agency without abbreviations and fail to provide a detailed agency address, including the street number, city, and ZIP code. This can hinder the ability of the Statewide Central Register (SCR) to send out responses efficiently and directly to the agency involved.

Errors in the applicant/household member area are also common. Applicants sometimes list only the names of adults or neglect to include all household members, both adults and children, regardless of whether they are related to the applicant. This oversight can impact the accuracy of the SCR database check, as thorough checks depend on having complete information about all household members.

In the address history section, applicants often provide incomplete addresses or leave out periods of their address history, leading to gaps that can affect the comprehensiveness of the check. For certain categories like adoptions or foster care, it is essential to include address histories for all household members over 18 for the past 28 years, associating each address history with the correct individual to avoid confusion.

Many individuals make the mistake of using post office box numbers instead of physical street addresses. This practice is not acceptable for SCR checks, which require detailed, physical locations to accurately perform background screenings.

Another commonplace error is found in the signature area. Applicants and household members often sign with variations of their names that do not match the names listed in the applicant/household member area. This discrepancy can cause confusion and delay the processing of the check. Moreover, forgetting to date the signatures or dating them outside the acceptable window renders the form invalid.

Not attaching additional pages correctly when more space is needed for addresses or household member details is another oversight. It's critical to staple any additional pages to the LDSS-3370 form to ensure all information is processed together without loss or separation of details.

Applicants often overlook the payment requirement for certain categories. Failure to include the required fee with the LDSS-3370 form can result in processing delays. Each form submission accompanying a fee must include a separate check or payment method as specified in the instructions.

Lastly, legibility issues can hinder the processing of the form. Illegible handwriting or typographical errors can lead to inaccuracies in entering data into the SCR database, affecting the outcome of the background check. Ensuring all information is clear, readable, and accurate is crucial for the form’s proper completion and submission.

Documents used along the form

Completing the LDSS-3370 form for a Statewide Central Register Database Check is a vital step for various purposes, including adoption, foster care, and child care provision. However, this form is often not the only document required in these situations. Several other forms and documents typically accompany or complement the LDSS-3370 form, helping to provide a comprehensive view of an applicant's background and suitability for roles involving the care of children. Below is a list of these forms and documents, each briefly described:

  • OCFS-4627 Request for Forms and Publications: This form is used to order a supply of LDSS-3370 forms or any other necessary OCFS forms. It's essential for agencies needing to maintain a regular inventory of these forms.
  • LDSS-2221A Report of Suspected Child Abuse or Maltreatment: This form is used by mandated reporters to report suspected cases of child abuse or maltreatment. It might be reviewed in conjunction with the LDSS-3370 form during background checks.
  • OCFS-6004 Clearance for Foster Care or Adoption: This document is a clearance form required for all foster care and adoption applications, ensuring that the applicant does not have a history of child abuse or maltreatment.
  • OCFS-3909 Medical Statement of Foster/Adoptive Parent and All Household Members: This medical form provides a health history and current health status of potential foster or adoptive parents and any household members, crucial for ensuring a safe environment for children.
  • OCFS-4940 Staff Exclusion List Check: A form used to ensure that individuals seeking employment or involvement with child care do not appear on the Staff Exclusion List, making them ineligible to work with vulnerable populations.
  • SCR Submission Confirmation Receipt: This receipt confirms that an SCR Database Check (LDSS-3370) submission has been received and processed, important for record-keeping and follow-up.
  • OCFS-4930 Request for Information - Foster and Adoptive Placements: A form that allows for the exchange of information between authorized agencies during the foster or adoption process, ensuring the child's needs and history are fully understood by potential caregivers.
  • Consent to Background Check: This document has applicants authorize the release of their criminal history, sex offender registry, and other background information. It is crucial for comprehensive screening.
  • SSA-89 Authorization to Release Social Security Number (SSN) Verification: This form authorizes the verification of an applicant's SSN, an important step in identity and financial background checks.
  • Self-Disclosure Statement: Applicants may be asked to fill out a self-disclosure form, discussing their background, particularly any legal issues or involvement in child welfare investigations, to accompany the LDSS-3370 form.

Together with the LDSS-3370 form, these documents play a critical role in ensuring the safety and well-being of children in foster care, adoption scenarios, and child care settings. They allow for a thorough background check of all individuals in a household or involved in child care, providing a comprehensive understanding of their suitability for caregiving roles.

Similar forms

The LDSS-3370 form, designed for Statewide Central Register Database Checks in New York, shares similarities with several other forms utilized in different contexts, such as employment, licensing, and volunteer screening. One similar document is the I-9 Employment Eligibility Verification form, which employers in the United States use to verify the identity and employment authorization of individuals hired for employment. Both the LDSS-3370 and I-9 forms require personal and identification details, though the I-9 specifically focuses on work eligibility in the U.S.

Another analogous document is the application for a Child Development Associate (CDA) Credential. This form necessitates comprehensive personal information, background checks, and professional qualifications akin to the LDSS-3370, which mandates background checks for individuals in childcare positions. However, the CDA Credential application places more emphasis on educational and professional qualifications in early childhood education.

The Home Study Form for foster care or adoption is also akin to the LDSS-3370, especially in the context of providing information on all household members and detailing previous addresses. Both forms serve to screen individuals for suitability in a caregiving role, though the Home Study is more in-depth, assessing the home environment and the applicant's parenting capabilities.

Volunteer application forms for non-profit organizations, which may include a background check section, bear resemblance to the LDSS-3370 regarding the need for personal information, background checks, and references. These forms are tailored to ensure that volunteers are suitable for roles, especially when working with vulnerable populations, similar to the LDSS-3370’s focus on safeguarding children.

The National Instant Criminal Background Check System (NICS) form, used for firearm purchases, similarly gathers personal information and conducts a background check to ensure the purchaser is legally allowed to buy a firearm. While serving a different ultimate purpose, the focus on background checks connects it to the LDSS-3370's intent to protect child welfare.

Professional licensing applications for careers such as nursing, teaching, or real estate, which demand detailed personal information, history of residence, and background checks, show similarities to the LDSS-3370 form. These professions require individuals to be thoroughly vetted to maintain public safety and trust, akin to the childcare roles the LDSS-3370 addresses.

College application forms, particularly those requiring comprehensive personal histories, recommendations, and sometimes background information, share the aspect of gathering extensive applicant details with the LDSS-3370 form. However, college applications typically focus more on educational history and future potential rather than background checks.

The Federal Bureau of Investigation (FBI) background check form, which is required for certain employment positions and visa applications, is also similar to the LDSS-3370. This form conducts a thorough background investigation, including criminal history, which is required for specific roles that necessitate high security and trustworthiness.

Lastly, international visa applications often require detailed personal information, past residence histories, and background checks, resembling the process outlined in the LDSS-3370. These applications assess the eligibility and potential risks of individuals entering a country, focusing on security and legal compliance, much like the LDSS-3370’s aim to ensure the safety of children in care environments.

Dos and Don'ts

When completing the LDSS-3370 form, careful attention to detail ensures the process is smooth and efficient. The following guidelines highlight both what you should do and what you should avoid for a successful submission.

Things you should do:

  • Review all instructions: Before filling out the form, carefully read through the instructions to understand the requirements fully.
  • Print clearly or type: Ensure all information is easily readable to avoid errors during data entry.
  • Include all household members: All adults and children, whether related to the applicant or not, should be listed in the designated area of the form.
  • Provide complete address histories: For the required period, include full addresses without using abbreviations. Post Office Box numbers are not accepted.
  • Record the agency code and Resource ID (RID) correctly: Double-check these identifiers to ensure your form is processed without delays.
  • Sign and date the form where necessary: Ensure all required signatures are present and correspond with the names listed on the form. The date should not be more than 6 months old.
  • Attach additional pages if needed: If space is insufficient, securely staple extra pages to the form, ensuring they are clearly marked and organized.

Things you shouldn't do:

  • Use abbreviations for the agency name or addresses: Always use full names and addresses to prevent any confusion.
  • Leave sections blank: If a section does not apply, clearly mark it as "NONE" to indicate it was not overlooked.
  • Sign in the wrong box: Be attentive to where applicants and household members over 18 should sign, ensuring it matches the name listed.
  • Submit without reviewing: Double-check the form for completeness and legibility to avoid it being returned for corrections.
  • Include a PO Box for addresses: Complete street addresses are required for all listed periods and individuals.
  • Forget to include a fee if necessary: Check if your submission category requires a fee, and ensure the correct amount and form of payment are included.
  • Use another LDSS-3370 form for additional information: Instead of using another form, attach a clearly labeled additional page for any extra information.

Misconceptions

When it comes to filling out government forms, it’s easy to get tangled in a web of myths and misconceptions, especially with complex forms like the LDSS-3370. This form, crucial for conducting background checks for individuals involved in childcare, foster care, adoption, and other sensitive areas, has its share of misunderstood elements. Let’s demystify some of these myths:

  • Every household member must sign the form: This is not entirely accurate. While it’s true that the form requires information about all household members, only the applicant and any household member who is 18 or older are required to sign the form in categories related to adoption, foster care, and family or group family day care. For other categories, only the applicant’s signature is necessary.
  • Post Office Box numbers are acceptable for the address section: This is incorrect. The LDSS-3370 form explicitly requires complete street addresses, including street name and number, city, state, and zip code. P.O. Box numbers are not acceptable because the form is used to conduct thorough background checks, which necessitate a detailed address history.
  • The form is only for child-related services: While the LDSS-3370 form is primarily used for vetting individuals in childcare, foster care, adoption, and similar areas, it also applies to candidates for roles that may not directly involve children but occur in settings where children are present. Therefore, its use is not limited solely to child-related services.
  • A new form is needed for additional household members: Not necessarily. The form allows for the listing of all household members in the designated section. If more space is needed, an additional page can be attached — specifically noted as "STAPLE TO LDSS-3370 (IF NEEDED)" — rather than using an entirely new form.
  • It's okay if the form is not legible as long as the information is complete: Clarity is crucial. The instructions explicitly state that all information on the form must be easily read to ensure data entry and results are accurate. An illegible form may be returned for corrections, delaying the entire process.
  • Any mistake on the form can be easily corrected after submission: Once submitted, correcting information on the LDSS-3370 can be complicated. Ensuring the form is complete and accurate before submitting it is vital. Mistakes might lead to delays or even the need to resubmit the form, so reviewing it for completeness and legibility is essential.

Understanding the LDSS-3370 form is crucial for anyone involved in services that require background checks against the Statewide Central Register Database. Clearing up these misconceptions can streamline the process, ensuring that the necessary legal and administrative steps are handled efficiently and accurately.

Key takeaways

Completing the LDSS-3370 form accurately is crucial for ensuring a smooth processing of background checks by the Statewide Central Register (SCR). Here are four key takeaways to remember when preparing your submission:

  • Ensure all information is legible and complete. The LDSS-3370 form requires clear, complete information for accurate data entry and results. Incompleteness or illegibility can lead to the form being returned for corrections, delaying the entire process.
  • Correctly detail agency and applicant information. It's essential to use the specific codes, like the three-digit agency code and the Resource ID (RID), correctly. For daycare providers, the Child Care Facility System (CCFS) Number must be used. Additionally, all household members, both adults and children, whether related to the applicant or not, must be listed with their correct details, including full names, relationship to the applicant, sex, and date of birth.
  • Include comprehensive address histories. Depending on the category, you may need to provide detailed address histories for up to the past 28 years. This information is vital for Adoption, Foster Care, and Family and Group Family Day Care categories, where it's required for both the applicant and any household member over 18. Ensure no periods are unaccounted for and attach supplemental pages if more space is needed.
  • Signatures are mandatory and must be up to date. The form requires signatures from the applicant and, in certain categories, any household member aged 18 and older. These signatures must correspond with the names provided in the form and must not be older than six months. This is a crucial final step to affirm the accuracy and truthfulness of the information provided.

By paying close attention to these key aspects, individuals and agencies can avoid common pitfalls and expedite the SCR background check process. Remember, the goal of this process is to protect and ensure the safety of children, making the meticulous completion of the LDSS-3370 form both a responsibility and a priority.

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