The LDSS-3370 form is a comprehensive document required by the Statewide Central Register Database Check to ensure the safety and well-being of children and vulnerable individuals in New York State. It meticulously gathers information about applicants and all household members for various screenings related to child care, foster care, and adoption services. Ensuring the form is completed accurately and legibly is crucial for processing and obtaining reliable results. For assistance in completing the form or to learn more about its requirements, click the button below.
Understanding the significance and correct completion of the LDSS-3370 form is essential for various entities and individuals engaged in services related to child welfare, including adoption, daycare, foster care, and others mandated by New York State regulations. This form serves a crucial role in the Statewide Central Register Database Check, aiming to ensure the safety and well-being of children. It requires detailed information about the applicant and all household members, emphasizing the necessity of accuracy and completeness for effective data entry and reliable outcomes. Specific guidance is provided for different sections such as agency information, applicant and household member details, address history, and the necessity for appropriate signatures depending on the category of application. Additionally, the instructions highlight the importance of legibility and completeness, as any errors or omissions can lead to the return of the form for corrections. With a correct understanding of how to fill out the form, including knowing the correct agency codes, providing comprehensive address histories for the last 28 years, and adhering to the signature guidelines, applicants can contribute to a speedy and successful processing of their application or employment approval processes, thereby supporting a system designed to protect children's welfare.
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.
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.
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
M
F
APPLICANT MAIDEN/ALIAS/
MARRIED NAME
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
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:
/ /
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
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.)
F–Prospective/new employee other than day care employees.
P–Applying to be a family day care provider. (fee required - see
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.
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)
*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
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.
FROM
TO
(Mo/Yr)
Other Household Members are: (please print clearly):
SCR USE
RELATIONSHIP
ONLY
TO APPLICANT
Filling out the LDSS-3370 form correctly is crucial for ensuring an efficient and timely process. This form is designed to facilitate certain types of background checks, and accuracy is key. Below are the steps to complete the form properly. By following these instructions, the process will be smoother for everyone involved.
Once the LDSS-3370 form is submitted, it will be processed accordingly. The information provided will be used to conduct a thorough background check as part of the screening process. Accuracy and completeness of the form play a crucial role in the speed and efficiency of the process.
The LDSS-3370 form is utilized to conduct a search in the New York Statewide Central Register Database. This search is necessary to identify if an individual, including household members, is the subject of an indicated report of child abuse or maltreatment. The form is commonly used in processes such as adoption, foster care, and for employees or volunteers in child care facilities.
The form must be completed by individuals applying to become adoptive or foster parents, child care providers, employees or volunteers working with children in various capacities, and those seeking to provide home-based child care. Additionally, all adult household members of the applicant need to sign the form if the application is for adoption, foster care, or family and group family day care.
Several pieces of information are necessary for the LDSS-3370 form, including:
Yes, a fee of $25.00 is required for processing the LDSS-3370 form for certain categories of applicants, such as those applying for licenses to operate child care facilities or to become child care providers. The payment must be in the form of a check or money order payable to the New York State Office of Children and Family Services.
The completed LDSS-3370 form, along with any necessary payment, should be mailed to the Statewide Central Register, P.O. Box 4480, Albany, NY 12204-0480.
Yes, if the space provided on the LDSS-3370 form is insufficient, additional pages may be attached. It's important to ensure that all information is clearly printed and that these pages are stapled to the main form.
For questions regarding the completion of the LDSS-3370 form or to order additional forms, you can call the SCR at 518-474-5297. To request more forms, access the (OCFS-4627) Request for Forms and Publications from the Office of Children and Family Services website or the automated forms hotline.
Filling out the LDSS-3370 form, an essential document for background checks in certain employment and volunteer situations, requires attention to detail and completeness. However, common mistakes can lead to processing delays or the return of the form for corrections. Here, we outline six frequent errors to avoid:
Attention to these details improves the accuracy and efficiency of the Statewide Central Register Database Check process, aiding in quicker turnaround times for clearances.
When processing the LDSS-3370 form, which is essential for conducting checks within the Statewide Central Register Database, several complementary documents and forms may be necessary to ensure a thorough and comprehensive process. These documents help in verifying the information provided, assessing the suitability of individuals for roles involving the care of children, and fulfilling legal and procedural obligations. They span a range of purposes, from identity verification to detailed historical checks.
Together, these forms and documents play a vital role in the comprehensive evaluation of individuals and households in contexts requiring scrutiny and vetting by the Statewide Central Register. Each document serves a unique purpose, contributing valuable information that supports informed decisions regarding child welfare and safety.
The LDSS-3370 form is intricately designed to screen individuals and household members to ensure child safety and welfare, a mission critical to various state and federal agencies. Its structure and intent closely mirror several other documents, each crucial in their respective fields of application. Here are six documents that share similarities with the LDSS-3370 form:
Each of these documents, while serving different sectors and purposes, embodies a unified commitment to ensuring the safety and well-being of children and vulnerable populations through comprehensive screening and information gathering.
When completing the LDSS-3370 form, accuracy and attention to detail are paramount. Here are some recommended dos and don'ts to help ensure your submission is accepted and processed without delay.
Following these guidelines will help ensure that your LDSS-3370 form is accurate and complete, thereby avoiding unnecessary delays or issues in processing your request.
When it comes to completing and understanding the LDSS-3370 form, there are several common misconceptions that can lead to confusion or mistakes. Here’s a look at six of these misunderstandings and the real facts behind them:
Understanding these key facts can help applicants accurately complete the LDSS-3370 form and streamline the process for both the applicants and the agencies reviewing the submissions.
When completing the LDSS-3370 form for a Statewide Central Register Database Check, it's critical to ensure accuracy and completeness for a smooth processing experience. Here are four key takeaways to guide you through filling out and using the form:
Adhering to these guidelines will help ensure the LDSS-3370 form is properly completed and submitted, facilitating a smoother and more efficient process for conducting the necessary database checks.
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