Homepage Blank Ldss 3370 PDF Template
Navigation

The LDSS-3370 form, revised in April 2011, is a crucial document for conducting checks against the Statewide Central Register Database, essential for individuals and agencies involved in child care, foster care, adoption, and similar sectors. This form is meticulously designed to ensure accurate data entry and results that significantly impact the safety and well-being of children. Its completion requires detailed personal and household information to identify any potential concerns regarding child abuse or maltreatment. Every section -- from agency information, including codes and contact details, to comprehensive applicant and household member data -- must be filled out with clarity and precision. Specific requirements for address history, extending back 28 years, vary by application type, underscoring the thorough nature of the screening process. Signatures, a testament to the veracity of the provided information, are mandatory and categorized by applicant type, with distinct stipulations for those involved in adoption, foster care, and day care services. Moreover, the form acts as a gateway for agencies to perform necessary background checks, with instructions and fees tailored to different applicant categories, emphasizing the form's role in safeguarding child welfare through meticulous screening processes.

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

Form Data

Fact Name Description
Form Title Instructions for Completing the Statewide Central Register Database Check Form LDSS-3370
Revision Date April 2011
Primary Use The form is used to request a check of the Statewide Central Register Database for child abuse or maltreatment records.
Key Sections Agency Information, Applicant/Household Member Information, Address History, Signature Area
Submission Address Statewide Central Register P.O. Box 4480, Albany, N.Y. 12204-0480
Form Availability Available online at the Office of Children and Family Services website and can be requested through the OCFS-4627 form.
Governing Law Section 424-a of the Social Services Law, requiring checks for applicants in specified childcare roles.

Instructions on Utilizing Ldss 3370

Filling out the LDSS-3370 form might seem daunting at first, but it is a straightforward process once you understand what each section requires. This form is crucial for conducting a Statewide Central Register Database Check, necessary for various applications related to childcare and family services. By following these steps carefully, you'll ensure that your form is complete and legible, helping to avoid any delays or issues with your submission.

  1. Gather all necessary information before you start, including full names, dates of birth, addresses for the past 28 years, and contact information for all household members.
  2. In the "AGENCY INFORMATION" section, enter your three-digit agency code in the top left-hand box. If applicable, follow it with the Resource I.D. (RID) in the next box. Daycare providers will use their Child Care Facility System (CCFS) Number instead of the RID.
  3. Fill in the Clearance Category letter code that applies to your situation in the middle box. This code is found on the back of the form.
  4. Include a phone number where you can be reached, ensuring the SCR can contact the agency liaison if necessary.
  5. Under "AGENCY ADDRESS AREA," ensure the agency name is written in full, no abbreviations. The agency liaison should be someone who can represent the agency but is not the applicant or a relative of the applicant. Include the complete address of the agency.
  6. In the "APPLICANT INFORMATION" section, list all household members, starting with the applicant. This includes adults and children, related or not. Write names clearly with the last name first, followed by the first and middle names.
  7. Fill out the section for maiden names, previous married names, or aliases for all applications where applicable. Use additional lines if there is more than one to list.
  8. Specify the relationship of each household member to the applicant in the first column, their sex in the M/F column, and complete dates of birth in the next.
  9. For the "ADDRESS AREA," provide complete address histories as required for your specific category. This includes street names, cities, and states for the last 28 years. Use supplemental pages if more space is needed, but do not use another LDSS-3370 form for this purpose.
  10. In the "SIGNATURE AREA," make sure the applicant and, if necessary, household members over 18, sign and date the form in the appropriate boxes. Ensure all signatures match the names provided in the Applicant/Household Member Area.
  11. Verify all information is complete and accurate before submitting the form to the Statewide Central Register at the address provided on the form.

After completing and submitting the LDSS-3370 form, the appropriate agency will process your application. This check is a vital step in ensuring the safety and wellbeing of children and families involved in various services. By providing complete and accurate information, you contribute to a smoother and faster processing time.

Obtain Answers on Ldss 3370

Welcome to the FAQ section for the LDSS-3370 form. This resource aims to provide answers to common questions about completing and submitting the Statewide Central Register Database Check Form (LDSS-3370). If you have further questions after reviewing this section, please don't hesitate to reach out to the appropriate contact for assistance.

  1. What is the LDSS-3370 form?

    The LDSS-3370 form is a document required by the New York State Office of Children and Family Services. It is used to perform a background check through the Statewide Central Register Database to identify any instances of child abuse or maltreatment reported against an individual or members of their household. This form is primarily used in contexts such as adoption, foster care, and employment or volunteering at child care facilities.

  2. Who needs to complete the LDSS-3370 form?

    Individuals applying for adoption, prospective or current foster care households, family and group family day care providers, certain employees, and volunteers associated with child care services need to complete this form.

  3. What information is required on the LDSS-3370 form?

    The form requires detailed personal information about the applicant and all household members, including minors. Required information includes full names (present and former), relationships to the applicant, sex, dates of birth, and comprehensive address history over the past 28 years.

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

    Yes, a fee of $25.00 is required for certain classifications of applicants, such as potential employees and care providers. This fee must be paid via a certified check, money order, or agency check made payable to "New York State Office of Children and Family Services."

  5. How do I submit the LDSS-3370 form?

    Once completed, the LDSS-3370 form should be mailed to the Statewide Central Register, P.O. Box 4480, Albany, NY 12204-0480.

  6. Can I submit the form electronically?

    No, currently the form needs to be mailed to the provided address along with any required fee.

  7. What if I make a mistake on the form?

    If a mistake is made, it is recommended to start over with a new form to ensure all information is legible and accurate. Incomplete or illegible forms will be returned to the sender for correction.

  8. Who can I contact if I have questions while filling out the form?

    If you have questions or require assistance, you can call the SCR at 518-474-5297 for guidance on properly completing the form.

  9. How long will it take to process the LDSS-3370 form?

    Processing times can vary. It is advisable to submit the form well in advance of any deadlines to accommodate any potential delays.

  10. How do I order more LDSS-3370 forms?

    To order more forms, you can access the (OCFS-4627) Request for Forms and Publications from the provided internet or intranet links and mail the completed request to the Office of Children and Family Services, Resource Distribution Center.

If your question was not answered in this FAQ, please review the instructions provided with the LDSS-3370 form or contact the SCR directly for more information.

Common mistakes

When completing the LDSS-3370 form, people often make several mistakes that could delay or complicate the process. These errors can be avoided by paying close attention to the instructions and ensuring that all information is complete and legible. Here are four common mistakes to watch out for:

  1. Leaving sections incomplete: Every section of the LDSS-3370 form needs to be filled out completely. Failure to do so will result in the form being returned for corrections. It's crucial to review each part and verify that no fields are left blank.
  2. Illegible handwriting: All information on the form must be easily read. If the form is filled out by hand, the handwriting must be clear and legible. Illegible forms can lead to inaccuracies in data entry and processing, causing delays.
  3. Incorrect or missing address history: For certain categories, such as Adoption, Foster Care, and Family and Group Family Day Care, a complete 28-year address history is required not only for the applicant but also for any household members 18 and older. It’s a common mistake to provide incomplete addresses or omit periods of residence. This includes failing to list all previous residences in detail, including street names, city, and state. Missing or incomplete address information can lead to an incomplete background check.
  4. Signature discrepancies: The names listed in the Applicant/Household Member Area must match the signatures. Differences between recorded names and signatures can cause confusion and require clarification. This discrepancy frequently occurs when nicknames or initials are used for signatures instead of the full legal names provided on the form.

To ensure the smooth processing of the LDSS-3370 form, applicants should double-check their entries for these common mistakes before submission. Completing the form accurately and legibly is essential for an efficient and successful background check process.

Documents used along the form

When working with the LDSS-3370 form, it's often necessary to complement it with additional documents and forms to ensure a comprehensive approach to the process it is part of. These additional documents often cater to different aspects of the application process, ranging from personal identification to further background checks. Understanding each document and its purpose can streamline the process, ensuring all necessary information is gathered efficiently.

  • OCFS-4627 Request for Forms and Publications: This is primarily used to order more supplies of the LDSS-3370 form or other related documents from the Office of Children and Family Services.
  • SSA-89 (Authorization for the Social Security Administration (SSA) To Release Social Security Number (SSN) Verification): Filed along with the LDSS-3370 to verify the SSN of the applicant with the SSA, ensuring the accuracy of their identification details.
  • DCFSA-1 (Day Care Facility System Application): For daycare providers, this application is necessary for registering with the Child Care Facility System, which might be referenced on the LDSS-3370 in certain contexts.
  • LDSS-2221A (Report of Suspected Child Abuse or Maltreatment): In the process of background checks, if there's suspicion of child abuse or maltreatment, this form is used to report those suspicions to the appropriate authorities.
  • OF-306 (Declaration for Federal Employment): Although a federal form, it might be required for positions that involve both federal oversight and state-level responsibilities, offering additional insight into the applicant’s eligibility.
  • SCR Request for Check of the Central Register of Child Abuse and Maltreatment (for Foster and Adoptive Parents): This is a specific check for those applying to be foster or adoptive parents, detailing if they have been involved in child abuse or maltreatment cases.
  • OCFS-3909 (Request for Information - Child Abuse and Maltreatment Registry): Similar to the LDSS-3370, this form is specifically focused on requests for information from the Child Abuse and Maltreatment Registry for background checking purposes.
  • OCFS-4930 (Staff Exclusion List Check Form): Required for individuals working with vulnerable populations to ensure they are not listed on the Staff Exclusion List, indicating they’ve been involved in abusive situations.
  • LDSS-3371 (Request for Clearance of Household Members in Foster and Adoptive Placements): Complements the LDSS-3370 by specifically requesting checks on all household members in foster and adoption situations.
  • OCFS-LDSS-7076 (Consent to Background Check): This form gives consent for a comprehensive background check, including criminal history, and is often used alongside the LDSS-3370 for thorough checks.

Efficiently navigating through the process involving the LDSS-3370 form and its complementary documents requires an understanding of the purpose and specific information each document provides. Whether for employment, foster care, adoption, or daycare provider certification, the collective information garnered from these forms ensures a safe and compliant environment for all parties involved.

Similar forms

  • The Employment Application Form is similar as it also collects personal details, employment history, and references to ensure candidates meet the criteria for the position they are applying for, similar to how the LDSS-3370 form screens candidates for their suitability in caregiving roles.

  • The Volunteer Application Form closely mirrors the LDSS-3370 in its collection of personal information, background, and references to screen individuals who wish to volunteer, especially in settings that involve vulnerable populations, ensuring they have no history of abusiveness or neglect.

  • Tenant Rental Application Forms are similar because they require comprehensive personal history, including previous addresses and financial information to assess the reliability and background of potential tenants, akin to how LDSS-3370 assesses the background of individuals in care settings.

  • The Foster Care Application shares similarities with the LDSS-3370, particularly in areas that scrutinize the backgrounds of potential foster parents and other household members to ensure the safety and wellbeing of foster children, demanding thorough personal and household member details.

  • Adoption Application Forms resemble the LDSS-3370 in that they gather detailed personal information, background checks, and family compositions to evaluate the suitability of prospective adoptive families, ensuring a safe and supportive environment for the child.

  • The Daycare Licensing Application is akin to the LDSS-3370 as both forms collect detailed information about the applicants and their households to ensure that children are entrusted to safe and capable providers, with a focus on the provider’s background and the living environment.

  • Background Check Authorization Forms for employment mimic the LDSS-3370 in their function to comprehensively screen an individual’s background for any history that may disqualify them from employment, prioritizing the safety and integrity of the workplace, similar to the safeguarding intentions of the LDSS-3370.

  • A Personal History Form for Licensing/Certification often required for professionals entering sensitive occupations, shares similarities with the LDSS-3370, as both entail detailed personal, educational, and professional histories to ensure the individuals meet stringent standards pertinent to their roles, particularly those involving care and trust.

Dos and Don'ts

When filling out the LDSS-3370 form, it’s important to approach the process with care and attention to detail. This document is used by the Statewide Central Register for background checks, which are critical for employment in child care, foster care, adoption, and other sensitive areas. To ensure smooth processing, here are several do’s and don’ts:

  • Do print clearly or type the information to avoid any misinterpretation of your details.
  • Do review every section of the form to confirm you’ve filled out all required information to prevent delays.
  • Do include complete address histories for the required period—28 years, to ensure thorough background checks.
  • Do list all household members, both adults and children, as their information is crucial for the comprehensive background check.
  • Do double-check the agency information section to ensure the three-digit agency code and other identifiers are correctly entered.
  • Do make sure that the name under which you sign matches the name provided in the applicant/household member area to avoid any confusion.
  • Do attach additional pages securely if more space is needed for address history, ensuring that it’s clear which individual each address history refers to.
  • Don’t use abbreviations for the agency name or addresses as this could lead to incorrect data entry.
  • Don’t leave any required fields incomplete, as this will result in the form being returned to you for corrections.
  • Don’t neglect to review the form for legibility—illegible forms will also be returned.
  • Don’t use PO Box numbers for addresses; full street addresses are required to process your background check properly.
  • Don’t sign the form if the signature date could be more than 6 months old by the time it reaches the SCR.
  • Don’t forget to provide detailed address histories for every individual as required, including providing complete dates of residence.
  • Don’t use another copy of the LDSS-3370 form for additional information—instead, attach a separate sheet.

By following these guidelines, you can ensure that your LDSS-3370 form is completed correctly and efficiently, supporting a smooth process for both the applicant and the reviewing agency.

Misconceptions

Understanding the LDSS-3370 form can sometimes be difficult, with various misconceptions floating around. It's important to set the record straight to ensure that this document is filled out correctly and efficiently.

Misconception 1: All household members need to sign the LDSS-3370 form.

This is incorrect. Only the applicant and, for certain categories such as Adoption, Foster Care, and Family and Group Family Day Care, household members who are 18 or over are required to sign the form. Other household members who are not applying do not need to sign.

Misconception 2: You need to list only current household members.

Actually, the form requires you to list all household members, including both adults and children, whether they are related to the applicant or not. This helps in getting an accurate database check from the Statewide Central Register.

Misconception 3: The form doesn’t need to be typed; handwriting is fine.

While it is acceptable to fill out the form in clear handwriting, typing the information ensures legibility, helping in processing the form more accurately and swiftly.

Misconception 4: You can use PO Box addresses for the address history.

Complete addresses are required on the LDSS-3370 form. PO Box addresses are not acceptable for this purpose. The form mandates detailed residential addresses, including street names and apartment numbers if applicable.

Misconception 5: Additional pages are not allowed if space runs out.

If you run out of space while filling the LDSS-3370, you're encouraged to attach additional pages. However, it's crucial to ensure that these pages are securely stapled to the main form and clearly identify the applicant's name and the associated address histories or household members.

Misconception 6: The LDSS-3370 form is only for child care providers.

Although child care providers must complete this form, it's also used for a variety of other purposes, including applications for foster care, adoption, and certain employment situations within agencies serving children. It's a comprehensive tool for background checks against the Statewide Central Register Database.

Misconception 7: Only New York State residents need to complete the LDSS-3370 form.

Anyone applying for roles or situations requiring a check against New York’s Statewide Central Register Database needs to complete the form, regardless of their current residence. This includes previous New York residents now living in other states or countries who are applying for positions or certifications within New York State.

  • Misconception 1 clarifies who needs to sign the form.
  • Misconception 2 highlights the requirement to list all household members.
  • Misconception 3 discusses the preference for typed information.
  • Misconception 4 explains the need for complete physical addresses.
  • Misconception 5 gives guidance on attaching additional pages if necessary.
  • Misconception 6 broadens the scope of the form's applicability beyond child care providers.
  • Misconception 7 addresses the geographical relevance of the form.

By understanding these key points, individuals and agencies can better navigate the process of completing the LDSS-3370 form, ensuring accurate and efficient processing.

Key takeaways

When completing the LDSS-3370 form, it's imperative to ensure all information is both complete and legible, helping to facilitate accurate data entry and results. This form is crucial for screenings related to various caregiving positions, such as daycare providers, and foster care or adoption applicants. Here are five key takeaways to keep in mind:

  • Every section of the form must be filled out with easily readable handwriting or typed to avoid delays and inaccuracies in processing.
  • Specifically, for agency information, the three-digit agency code and Resource ID (RID) or Child Care Facility System (CCFS) Number, where applicable, must be accurately entered. These codes are essential for identifying the submitting entity.
  • It's mandatory to list all household members, both adults and children, regardless of their relationship to the applicant, in the applicant/household member area. This comprehensive approach is designed to ensure a thorough background check.
  • For sections requiring address history, it's critical to provide complete addresses (including street name and number, city, and state) for the past 28 years, ensuring no gaps. Different categories may require varied levels of detail about address history.
  • Signatures are required from the applicant and, depending on the category (such as adoption, foster care, and family or group family day care), additional signatures may be needed from other adult household members. The form must be signed as per the instructions, aligning with the names provided in the applicant/household member area, and dated correctly to be considered valid.

It's also essential to note that a form with a signature date more than six months old will not be accepted. For any questions about the form or its completion, contacting the Statewide Central Register (SCR) is recommended. Mailing the completed form as directed ensures it reaches the appropriate office for processing. This form plays a critical role in the safety and well-being of children in care situations, making accurate and complete submissions paramount.

Please rate Blank Ldss 3370 PDF Template Form
4.87
Incredible
15 Votes