LDSS-3370 (Rev. 04/2011)

Instructions for Completing the Statewide Central Register Database Check Form

LDSS-3370

- ALL information on the form must be easily read so that data entry and results are accurate. Each SCR Database Check 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.

THE PROPER WAY 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.)

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

- Clearance Category letter code (see back of Form LDSS-3370) 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, 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 in order 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, indicate NONE on the line below “Maiden/Alias”.

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

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

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

ADDRESS AREA:

The information required varies depending on the particular category:

- For Adoption, Foster Care and Family and Group Family Day Care (see back of form for categories), provide addresses for the applicant and any household member who is 18 and older. We need this information for the last 28 years. Attach supplemental pages if necessary, but do not use another LDSS-3370 form to list this additional information. Be sure to associate address histories with particular individuals (i.e., indicate which addresses are for which household members).

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

- Complete addresses are required. Include street name and city/town/village. Also include street number and apartment number. Post Office Box numbers are not acceptable. If the applicant has lived abroad, indicate country and dates of residence. If the applicant has spent time in the military, list base names and locations along with dates. 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 for this additional information.

SIGNATURE AREA:

Signatures required depend upon the particular category:

- For Adoption, Foster Care and Family and Group Family Day Care (see back of form for category), signatures are needed from the applicant and any household member who is 18 or older.

- 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 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/yy). The SCR will not accept a form with a signature date more than 6 months old.

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

MAIL YOUR COMPLETED LDSS-3370 FORM TO:

STATEWIDE CENTRAL REGISTER

P.O. BOX 4480

ALBANY, N.Y. 12204-0480

TO ORDER A SUPPLY OF LDSS-3370 FORMS:

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

Internet: http://www.ocfs.state.ny.us/main/forms/cps/ and mail the completed OCFS-4627 Request for Forms and Publications, to:

The Office of Children and Family Services, Resource Distribution Center, 11 fourth Ave, Rensselaer, NY 12144.

LDSS-3370 (Rev. 04/2011) 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 CODE:

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 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 form

FOR ALL CATEGORIES: Complete the following for yourself, your spouse, your children and any other person(s) in your home at the present time. MAKE SURE YOU COMPLETE ALL MAIDEN NAME/ALIAS SECTIONS THAT APPLY. IF NONE, STATE “NONE” List RELATIONSHIP in the fields below

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

NAME:

AGENCY LIAISON:
STREET ADDRESS:
CITY:	STATE:	ZIP CODE:
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 N.Y.S. 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

Relationship to

Applicant	LAST NAME	FIRST NAME	SEX

M/F	DATE OF BIRTH

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

CURRENT STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

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

APPLICANT’S SIGNATURE	DATE

EIGHTEEN YEARS OLD OR OVER:

I understand that as a person eighteen years of age or over in a home of an applicant to become an Adoptive or a Foster Parent or a Family or Group Family Day 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

SIGNATURE	DATE

LDSS-3370 (Rev. 04/2011) 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 eighteen years old and over 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 3-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 3 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 Resource ID (RID) number. (Contact your licensing agency/Regional Office if you have any questions).

RESOURCE I.D. (RID)

Record your RESOURCE I.D. (RID) in this field. OCFS, OMH, OMRDD, DOH, OASAS and SED licensed agencies and programs, and Local Departments of Social Services, have RID’S as of 9/01. Verify your RID with your licensing agency. If you need assistance, email: ocfs.sm.conn_app@ocfs.state.ny.us

CLEARANCE CATEGORIES

Record the appropriate category.

F - Prospective/new employee other than day care employees. (fee required - see below)*

D - Prospective employee (Local DSS district - bill against reimbursement)**

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

S - Provider of goods/services

Y - Applying to be a group family day care assistant. (fee required - see below)*

Q - Applying to be group family day care provider. (fee required - see below)*

Z - Prospective volunteer/consultant.

X - Applying to be adoptive parents pursuant to an application pending before the inquiring agency.

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

R - Applying to be kinship foster parents.

P - Applying to be family day care provider. (fee required - see below)*

N - Applying for a license to operate a day care center. (To be submitted by authorized licensing agency only.) (fee required - see below)*

M - Director of a summer camp, overnight camp, day camp or traveling day camp.

E - Current employee.

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

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 NO OTHER HOUSEHOLD MEMBERS, record NONE on line below MAIDEN/ALIAS.

*Social Service Law 424-a requires the collection of a $25.00 fee for certain categories. 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 also is to include the applicant's name and the agency code.

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

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

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

MAIL YOUR COMPLETED LDSS-3370 FORM TO:

STATEWIDE CENTRAL REGISTER

P.O. BOX 4480, Attention: Service Center Unit

ALBANY, N.Y. 12204-0480

TO ORDER A SUPPLY OF LDSS-3370 FORMS:

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

Internet: http://www.ocfs.state.ny.us/main/forms/cps/ and mail the completed OCFS-4627 Request for Forms and Publications, to:

The Office of Children and Family Services, Resource Distribution Center, 11 fourth Ave, Rensselaer, NY 12144. If you have difficulty accessing a form on either site, you can call the automated forms hotline at 518-473-0971.

LDSS-3370 (Rev. 04/2011)

STAPLE TO LDSS-3370 (IF NEEDED)

STATEWIDE CENTRAL REGISTER DATABASE CHECK FORM

ADDITIONAL PAGE

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

APPLICANT NAME:
Print clearly, All dates must be consecutive. Be sure to associate address histories with particular individuals
Previous Street Address	City	State	Zip	From	To

LDSS-3370 (Rev. 04/2011)

STAPLE TO LDSS-3370 (IF NEEDED)

STATEWIDE CENTRAL REGISTER DATABASE CHECK FORM

ADDITIONAL PAGE

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

APPLICANT NAME:
Other Household Members are (please print clearly):
SCR Use Only	Relationship To Applicant	Last Name	First Name	Sex	Date of Birth
M/F	M	D	Y

LDSS-3370

Statewide Central Register Database Check

LDSS-3370; Statewide Central Register; Database Check Form, SCR;

ax9740

2012-01-05

ABalander

SCR

Jackie Jensen

OCFS