In order to make an accurate and complete estate plan, it is important to know all the facts. One of the many documents you will need to create your plan is Form Ldss 2221A. This form is used to report information about the assets in your estate and the individuals who stand to inherit them. Knowing what this form is and how to complete it can help ensure that your plan is thorough and accurately reflects your wishes.
The table includes information about the form ldss 2221a. You'll have the likely time you'll need to fill in the form as well as further details.
Question | Answer |
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Form Name | Form Ldss 2221A |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | 2221a, acs mandated reporter form, ecdss child protection report form, 2221a child abuse form |
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Report Date |
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Case ID |
Call ID |
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NEW YORK STATE |
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OFFICE OF CHILDREN AND FAMILY SERVICES |
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Local Case # |
Local Dist/Agency |
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REPORT OF SUSPECTED |
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Time |
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CHILD ABUSE OR MALTREATMENT |
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SUBJECTS OF REPORT |
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List all children in household, adults responsible and alleged subjects. |
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Sex |
Birthday or Age |
Race |
Ethnicity |
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Relation |
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Role |
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Line # Last Name |
First Name |
Aliases |
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(M, F, Unk) |
Mo/Day/ Yr |
Code |
(Ck Only If Hispanic/Latino) |
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Code |
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MORE |
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List Addresses and Telephone Numbers (Using Line Numbers From Above)
(Area Code) Telephone No.
BASIS OF SUSPICIONS
Alleged suspicions of abuse or maltreatment. Give child(ren)'s line number(s). If all children, write "ALL".
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DOA/Fatality |
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Child's Drug/Alcohol Use |
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Swelling/Dislocation/Sprains |
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Fractures |
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Poisoning/Noxious |
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Educational Neglect |
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Substances |
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Internal Injuries (e.g., Subdural Hematoma) |
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Choking/Twisting/Shaking |
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Emotional Neglect |
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Lacerations/Bruises/Welts |
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Lack of Medical Care |
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Inadequate |
Food/Clothing/Shelter |
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Burns/Scalding |
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Malnutrition/Failure to Thrive |
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Lack of Supervision |
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Excessive Corporal Punishment |
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Sexual Abuse |
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Abandonment |
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Inappropriate Isolation/Restraint (Institutional Abuse Only) |
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Inadequate Guardianship |
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Parent's Drug/Alcohol Misuse |
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Inappropriate Custodial Conduct (Institutional Abuse Only) |
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Other (specify) |
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State reasons for suspicion, including the nature and extent of each child's injuries, abuse or |
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(If known, give time/date of alleged incident) |
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maltreatment, past and present, and any evidence or suspicions of "Parental" behavior |
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contributing to the problem. |
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YR |
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Time |
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PM |
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Additional sheet attached with more explanation. |
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The Mandated Reporter Requests Finding of Investigation |
YES |
NO |
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CONFIDENTIAL |
SOURCE(S) OF REPORT |
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CONFIDENTIAL |
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NAME
(Area Code) TELEPHONE NAME
(Area Code) TELEPHONE
ADDRESS
ADDRESS
AGENCY/INSTITUTION
AGENCY/INSTITUTION
RELATIONSHIP
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Med. Exam/Coroner |
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Physician |
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Hosp. Staff |
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Law Enforcement |
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Neighbor |
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Relative |
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Instit. Staff |
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Social Services |
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Public Health |
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Mental Health |
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School Staff |
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Other (Specify) |
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For Use By |
Medical Diagnosis on Child |
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Signature of Physician who examined/treated child |
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(Area Code) Telephone No. |
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Physicians |
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X |
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Only |
Hospitalization Required: |
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None |
Under 1 week |
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Over 2 weeks |
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Actions Taken Or |
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Medical Exam |
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Removal/Keeping |
Not. Med Exam/Coroner |
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About To Be Taken |
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Photographs |
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Hospitalization |
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Returning Home |
Notified DA |
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Signature of Person Making This Report:
X
Title
Date Submitted
Mo. Day Yr.
TO ACCESS A COPY OF THE
TO ORDER A SUPPLY OF FORMS ACCESS FORM
If you have difficulty accessing this form from either site, you can call The Forms Hot Line at
NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES
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RACE |
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ETHNICITY |
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RELATION CODES |
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ROLE |
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LANGUAGE |
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CODE |
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CODE |
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FAMILIAL REPORTS |
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CODE |
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CODE |
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(Choose One) |
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(Choose One) |
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(Choose One) |
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AA: Black or |
(Check Only If |
AU: Aunt/Uncle |
XX: Other |
AB: Abused Child |
CH: Chinese |
KR: Korean |
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AL: Alaskan Native |
Hispanic/ Latino) |
CH: Child |
PA: Parent |
MA: Maltreated Child |
CR: Creole |
MU: Multiple |
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AS: Asian |
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GP: Grandparent |
PS: Parent Substitute |
AS: Alleged Subject |
EN: English |
PL: Polish |
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NA: Native American |
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FM: Other Family Member |
UH: Unrelated Home Member |
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(Perpetrator) |
FR: French |
RS: Russian |
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PI: Native Hawaiian/Pacific Islander |
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FP: Foster Parent |
UK: Unknown |
NO: No Role |
GR: German |
SI: Sign |
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WH: White |
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DC: Daycare Provider |
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UK: Unknown |
HI: Hindi |
SP: Spanish |
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XX: Other |
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HW: Hebrew |
VT: Vietnamese |
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IAB REPORTS ONLY |
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UNK: Unknown |
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AR: Administrator |
IN: Instit. |
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IT: Italian |
XX: Other |
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CW: Child Care Worker |
IP: Instit. Pers/Vol. |
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JP: Japanese |
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DO: Director/Operator |
PI: Psychiatric Staff |
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Abstract of Sections from Article 6, Title 6, Social Services Law
Section 412. Definitions
1.Definition of Child Abuse, (see also N.Y.S. Family Court Act Section 1012(e))
An “abused child” is a child less than eighteen years of age whose parent or other person legally responsible for his care:
1)Inflicts or allows to be inflicted upon the child serious physical injury, or
2)Creates or allows to be created a substantial risk of physical injury, or
3)Commits sexual abuse against the child or allows sexual abuse to be committed.
2.Definition of Child Maltreatment, (see also N.Y.S. Family Court Act, Section 1012(f))
A “maltreated child” is a child under eighteen years of age whose physical, mental or emotional condition has been impaired or is in imminent danger of becoming impaired as a result of the failure of his parent or other person legally responsible for his care to exercise a minimum degree of care:
1)in supplying the child with adequate food, clothing, shelter, education, medical or surgical care, though financially able to do so or offered financial or other reasonable means to do so; or
2)in providing the child with proper supervision or guardianship; or
3)by unreasonably inflicting, or allowing to be inflicted, harm or a substantial risk thereof, including the infliction of excessive corporal punishment; or
4)by misusing a drug or drugs; or
5)by misusing alcoholic beverages to the extent that he loses
6)by any other acts of a similarly serious nature requiring the aid of the Family Court; or
7)By abandoning the child.
Section 415. Reporting Procedure. Reports of suspected child abuse or maltreatment shall be made immediately by telephone and in writing within 48 hours after such oral report.
Submit the written paper copy of the
where the abused/maltreated child resides. To locate your local DSS, visit this site http://www.ocfs.state.ny.us/main/localdss.asp.
Residential Institutional Abuse Reports: Submit a paper copy of form, LDSS 2221A, originally signed. It must be submitted directly to the Office of Children and Family Services (OCFS) Regional Office, associated with the county in which the abused/maltreated child is in care.
NYS CHILD ABUSE AND MALTREATMENT REGISTER:
Section 419. Immunity from Liability, Pursuant to Section 419 of the Social Services Law, any person, official, or institution participating in good faith in the making of a report of suspected child abuse or maltreatment, the taking of photographs, or the removal or keeping of a child pursuant to the relevant provisions of the Social Services Law shall have immunity from any liability, civil or criminal, that might otherwise result by reason of such actions. For the purpose of any proceeding, civil or criminal, the good faith of any such person, official, or institution required to report cases of child abuse or maltreatment shall be presumed, provided such person, official or institution was acting in discharge of their duties and within the scope of their employment, and that such liability did not result from the willful misconduct or gross negligence of such person, official or institution.
Section 420. Penalties for Failure to Report.
1.Any person, official, or institution required by this title to report a case of suspected child abuse or maltreatment who willfully fails to do so shall be guilty of a class A misdemeanor.
2.Any person, official, or institution required by this title to report a case of suspected child abuse or maltreatment who knowingly and willfully fails to do so shall be civilly liable for the damages proximately caused by such failure.
STAPLE TO
REPORT OF SUSPECTED
CHILD ABUSE OR MALTREATMENT
(Use only if the space on the
Report Date |
Case ID |
Call ID |
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Time |
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Local Case # |
Local Dist/Agency |
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PERSON MAKING
THIS REPORT:
Print clearly if filling out hard copy.
Continued: State reasons for suspicion, including the nature and extent of each child's injuries, abuse or maltreatment, past and present, and any evidence or suspicions of "Parental" behavior contributing to the problem.
(If known, give time/date of alleged incident)
MO
DAY
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Time : |
AM PM |