Mandated Reporter Form Ldss 2221A Details

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.

QuestionAnswer
Form NameForm Ldss 2221A
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names2221a, acs mandated reporter form, ecdss child protection report form, 2221a child abuse form

Form Preview Example

LDSS-2221A (Rev. 10/2008) FRONT

 

 

 

Report Date

 

Case ID

Call ID

 

 

 

NEW YORK STATE

 

 

 

 

 

 

 

 

 

 

 

 

OFFICE OF CHILDREN AND FAMILY SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Local Case #

Local Dist/Agency

 

 

 

REPORT OF SUSPECTED

 

 

 

Time

AM

 

 

CHILD ABUSE OR MALTREATMENT

 

 

:

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBJECTS OF REPORT

 

 

 

 

 

 

 

 

List all children in household, adults responsible and alleged subjects.

 

 

Sex

Birthday or Age

Race

Ethnicity

 

Relation

 

Role

Lang.

Line # Last Name

First Name

Aliases

 

(M, F, Unk)

Mo/Day/ Yr

Code

(Ck Only If Hispanic/Latino)

Code

 

Code

Code

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MORE

 

 

 

 

 

 

 

 

 

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".

 

 

DOA/Fatality

 

 

 

 

Child's Drug/Alcohol Use

 

 

Swelling/Dislocation/Sprains

 

 

Fractures

 

 

 

 

Poisoning/Noxious

 

 

 

 

Educational Neglect

 

 

 

 

 

 

 

Substances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internal Injuries (e.g., Subdural Hematoma)

 

 

 

 

Choking/Twisting/Shaking

 

 

Emotional Neglect

 

 

 

Lacerations/Bruises/Welts

 

 

 

 

Lack of Medical Care

 

 

Inadequate

Food/Clothing/Shelter

 

 

Burns/Scalding

 

 

 

 

Malnutrition/Failure to Thrive

 

 

Lack of Supervision

 

 

 

 

 

 

 

 

 

 

 

 

Excessive Corporal Punishment

 

 

 

 

Sexual Abuse

 

 

 

 

Abandonment

 

 

 

Inappropriate Isolation/Restraint (Institutional Abuse Only)

 

 

Inadequate Guardianship

 

 

Parent's Drug/Alcohol Misuse

 

 

Inappropriate Custodial Conduct (Institutional Abuse Only)

 

 

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State reasons for suspicion, including the nature and extent of each child's injuries, abuse or

 

(If known, give time/date of alleged incident)

 

maltreatment, past and present, and any evidence or suspicions of "Parental" behavior

MO

 

 

 

 

 

 

contributing to the problem.

 

 

 

 

 

 

DAY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

:

AM

PM

 

Additional sheet attached with more explanation.

 

The Mandated Reporter Requests Finding of Investigation

YES

NO

 

 

CONFIDENTIAL

SOURCE(S) OF REPORT

 

 

 

 

CONFIDENTIAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

(Area Code) TELEPHONE NAME

(Area Code) TELEPHONE

ADDRESS

ADDRESS

AGENCY/INSTITUTION

AGENCY/INSTITUTION

RELATIONSHIP

 

 

Med. Exam/Coroner

 

 

Physician

 

 

Hosp. Staff

 

 

Law Enforcement

 

 

Neighbor

 

Relative

 

 

Instit. Staff

 

 

Social Services

 

 

Public Health

 

Mental Health

 

School Staff

 

Other (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Use By

Medical Diagnosis on Child

 

 

 

Signature of Physician who examined/treated child

 

 

(Area Code) Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physicians

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Only

Hospitalization Required:

 

None

Under 1 week

 

1-2 weeks

 

Over 2 weeks

 

 

 

 

 

 

 

 

Actions Taken Or

 

 

Medical Exam

 

 

X-Ray

 

Removal/Keeping

Not. Med Exam/Coroner

 

About To Be Taken

 

 

Photographs

 

 

Hospitalization

 

Returning Home

Notified DA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Person Making This Report:

X

Title

Date Submitted

Mo. Day Yr.

LDSS-2221A (Rev. 10/2008) REVERSE

TO ACCESS A COPY OF THE LDSS-2221A FORM: Via Internet: http://www.ocfs.state.ny.us/main/forms/cps/ Via Intranet: http://ocfs.state.nyenet/admin/forms/SCR/ OR

TO ORDER A SUPPLY OF FORMS ACCESS FORM (OCFS-4627) Request for Forms and Publications, from either site above, fill it out and send to: Office of Children and Family Services, Resource Distribution Center, 11 Fourth Ave, Rensselaer, NY 12144.

If you have difficulty accessing this form from either site, you can call The Forms Hot Line at 518-473-0971. Leave a detailed message including your name, address, city, state, the form number you need, the quantity and a phone number in case we need to contact you.

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

 

RACE

 

 

ETHNICITY

 

 

RELATION CODES

 

 

ROLE

 

 

LANGUAGE

 

 

CODE

 

 

CODE

 

 

FAMILIAL REPORTS

 

 

CODE

 

 

 

CODE

 

 

 

 

 

 

 

 

(Choose One)

 

 

(Choose One)

 

 

 

 

 

 

 

 

(Choose One)

 

 

 

 

 

AA: Black or African-American

(Check Only If

AU: Aunt/Uncle

XX: Other

AB: Abused Child

CH: Chinese

KR: Korean

AL: Alaskan Native

Hispanic/ Latino)

CH: Child

PA: Parent

MA: Maltreated Child

CR: Creole

MU: Multiple

 

 

 

AS: Asian

 

 

 

GP: Grandparent

PS: Parent Substitute

AS: Alleged Subject

EN: English

PL: Polish

NA: Native American

 

 

 

FM: Other Family Member

UH: Unrelated Home Member

 

(Perpetrator)

FR: French

RS: Russian

PI: Native Hawaiian/Pacific Islander

 

 

 

FP: Foster Parent

UK: Unknown

NO: No Role

GR: German

SI: Sign

WH: White

 

 

 

DC: Daycare Provider

 

 

UK: Unknown

HI: Hindi

SP: Spanish

XX: Other

 

 

 

 

 

 

 

 

HW: Hebrew

VT: Vietnamese

 

 

 

 

IAB REPORTS ONLY

 

 

 

UNK: Unknown

 

 

 

 

AR: Administrator

IN: Instit. Non-Prof

 

 

 

IT: Italian

XX: Other

 

 

 

 

 

 

 

CW: Child Care Worker

IP: Instit. Pers/Vol.

 

 

 

JP: Japanese

 

 

 

 

 

 

 

 

 

DO: Director/Operator

PI: Psychiatric Staff

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 self-control of his actions; or

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 LDSS-2221A form originally signed to: the County Department of Social Services (DSS)

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: 1-800-635-1522 (FOR MANDATED REPORTERS ONLY)

1-800-342-3720 (FOR PUBLIC CALLERS)

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.

LDSS-2221A (Rev. 10/2008) ATTACHMENT

STAPLE TO LDSS-2221A (IF NEEDED)

REPORT OF SUSPECTED

CHILD ABUSE OR MALTREATMENT

(Use only if the space on the LDSS-2221A under “Reasons for Suspicion” is not enough to accommodate your information)

Report Date

Case ID

Call ID

 

 

 

 

Time

AM

Local Case #

Local Dist/Agency

 

 

 

 

 

: PM

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

YR

Time :

AM PM

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