Form Ocfs 4939 is a form that is used to report suspected child abuse or maltreatment in New York State. This form must be filled out and submitted to the local social services agency within 48 hours of suspecting that a child has been abused or maltreated. The purpose of this form is to provide social service agencies with information about potential abuse and allow them to begin an investigation into the matter. Failing to report suspected child abuse can result in criminal penalties, so it is important to understand when and how to fill out Form Ocfs 4939.
| Question | Answer |
|---|---|
| Form Name | Form Ocfs 4939 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | DEPARTMENTS, ocfs forms, 2010, sheriffs |
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
PROVIDER NOTIFICATION OF LICENSING OR REGISTRATION
TO FIRE AND POLICE OR SHERIFF DEPARTMENTS
As a child day care provider you are required to give written notification concerning the location of your day care program to your local fire and police departments. If your local municipality does not have a fire or police department, the sheriff must be notified instead. This must be done within in five (5) days after receiving your license or registration. Keep a copy of the completed notification in your files and document where and when you sent the notice. You may be asked to provide proof of notification during the course of inspection of your day care program. If you have 911 in your community, you may also want to inform them. If there is any change in any of this information the appropriate local fire, police or sheriff’s departments must be notified.
COMPLETE THIS FORM AND SEND IT TO
YOUR FIRE AND POLICE OR SHERIFF DEPARTMENTS
This form may be copied
NAME OF PROVIDER/PROGRAM:
ADDRESS:
CITY/TOWN:
ZIP CODE:
PHONE NUMBER (AREA CODE):
()
I am (check one)
Day Care Center
School Age Program
Group Family Day Care Home
Family Day Care Home
I am licensed or registered to provide day care to a maximum of |
|
children who range in age |
||||
from |
|
to |
|
years of age. |
|
|
I provide child day care on the following days and times, (check appropriate days and write in hours of care):
Monday…………. Hours
Tuesday………… Hours
Wednesday…….. Hours
Thursday……….. Hours
Friday…………… Hours
Saturday………… Hours
Sunday………….. Hours
AM PM
AM PM
AM PM
AM PM
AM PM
AM PM
AM PM
to
to
to
to
to
to
to
AM PM
AM PM
AM PM
AM PM
AM PM
AM PM
AM PM
ADDRESS OF FIRE DEPARTMENT NOTIFIED:
ADDRESS OF POLICE OR SHERIFF’S DEPARTMENT NOTIFIED:
PROVIDER’S SIGNATURE:
X
DATE:
Remember to retain a copy for your files.