The LDSS 3370 form is the Statewide Central Register Database Check Form, essential for individuals seeking to work with children in various capacities, such as adoption or foster care. Completing this form accurately is crucial, as any missing or illegible information can lead to delays or rejections. Ensure you fill out the form carefully to facilitate a smooth process; start by clicking the button below to access it.
The LDSS-3370 form plays a crucial role in the process of conducting background checks through the Statewide Central Register (SCR) in New York. This form is primarily used by agencies seeking to verify the history of individuals applying for roles in child care, foster care, and adoption. It requires comprehensive information about both the applicant and all household members, ensuring that no detail is overlooked. Accurate completion is essential; every section must be legible and filled out correctly to avoid delays, as incomplete or illegible submissions will be returned for corrections. The form includes specific areas for agency identification, applicant details, and household member information, along with signature requirements that vary based on the category of clearance requested. Furthermore, it mandates a detailed address history for the last 28 years for applicants and relevant household members, emphasizing the importance of transparency in these sensitive processes. The instructions provided with the form guide users through each step, ensuring that all necessary information is submitted for a thorough review. Understanding the nuances of the LDSS-3370 form is vital for any agency or individual involved in child welfare services, as it lays the groundwork for safeguarding children and ensuring that those entrusted with their care meet the necessary standards.
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.
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.
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
M
F
APPLICANT MAIDEN/ALIAS/
MARRIED NAME
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
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:
/ /
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
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.)
F–Prospective/new employee other than day care employees.
P–Applying to be a family day care provider. (fee required - see
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.
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)
*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
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.
FROM
TO
(Mo/Yr)
Other Household Members are: (please print clearly):
SCR USE
RELATIONSHIP
ONLY
TO APPLICANT
Completing the LDSS-3370 form requires careful attention to detail to ensure that all information is accurate and legible. Once the form is filled out correctly, it will be submitted to the Statewide Central Register for processing. This step is crucial for moving forward with the necessary checks related to child care and family services.
What is the LDSS-3370 form?
The LDSS-3370 form is used for the Statewide Central Register Database Check. This form helps to gather information about applicants and household members who may be involved in child care, foster care, or adoption processes in New York State.
Who needs to complete the LDSS-3370 form?
All applicants for adoption, foster care, and family or group family day care must complete this form. Additionally, all household members, including children and adults, must be listed on the form, regardless of their relationship to the applicant.
How should I fill out the applicant information section?
In the applicant section, list all household members with their last name first, followed by their first and middle names. Include any maiden names or aliases on the designated lines. If there are no other household members, simply write "NONE" in the appropriate space.
What addresses do I need to provide?
For adoption, foster care, and family/group family day care, you need to provide your address history for the last 28 years for yourself and any household members over 18. For other categories, only the applicant's address history is required. Make sure to include complete addresses and avoid using P.O. Box numbers.
Are signatures required on the form?
Yes, signatures are necessary. For adoption, foster care, and family/group family day care, both the applicant and any household members over 18 must sign. For other categories, only the applicant's signature is needed. All signatures must match the names listed on the form and be dated.
What happens if the form is incomplete?
If the LDSS-3370 form is incomplete or illegible, it will be returned to the agency for corrections. To avoid delays, ensure all sections are filled out accurately and clearly.
Where do I send the completed form?
The completed LDSS-3370 form should be mailed to the Statewide Central Register at P.O. Box 4480, Albany, N.Y. 12204-0480. Make sure to double-check the address before sending it off.
How can I order more LDSS-3370 forms?
You can order additional forms by accessing the OCFS-4627 Request for Forms and Publications. This can be done via the Intranet or Internet. Complete the request and send it to the Office of Children and Family Services, Resource Distribution Center, at 11 Fourth Ave, Rensselaer, NY 12144.
What should I do if I have questions about the form?
If you have questions regarding how to complete the LDSS-3370 form, you can call the Statewide Central Register at 518-474-5297 for assistance.
When filling out the LDSS-3370 form, many individuals make common mistakes that can lead to delays or the return of their application. One frequent error is not providing complete information in the agency section. This includes failing to include the three-digit agency code or the Resource I.D. (RID). Each of these elements is essential for proper processing, and missing them can cause the form to be deemed incomplete.
Another mistake occurs in the applicant and household member area. Some people do not list all household members, including adults and children, regardless of their relationship to the applicant. It's important to ensure that every person living in the household is accounted for. Omitting a household member can result in an inaccurate response and further complications.
Legibility is crucial when completing the form. Many applicants write or type their information in a way that is difficult to read. This can lead to misunderstandings and errors in processing. Clear handwriting or typing can help ensure that all data is accurately entered into the system.
Another common oversight involves the signature area. Applicants sometimes forget to sign the form or provide a signature that does not match the name listed. Each signature must correspond with the name as recorded on the form. Additionally, dates must be included, and signatures that are older than six months will not be accepted.
Address history is also a frequent source of errors. Applicants may not provide complete addresses, including street numbers, names, and apartment numbers. Using Post Office Box numbers is not acceptable. Incomplete address histories can lead to further inquiries and delays in processing the application.
Finally, individuals often overlook the importance of reviewing the entire form before submission. Failing to double-check for completeness and accuracy can result in unnecessary returns and delays. Taking the time to review the form can help ensure that all required information is included and legible.
The LDSS-3370 form is a crucial document used in the process of conducting background checks for individuals involved in child care services, adoption, or foster care in New York State. Alongside this form, several other documents and forms are often required to ensure a comprehensive review of the applicant's background. Below is a list of these additional forms and documents, each serving a specific purpose in the application process.
These documents collectively play an essential role in the thorough evaluation of individuals seeking to work in child care settings. By ensuring that all required forms are completed accurately and submitted, agencies can maintain a safe environment for children and comply with legal requirements. Understanding the purpose of each document is vital for both applicants and agencies involved in this important process.
When filling out the LDSS-3370 form, attention to detail is crucial. Here’s a helpful list of what to do and what to avoid to ensure your form is processed smoothly.
Misconceptions about the LDSS-3370 form can lead to confusion and errors in the application process. Here are five common misconceptions, along with clarifications to ensure accurate submissions:
Key Takeaways for Filling Out and Using the LDSS-3370 Form