Forms LDSS

The list comprises forms that cover a wide range of services, including adoption agreements (LDSS-0570, LDSS-4623), medical evaluations (LDSS-0571, LDSS-3239), child care registrations (LDSS-0792), and fire safety inspections (LDSS-4388). The forms also include medication consent forms (LDSS-7002, LDSS-7003, LDSS-7004), health care plans (LDSS-7000, LDSS-7006), and personal allowance accounts (LDSS-2853, LDSS-2854, LDSS-2855).

Some of the forms are specific to certain programs or institutions. For instance, LDSS-4699 and LDSS-4700 are enrollment forms for legally exempt in-home and group child care programs, respectively. LDSS-2865 and LDSS-2865B are applications for approval of family type homes for adults, and LDSS-3123 is an incident report form for such homes.

Abbreviations are used throughout the list, reflecting the standard practice in social services. LDSS stands for Local Department of Social Services, which refers to the county-level agency responsible for administering social services in New York State. Other abbreviations used in the list include FTHA (Family Type Home for Adults), DARC (Division of Adult and Aging Services), DAS (Division of Administrative Services), and IV-E (Title IV-E of the Social Security Act), among others.

• LDSS-0570: Adoptive Placement Agreement is a legal agreement form that outlines the terms and conditions of placement in adoption for adoptive parents and social services agency.
• LDSS-0571: Medical Report of Prospective Adoptive Parent is a medical evaluation form filled by a licensed physician to assess the physical and mental health of prospective adoptive parents.
• LDSS-0792: Day Care Registration is a registration form used to enroll children in New York State day care programs.
• LDSS-0792A: Individual Allergy and Anaphylaxis Emergency Action Card is an emergency card filled out by parents or guardians of children enrolled in day care programs to provide important information about allergies and anaphylaxis.
• LDSS-0857: Application to Adopt - Part 1 Family Adoption Registry Information is an application form for the Family Adoption Registry that collects information on prospective adoptive parents.
• LDSS-2221A: Report of Suspected Child Abuse or Maltreatment is a mandatory form used to report suspected child abuse or maltreatment to the relevant authorities.
• LDSS-2853: Statement Offering Personal Allowance Account is a form used to establish a personal allowance account for residents of long-term care facilities.
• LDSS-2854: Personal Allowance Register is a form used to keep track of personal allowance funds for residents of long-term care facilities.
• LDSS-2855: Personal Allowance Summary is a summary sheet that provides an overview of personal allowance expenditures for residents of long-term care facilities.
• LDSS-2865: Application for Approval Family Type Home for Adults is a form used to apply for approval to operate a family-type home for adults.
• LDSS-2865B: FTHA Application Independent-Verification Check List is a checklist used to verify compliance with regulations for operating a family-type home for adults.
• LDSS-2949: Personal Data Sheet is a form used to collect personal information from individuals applying for social services.
• LDSS-2999: School District Notification of Foster Child Placed in a Foster Family, Agency Boarding, Or Group Home is a form used to notify school districts when foster children are placed in new living arrangements.
• LDSS-3026: Chronological Admission and Discharge Register is a log used to record admissions and discharges of residents in long-term care facilities.
• LDSS-3027: Inventory of Residents Property Held by Facility for Safe Keeping is a form used to document property held by long-term care facilities for safekeeping.
• LDSS-3123: Incident Report FTHA (DARC)(DAS) is a form used to report incidents that occur in family-type homes for adults.
• LDSS-3239: Medical Evaluation (Operator) is a medical evaluation form completed by a licensed physician for operators of child care programs.
• LDSS-3370: Statewide Central Register Database Check is a form used by authorized agencies to screen individuals for potential history of child abuse or neglect in New York State.
• LDSS-3370 - Statewide Central Register Database Check Form and Instructions for Completing the (DCCS Version) provides instructions for completing the LDSS-3370 form for screening individuals for potential history of child abuse or neglect in New York State.
• LDSS-3370a: Organizations Entitled to Conduct Database Checks Under Section 424-A of the Social Services Law is a list of organizations that are authorized to conduct database checks for potential history of child abuse or neglect in New York State.
• LDSS-3371A: Notification of Social Service Law 424-a Procedures is a form used to inform organizations of their requirements when conducting database checks for potential history of child abuse or neglect in New York State.
• LDSS-3371B: Notification of Social Service Law 424-a Procedures is a form used to inform organizations of their requirements when conducting database checks for potential history of child abuse or neglect in New York State.
• LDSS-3416: Religious Designation of a Child (Model Form) is a model form used to designate the religious preference of a child in the foster care system.
• LDSS-3424: School District Notification of Financial Responsibility for Educationally Handicapped Foster Child Placed in a Child Care Institution is a form used to notify school districts of their financial responsibility for educationally handicapped foster children placed in child care institutions.
• LDSS-3633: Individual Resident Fund Record Account is a form used to keep track of funds belonging to residents of long-term care facilities.
• LDSS-3634: Resident Medication Record is a form used to keep track of medications administered to residents of long-term care facilities.
• LDSS-3635: MEDICATION LOG is a log used to keep track of medications administered to residents of long-term care facilities.
• LDSS-3705: Special Needs Fund Individual Resident Log is a log used to keep track of special needs funds for individual residents of long-term care facilities.
• LDSS-3806: Notice to be Given Applicants for or Recipients of Services When Requesting Social Security Numbers is a form used to inform applicants and recipients of their rights when asked to provide their social security numbers.
• LDSS-4055: Residential Placement Assessment Form is a form used to assess the appropriateness of a residential placement for an individual.
• LDSS-4388: Fire Safety Inspection For Family Type Homes For Adults is a form used to conduct fire safety inspections in family-type homes for adults.
• LDSS-4438: Emergency Plan Child Day Care Centers, School Age Child Care Programs, and Legally Exempt Group Child Care Programs is a form used to develop emergency plans for child day care centers, school-age child care programs, and legally exempt group child care programs.
• LDSS-4439: Record of Evacuation Drills is a form used to record evacuation drills conducted at child day care centers, school-age child care programs, and legally exempt group child care programs.
• LDSS-4440: Schedule of Daily Program Activities-Child Care Programs is a form used to outline daily program activities at child care programs.
• LDSS-4443: Child Care Attendance Sheet is a form used to record attendance at child care programs.
• LDSS-4505: FTHA Family Type Home for Adults Certification of Child Support Obligations is a form used to certify that family type home operators are meeting their child support obligations.
• LDSS-4553: Child Care On Site Inspection Report is a form used to report on-site inspections of child care programs.
• LDSS-4623: Adoption Subsidy Agreement And Non-Recurring Adoption Expenses Agreement - Cover Sheet is a cover sheet for the Adoption Subsidy Agreement and Non-Recurring Adoption Expenses Agreement.
• LDSS-4623(G): Adoption Subsidy Agreement and Non-Recurring Adoption Expenses Agreement - Glossary provides definitions and explanations of terms used in the Adoption Subsidy Agreement and Non-Recurring Adoption Expenses Agreement.
• LDSS-4623A: Adoption Subsidy and Non-Recurring Adoption Expenses Agreement - Initial Application is an application form for adoptive parents to request adoption subsidy and non-recurring adoption expenses.
• LDSS-4623B: Adoption Subsidy and Non-Recurring Adoption Expenses Agreement - Post Finalization Application is an application form for adoptive parents to request adoption subsidy and non-recurring adoption expenses after finalization of the adoption.
• LDSS-4623C-1: Adoption Subsidy and Non-Recurring Adoption Expenses Agreement - Technical Amendment is a form used to make technical amendments to the Adoption Subsidy Agreement and Non-Recurring Adoption Expenses Agreement.
• LDSS-4623C-2: Adoption Subsidy and Non-Recurring Adotion Expenses Agreement - Upgrade or Substantive Amendment is a form used to make substantive amendments to the Adoption Subsidy Agreement and Non-Recurring Adoption Expenses Agreement.
• LDSS-4623D: Adoption Subsidy and Non-Recurring Adoption Expenses Agreement - Non-Recurring Adoption Expenses Reimbursement Form is a form used to request reimbursement for approved non-recurring adoption expenses.
• LDSS-4699: Enrollment Form for Provider of Legally Exempt In-Home Child Care and Legally Exempt Family Child Care is a form used by providers of legally exempt child care to enroll with the New York State Office of Children and Family Services.
• LDSS-4699a: Legally Exempt Program Enrollment Form Information and Instructions Guide provides information and instructions for completing the Enrollment Form for Provider of Legally Exempt In-Home Child Care and Legally Exempt Family Child Care.
• LDSS-4700: Enrollment Form for Legally Exempt Group Child Care Program is a form used by providers of legally exempt group child care programs to enroll with the New York State Office of Children and Family Services.
• LDSS-4700a: Instructions for Enrollment Form for Legally Exempt Group Child Care Program provides information and instructions for completing the Enrollment Form for Legally Exempt Group Child Care Program.
• LDSS-4702: Legally-Exempt Group Child Care Program with Enhanced Requirements is a form used by providers of legally-exempt group child care programs that meet enhanced requirements to enroll with the New York State Office of Children and Family Services.
• LDSS-4703: Health Care Plan Legally-Exempt Group Child Care Program is a form used by providers of legally-exempt group child care programs to submit a health care plan.
• LDSS-4783: Delinquent Family Share for Child Care Benefits is a form used by local social services districts to pursue delinquent family share payments for child care benefits.
• LDSS-4809: Initial Foster Child Eligibility Checklist is a form used to determine the eligibility of a child for placement in foster care.
• LDSS-4810: Re-determination of Title IV-E Eligibility Checklist (Foster Care) is a form used to re-determine the eligibility of a child for Title IV-E foster care funding.
• LDSS-7000: Health Care Plan for the Administration of Medication for Legally-Exempt Provider is a plan used by legally-exempt child care providers to administer medication to children in their care.
• LDSS-7002: Medication Consent Form (Child Day Care Programs) is a form used to obtain written consent from parents or guardians for child care programs to administer medication to their child.
• LDSS-7003: Verbal Medication Consent Form and Log of Administration is a form used to document verbal consent from parents or guardians for child care programs to administer medication to their child.
• LDSS-7004: Log of Medication Administration is a log used to document the administration of medication to children in child care programs.
• LDSS-7005: Medication Error Report Form is a form used to report errors made during the administration of medication to children in child care programs.
• LDSS-7005-S: Formulario de Informe de Error de Medicacion is the Spanish version of the Medication Error Report Form.
• LDSS-7006: Individual Health Care Plan for a Child with Special Health Care Needs is a plan used to address the specific health care needs of children with special health care needs in child care programs.
• LDSS-7014: FTHA Personal History of Applicant Family Type Home for Adults is a form used by applicants for family-type homes for adults to provide personal history information.
• LDSS-7015: Amendment to a Fully Executed and Approved Adoption Subsidy Agreement is a form used to amend an existing Adoption Subsidy Agreement.
• LDSS-7018: Notification of Foster Care Level of Care and Room and Board Payment is a form used to notify foster care providers of the level of care and room and board payments for the children in their care.
• LDSS-7031: Transmittal for Parent Locator Service Search is a form used by local social services districts to transmit information to the New York State Office of Temporary and Disability Assistance for parent locator service searches.
• LDSS-7040: Environmental Hazards Guidance Sheet is a form used by child care programs to identify potential environmental hazards and take appropriate action.

In conclusion, these forms play a crucial role in ensuring the smooth administration of social services and providing support to those in need. They assist in safeguarding the welfare of children, foster care residents, and adults with special needs. The forms also aid in tracking and monitoring individuals' progress, ensuring that they receive appropriate care and assistance to achieve their goals.