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|LDSS-2221A (Rev. 09/2016) FRONT |Report date |Case ID |Call ID |

|NEW YORK STATE |      |      |      |

|OFFICE OF CHILDREN AND FAMILY SERVICES | | | |

|REPORT OF SUSPECTED | | | |

|CHILD ABUSE OR MALTREATMENT | | | |

| |Time | AM |Local case # |Local dist./agency |

| |   :   |PM |      |      |

|SUBJECTS OF REPORT |

|List all children in household, adults responsible and alleged subjects. |Sex |Birthday or |Race |Ethnicity |Relation|Role |Lang. |

|Line # Last name First name |(m, f, |Age |code |(Ck only if |code |code |code |

|Aliases |unk) |mo/day/yr | |hispanic/latino) | | | |

| 1.       |      |

|      |      |

|      |      |

|BASIS OF SUSPICIONS |

|Alleged suspicions of abuse or maltreatment. Give child(ren)'s line number(s). If all children, write "ALL". |

|      | |DOA/fatality |      | |Poisoning/noxious substances |      | |Swelling/dislocation/sprains |

|      | |Fractures |      | | Choking/twisting/shaking |      | |Educational neglect |

|      | |Internal injuries (e.g., subdural hematoma) |      | |Lack of medical care |      | |Emotional neglect |

|      | |Lacerations/bruises/welts |      | |Malnutrition/failure to thrive |      | |Inadequate food/clothing/shelter |

|      | |Burns/scalding |      | |Sexual abuse |      | |Lack of supervision |

|      | |Excessive corporal punishment |      | |Inadequate guardianship |      | |Abandonment |

|      | |Child's drug/alcohol use |      | |Other (specify) |      |      | |Parent's drug/alcohol misuse |

| | | | | |      |

|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 contributing to |MO       |

|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 |

| |

|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 Notify medical examiner/coroner |

|About to be taken | Photographs Hospitalization Returning home Notified DA |

|Signature of Person Making This Report: |Title |Date Submitted |

|X |      |mo. day yr. |

| | |   /    /      |

LDSS-2221A (Rev. 09/2016) REVERSE

TO ACCESS A COPY OF THE LDSS-2221A FORM: Via Internet: http://ocfs.ny.gov/main/documents/forms_keyword.asp OR

TO ORDER A SUPPLY OF FORMS ACCESS FORM (OCFS-4627) Request for Forms and Publications, from the site above, fill it out and send to: THE OFFICE OF CHILDREN AND FAMILY SERVICES, FORMS AND PUBLICATIONS UNIT, 52 WASHINGTON ST. ROOM 134 NORTH, RENSSELAER, NY 12144-2834. If you have difficulty accessing this form from either site, you can call the Forms Order 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 |(Check Only If |AU: Aunt/Uncle |

|African-American|Hispanic/ Latino) | |

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

|maltreatment, past and present, and any evidence or suspicions of "Parental" behavior contributing to the problem. |MO       |

|      |DAY       |

| |YR       |

| |Time    :   AM PM |

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