LDSS-2221AReportofSuspectedChildAbuseorMaltreatment.doc

LDSS-2221A (Rev. 9/2007) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES REPORT OF SUSPECTED CHILD ABUSE OR MALTREATMENT Report Date Case ID Call ID Time : AM PM Local Case # Local Dist/Agency SUBJECTS OF REPORT List all children in household, adults responsible and alleged subjects. Line # Last Name First Name Aliases Sex (M, F, Unk) Birthday or Age Mo/Day/ Yr Race Code Ethnicity (Ck Only If Hispanic/Latino) Relation Code Role Code Lang. 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 Childs Drug/Alcohol Use Swelling/Dislocation/Sprains Fractures Poisoning/Noxious Substances Educational Neglect 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 Parents Drug/Alcohol Misuse Inappropriate Custodial Conduct (Institutional Abuse Only) Other (specify) State reasons for suspicion, including the nature and extent of each childs 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 Additional sheet attached with more explanation. The Mandated Rep