Early Childhood Education Forms

2018 – 2019

Course Requirements

Employment Application

OCFS-6001 Volunteer Information

OFCS-6002 Statement of Qualifications

OFCS-6003 Reference List

OCFS-6005 Criminal Conviction Statement

LDSS-3370 Statewide Central Register

OCFS-4930 NYS Fingerprinting

Early Childhood Education

Course Requirements

1. Attendance Policy: All students are expected to be in attendance every day. Work that is missed can rarely be made up.

Each class is equivalent to 3 days of a regular class. If a student must be absent from BOCES, a phone call must be made

prior to class to one of the following extensions at 716-731-6800, ext. 4500 (early childhood classroom), or 4509

(attendance office). Please leave a voice mail message with your name, instructor and date of absence if you call after

school hours or there is no answer. Students are expected to bring in an excuse for days missed following the day of an

absence even if the absence was called in. Students are responsible for all lessons and assignments that are

missed due to absence.

2. Uniform and Appropriate Attire: The early childhood education required uniform consists of a navy blue cobbler

apron and name tag that is purchased in class ($27.00). Students must be prepared to wear their uniform on every

preschool day. Appropriate attire is required with the uniform as well as on all non-preschool days. Appropriate attire

includes a neat shirt with sleeves (no crop-tops or tank tops/camis), pants or jeans, and rubber-soled shoes (sneakers are

best). The following items are inappropriate for preschool – platform, chunky or open-toed shoes; shoes without backs

on them (no slip-ons); dangling or excessive jewelry; facial piercings, visible body piercings and/or tongue rings; visible

tattoos, hats, chains, baggy pants, shorts, pants with words on them, short skirts/dresses, etc.

3. Supplies and Program Costs: Students are responsible for replenishing and/or replacing supplies as they are used or

lost. All supplies should be labeled with student’s first and last name. Students MUST be prepared with all materials and

supplies each class day.

4. New York State Office of Child & Family Services Licensing Paperwork: The New York State Office of Child and

Family Services very closely regulates the rules and procedures for child care centers. For this reason, the Early

Childhood Education program must require the following items from all students before they will be able to work in the

day care: OCFS Clearance Form, fingerprints/criminal history check, job application and physical form (with results of

Mantoux tuberculin test). All items will be able to be completed at BOCES during regular class time with the exception

of the physical form. This must be completed by the student’s physician. Physical forms can be brought to school by

students or can be mailed directly to BOCES. Student WILL NOT be permitted to work with children until ALL

paperwork has been turned in!

5. Niagara Preschool Learning Center: Student will participate in the preschool on every day assigned to that student. The Niagara Preschool Learning Center operates Monday, Wednesday and Friday mornings 8:30 a.m. – 10:45 a.m. and

Tuesday and Thursday afternoons 12:25 p.m. – 2:35 p.m. Students work in cooperative groups and rotate through a

schedule that permits opportunities to teach preschool children, conduct observations, work with parents and families,

and prepare snack. It is the student’s responsibility to check the schedule for all practical assignments.

6. Confidentiality: Personal happenings about children and their families may be shared with students by the instructor,

preschool supervisor, day care director or preschool parents themselves. This information must remain in the classroom.

It is inappropriate and unprofessional to discuss specific children and their families outside of our learning environment.

7. Skills USA classroom competition: ALL students are required to participate in the early childhood education classroom

competition whether they are a member of SkillsUSA or not. Students are required to research an activity based on a

theme and center area of the preschool. They will then type a lesson plan, prepare the activity and conduct the lesson in

preschool with the preschool children.

8. Shadowing/Field Experience: Every student is required to complete 2 weeks of shadowing experience. To be eligible

for shadowing/field experience, students must meet the following basic minimum requirements:

Maintain an average of 80% or better

No disciplinary issues at BOCES and/or home school. This includes ALC, ISS, ISR, or suspension for any

reason.

All assignments completed including all preschool assignments, plan book, time sheets, observations, reflections.

Student is responsible for contacting and arranging field experience. This could be completed in an elementary

school classroom or NYS licensed child care center.

Student is responsible for their own transportation.

9. Field Trips: Every student is expected to attend ALL field trips that occur 1 – 3 times per year. Students who are failing

the current marking period or for the year to date will not be permitted to go on the field trip. Students with disciplinary

issues at BOCES and/or their home school will also not be permitted to attend the field trip. This includes ALC, ISS,

ISR, or suspension for any reason.

10. Professional Development: Early Childhood Education students are required to participate in several professional

development workshops, seminars or trainings regardless of previous training. These experiences are conducted either

online or by highly trained professionals and are the same trainings that actual teachers receive. Trainings may include,

but not limited to, “Disabilities Awareness Training,” “Identification and Reporting of Child Abuse for the Mandated

Reporter,” and “Red Cross Adult CPR/Infant & Child CPR and Standard First Aid” [note: there is a $27.00 charge for

the Red Cross training]. All students are required to have a personal email that they are able to access (free email is

available through google.com, yahoo.com, etc.) to register for the online training requirements.

11. Community Service: Early childhood education students are required to complete 10 hours of community service each

year in the program. Students may meet this requirement by volunteering at any of a variety of community-based

organizations and/or charities that benefit children and families. All community service must be approved by the

instructor prior to participation. Student must complete the necessary paperwork (community service form) and provide

documentation indicating completion of service and the number of hours obtained.

12. Behavioral Review: Exemplary behavior is expected of students in the Early Childhood Education program every day

and whether young children are present or not. As student teachers participating in a working preschool program and

shadowing/field experience in a licensed child care center or elementary school classroom as required by the course

requirements, any inappropriate behavior while at BOCES or outside of BOCES (at their home high school, in the

community, etc.) may be reviewed by the instructor and BOCES administration and placement in the early childhood

program may be terminated immediately as a result.

13. Professional Portfolio: Each student will develop a professional portfolio throughout their experiences in the early

childhood education class. This portfolio is a collection of student work, essays, professional article summaries,

observations, etc. Students begin developing their portfolios in September with the guidance of the instructor. The

professional portfolio will be graded two times each year: midterm exam grade and final exam grade.

14. Final Exam: The Early Childhood Education final exam consists of three (3) parts: practical portion (lesson in

preschool, professional portfolio, and 100-question, multiple choice written exam.

15. Articulation Agreements: Students who complete both ECE I – Introduction to Early Childhood Education and ECE II

– Advanced Early Childhood Education, maintain at least an 85% average, are not absent more than 15 days, and acquire

200 hours working with children are eligible for articulation agreements with the following colleges:

Niagara County Community College courses:

HUS 102 Human Services Internship I (3 credits)

HUS 103 Human Services Internship II (3 credits)

Erie County Community College courses:

CC 260 Creative Art Experiences for Young Children (3 credits) [upon successful completion of

CC 202, CC 203, and CC 250]

SUNY Cobleskill course:

ECHD 101 – Basics of Early Childhood (3 credits granted)

I have read and understand the Course Requirements for Early Childhood Education.

Student Signature: Date

Parent Signature: Date

1

Early Childhood Education

Employment Application

Applicant Information

Full Name: Date:

Last First M.I.

Address:

Street Address Apartment/Unit #

City State ZIP Code

Phone: Email

Are you a citizen of the United States? YES

NO

If no, are you authorized to work in the U.S.? YES

NO

Have you ever worked for this company? YES

NO

If yes, when?

Have you ever been convicted of a misdemeanor or felony? YES

NO

If yes, explain:

Education

High School: Address:

From: To: Did you graduate? YES

NO

Diploma::

College: Address:

From: To: Did you graduate? YES

NO

Degree:

Other: Address:

From: To: Did you graduate? YES

NO

Degree:

References

Please list two references.

Full Name: Relationship:

Company: Phone:

Address:

Full Name: Relationship:

Company: Phone:

Address:

2

Employment

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES

NO

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES

NO

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature: Date:

OCFS-6000 (Rev.7/2015)

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

STAFF, VOLUNTEER AND HOUSEHOLD MEMBER REQUIRED FORMS LIST CHILD DAY CARE PROGRAMS

Staff means all personnel, including directors, caregivers, and non-caregivers, temporary personnel, teachers, aides, para-professionals, cooks, custodians, administrative staff and all other person(s) employed by a child care program.

Volunteer means any unpaid person that is not a caregiver or staff who is present at the day care program for the purpose of assisting with the care of children or the operation of the child care program. A volunteer is not employed by the program and he or she may not be counted in the supervision ratio and may not be left unsupervised with children in care.

The following individual forms listed must be completed as noted in the chart below.

OCFS-6001 STAFF, VOLUNTEER, AND HOUSEHOLD MEMBER INFORMATION – All Modalities

OCFS-6002 QUALIFICATIONS – All Modalities

OCFS-6003 REFERENCES – All Modalities

OCFS-6004 STAFF, VOLUNTEER, AND HOUSEHOLD MEMBER MEDICAL STATEMENT – All Modalities

OCFS-6005 CRIMINAL CONVICTION STATEMENT – All Modalities

LDSS-3370 STATEWIDE CENTRAL REGISTER DATABASE CHECK FORM AND INSTRUCTIONS FOR COMPLETING THE -DCCS version

OCFS-4930 REQUEST FOR NYS FINGERPRINTING SERVICES *Staff with fingerprint images on file with OCFS may be eligible for a waiver. Contact the licensor/registrar or Director

of the program for more information.

OCFS-6022 STAFF EXCLUSION LIST CHECK

Requirement G/FDC and SDCC

Caregivers

G/FDC Household

Member 18 & Older

G/FDC Household

Member Under 18 Years Old

G/FDC and SDCC

Volunteer

DCC/SACC Staff

DCC/SACC Volunteer

OCFS-6001 X X X X X X

OCFS-6002 X X X

OCFS-6003 X X X

OCFS-6004 X X X X X

OCFS-6005 X X X X X

LDSS-3370 X X X X X

OCFS-4930 X X X X X

*Staff with fingerprint images on file with OCFS may be eligible for a waiver. Contact the licensor/registrar or Director of the program for more information.

OCFS-6022 X X X X X

OCFS- 6001 (7/2015)

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

STAFF, VOLUNTEER, AND HOUSEHOLD MEMBER INFORMATION CHILD DAY CARE PROGRAMS

INSTRUCTIONS:

Please PRINT clearly

If you are not sure which role to choose, refer to child day care regulations and/or consult with your licensor or registrar.

PROGRAM NAME:

FACILITY ID NUMBER:

PERSONS NAME:

DATE:

TYPE OF PROGRAM: Family Day Care, Group Family Day Care and Small Day Care Centers

Day Care Center and School-Age Child Care

All Programs

ROLE: Provider Substitute

Assistant

Household Member (GFDC/FDC)

Director

Group Teacher

Assistant Teacher

Volunteer

Employee

IDENTIFYING INFORMATION

MR.

MRS.

MS.

NAME (Last, First, MI):

ADDRESS:

APT:

FLOOR:

CITY:

STATE:

ZIP:

PHONE:

E-MAIL:

DATE OF BIRTH (mm/dd/yyyy):

/ /

OCFS- 6002 (7/2015)

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

QUALIFICATIONS CHILD DAY CARE PROGRAMS

PROGRAM NAME:

FACILITY ID NUMBER:

NAME OF PERSON WITH PENDING ROLE:

DATE OF BIRTH (mm/dd/yyyy):

The New York State Office of Children and Family Services (OCFS) child day care regulations identify qualifications and minimum requirements for caregiving staff in child day care programs. The information is included in section .13 of the Regulations. Regulations can be obtained at ocfs.ny.gov/main/childcare/default.asp and from your licensor/registrar.

INSTRUCTIONS:

Consult OCFS Regulations for qualification and minimum requirements for your role.

Complete sections that apply to your role in the program. You may attach a resume.

You may be asked to submit additional documentation to demonstrate education, training, or childcare experience.

Please PRINT clearly

TYPE OF PROGRAM: Family Day Care, Group Family Day Care and Small Day Care Centers

Day Care Center and School-Age Child Care

ROLE IN PROGRAM Provider

Assistant

Substitute

Director

Group Teacher

Assistant Teacher

Education/Training (if applicable for pending role)

Date Range Degree, Major, Name of Credential, or Training

Institution Number of Credits (if applicable)

Child Care Experience

Date Range Description Location Age of Children

Supervisory Experience (applicable for pending role of Director at Day Care Center/School-Age Child Care Program)

Date Range Description Location

OCFS- 6003 (7/2015)

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

REFERENCES CHILD DAY CARE PROGRAM

INSTRUCTIONS: Please provide complete information for three people we can contact as references Relatives may NOT be used as references If you have been employed outside the home, please include an employer as one of your references Please PRINT clearly PROGRAM NAME:

FACILITY ID NUMBER:

NAME:

TYPE OF PROGRAM Family Day Care, Group Family Day Care and Small Day Care Centers

Day Care Center and School-Age Child Care

ROLE IN PROGRAM Provider

Assistant

Substitute

Director

Teacher

Volunteer

REFERENCE #1 Please check appropriate reference type: Personal Employment

MR. MRS. MS.

NAME (Last, First, MI):

BUSINESS NAME:

APT:

FLOOR:

ADDRESS:

CITY:

STATE:

ZIP:

DAYTIME PHONE:

( )

E-MAIL:

Does reference speak English? Yes No If NO, please specify language spoken:

REFERENCE #2 Please check appropriate reference type: Personal Employment

MR. MRS. MS.

NAME (Last, First, MI):

BUSINESS NAME:

APT:

FLOOR:

ADDRESS:

CITY:

STATE:

ZIP:

DAYTIME PHONE:

( )

E-MAIL:

Does reference speak English? Yes No If NO, please specify language spoken:

REFERENCE #3 Please check appropriate reference type: Personal Employment

MR. MRS. MS. NAME (Last, First, MI):

BUSINESS NAME:

APT:

FLOOR:

ADDRESS:

CITY:

STATE:

ZIP:

DAYTIME PHONE:

( )

E-MAIL:

Does reference speak English? Yes No If NO, please specify language spoken:

OCFS- 6005 (7/2015) FRONT

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

CRIMINAL CONVICTION STATEMENT CHILD DAY CARE PROGRAMS

INSTRUCTIONS:

ALL people with the roles below must complete and sign this Criminal Conviction Statement regardless of conviction status

This form is in addition to being fingerprinted Please PRINT clearly PROGRAM NAME:

FACILITY ID NUMBER:

PERSON'S NAME:

DATE OF BIRTH (mm/dd/yyyy):

TYPE OF PROGRAM Family Day Care, Group Family Day Care and Small Day Care Centers

Day Care Center and School-Age Child Care

All Programs

ROLE Provider Substitute

Assistant

Household Member (GFDC/FDC) (over 18)

Director

Group Teacher

Assistant Teacher

Volunteer

Employee

CONVICTION STATEMENT

Have you previously completed a Conviction Statement?

NO, this is the first conviction statement I am signing for child day care.

YES, I have signed a previous conviction statement for child day care and…

All of the following convictions (if any) were previously reported OR

I have added new convictions since the last statement.

CERTIFICATION

In accordance with Section 390-b(1)(b) of the Social Services Law, I certify that to the best of my knowledge and belief:

I HAVE I HAVE NOT been convicted of a crime in New York State or other State or Federal court.

(A crime is a misdemeanor or felony only; this does not include violations. You do not need to disclose crimes that the court designated with a "Youthful Offender" status.)

RECORD OF ALL CONVICTIONS

EXAMPLE: Type of Crime Penal Code Section Date of

Conviction County or Court of

Arraignment Petit Larceny 155.25 5/1/2013 Albany

Complete the information below and submit with record of conviction or certification of court arraignment. In addition, you may provide written justification on the back of this sheet, explaining why you should be allowed to care for children regardless of any conviction.

Type of Crime Penal Code Section (if known)

Date of Conviction (mm/dd/yyyy)

County or Court of Arraignment

To the best of my knowledge the information provided above is true and accurate. I understand that my failure to truthfully and accurately state whether I have been convicted of a crime and/or to provide truthful and accurate information concerning the conviction(s) may constitute grounds for dismissal or denial of employment, or suspension, limitation or revocation of the license or registration to provide child care at this site.

SIGNATURE: DATE: (mm/dd/yyyy):

(continued on reverse side)

OCFS- 6005 (7/2015) REVERSE

PROGRAM NAME:

FACILITY ID NUMBER:

PERSON'S NAME:

DATE OF BIRTH (mm/dd/yyyy):

CRIMINAL CONVICTION STATEMENT (continued)

Please provide your justification below, explaining why you should be allowed a role to care for children despite your conviction history. You may attach your own sheets if you prefer not to use this page.

LDSS-3370 (Rev. 10/2014)-DCCS version

Instructions for Completing the Statewide Central Register Database Check Form

LDSS-3370

- ALL information on the form must be easily read so that data entry and results are accurate. Each SCR Database Check 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.

THE PROPER WAY 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.)

- Daycare providers must place their Child Care Facility System (CCFS) Number in the box next to Resource ID (RID), in lieu of Resource ID number. (Contact your licensing agency/Regional Office if you have any questions).

- Clearance Category letter code (see back of Form LDSS-3370) 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, 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 in order 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, indicate NONE on the line below “Maiden/Alias”.

- First column: indicate the relationship to the applicant of each person listed. (Spouse, son, daughter, mother, father, friend, etc.)

- Sex M/F column: fill in either M (Male) or F (Female) for every person listed.

- Date of Birth column: fill in complete date of birth (mm/dd/yy) for everyone listed on the form.

ADDRESS AREA:

The information required varies depending on the particular category:

- For Adoption, Foster Care and Family and Group Family Day Care (see back of form for categories), provide addresses for the applicant and any household member who is 18 and older. We need this information for the last 28 years. Attach supplemental pages if necessary, but do not use another LDSS-3370 form to list this additional information. Be sure to associate address histories with particular individuals (i.e., indicate which addresses are for which household members).

- For all other categories, only the applicant’s address history is required – for the last 28 years. - Complete addresses are required. Include street name and city/town/village. Also include street number and apartment number. Post Office Box numbers are not acceptable. If the applicant has lived abroad, indicate country and dates of residence. If the applicant has spent time in the military, list base names and locations along with dates. 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 for this additional information.

SIGNATURE AREA:

Signatures required depend upon the particular category:

- For Adoption, Foster Care and Family and Group Family Day Care (see back of form for category), signatures are needed from the applicant and any household member who is 18 or older.

- 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 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/yy). The SCR will not accept a form with a signature date more than 6 months old.

If you have questions regarding proper completion of this form, please call the SCR at 518-474-5297.

SUBMIT YOUR COMPLETED LDSS-3370 FORM TO YOUR LICENSOR OR REGISTRAR

BE SURE TO INCLUDE THE REQUIRED FEE

TO ORDER A SUPPLY OF LDSS-3370 FORMS:

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 OFFICE OF CHILDREN AND FAMILY SERVICES, RESOURCE DISTRIBUTION CENTER, 11 FOURTH AVE, RENSSELAER, NY 12144.

LDSS-3370 (Rev. 10/2014)-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 CODE:

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 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 form

FOR ALL CATEGORIES: Complete the following for yourself, your spouse, your children and any other person(s) in your home at the present time. MAKE SURE YOU COMPLETE ALL MAIDEN NAME/ALIAS SECTIONS THAT APPLY. IF NONE, STATE “NONE” List RELATIONSHIP in the fields below

(see reverse side for instructions) Attach additional page if necessary.

AGENCY NAME:

AGENCY LIAISON:

STREET ADDRESS:

CITY: STATE: ZIP CODE:

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 N.Y.S. 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.

APPLICANT/HOUSEHOLD MEMBER AREA *PLEASE TYPE OR PRINT CLEARLY

RELATIONSHIP TO APPLICANT

LAST NAME FIRST NAME SEX M/F

DATE OF BIRTH

APPLICANT

MAIDEN/ALIAS

Please provide your current address and any other addresses at which you have resided for the last 28 years, including street, city and state. For Adoption, Foster Care, Family and Group Family Day Care, also include the same address history for household members 18 of age and older.

CURRENT STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

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

APPLICANT’S SIGNATURE DATE

EIGHTEEN YEARS OLD OR OVER:

I understand that as a person eighteen years of age or over in a home of an applicant to become an Adoptive or a Foster Parent or a Family or Group Family Day 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 DATE

SIGNATURE DATE

LDSS-3370 (Rev. 10/2014)-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 eighteen years old and over 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 3-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 3 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

Resource ID (RID) number. (Contact your licensing agency/Regional Office if you have any questions).

RESOURCE I.D. (RID)-Record your RESOURCE I.D. (RID) in this field. OCFS, OMH, OMRDD, DOH, OASAS and SED licensed agencies

and programs, and Local Departments of Social Services, have RID’S as of 9/01. Verify your RID with your licensing agency. If you need assistance, email: ocfs.sm.conn_app@ocfs.ny.gov

CLEARANCE CATEGORIES - Record the appropriate category.

A – Adult Services/Family Type Home for Adults Q - Applying to be group family day care provider. (fee required see below)*

D - Prospective employee (Local DSS district - bill against reimbursement)**

R - Applying to be kinship foster parents.

E - Current employee. S - Provider of goods/services

F - Prospective/new employee other than day care employees.

(fee required - see below)*

U - Universal Pre-K Teacher (fee required – see below)*

J - Over 18 Household member (with no child care role) W - Applying to be foster parents or family care home providers.

M - Director of a summer camp, overnight camp, day camp or

traveling day camp.

X - Applying to be adoptive parents pursuant to an application

pending before the inquiring agency.

N - Applying for a license to operate a day care center. (To be

submitted by authorized licensing agency only.) (fee required - see below)*

Y - Prospective Day Care employee (fee required - see below)*

- Applying to be a Group Family Day Care Assistant. (fee required see below)*

P - Applying to be family day care provider. (fee required - see below)*

Z - Prospective volunteer/consultant.

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) (at least one person must be so designated)-USE FIRST LINE

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)

IF NO OTHER HOUSEHOLD MEMBERS, record NONE on line below MAIDEN/ALIAS.

*Social Service Law 424-a requires the collection of a $25.00 fee for certain categories. 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 also is to include the applicant's name and the agency code. N.B.: a separate check must accompany each form.

**Social Service 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 LDSS-3370 FORM TO YOUR LICENSOR OR REGISTRAR BE SURE TO INCLUDE THE REQUIRED FEE

TO ORDER A SUPPLY OF LDSS-3370 FORMS:

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 OFFICE OF CHILDREN AND FAMILY SERVICES, RESOURCE DISTRIBUTION CENTER, 11 FOURTH AVE, RENSSELAER, NY 12144.

If you have difficulty accessing a form on either site, you can call the automated Forms Request Line at 518-473-0971.

OCFS-4930 (08/2014)

NEW YORK STATE OFFICE OF CHILDREN & FAMILY SERVICES

REQUEST FOR NYS FINGERPRINTING SERVICES Information Form

(To be completed by Provider or Foster Care/Adoption Agency)

Enrollment Information:

Applicant must have an appointment to be fingerprinted. At appointment, applicant will need to bring this form and acceptable ID as noted on reverse.

Appointments can be obtained by contacting vendor at one of the following:

Website: www.Identogo.com or the Call Center: 877-472-6915

Contributor Agency Section:

ORI: NY922130Z Contributor

Agency:

NYS Office of Children & Family Services

Job or License Type: Child Day Care Foster Care/Adoption Mentor

OCFS Employee (employee / peace officer – please circle one)

Facility/Agency ID Number: Additional Agency ID Info: N/A

(FOSTER CARE/ADOPTION ONLY)

Facility Name/Address:

Applicant Section: New Submission Resubmission

Name of Applicant:

Alias / Maiden Name:

Street Address:

City, State, & Zip:

Date of Birth: Sex: Male Female Other Ethnicity: Hispanic Non Hispanic

Race: White Black American Indian/Alaskan Native Asian/Pacific Islander

Other Unknown

Skin Tone: Eye Color: Hair Color:

Height: ft in Weight: lbs.

State / Country of Birth:

Role of Applicant (please check one):

CHILD DAY CARE: Director (D) Provider (F) Employee/Teacher/Volunteer (T) Household Member over the age of 18

FOSTER CARE: Foster Parent (FP) Relative Foster Parent (RFP) Foster Child (FC)

Household Member of a Foster Parent over the age of 18 (FHM)

Household Member of a Relative Foster Parent over the age of 18 (RHM)

ADOPTION: Adoptive Parent (AP) Household Member of an Adoptive Parent over the age of 18 (AHM)

Additional Information: (Foster Care Only)

CONNECTIONS Home Resource ID# N/A

CONNECTIONS Person ID# N/A

OCFS-4930 (08/2014)

Accepted Forms of Identification:

NOTE: Applicant MUST present two (2) forms of ID, at least one of which must have a photo (see Column A):

Column A - Valid Photo Identification:

U.S. Passport (unexpired or expired)

Permanent Resident Card

Alien Registration Receipt Card

Unexpired Foreign Passport

Driver’s License or Photo ID Card (issued by U.S. State or Territory)

School or College ID Card (with photo)

Unexpired Employment Authorization with photo (Form I-766, I-688, I-688A or B)

Photo ID Card issued by federal, state, or local govt.

Column B - Valid Supplementary Identification:

Voter registration card

U.S. Military card or draft record

Military dependent’s ID card

Coast Guard Merchant Mariner Card

Native American Tribal Document

Canadian Driver’s License

U.S. Social Security Card

Original or certified copy of a Birth Certificate issued by authorized U.S. agency with official seal

Certification of Birth Abroad (issued by U.S. Department of State)

U.S. Citizen ID Card (Form I-7)

Identification if under 18 and nothing else available:

School record or report card

Clinic, doctor, or hospital record

Hard-to-print applicants and household members over the age of 18 who suffer disabling conditions that prevent them from leaving the home may need to be printed in the traditional format of ink-and-rolled prints. Those fingerprints should be accompanied by a completed OCFS-4930 Request for NYS Fingerprinting Services Form and forwarded to MorphoTrust USA at the following address:

MorphoTrust USA

Card Scan Department

3051 Hollis Drive, Suite 310

Springfield, IL 62704

Enrollment Website address: www.Identogo.com

Call Center phone number: 877-472-6915