Dss-2221a Report Of Suspected Child Abuse Or Maltreatment Form
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1
2
3Report Date
Case ID
Call ID
LDSS-2221A (Rev. 10/2008) FRONT
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
AM Local Case #
Local Dist/Agency
REPORT OF SUSPECTED
Time
PM
CHILD ABUSE OR MALTREATMENT
:
SUBJECTS OF REPORT
Sex
Birthday or Age
Race
Ethnicity
List all children in household, adults responsible and alleged subjects.
Relation
Role
Lang.
(M, F, Unk)
Mo/Day/ Yr
Code
(Ck Only If Hispanic/Latino)
Line #
Last Name
First Name
Aliases
Code
Code
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
Child's Drug/Alcohol Use
Swelling/Dislocation/Sprains
Poisoning/Noxious
Fractures
Educational Neglect
Substances
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
Parent's Drug/Alcohol Misuse
Inappropriate Custodial Conduct (Institutional Abuse Only)
Other (specify)
(If known, give time/date of alleged incident)
State reasons for suspicion, including the nature and extent of each child's injuries, abuse or
maltreatment, past and present, and any evidence or suspicions of "Parental" behavior
MO
contributing to 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
M ed. Exam/Coroner
Physician
Hosp. Staff
Law Enforcement
Neighbor
Relative
Instit. Staff
Social Services
Public
Mental Health
School Staff
Other (Specify)
Medical Diagnosis on Child
Signature of Physician who examined/treated child
(Area Code) Telephone No.
For Use By
X
Physicians
Only
Hospitalization Required:
None
Under 1 week
1-2 weeks
Over 2 weeks
Medical Exam
X-Ray
Removal/Keeping
Not. Med Exam/Coroner
Actions Taken Or
Photographs
Hospitalization
Returning Home
Notified DA
About To Be Taken
Signature of Person Making This Report:
Title
Date Submitted
Mo.
Day
Yr.
X
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