Early Intervention Program Guidance on Early Intervention Program Records

Instructions for Completing the State Central Register Database Check Form LDSS-3370 Rev. 1/02

- It is extremely important that all information on the form can 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 FILL OUT THE FORM:

AGENCY INFORMATION

TOP LINE OF FORM:

- The three-digit agency code should 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.)
- Clearance Category letter code (see back of Form LDSS-3370) should be placed in the middle box.
- Phone number (with area code) enables the SCR to contact the agency liaison if this becomes necessary.
- The last box on this line 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.
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Agency Address: Must include street, city and zip code to ensure proper mailing of our response.

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 ensure an accurate response. Record all names with the last name first, then first 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: for SCR use only -- leave this blank.
- Second 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 Day Care (see back of form for categories), provide addresses for the applicant and everyone in the household who is 18 or older. We need this information from January 1973 or from the date the applicant turned 18 (if this is later than January 1973) to the present. 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).
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For all other categories, only the applicant's address history is required -- from January 1973 or from the date the applicant turned 18 if after January 1973.
- 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 back to January 1973 or the applicant's 18th birthday. 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 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 should 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 should sign in the boxes marked "Applicant's Signature"; household members over 18 who are not applicants should 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 any questions concerning these instructions, call (518) 474-5297.
Forms may be ordered by writing:
NYS Family Assistance
Bureau of Forms & Print Management
PO Box 1990
Albany, NY 12201

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Attachments:

Additional Page for Other Household Members

Additional Page for Address History of Household Members