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 THE PROPER WAY TO FILL OUT THE FORM: AGENCY INFORMATION - 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.) <- Agency Name: Please use full name, no abbreviations. APPLICANT INFORMATION <- ALL HOUSEHOLD MEMBERS, ADULTS AND CHILDREN, WHETHER RELATED TO THE APPLICANT OR NOT, ARE TO BE LISTED IN THIS AREA OF THE FORM. The information required varies depending on the particular category: Signatures required depend upon the particular category: If you have any questions concerning these instructions, call (518) 474-5297.
<- 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 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:
<- Remember to
<- 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.)
<- 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.
<- For Adoption,Foster Care and Family Day Care (see back of form for categories), provide addresses for the applicant
- 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.
<- For Adoption, Foster Care and< Family Day Care (see back of form for category), signatures are needed from the applicant
<- 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).
Forms may be ordered by writing:
NYS Family Assistance
Bureau of Forms & Print Management
PO Box 1990
Albany, NY 12201Attachments: