After a mandated reporter phones a suspicion of child abuse or maltreatment to the Statewide Central Register (SCR), this signed written report must follow within 48 hours. Clinicians meet it when an exam or visit gives them reasonable cause to suspect that a parent or other person legally responsible has harmed a child. It goes to the local child protective services (CPS) unit, which investigates and decides within 60 days whether the report is indicated or unfounded.
The mandated reporter who made the oral report completes and signs the whole form. A box marked for use by physicians only takes the medical diagnosis and the signature of the physician who examined or treated the child; the family completes no part of it.
Enter the report date and time and the Call ID the SCR specialist assigned during your oral report; OCFS tells reporters to ask for it. The Case ID, local case number and local district or agency fields tie the written report to the case the SCR registered and sent to local CPS, so fill in whatever you were given on the call.
List all children in the household, the adults responsible and the alleged subjects, one per numbered line: last and first name, aliases, sex, birthday or age, race code, a Hispanic or Latino check, relation code, role code and language code. The codes are printed on the reverse, for example AB for abused child, MA for maltreated child and AS for alleged subject. Then list addresses and telephone numbers by line number.
Check each alleged form of abuse or maltreatment and write the child's line number beside it, or ALL if it applies to every child. Options include DOA or fatality, fractures, internal injuries such as subdural hematoma, lacerations, bruises or welts, burns or scalding, choking, twisting or shaking, sexual abuse, sex trafficking, lack of medical care, malnutrition or failure to thrive, lack of supervision, excessive corporal punishment, abandonment and parent's drug or alcohol misuse.
Describe the nature and extent of each child's injuries, abuse or maltreatment, past and present, and any evidence or suspicion of parental behavior contributing to the problem, with the time and date of the alleged incident if known. OCFS's guide notes that reasonable cause can be as simple as distrusting an explanation for an injury. Check the box if an additional sheet is attached, and answer whether you request the finding of the investigation.
Give the name, telephone, address, email and agency or institution of each person making the report, and check the relationship to the child: medical examiner or coroner, physician, hospital staff, law enforcement, social services, public health, mental health, school staff or other. This section is confidential, and CPS may not release it to the subject of the report without written permission.
Enter the medical diagnosis on the child, then sign as the physician who examined or treated the child and add a phone number. Check hospitalization required: none, under 1 week, 1 to 2 weeks or over 2 weeks. Mark the actions taken or about to be taken: medical exam, X-ray, removal or keeping, notifying the medical examiner or coroner, photographs, hospitalization, returning home, or notifying the district attorney.
The person making the report signs, adds their title and enters the date submitted. OCFS asks for the written paper copy that was originally signed, so sign the copy you send rather than mailing an unsigned printout. CPS may later ask for records essential to the investigation; OCFS's guide says the mandated reporter decides which records those are and provides them.
The back of the form lists the race, ethnicity, relation, role and language codes used in Subjects of Report. It also summarizes the law: the definitions of an abused child and a maltreated child under Section 412, the Section 415 rule of an immediate phone report plus a written report within 48 hours, immunity for good-faith reporting under Section 419, and Section 420 penalties for failing to report.
Use the attachment only if the space under reasons for suspicion is not enough. Repeat the report date, Case ID, Call ID, time, local case number and agency, name the person making the report, and continue the narrative of each child's injuries and contributing parental behavior. Staple it to the LDSS-2221A and print clearly if filling it out by hand.
Download the current version from the source each time; forms change without notice.
Report of Suspected Child Abuse or Maltreatment
Report of Suspected Child Abuse or Maltreatment (LDSS-2221A-S)
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Sources for this guide
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Within 48 hours of the oral report to the Statewide Central Register. Section 415 of the Social Services Law requires reports to be made immediately by telephone and then in writing within 48 hours. The written report goes to the local department of social services where the child resides, not to the SCR.
Every mandated reporter who makes an oral report to the SCR must follow it with the signed LDSS-2221A. New York's list covers physicians, residents, interns, physician assistants, nurses, psychologists, dentists, optometrists, chiropractors, EMTs, social workers, mental health professionals and many others, when they are acting in their professional role and have reasonable cause to suspect abuse or maltreatment.
Yes. OCFS posts a Spanish version, LDSS-2221A-S, alongside the English form. The report is also available in Bengali, Simplified and Traditional Chinese, French, Haitian Creole, Italian, Korean, Polish, Russian, Urdu and Yiddish, all as Word files on the OCFS Child Protective Services page.
The Social Services Law keeps the source of a report confidential. OCFS and local CPS may not release information identifying the reporter to the subject of the report without the reporter's written permission, though it can be shared with court officials, police and district attorneys in certain circumstances. The Source(s) of Report section is marked confidential on the form.