Child Care Forms

Child Care Forms

Licensed/Registered Provider

LDSS-3370 Statewide Central Register Database Check
(LDSS-3370 Word) (LDSS-3370 PDF)
LDSS-4434-1 Caregiver Medical Statement (All Modalities)
(LDSS-4434-1 Word 100 KB)
LDSS-4434-4 Household Member Medical Statement
(LDSS-4434-4 Word 121 KB) (LDSS-4434-4 PDF 46 KB)
LDSS-4436 Incident Report for Child Day Care
(LDSS-4436 57 KB) (LDSS-4436 PDF 17 KB)
LDSS-4438DCC Emergency Planning Guide
(LDSS-4438DCC PDF 1219 KB)
LDSS-4438FDC-GFDC Emergency Planning Guide
(LDSS-4438FDC-GFDC PDF 1209 KB)
LDSS-4438SACC Emergency Planning Guide
(LDSS-4438SACC PDF 1264 KB)
LDSS-4439 Record of Fire Drills for Child Day Care
(LDSS-4439 Word 90 KB) (LDSS-4439 PDF 66 KB)
LDSS-4440 Schedule of Program Activities for Child Day Care
(LDSS-4440 Word 86 KB) (LDSS-4440 PDF 55 KB)
LDSS-4441 Discipline Policy Statement for Child Day Care
(LDSS-4441 Word 44 KB) (LDSS-4441 PDF 49 KB)
LDSS-4442 Menu Planning for Child Day Care
(LDSS-4442 Word 54 KB) (LDSS-4442 PDF 45 KB)
LDSS-4443 Daily Attendance Record Child Day Care
(LDSS-4443 Word 398 KB) (LDSS-4443 PDF 18 KB)
OCFS-4411 Potassium Iodide-KI Refusal-Opt-Out Form
(OCFS-4411 34 KB) (OCFS-4411 PDF 11 KB)
OCFS-4411S Formulario Para Rehusar El Yoduro De Potasio-KI
(OCFS-4411S 38 KB) (OCFS-4411S PDF 11 KB)
OCFS-4622 Notice to Expunge Associated Fingerprint Cards
(OCFS-4622 40 KB) (OCFS-4622 PDF 11 KB)
OCFS-4659 Waiver for Submission of a Duplicate Fingerprint Card
(OCFS-4659 72 KB) (OCFS-4659 PDF 21 KB)
OCFS-4879 Day Care Program Training Tracking Chart
(OCFS-4879 Word 233 KB) (OCFS-4879 PDF 18 KB)
OCFS-4879S HOJA PARA REGISTRAR LA CAPACITACION DEL PERSONAL EN UN PROGRAMA DE CUIDADO DIURNO
(OCFS-4879S Word 202 KB) (OCFS-4879S PDF 18 KB)
OCFS-4880 Individual Training Tracking Form for Child Care Personnel
(OCFS-4880 Word 221 KB) (OCFS-4880 PDF 17 KB)
OCFS-4880S HOJA PARA REGISTRAR LA CAPACITACION INDIVIDUAL EN UN PROGRAMA DE CUIDADO DIURNO
(OCFS-4880S Word 208 KB) (OCFS-4880S PDF 17 KB)
OCFS-4887 Request for Waiver
(OCFS-4887 44 KB) (OCFS-4887 PDF 10 KB)
OCFS-4887S Solicitud de Exencion o Dispensacion
(OCFS-4887S 44 KB)
OCFS-4890 Report of Death of Child Care
(OCFS-4890 Word 87 KB) (OCFS-4890 PDF 14 KB)
OCFS-4926 Fuel Burning System Inspection
(OCFS-4926 Word 118 KB)
OCFS-4930 Request for NYS Fingerprinting Services Info Form
(OCFS-4930 Word 74 KB) (OCFS-4930 PDF 21 KB)
OCFS-4930-1 Guidelines for Fingerprinting
(OCFS-4930-1 Word 35 KB)
OCFS-4930-1S Guia para Obtener Impresiones Digitales
(OCFS-4930-1S Word 34 KB)
OCFS-4930S Solicitud de Servicios de Impresiones Digitales
(OCFS-4930S Word 70 KB)
OCFS-4932 FAMILY AND GROUP FAMILY DAY CARE PROVIDER REQUEST TO REMOVE STREET ADDRESS AND MAP FROM THE OFFICE OF CHILDREN AND FAMILY SERVICES WEBSITE
(OCFS-4932 Word 49 KB)
OCFS-4932S SOLICITUD PARA RETIRAR DEL PORTAL DE LA AGENCIA DIRECCION Y EL MAPA ASOCIADO CON LA DIRECCION DE UN HOGAR DE CUIDADO DIURNO EN FAMILIA O DE UN GRUPO EN FAMILIA
(OCFS-4932S Word 55 KB)
OCFS-4939 Provider Notification of Licensing or Registration to Fire and Police or Sheriff Departments
(OCFS-4939 Word 74 KB) (OCFS-4939 PDF 14 KB)
OCFS-4939S Notificacion del Proveedor(a) de Cuidado Infantil a los Departamentos de Bomberos y de la Policia sobre su Licencia o Registro
(OCFS-4939S Word 71 KB)
OCFS-LDSS-0792 Day Care Registration
(OCFS-LDSS-0792 Word 79 KB) (OCFS-LDSS-0792 PDF 57 KB)
OCFS-LDSS-4433 Medical Statement of Child in Childcare
(OCFS-LDSS-4433 Word 163 KB) (OCFS-LDSS-4433 PDF 40 KB)
OCFS-LDSS-4838 DCC-Monthly Fire-Safety Inspection for DCC Director or Designee
(OCFS-LDSS-4838 Word 454 KB) (OCFS-LDSS-4838 PDF 227 KB)
OCFS-LDSS-7002 Written Medication Consent Form
(OCFS-LDSS-7002 PDF 36 KB)
OCFS-LDSS-7002S Formulario de Consentimiento Escrito para Medicamentos
(OCFS-LDSS-7002S 174 KB)
OCFS-LDSS-7003 Verbal Medication Consent Form and Log of Administration
(OCFS-LDSS-7003 PDF 25 KB)
OCFS-LDSS-7003S- Formulario de Consentimiento Verbal y Administacion del Registro
(OCFS-LDSS-7003S- PDF 26 KB)
OCFS-LDSS-7004 Log of Medication Administration
(OCFS-LDSS-7004 PDF 36 KB)
OCFS-LDSS-7005 Medication Error Report Form
(OCFS-LDSS-7005 PDF 30 KB)
OCFS-LDSS-7005S Formulario de Informe de Error de Medicacion
(OCFS-LDSS-7005S PDF 25 KB)
OCFS-LDSS-7006 Individual Health Care Plan for a Child with Special Health Care Needs
(OCFS-LDSS-7006 PDF 29 KB)
OCFS-LDSS-7006S Plan Individual de Cuidado de la Salud para un Nino(a) con Necesidades Especiales de Cuidado de la Salud
(OCFS-LDSS-7006S PDF 32 KB)
OCFS-LDSS-7019 Illness Injury and Indicators of Abuse Log
(OCFS-LDSS-7019 Word 238 KB) (OCFS-LDSS-7019 PDF 29 KB)
OCFS-LDSS-7019S Registro de Enfermedades, Lesiones e Indicadores de Abuso
(OCFS-LDSS-7019S Word 234 KB) (OCFS-LDSS-7019S PDF 33 KB)
OCFS-LDSS-7020 Health Care Plan - Day Care Center
(OCFS-LDSS-7020 Word 616 KB) (OCFS-LDSS-7020 1 KB)
OCFS-LDSS-7020S Plan De Atencion Medica-Centro de Cuidado Infantil-Guarderia Infantil
(OCFS-LDSS-7020S 586 KB) (OCFS-LDSS-7020S PDF 157 KB)
OCFS-LDSS-7021 Health Care Plan - Family Day Care Center - Group Family Day Care Center - Small Day Care Centers
(OCFS-LDSS-7021 Word 602 KB)
OCFS-LDSS-7021S Plan De Atencion Medica - Hogar de Cuidado Diurno en Familia - Hogar de Cuidado Diurno de un Grupo en Familia - Centro Pequeno de Cuidado Infantil
(OCFS-LDSS-7021S 553 KB) (OCFS-LDSS-7021S PDF 190 KB)
OCFS-LDSS-7022 Health Care Plan - School Age Child Care
(OCFS-LDSS-7022 Word 574 KB)
OCFS-LDSS-7024 Evaluation of my Most Recent Licensing-Registration Experience
(OCFS-LDSS-7024 Word 68 KB) (OCFS-LDSS-7024 PDF 13 KB)
OCFS-LDSS-7035 Assistant Information-Group Family Day Care
(OCFS-LDSS-7035 Word 44 KB) (OCFS-LDSS-7035 PDF 22 KB)
OCFS-LDSS-7036 Assistant Qualifications
(OCFS-LDSS-7036 Word 70 KB) (OCFS-LDSS-7036 PDF 36 KB)
OCFS-LDSS-7037 Assistant References
(OCFS-LDSS-7037 Word 68 KB) (OCFS-LDSS-7037 PDF 23 KB)
OCFS-LDSS-7038 Assistant Criminal History Review
(OCFS-LDSS-7038 Word 62 KB) (OCFS-LDSS-7038 PDF 34 KB)
OCFS-LDSS-7040 Environmental Hazards Guidance Sheet
(OCFS-LDSS-7040 Word 85 KB) (OCFS-LDSS-7040 PDF 99 KB)
OCFS-LDSS-7041 Directions for Completing the Environmental Hazards Statement
(OCFS-LDSS-7041 Word 50 KB) (OCFS-LDSS-7041 PDF 80 KB)
OCFS-LDSS-7042 Environmental Hazard Information Form Parts I and II
(OCFS-LDSS-7042 Word 71 KB) (OCFS-LDSS-7042 PDF 127 KB)
OCFS-LDSS-7043 Plan of Study Commitment for Head of Group for Preschoolers Infants and Toddlers
(OCFS-LDSS-7043 Word 51 KB) (OCFS-LDSS-7043 PDF 28 KB)
OCFS-LDSS-7044 Plan of Study Commitment for Director of Day Care Center
(OCFS-LDSS-7044 Word 60 KB) (OCFS-LDSS-7044 PDF 33 KB)

Legally-Exempt Provider

OCFS-4915 History of Criminal Convictions and Parental Acknowledgment
(OCFS-4915 42 KB) (OCFS-4915 PDF 11 KB)
OCFS-4915-S Historial de Convicciones Criminales y Reconocimiento del Padre-Madre
(OCFS-4915-S 48 KB) (OCFS-4915-S PDF 9 KB)
OCFS-4916 History of Day Care Enforcement and Parental Acknowledgment
(OCFS-4916 42 KB) (OCFS-4916 PDF 15 KB)
OCFS-4916S Historial de Ejecutoria de Cuidado Diurno y Reconocimiento del Padre-Madre
(OCFS-4916S 45 KB) (OCFS-4916S PDF 15 KB)
OCFS-4917 History of Termination of Parental Rights and-or Court Ordered Article 10 - Removal of a Child and Parental Acknowledgment
(OCFS-4917 46 KB) (OCFS-4917 PDF 16 KB)
OCFS-4917-S Historial de Terminacion de Derechos Paternos-Maternos y-o Retiro de Ninos por Orden del Tribunal Segun Articulo 10 y Reconocimiento Paterno-Materno
(OCFS-4917-S 50 KB) (OCFS-4917-S PDF 17 KB)
OCFS-7026 Enrollment Information Packet for Legally-Exempt Providers
(OCFS-7026 Word 278 KB) (OCFS-7026 PDF 333 KB)
OCFS-7026-S Paquete de Informacion Sobre la Inscripcion para Proveedores Legalmente Exentos
(OCFS-7026-S Word 369 KB) (OCFS-7026-S PDF 347 KB)
OCFS-LDSS-4699 Enrollment Form for Provider of Legally-Exempt Family Child Care and Legally -Exempt in-Home Child Care
(OCFS-LDSS-4699 594 KB) (OCFS-LDSS-4699 608 KB)(OCFS-LDSS-4699 PDF 611 KB)
OCFS-LDSS-4699-1 Employment of Minors
(OCFS-LDSS-4699-1 52 KB) (OCFS-LDSS-4699-1 PDF 17 KB)
OCFS-LDSS-4699-1A Employment of Minors -Information
(OCFS-LDSS-4699-1A 46 KB) (OCFS-LDSS-4699-1A PDF 112 KB)
OCFS-LDSS-4699-1AS Informacion Sobre el Empleo de Menores
(OCFS-LDSS-4699-1AS 64 KB) (OCFS-LDSS-4699-1AS PDF 24 KB)
OCFS-LDSS-4699-1S Empleo de Menores
(OCFS-LDSS-4699-1S 52 KB) (OCFS-LDSS-4699-1S PDF 17 KB)
OCFS-LDSS-4699-2 Legally Exempt In-Home Child Care Provider Agreement Form
(OCFS-LDSS-4699-2 42 KB) (OCFS-LDSS-4699-2 PDF 78 KB)
OCFS-LDSS-4699-2A Parental Responsibilities When Employing a Legally Exempt In-Home Child Care Provider
(OCFS-LDSS-4699-2A 35 KB) (OCFS-LDSS-4699-2A PDF 106 KB)
OCFS-LDSS-4699-2AS Responsabilidades de los Padres al Emplear un Proveedora de Cuidado Infantil en el Hogar Legalmente Exento
(OCFS-LDSS-4699-2AS 36 KB) (OCFS-LDSS-4699-2AS PDF 71 KB)
OCFS-LDSS-4699-2S Acuerdo del Proveedor(a) de Cuidado Infantil a Domicilio Legalmente Exento
(OCFS-LDSS-4699-2S 44 KB) (OCFS-LDSS-4699-2S PDF 11 KB)
OCFS-LDSS-4699-3 Legally-Exempt Provider Training Record Form
(OCFS-LDSS-4699-3 Word 50 KB) (OCFS-LDSS-4699-3 PDF 23 KB)
OCFS-LDSS-4699-3S Registro de Entrenamiento para Proveedores de Cuidado Infantil Legalmente Exento
(OCFS-LDSS-4699-3S Word 48 KB) (OCFS-LDSS-4699-3S PDF 22 KB)
OCFS-LDSS-4699S Formulario de Inscripcion para Proveedores de Servicios de Cuidado Infantil en Familia Legalmente Exento y de Cuidado Infantil a Domicilio Legalmente Exento
(OCFS-LDSS-4699S 631 KB) (OCFS-LDSS-4699S PDF 224 KB)
OCFS-LDSS-4700 Enrollment form for Provider of Legally-Exempt Group Child Care
(OCFS-LDSS-4700 438 KB) (OCFS-LDSS-4700 PDF 422 KB)
OCFS-LDSS-7000 Health Care Plan for the Administration of Medication for Legally-Exempt Provider
(OCFS-LDSS-7000 244 KB) (OCFS-LDSS-7000 PDF 66 KB)
OCFS-LDSS-7000S Instrucciones para Completar el Plan de Salud para la Administracion de Medicamentos para Proveedores Legalmente Exentos
(OCFS-LDSS-7000S 293 KB) (OCFS-LDSS-7000S PDF 72 KB)
OCFS-LDSS-7001 Instructions for Completing the Health Care Plan for the Administration of Medication for Legally-Exempt Provider
(OCFS-LDSS-7001 Word 106 KB) (OCFS-LDSS-7001 PDF 109 KB)
OCFS-LDSS-7001S Instrucciones para Completar el Plan de Salud para la Administracion de Medicamentos del Proveedor Legalmente Exento
(OCFS-LDSS-7001S Word 102 KB) (OCFS-LDSS-7001S PDF 123 KB)
OCFS-LDSS-7002 Written Medication Consent Form
(OCFS-LDSS-7002 Word 146 KB)
OCFS-LDSS-7003 Verbal Medication Consent Form and Log of Administration
(OCFS-LDSS-7003 141 KB)
OCFS-LDSS-7003S- Formulario de Consentimiento Verbal y Administacion del Registro
(OCFS-LDSS-7003S- 151 KB)
OCFS-LDSS-7004 Log of Medication Administration
(OCFS-LDSS-7004 Word 208 KB)
OCFS-LDSS-7004S Registro de Administracion de Medicamentos
(OCFS-LDSS-7004S 182 KB)
OCFS-LDSS-7005 Medication Error Report Form
(OCFS-LDSS-7005 Word 115 KB)
OCFS-LDSS-7005S Formulario de Informe de Error de Medicacion
(OCFS-LDSS-7005S Word 116 KB)
OCFS-LDSS-7006 Individual Health Care Plan for a Child with Special Health Care Needs
(OCFS-LDSS-7006 Word 83 KB)
OCFS-LDSS-7006S Plan Individual de Cuidado de la Salud para un Nino(a) con Necesidades Especiales de Cuidado de la Salud
(OCFS-LDSS-7006S Word 83 KB)
OCFS-LDSS-7007 Obtaining Authorization to Administer Medication to Subsidized Children in Legally Exempt Care
(OCFS-LDSS-7007 Word 66 KB) (OCFS-LDSS-7007 PDF 58 KB)
OCFS-LDSS-7008 Administration of Medication by Legally-Exempt Child Care Provider
(OCFS-LDSS-7008 Word 47 KB) (OCFS-LDSS-7008 PDF 44 KB)
OCFS-LDSS-7008S Administracion de Medicamentos por el Proveedor de Cuidado Infantil Legalmente Exento
(OCFS-LDSS-7008S Word 51 KB) (OCFS-LDSS-7008S PDF 72 KB)
OCFS-LDSS-7028-1 Home Inspection Report for Legally Exempt Family Child Care Provider
(OCFS-LDSS-7028-1 Word 462 KB) (OCFS-LDSS-7028-1 PDF 79 KB)
OCFS-LDSS-7028-2 Corrective Action Plan for Legally Exempt Child Care Provider
(OCFS-LDSS-7028-2 Word 96 KB) (OCFS-LDSS-7028-2 PDF 23 KB)
OCFS-LDSS-7028-3 Attachment to the Home Inspection Report for Legally Exempt Family Child Care Provider
(OCFS-LDSS-7028-3 Word 114 KB) (OCFS-LDSS-7028-3 PDF 35 KB)

Local Department of Social Services

Autism Awareness Brochure-Pub 4998
(Autism PDF 1524 KB) (Autism PDF 126 KB)(Autism PDF 62 KB)(Autism PDF 54 KB)
OCFS-LDSS-4433 Medical Statement of Child in Childcare
(OCFS-LDSS-4433 Word 163 KB) (OCFS-LDSS-4433 PDF 40 KB)
OCFS-LDSS-4779 Approval of Your Application for Child Care Benefits
(OCFS-LDSS-4779 Word 85 KB)
OCFS-LDSS-4779S APROBACION DE SU SOLICITUD PARA BENEFICIOS DE CUIDADO DE NINOS
(OCFS-LDSS-4779S Word 86 KB)
OCFS-LDSS-4780 DENIAL OF YOUR APPLICATION FOR CHILD CARE BENEFITS
(OCFS-LDSS-4780 Word 67 KB)
OCFS-LDSS-4780S DENEGACION DE SU SOLICITUD PARA BENEFICIOS DE CUIDADO DE NINOS
(OCFS-LDSS-4780S Word 69 KB)
OCFS-LDSS-4781 NOTICE OF INTENT TO CHANGE CHILD CARE BENEFITS
(OCFS-LDSS-4781 Word 86 KB)
OCFS-LDSS-4781S NOTIFICACION SOBRE EL INTENTO DE CAMBIAR LOS BENEFICIOS DE CUIDADO DE NINOS
(OCFS-LDSS-4781S Word 78 KB)
OCFS-LDSS-4782 NOTICE OF INTENT TO DISCONTINUE CHILD CARE BENEFITS
(OCFS-LDSS-4782 Word 63 KB)
OCFS-LDSS-4782S NOTIFICACION SOBRE EL INTENTO DE DISCONTINUAR BENEFICIOS DE CUIDADO DE NINOS
(OCFS-LDSS-4782S Word 66 KB)
OCFS-LDSS-7009 Notice of Child Care Assistance Overpayment and Repayment Requirements
(OCFS-LDSS-7009 Word 88 KB) (OCFS-LDSS-7009 PDF 42 KB)
OCFS-LDSS-7009S Notificacion de Sobrepago de Asistencia Para Cuidado Infantil Y Requisitos de Devolucion
(OCFS-LDSS-7009S Word 97 KB)
OCFS-LDSS-7010 notice of Fraud Determination-Disqualification for Child Care Benefits and Repayment Plan
(OCFS-LDSS-7010 Word 96 KB) (OCFS-LDSS-7010 PDF 44 KB)
OCFS-LDSS-7010S Notificacion de Determinacion de Fraude Descalificacion Para Recibir Beneficios de Cuidado Infantil Y Plan de Devolucion de Pagos
(OCFS-LDSS-7010S Word 125 KB)

Order Hard Copies of Forms

To order hard copies of available forms developed by the New York State Office of Children and Family Services (OCFS), complete the "Request for Forms and Publications" form (OCFS-4627) Microsoft Word - OCFS-4627 / Adobe PDF - OCFS-4627 and mail your request to:

OCFS Resource Distribution Center
11 Fourth Ave
Rensselaer, NY 12144-2629
OR
Call the Forms Hotline: 518-473-0971