Adult Protective Services
Protective Services for Adults Forms
- LDSS-2865 Application for Approval Family-Type Home for Adults
(LDSS-2865 Microsoft Word 121 KB) (LDSS-2865 Adobe PDF 23 KB) - LDSS-2865B FTHA Application Independent-Verification Check List
(LDSS-2865B Microsoft Word 46 KB) (LDSS-2865B Adobe PDF 28 KB) - LDSS-3123 Incident Report (DARC)(DAS)
(LDSS-3123 Microsoft Word 62 KB) (LDSS-3123 Adobe PDF 43 KB) - LDSS-3239 Medical Evaluation (Operator)
(LDSS-3239 Microsoft Word 33 KB) (LDSS-3239 Adobe PDF 19 KB) - LDSS-3633 Individual Resident Fund Record Account
(LDSS-3633 Microsoft Word 100 KB) (LDSS-3633 Adobe PDF 44 KB) - LDSS-3634 Resident Medication Record
(LDSS-3634 Microsoft Word 63 KB) (LDSS-3634 Adobe PDF 31 KB) - LDSS-3635 MEDICATION LOG
(LDSS-3635 331 KB) (LDSS-3635 Adobe PDF 13 KB) - LDSS-3705 Special Needs Fund Individual Resident Log
(LDSS-3705 Microsoft Word 32 KB) (LDSS-3705 Adobe PDF 16 KB) - LDSS-4505 Family Type Home for Adults Certification of Child Support Obligations
(LDSS-4505 Microsoft Word 41 KB) (LDSS-4505 Adobe PDF 26 KB) - OCFS-3122 Family Type Homes for Adults - Medical Evaluation (Resident)
(OCFS-3122 Microsoft Word 76 KB) (OCFS-3122 Adobe PDF 46 KB) - OCFS-3913 Residents Special Needs Expenditure Log
(OCFS-3913 64 KB) - OCFS-3914 Health and Safety Equipment and Substitute Care Expenditure Log
(OCFS-3914 Microsoft Word 75 KB) (OCFS-3914 Adobe PDF 11 KB) - OCFS-LDSS-2853 Statement Offering Personal Allowance Account
(OCFS-LDSS-2853 Microsoft Word 36 KB) (OCFS-LDSS-2853 Adobe PDF 18 KB) - OCFS-LDSS-2854 Personal Allowance Register
(OCFS-LDSS-2854 Microsoft Word 145 KB) (OCFS-LDSS-2854 Adobe PDF 69 KB) - OCFS-LDSS-2855 Personal Allowance Summary
(OCFS-LDSS-2855 Microsoft Word 252 KB) (OCFS-LDSS-2855 Adobe PDF 122 KB) - OCFS-LDSS-2949 Personal Data Sheet
(OCFS-LDSS-2949 Microsoft Word 77 KB) (OCFS-LDSS-2949 Adobe PDF 50 KB) - OCFS-LDSS-3026 Chronological Admission and Discharge Register
(OCFS-LDSS-3026 Microsoft Word 126 KB) (OCFS-LDSS-3026 Adobe PDF 58 KB) - OCFS-LDSS-3027 Inventory of Residents Property Held by Facility for Safe Keeping
(OCFS-LDSS-3027 Microsoft Word 74 KB) (OCFS-LDSS-3027 Adobe PDF 34 KB) - OCFS-LDSS-7014 Personal History of Applicant Family Type Home for Adults
(OCFS-LDSS-7014 Microsoft Word 44 KB) (OCFS-LDSS-7014 Adobe PDF 23 KB) - OCFS-LDSS-7016 Plan for Fire, Disaster or Other Emergency Evactuation of Residents Operator or Substitute Caretaker
(OCFS-LDSS-7016 Microsoft Word 74 KB) (OCFS-LDSS-7016 Adobe PDF 41 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, 4th Ave
Rensselaer, NY 12144-2629
OR
Call the Forms Hotline: 518-473-0971
