Protective Services for Adults Forms

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