New York State Child Protective Services Manual Appendices Chapter 14: Appendices Forms (non-CONNECTIONS) ................................................................................ A-1 1. New York State Unified Court System (UCS) Family Court: Child Protective Forms ............................................................................................................... A-1 2. New York State application for certain benefits and services (LDSS-2921 Statewide, [Rev. 7/16]) ....................................................................................... A-1 3. Plan of Safe Care (NYS OCFS Form-2196) ....................................................... A-1 4. Forms to implement, relaunch, or modify a family assessment response (FAR) A-1 Model letters .......................................................................................................... B-1 1. Sharing of confidential client-identifiable information between Child Protective Services (CPS) and Protective Services for Adults (PSA) .................................. B-1 2. Model letter – consent for temporary placement of child(ren) in foster care (pursuant to FCA §1021) ................................................................................... B-3 3. Intent to ask Family Court for a temporary removal (per FCA §1023) ................ B-4 4. Mandatory reporter consent to release identifying information ........................... B-5 5. Model notice of existence of a report (sent by a custodial agency where children are in foster care in a different social services district) .......................... B-6 6. Relative model notification letter ........................................................................ B-7 7. Parent of sibling (model) notification letter ......................................................... B-9 8. Non-relative notification letter ............................................................................B-10 Alternative notice of existence of report letters .................................................. C-1 Notice of child custody proceeding for Native American child .......................... D-1 Definitions of allegations related to child abuse and maltreatment ..................... E-1 1. Fractures ........................................................................................................... E-1 2. Internal injuries .................................................................................................. E-2 3. Lacerations / Bruises / Welts .............................................................................. E-3 4. Swelling / Dislocations / Sprains ........................................................................ E-4 5. Choking / Twisting / Shaking .............................................................................. E-5 6. Burns / Scalding ................................................................................................. E-5 7. Poisoning / Noxious substances ........................................................................ E-6 8. Excessive corporal punishment ......................................................................... E-7 9. Parent's drug / Alcohol misuse ........................................................................... E-7 December 2019 Appendices New York State Child Protective Services Manual 10. Child's drug / Alcohol use ................................................................................... E-8 11. Lack of medical care / Medical neglect .............................................................. E-9 12. Educational neglect...........................................................................................E-10 13. Emotional neglect .............................................................................................E-12 14. Sexual abuse ....................................................................................................E-13 15. Allowing sex abuse to occur ..............................................................................E-27 16. Malnutrition / Failure-to-thrive ...........................................................................E-28 17. Inadequate food / clothing / shelter ...................................................................E-30 18. Inadequate guardianship ..................................................................................E-30 19. Lack of supervision ...........................................................................................E-31 20. Abandonment ...................................................................................................E-32 21. Dead on arrival (DOA) / Fatality ........................................................................E-33 22. Other ..............................................................................................................E-33 Standards of evidence for each child protective process stage ......................... F-1 Criminal justice system ......................................................................................... G-1 1. Types of crimes ................................................................................................. G-1 2. Specific crimes relating to child abuse and maltreatment cases ......................... G-1 3. Steps in the Criminal Justice process ................................................................ G-1 Title 6 of Article 6 of the Social Services Law ..................................................... H-1 Article 10 of the Family Court Act .......................................................................... I-1 New York State regulations regarding child abuse and maltreatment: Part 432 - Codes Rules and Regulations .............................................................. J-1 Model memorandum of understanding ................................................................ K-1 1. Roles of and responsibilities of child protective services and the district attorney in investigations of child abuse and maltreatment ................................ K-1 2. Appointment of liaisons ...................................................................................... K-2 3. Referral of reports of suspected child abuse and maltreatment .......................... K-3 4. Identification and notification of law enforcement agencies ................................ K-4 5. Procedures for communication during joint CPS / law enforcement investigations of child abuse and maltreatment .................................................. K-4 Child Fatality Investigations .................................................................................. L-1 1. Fatality report checklists ..................................................................................... L-1 December 2019 Appendices New York State Child Protective Services Manual Appendices SCR .............................................................................................................. L-1 Non-SCR ...................................................................................................... L-1 2. SCR reported fatality checklist ............................................................................ L-2 3. Non-SCR reported fatality checklist .................................................................... L-5 4. Investigating sleep related fatality and injury CPS reports ................................... L-8 Some recommended steps for obtaining information .................................... L-8 Important information to obtain ..................................................................... L-9 5. Making the determination .................................................................................. L-10 Bed sharing ................................................................................................ L-11 Unattended sleeping infant ......................................................................... L-13 Kinship Care .......................................................................................................... M-1 Documentation guidelines for Family Assessment Response (FAR) cases ..... N-1 1. Report received ................................................................................................. N-1 2. 24-hour assessment of safety ............................................................................ N-1 3. Initial contact with the family .............................................................................. N-1 4. Description of FAR, notification to the family, and agreement to participate ....... N-2 5. 7-day safety assessment ................................................................................... N-2 6. Family-Led assessment ..................................................................................... N-3 7. Engagement ...................................................................................................... N-3 8. Solution focused practice ................................................................................... N-4 9. Safety and Risk .................................................................................................. N-4 10. Family Led Assessment Guide (FLAG) .............................................................. N-5 11. Non-custodial or absent parent .......................................................................... N-5 12. Collateral contacts ............................................................................................. N-6 13. Cultural