NY DSS 3123 2015-2025 free printable template
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New York State Department of Health Adult Care Facility INCIDENT REPORT DSS-3123 Rev. 05/12 Facility Name County Date of Incident Time Regulations 487. 7 d 1-13 488. 7 b 1-13 490. 7 d 1-11 Resident Name I. Reportable Incidents to the Department s Regional Office Resident s whereabouts were unknown for more than 24 hours Resident assaults or injures or is assaulted or injured by another resident staff or others Resident attempted or committed suicide if resident died must also check resident...
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How to fill out NY DSS 3123
01
Obtain the NY DSS 3123 form from the NY Department of Social Services website or local office.
02
Carefully read the instructions provided with the form to understand the requirements.
03
Fill out personal information including name, address, and contact details in the designated sections.
04
Provide details about the individual or family situation requiring assistance.
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Attach any necessary supporting documents as required by the form, such as income verification or proof of residency.
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Review the completed form for accuracy and completeness.
07
Submit the form to the appropriate department or agency as indicated in the instructions.
Who needs NY DSS 3123?
01
Individuals seeking assistance from the New York State Social Services.
02
Families applying for financial aid or other support services.
03
Persons in need of public assistance due to unforeseen circumstances.
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What is NY DSS 3123?
NY DSS 3123 is a form used by the New York State Department of Social Services for reporting certain information related to social services programs.
Who is required to file NY DSS 3123?
Entities or individuals who are recipients of specific social services funding or support in New York State are required to file NY DSS 3123.
How to fill out NY DSS 3123?
To fill out NY DSS 3123, you must provide accurate information as prompted on the form, ensure that all required fields are completed, and follow the instructions provided by the New York State Department of Social Services.
What is the purpose of NY DSS 3123?
The purpose of NY DSS 3123 is to collect relevant data from service providers regarding the usage of social services funding and to ensure compliance with state regulations.
What information must be reported on NY DSS 3123?
NY DSS 3123 requires reporting information such as the type of services provided, the number of clients served, funding amounts, and any other data pertinent to the social services program.
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