Fillable Department of Social Services (County of Erie, New York)

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Department of Social Services (County of Erie, New York)

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U.S.A. forms for County of Erie, New York

BROWSE COUNTY OF ERIE, NEW YORK (NY) FORMS

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Foster Care Ombudsperson Complaint Form
Department of Social Services
Office of the Foster Care Ombudsperson
B-5844 (5/2019)
If efforts to resolve your complaint with your caseworker and/or supervisor have been unsuccessful, and you wish to
file a complaint, please contact the Foster Care Ombudsperson at Foster Care Ombudsperson, 95 Franklin Street,
Room 862, Buffalo, New York 14202, or email at fostercarehelp@erie.gov.
COMPLAINTANT INFORMATION
NAME
TELEPHONE NUMBER
ADDRESS (Number and Street, City, State and Zip Code)
EMAIL ADDRESS
RELATIONSHIP TO CHILDREN
CASE INFORMATION
NAME OF CASEWORKER, SUPERVISOR AND/OR ANY OTHER STAFF INVOLVED
TYPE OF CASE
Foster Care Adoption Other: _________________________
CHILD / CHILDREN INFORMATION
NAME OF CHILD(REN) DATE OF BIRTH
PERSON WITH WHOM
CHILD RESIDES
RELATIONSHIP
INFORMATION ON OTHER ADULTS INVOLVED
PHONE NUMBER
RELATIONSHIP
COMPLAINT
The Foster Care Ombudsperson may receive, investigate, and attempt to resolve any complaint associated with foster care
alleging that the Department of Social Services or a Voluntary Agency contracted with the Department of Social Services, by
action or omission, failed to protect the physical or mental health or safety of any child or failed to follow specific laws, rules, or
written policies. Within this context, briefly describe your complaint.
List the steps you have taken to resolve your complaint:
Please describe what you would consider a reasonable resolution to your complaint:
SIGNATURE
I hereby acknowledge that the Foster Care Ombudsperson may use my name when
discussing my complaint with the caseworker and/or his or her supervisor.
Please note that your complaint will be investigated with care and that there will be no
retaliation associated with your filing a claim.
SIGNATURE
DATE SIGNED
PRINTED NAME
Email to fostercarehelp@erie.gov
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Department of Social Services (County of Erie, New York)

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Completed 17 July 2020

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