Form 1 Virtual Conference Registration

Child Welfare Virtual Conference: [Title]: Registration Form

OMB Control No.: xxxx-xxxx

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Expiration Date: xx/xx/20xx

Registration Form

#	Registration Field	Field Type
1	First Name*	Text
2	Last Name*	Text
3	Email Address*	Text
4	State*	Picklist (All States, U.S. territories)
5	Time Zone*	Picklist
6	How did you hear about the conference?	Capacity Building Collaborative webpage  Center’s Liaison  Listserv  Colleague   Hard-copy publication  Search engine (e.g., Google, Yahoo)  Social media (e.g., Facebook, Twitter)  Link from another webpage   Other (please specify):__________
7	Did you participate in last year’s Virtual Expo (July 2016)?	Y/N
8	Employer/Organization*	Text
9	Which best describes your employer/organization? (Select one)*	State Child Welfare Agency County Child Welfare Agency Territorial Child Welfare Agency Tribal Child Welfare Agency State or County Court/Legal System Tribal Court/Legal System Private or Community-based Child Welfare Agency Local Government/Tribal Council Law Enforcement Organization Primary Care/Health Care Services Provider Behavioral/Mental Health Services Provider Substance Abuse Services Provider Domestic Violence Services Provider Juvenile Justice Organization Primary/Secondary Education College/University Technical Assistance Provider Federal Government Other Not Applicable
10	Primary Role*	State/County/Territory/Tribal Agency Agency Director/Deputy Director Program/Middle Manager Supervisor Caseworker/Direct Practice Worker/Frontline staff Parent Partner State/County/Territory/Tribal Court CIP or TCIP Director/Coordinator CIP or TCIP Staff Judge Attorney for Child Welfare Agency Attorney for Parent Attorney for Child Attorney Guardian Ad Litem Court Administrative Officer Court/Attorney Data Manager/IT Staff Court Appointed Special Advocate/Non-attorney GAL/Advocate Court Case Worker/Social Worker School/University Dean/Director/Administrator Teaching Faculty Training Academy Leadership/Staff Research Faculty/Staff (non-teaching role) Student Other Technical Assistance Provider Other Not Applicable
11	Which of the following best describes your primary work responsibilities? (Select one)*	Workforce Development/Training Continuous Quality Improvement/ Evaluation Information Technology/SACWIS/Data Systems Indian Child Welfare Act Primary or Secondary Prevention Child Protective Services In-home Services/Promoting Safe and Stable Families Foster Care/Placement/ Licensing/Reunification Adoption/Guardianship Youth in Transition/Chafee/ Independent Living Programs Other Not Applicable
12	How many years of experience do you have working in child welfare? (Select one)*	Less than 1 year 1–5 years of service 6–10 years of service 11–15 years of service 16+ years of service Not Applicable
13	How do you plan on participating in the Virtual Expo?*	Computer (PC) Computer (Mac) Tablet Smartphone Combination of technologies (computer, tablet, and/or smartphone)
14	If you plan on participating in a group (sharing one registration), how many people will be in your group?*	Text
15	Which track do you plan on participating in?(You will be able to change your track later if you want)*	Frontline Administrative/Management
16	Why are you attending the conference?*	Text
17	We are looking for volunteers to participate in a virtual 1.5 hour focus group or a 30-minute individual telephone interview, 1-2 weeks after the Virtual Expo. The purpose of these focus groups and interviews are to get more detailed feedback about your experience with the Virtual Expo. Can we contact you about your availability?*	Y/N

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