Webinar Registration

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to tailor capacity building products and services to better meet the needs of child welfare professionals. Public reporting burden for this collection of information is estimated to average 2 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Brian Deakins at the Children’s Bureau, Administration for Children and Families by email at Brian.Deakins@acf.hhs.gov.

OMB Control No. 0970-0494

Expiration Date: xx/xx/xx

Webinar Registration Form

Completion of the webinar registration form should take approximately 2 minutes. The information that you share will be only be used to help us evaluate and improve our webinars. In some cases, we may contact you to learn about your experience with the webinar. Your privacy is important. Your personal information will be kept private. This is a Capacity Building Collaborative event and, as such, information provided during registration may be shared with the Children’s Bureau. Information may also be used for Capacity Building Collaborative evaluation purposes with identifying information held in confidence and all reporting done in aggregate. Completion of this form is voluntary.

Fields marked with an asterisk (*) are required.

Section 1

New CapLEARN Field Name	New CapLEARN Field Type
E-mail address*	Text
First Name*	Text
Last Name*	Text
Jurisdiction*	Pick List of 50 States, US Territories, and Other
Job Title	Text
Employer/Organization*	Text
Which best describes you? (Select All That Apply)*	Child Welfare Professional Other Health or Human Services Professional Legal Professional Education Professional Student/Intern Current or Former Foster Youth Biological Parent/Relative Caregiver/Family Member Non-Relative Foster or Adoptive Family Member Community Member/Community Leader/Tribal Elder Other
Which best describes your employer/organization? (Select One)*	Not Applicable
	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 Child Welfare Agency Under Contract for Services
	Community-Based Service Provider
	Child Welfare Training Academy/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 (non Child Welfare Training Organization)
	Technical Assistance Provider
	Federal Government
	Other
For those who work in a Child Welfare Agency, what is your primary role? (Select One)	Agency Director/Deputy Director Program/Middle Manager Supervisor Caseworker/Direct Practice Worker/Frontline staff Policy Writer/Coordinator Federal Requirements/Reporting Lead/Coordinator(e.g. CFSR, CFSP, PIP) CQI/QA staff (e.g. director, analyst, case reviewer) Training Director/Trainer/Curriculum Developer Family Leader/Partner Youth Leader/Partner Court Appointed Special Advocate (CASA) Student Intern Other
Which of the following best describes your primary work responsibilities in the agency? (Select Up to Three)	Administration Workforce Development/Training Continuous Quality Improvement/Evaluation Information Technology/SACWIS/Data Systems Indian Child Welfare Act Primary Prevention Child Protective Services In-home Services/Promoting Safe and Stable Families Foster Care- Case Management Foster Care – Recruitment/Training/Licensing of Resource Families Adoption/Guardianship Youth in Transition/Chafee/Independent Living Programs Other
For Court and Legal Professionals, which of the following best describes your primary role? (Select One)	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 Other
For education and university professionals, which of the following best describes your primary role? (Select One)	Dean/Director/Administrator Teaching Faculty Research Faculty/Staff (non-teaching role) Student Other
How many years of experience do you have working in child welfare? (Select One)*	Not Applicable Less than 1 year 1–5 years of service 6–10 years of service 11–15 years of service 16+ years of service
What was the highest level of education you completed? (Select One)*	Some K-12 education (or equivalent) High school graduate (or equivalent) Some college (1-4 years, no degree) Associate’s degree (including occupational or academic degrees) Bachelor’s degree (BA, BS, AB, BSW, etc.) Master’s degree (MA, MS, MSW, etc.) Doctoral degree (MD, JD, PhD, EdD, etc.)
If you have a degree in social work, what type of degree do you have? (Select All That Apply)*	Not applicable BSW or equivalent MSW or equivalent PhD or DSW
If you are joining in a group, please enter the total number of participants?	Number
One of the below open ended question will be added to each event registration:
OPTIONAL What would be important for you to learn from this event?	Open ended
OPTIONAL Do you have any questions you would like to submit to the organizers or presenters ahead of the event?	Open ended
OPTIONAL Questions/Comments	Open ended

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