Center for Tribes (CBCT) Evaluation: Request for Services Form

PURPOSE: Upon receipt of an Inquiry Form, Center staff call a representative of the Tribal program to establish eligibility and briefly describe Services. If the representative is still interested, Center staff complete this Tribal Request for Services Form to collect additional contact information, requested services, eligibility, other technical assistance being received, and child welfare jurisdiction.

OMB #: 0970-0XXXX

Expiration Date: XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: This collection of information will be used to collect a tribal child welfare program’s contact information, purpose of their request for services, and eligibility for technical assistance. Public reporting burden for this collection of information is estimated to average 60 minutes 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. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. If you have any comments on this collection of information, please contact Roshanda Shoulders, ACF, Administration on Children, Youth and Families by e-mail at Roshanda.Shoulders@ACF.hhs.gov.

Tribal Request for Services Form

Thank you for your interest in the Capacity Building Center for Tribes. We are a technical assistance center funded by the Children’s Bureau to provide services in partnership with tribes that receive federal Title IV-B and/or Title IV-E funding to operate a tribal child welfare program. Information provided in this form helps guide planning for potential capacity building technical assistance services.

For helpful tools and resources for tribal child welfare professionals and programs, be sure to visit the Tribal Information Exchange at www.tribalinformationexchange.org.

Contact Information
Date of Request:	Click or tap to enter a date.
Tribal Program Name:	Click or tap here to enter text.
Department/Agency Requesting Services:	Click or tap here to enter text.
Requestor Name:	Click or tap here to enter text.	Requestor Title:	Click or tap here to enter text.
Primary Contact:	☐ Yes ☐ No If no, Primary Contact Name:		Click or tap here to enter text.
Work Phone:	Click or tap here to enter text.	Mobile Phone:	Click or tap here to enter text.
Email Address:	Click or tap here to enter text.
Program Address:	Click or tap here to enter text.	City, State, Zip:	Click or tap here to enter text.

Purpose of Request

Please tell us more about your request for services.

Click or tap here to enter text.

What services or materials (if any) have you accessed from the Center for Tribes?

Click or tap here to enter text.

Capacity Building Services Eligibility Note: Tribal funding information assists with determining eligibility for technical assistance. Services are available for tribes who receive Title IV-B or Title IV-E funding.
Does your tribe receive Title IV-B (Subparts 1 and/or 2) funds?	☐ Yes ☐ No
Does your tribe receive Title IV-E funds?	☐ Yes ☐ No If yes, please indicate: ☐ Tribal-State Agreement ☐ Direct Title IV-E

Menu of Center Service Areas The following list is an example of service areas which the Capacity Building Center for Tribes can provide capacity building technical assistance with your tribal program. Please identify those you feel are most important to improving your tribal child welfare program.
☐ Child Welfare Practice Mapping ☐ Child Welfare-Tribal Court Collaboration ☐ Community Engagement ☐ Continuous Quality Improvement/Quality Assurance ☐ Data/Technology ☐ Family Preservation ☐ Foster/Kinship/Adoption Programs ☐ Leadership Support ☐ Permanency Practice, including Tribal Customary Adoption	☐ Practice/Operations Manual ☐ Program Policies and Procedures ☐ Prevention Services ☐ Organizational Assessment ☐ Strategic Planning ☐ Trauma-Informed Care ☐ Title IV-B Plan Supports ☐ Title IV-E Supports ☐ Tribal-State Partnerships ☐ Workforce Development ☐ Other: Click or tap here to enter text.

Current Child Welfare Assistance/Capacity Building
Is your tribal child welfare program currently receiving technical assistance or capacity building services?	☐ Yes ☐ No
If yes, please describe the service(s) your program is receiving:	Click or tap here to enter text.

Child Welfare Capacity Building Service Agencies Have you requested technical assistance for Title IV-B and/or Title IV-E services or for general child welfare services with any of the following child welfare capacity building service agencies?
Check the box if you have requested services from any of the following entities:	Name of person you contacted:	Did your tribal agency receive assistance?
☐ Children’s Bureau ☐ Regional Office ☐ Central Office	Click or tap here to enter text.	☐ Yes ☐ No If yes, please describe the result of your request: Click or tap here to enter text.
☐ Bureau of Indian Affairs (BIA)	Click or tap here to enter text.	☐ Yes ☐ No If yes, please describe the result of your request: Click or tap here to enter text.
☐ Private Providers (examples) ☐ National Indian Child Welfare Association (NICWA) ☐ Casey Family Programs ☐ Other, Click or tap here to enter text.	Click or tap here to enter text.	☐ Yes ☐ No If yes, please describe the result of your request: Click or tap here to enter text.

Child Welfare Jurisdiction
Does the Bureau of Indian Affairs (BIA) provide any part of your tribal child welfare services?	☐ Yes ☐ No
If yes, please describe which services the BIA provides:	Click or tap here to enter text.
Is your tribe self-governing?	☐ Yes ☐ No
Is your tribe subject to Public Law-280?	☐ Yes ☐ No
Are there other jurisdictional considerations that affect tribal child welfare services?	☐ Yes ☐ No
If yes, please explain:	Click or tap here to enter text.

Office Use Only
Date Request for Services received:	Click or tap to enter a date.
Date Request for Services Discussed with TCWP:	Click or tap to enter a date.
Date TCWP referred to TIE:	Click or tap to enter a date.
Additional notes:	Click or tap here to enter text.
Date Assigned to CW Specialist:	Click or tap to enter a date.
Date of Initial Exploration Call:	Click or tap to enter a date.
Date of Debrief Call:	Click or tap to enter a date.
Debrief Call Participants:	Click or tap here to enter text.
Date of Call with TCWP following Debrief Call:	Click or tap to enter a date.

Capacity Building Center for Tribes

Integrated Services Inquiry Form

V01 rev. 06-24-20