Center for States (CBCS) Evaluation: Event Registration

Event Registration

PURPOSE: Participants will register for Center for States-hosted events using the following questions. Registration is programmed into the virtual event platform (Adobe Connect, etc.) or survey platform (Qualtrics, etc.).

OMB #: 0970-0XXXX

Expiration Date: XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to gather basic registration information on capacity building 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. The control number for this project is 0970-XXXX. The control number expires on XX/XX/XXXX. If you have any comments on this collection of information, please contact Beth Claxon, ACF, Administration on Children, Youth and Families by e-mail at Beth.Claxon@acf.hhs.gov.

Instructions for Event Registration

Participants will register for Center for States-hosted events using the following questions. Registration is programmed into the virtual event platform (Adobe Connect, etc) or survey platform (Qualtrics, etc.). Required questions are denoted by a red asterisk (*).

Registration Form Introduction Text

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 private and all reporting done in aggregate.

1. Email Address*: __________

2. First Name*: __________

3. Last Name*: __________

4. Which best describes you*? (select all that apply)

   • Child Welfare Professional

   • Other Health or Human Services Professional

   • Legal Professional

   • Education Professional

   • Student/Intern

   • Current/Former Youth or Young Adult in Foster or Extended Care

   • Biological Parent/Relative Caregiver/Family Member

   • Non-Relative Foster or Adoptive Family Member

   • Community Member/Community Leader/Tribal Elder

   • Other

5. Jurisdiction*: __________ (pull down menu of US States and Territories)

6. If affiliated with a Tribe, for which Tribe or Tribal Consortia do you work or provide contracted services? __________ (select all that apply from pull down menu of all title IV-B and IV-E Tribes)

7. Position: __________

8. Employer Organization*: __________

9. What best describes your employer/organization*?

   • 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 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

10. For those who work in a child welfare agency, what is your primary role?

    • State Director

    • Regional/Area Director

    • County Director

    • Program Manager/Coordinator

    • Supervisor

    • Front Line Staff/Worker

    • Student Intern

    • Other

    • Parent (includes birth parent, foster parent, kinship/adoptive parent)

    • Parent Partner or Family Leader

11. Which of the following best describes your primary work responsibilities in the agency?

    • Child Welfare Leadership

    • Continuous Quality Improvement/Quality Assurance/Data Analysis

    • CFSR/PIP/CFSP/APSR

    • Policy Development

    • Child Welfare Training

    • Child Welfare Information Systems

    • Indian Child Welfare Act Implementation

    • Child Protective Services - Intake

    • Child Protective Services - Investigation/Assessment

    • Primary Prevention, In-Home Services

    • Foster Care - Case Management

    • Foster Care - Recruitment/Training/Licensing of Resource Families

    • Foster Care - Independent Living/Youth

    • Adoption/Guardianship

    • Youth Leadership/Participation

    • Family Leadership/Participation

    • Court Improvement

    • Legal Representation (of agency/parents/children)

    • Judicial Decision Making

    • Social Work Education

    • Research and Evaluation

    • Student

    • Other Area of Child Welfare-Related Work

    • None of the Above/Not Applicable

12. For court and legal professionals, what is your primary role?

    • 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

13. For education and university professionals, what is your primary role?

    • Dean/Director/Administrator

    • Teaching Faculty

    • Training Academy Leadership/Staff

    • Research Faculty/Staff (non-teaching role)

    • Student

    • Other

14. How many years of experience do you have working in the child welfare*?

    • 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

15. Which was the highest level of education you completed?

    • 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.)

    • Professional degree (MD, DDC, JD, etc.)

    • Doctoral degree (PhD, EdD, etc.)

16. If you have a degree in social work, what type of degree do you have?

    • Not applicable

    • BSW or equivalent

    • MSW or equivalent

    • PhD or DSW

17. Do you plan on participating in a group? (sharing one registration)

    • No

    • Yes

      • [If yes] In addition to yourself, how many people will be in your group? If you don’t know the exact number at this time, please provide an estimate (e.g., 2, 10): __________

18. The Center for States would like your feedback to improve our messaging and service delivery. May we contact you in the future to provide further feedback or to participate in a survey, interview or focus group?

    • No

    • Yes

19. Please tell us why you are registering for this event today: __________

20. Questions/Comments: __________

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