Child Welfare Virtual Conference Registration Form

C hild Welfare Virtual Expo

Registration Form

OMB Control No.: 0970-0501

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) The purpose of this information collection is to better understand how the Capacity Building Center for States, a service of the Children’s Bureau, is engaging and making resources available to Child Welfare Virtual Expo audiences. Public reporting burden for this collection of information is estimated to average 3 minutes per respondent, including the time for reviewing instructions. This is a voluntary collection of information. A federal agency may not conduct or sponsor, and no individual or entity is required to respond to, nor shall an individual or entity be subject to a penalty or failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless that collection of information displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Lisbeth Ensley, Center for States, by e-mail at Lisbeth.Ensley@icf.com.

Expiration Date: xx/xx/xxxx

This is a Child Welfare 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 the Capacity Building Collaborative’s evaluation purposes, with identifying information held private and all reporting done in aggregate.

#	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 Capacity Building Center for States Liaison Listserv Colleague Hard-copy publication Search engine (e.g., Google, Yahoo) Capacity Building Collaborative social media (e.g., Facebook, Twitter) Capacity Building Center for Courts Capacity Building Center for Tribes Child Welfare Information Gateway National Child Welfare Workforce Institute (NCWWI) Quality Improvement Center on Workforce Development (QIC-WD) Children’s Bureau Learning and Coordination Center (CBLCC) Other (please specify):__________
7	Have you participated in a previous Child Welfare Virtual Expo?	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/ally Kinship navigator Independent living (IL)/Education and Training Voucher (ETV) coordinator Youth/young adult leader Parent/caregiver 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 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	Do you identify as a family or young adult who is currently or formerly involved with the child welfare system?	Yes No Decline to answer
14	If you plan on participating in a group (sharing one registration), how many people will be in your group?*	Text
15	Would you like to receive information from the Center for States about a future Child Welfare Virtual Expo?	Y/N

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