Evaluation of the Improving Child Welfare Outcome through Systems of Care Grant Program - Organizational Structure Form for Non-Case Study Sites

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Public reporting burden for this collection of information is estimated to be 1 hour to complete this questionnaire. 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. The control number for this project is 0970-0288. The control number expires on X/X/XXXX.

rganizational Structure

Submission Instructions: This form asks you to describe and diagram the roles and relationships of key players involved with the Systems of Care initiative at the end of year five.

1. Target Community Organizational Structure

A. Lead Child Welfare agency. Identify the lead Systems of Care Child Welfare agency. The lead child welfare agency is identified as the contractual and fiscal lead for the implementation of your Systems of Care initiative.

B. Child Welfare administrative structure. Identify which of the following best described your Systems of Care Child Welfare agency:

• state administered;

• state supervised, county administered;

• state administered with strong county structure and discretion;

• county administered with strong state support;

• county administered;

• city administered; or,

• administered specific to your jurisdictional needs (please specify here).

C. Other relevant agencies: List other city, county, and/or state service agencies that might also be working with your target population, but may or may not be involved in the systems of care initiative, directly. For example, your local juvenile justice department might be serving some of the youth in your target population, but the department may not be directly (or actively) involved in your local initiative, at least at this time. Please indicate whether each agency is involved directly with your systems of care.

2. Systems of Care Organizational Structure

A. Collaborative groups, coalitions, community agencies, organizations, and groups involved in the initiative: In addition to the organizations that are formal systems in your community that address the needs of your target population, there are several other groups that may be involved with the initiative such as parent groups, universities, or community service organizations. List the names of these groups affiliated with Systems of Care and how they related to the lead Systems of Care child welfare agency.

Role: For each agency, organization, or group listed describe its role in Systems of Care. Please describe if and how these groups relate to the state and/or county agencies.

B. Diagram of Systems of Care Organizational Structure

Please draw a simple chart depicting the organizational structure of your Systems of Care initiative. The drawing should show the relationships among collaborative groups and coalitions in your community. The relationship should show how the collaborative groups relate to the state or county level, if relevant. Please use asterisk to note any groups that were in existence prior to your Systems of Care efforts.

1. TARGET COMMUNITY ORGANIZATIONAL STRUCTURE

A. Lead Child Welfare Agency

Lead Agency:

B. Child Welfare Administrative Structure

Please check which administrative structure best represents your SoC site
	state administered;
	state supervised, county administered;
	state administered with strong county structure and discretion;
	county administered with strong state support;
	county administered;
	city administered; or,
	administered specific to your jurisdictional needs (please specify here).

C. Other Relevant Agencies, Organizations and Groups Involved with the Target Population

A. Agency, Organization, or Group Name		B. Please indicate how each agency is involved with the target population (i.e., provides direct services)
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2. Systems of Care Organizational Structure

A. Collaborative groups, coalitions, community agencies, organizations, and groups involved in the initiative

In addition to the organizations that are formal systems in your community that address the needs of your target population, there are several other groups that may be involved with the initiative such as parent groups, universities, or community service organizations. List the names of these groups affiliated with Systems of Care and how they related to the lead Systems of Care child welfare agency. Please use an asterisk to note any groups that were in existence prior to the start of your Systems of Care efforts.

Role: For each agency, organization, or group listed describe its role in Systems of Care. Please describe if and how these groups relate to the state and/or county agencies.

Collaborative groups, coalitions, community agencies, and organizations involved		Role
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B. Diagram of Systems of Care Organizational Structure