Form 1 CapLearn Registration

Evaluation of the Child Welfare Capacity Building Collaborative: Part II

CapLearn Registration

CapLEARN Registration

OMB: 0970-0494

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OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx



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Public reporting burden for this collection of information is estimated to be 5 minutes per response 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.

Proposed CapLEARN Registration Fields



CapLEARN is designed to promote learning and support professional development. Please take a moment to create a CapLEARN account. The information that you share will be only be used to help us evaluate and improve our products and services. In some cases, we may contact you to learn about your experience with CapLEARN. Your privacy is important. Your personal information, participation, and CapLEARN scores will be kept confidential, unless you choose to share them (for example, to create a certificate of completion that can be used to apply for Continuing Education Units).

Fields marked with an asterisk (*) are required.

Section 1

New CapLEARN Field Name

New CapLEARN Field Type

First Name*

Text

Last Name*

Text

Address (Select One)*

Picklist (All states, U.S. territories)

E-mail address*

Text

E-mail address confirmation*

Text

Age (Select One)

19 or under

20-29

30-39

40-49

50-59

60-69

70 or over

Gender (Select One)

Female

Male

Transgender

Race/Ethnicity (Select All That Apply)

American Indian/Alaska Native

Asian

Black/African American

Hawaiian/Other Pacific Islander

Hispanic/Latino

White

Other

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 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

Employer/Organization

Text

Job Title

Text



Section 2


New CapLEARN Field Name

New CapLEARN Field Type

What is your primary role in the agency (Select One)*


Agency Director/Deputy Director

Program/Middle Manager

Supervisor

Caseworker/Direct Practice Worker/Frontline staff

Parent Partner

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 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

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

Which of the following best describes your primary role? (Select One)*


Dean/Director/Administrator

Teaching Faculty

Training Academy Leadership/Staff

Research Faculty/Staff (non-teaching role)

Student

Other



Section 3


New CapLEARN Field Name

New CapLEARN Field Type

For which State, County, or Territorial Government, do you work or provide contracted services? (Select All That Apply)*

Not Applicable

Picklist (All States and U.S. Territories)

Other

For which Tribe or Tribal Consortia do you work or provide contracted services? (Select All That Apply)*

Not Applicable

Picklist (All title IV-B and IV-E Tribes)

Other



Section 4

New CapLEARN Field Name

New CapLEARN Field Type

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.)

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

  • Doctoral degree (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

In a sentence or two please share why you are registering for CapLEARN?

Text






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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPho, Hung
File Modified0000-00-00
File Created2021-01-23

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