Form 1 CapLearn registration fields

OMB Control Number: 0970-0401

               Expiration Date: 05-31-2018

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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