Part A—Indian Child Welfare Act Data

OMB Control No. 1076-0131, Expires xx/xxxx

INDIAN CHILD WELFARE QUARTERLY AND ANNUAL REPORT

Directions: Tribes must only fill out the section(s) (Part A and/or Part B) below that pertains to their tribal program(s).

PART A - INDIAN CHILD WELFARE ACT (ICWA) DATA ICWA Contract/Grant No. _______________________

Name of Program _____________________________

1. Do you have any Tribal/State Agreements, i.e. Title IV-E Agreements, etc. involving child welfare/assistance? ___ Yes or ___ No (Check One) Please explain: ­________________________________

_____________________________________________________________________________________

2. ICWA Notifications	Q1	Q2	Q3	Q4	TOTAL
Total Number New Received
Total Number Acted On
Participated in State Court Hearing
Participated in Case Planning
Transferred to Tribal Court
Placement with Relative
Placement in Indian Foster Home
Placement in non-Indian Foster Home
Total Number New Acted On (Non-Tribal)
3. Placement Funding Source	Q1	Q2	Q3	Q4	TOTAL
Title IV-E
BIA Child Assistance
Other, Please specify

PART B – TRIBAL CHILD ABUSE AND NEGLECT DATA (Only those Tribes/Grantees that operate a child protection programs should complete Part B. If the Tribe’s child protection program is carried out by the State, then Part B of this form is not required. )
Tribal Child Abuse and Neglect Data	Q1		Q2	Q3	Q4		TOTAL
Total Reports/Referrals Received
Substantiated
Unsubstantiated
Sexual Abuse
Physical Abuse
Neglect
Alcohol Involved
Drugs and/or Inhalants
Recurring Cases
Cases of Siblings Involved
Placements Out of Home
Petition to Tribal Court
Referral to Tribal Social Services
Domestic Violence Involved
Total Number of Child Protection Workers
Name of Tribe:
Fiscal Year:		Date:
Preparer’s Signature & Title:
Preparer’s Name (Please Print):

INSTRUCTIONS

Indian Child Welfare Quarterly and Annual Report

The Tribe/Grantee should complete the Indian Child Welfare Quarterly and Annual Report on a quarterly basis, in accordance with the following schedule:

Reporting by Fiscal Year
For reporting period:	Please submit your report by:
Q1: First Quarter (October 1 - December 31)	30 days after the end of Q1
Q2: Second Quarter (January 1 - March 31)	30 days after the end of Q2
Q3: Third Quarter (April 1 – June 30)	30 days after the end of Q3
Q4: Fourth Quarter (July 1 – September 30)	45 days after the end of Q4
End of the Year Total

Reporting Requirements

There are two parts to the Indian Child Welfare Quarterly and Annual Report: Part A – Indian Child Welfare Act (ICWA) Data, and Part B – Child Abuse and Neglect Data.

Part A: All Tribes/Grantees should complete Part A.

Part B: Only those Tribes/Grantees that operate a child protection programs should complete Part B. If the Tribe’s child protection program is carried out by the State, then Part B of this form is not required.

Explanation of Reporting Indicators

Note: All quarterly entries should be “new” for each quarter. Do not “carryover” quarterly entries. The End of Year (EOY) total should be the sum of all four quarters.

For example: For Q1, there were two new children placed in foster homes;

In Q2, there were no new children placed;

In Q3, there was one new child placed;

In Q4, there were no new children placed.

The total for EOY = 3 children placed in foster homes during the fiscal year.

PART A – INDIAN CHILD WELFARE ACT (ICWA) DATA

Identify the ICWA Contract/Grant No. and the Name of the Program.

1. Do you have any Tribal/State Agreements regarding child welfare/assistance?

Please indicate whether the Tribe has a Tribal/State Agreement regarding child welfare/assistance by checking the appropriate response (“yes” or “no”).

Next, please explain the different types of agreements your Tribe has in place with the State (if any). For example: Title IV-E agreements, Title IV-E contracts, Joint Power Agreements, and so forth. If your Tribe has no Agreements in place, please write “none”.

2. ICWA Notifications

1. Total Number Received – Enter the number of new ICWA notifications your Tribe received during the quarter.

2. Total Number Acted On – Enter the number of new ICWA notifications the Tribe acted on during the quarter. “Acted on” means action taken by the Tribe after receiving and processing the ICWA notification.

1. Participated in State Hearing – Enter the number of new ICWA cases in which your Tribe participated in a state court hearing.

2. Participated in Case Planning – Enter the number of new ICWA cases in which your Tribe participated in case planning.

3. Transferred to Tribal Court – Enter the number of new ICWA cases transferred from a State Court to Tribal Court.

4. Placement with Relative – Enter the number of new children placed with the Indian child’s relative as of the end of the quarter.

5. Placement in Indian Foster Home – Enter the number of new children placed in Indian/Tribal foster homes as of the end of the quarter.

6. Placement in non-Indian Foster Home – Enter the number of new children placed in non-Indian/non-Tribal foster homes as of the end of the quarter.

1. Total Acted On (Non-Tribal): Enter the number of new ICWA notifications regarding non-tribal members the Tribe acted on during the quarter. “Acted on” means action taken by the Tribe after receiving and processing the ICWA notification. “Non-tribal” means a case when the child or parents are not members of a Federally recognized tribe.

3. Placement Funding Source

1. Title IV-E – Enter the number of new child placements for the quarter that are paid through Title IV-E funds under the Child Welfare and Adoption Assistance Act of 1980 (P.L. 96-272).

2. BIA Child Assistance – Enter the number of new child placements for the quarters that were paid through BIA Child Care Assistance.

3. Other, Please specify – Enter the number of new child placements for each quarter that are paid through sources other than IV-E or BIA Child Care Assistance. Please explain/provide examples of the other sources in each applicable quarter.

PART B – TRIBAL CHILD ABUSE AND NEGLECT DATA

1. Tribal Child Abuse and Neglect Data

1. Total Reports/Referrals Received – Enter the number of child abuse and neglect reports your Tribe received during the quarter.

   1. Substantiated – Enter the number of child abuse and neglect reports substantiated during the quarter.

   2. Unsubstantiated – Enter the number of child abuse and neglect reports unsubstantiated during the quarter.

   3. Sexual Abuse – Enter the number of child abuse and neglect reports involving sexual abuse.

   4. Physical Abuse – Enter the number of child abuse and neglect reports involving physical abuse

   5. Neglect – Enter the number of child abuse and neglect reports involving neglect.

   6. Alcohol Involved – Enter the number of child abuse and neglect reports involving alcohol.

   7. Drugs and/or Inhalants Involved – Enter the number of child abuse and neglect reports involving drugs and/or inhalants.

   8. Recurring Cases – Enter the number of child abuse and neglect reports in which the child and/family has had previous reports made

   9. Cases of Siblings Involved – Enter the number of child abuse and neglect reports involving siblings.

10. Placements Out of Home – Enter the number of child abuse and neglect reports resulting in the child’s placement out of the home.

11. Petition to Tribal Court – Enter the number of child abuse and neglect reports that result in a petition to tribal court.

12. Referral to Tribal Social Services – Enter the number of child abuse and neglect reports referred to Tribal Social Services.

13. Domestic Violence Involved – Enter the number of child abuse and neglect reports involving domestic violence.

14. Total No. Of Child Protection Workers – Enter the number of child protection workers in the tribe’s child protection system. Fractions can be entered. For example, if the tribe has one worker who spends 20 hours during a work week doing child protection, ½ or .5 may be entered. For this category, no yearly total is applicable.

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The preparer (i.e., Tribe/Grantee) must sign and date the form, and send it to their appropriate BIA Regional ICWA contact the due dates listed on the first page (after each quarter). The ICWA contact must make a copy of the report for their files, and forward the original to the following Central Office contact:

Evangeline Campbell, Division of Human Services Chief

Department of Interior – BIA, Office of Indian Services

1849 C Street, NW (MS-4513-MIB)

Washington, DC 20240

Please direct any questions on this form

to the Bureau of Indian Affairs (BIA) ICWA Coordinator for the appropriate BIA Region.

PAPERWORK REDUCTION ACT STATEMENT

This information is being collected for management, planning and budgetary purposes and to provide BIA with baseline data for setting and measuring performance goals. Response to this request is required to obtain a benefit in accordance with 25 CFR 23. You are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this form is estimated to average 15 minutes per response per section (Part A and Part B), including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-3642, Washington, DC 20240.

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