Center for Tribes Demographic Survey

Capacity Building Center for Tribes

Tribal Demographic Survey

OMB Control No.: 0970-0484 Expiration Date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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.

Official Tribe Name:

Date:

Contact Information

Program Name _____________________________________________________________

Contact ___________________________________________________________________

Title ______________________________________________________________________

Address ___________________________________________________________________

__________________________________________________________________________

Phone ___________________________________________

Email ____________________________________________

Website __________________________________________

Tribal Population and Location
# enrolled tribal members
# or % of enrolled tribal members living on-reservation or within tribal boundaries
# or % of tribal population under age 18
Approximate size (e.g., acres) of reservation or tribal communities
State(s) in which reservation/tribal communities are located
Children’s Bureau Region
BIA Region
Law Enforcement, Tribal Court, and Judiciary
Which agencies provide law enforcement for the tribe? (circle all that apply)	Tribe	BIA	State	County	FBI	Other (name):
Which law enforcement agency/agencies most often assists with child welfare matters? (circle all that apply)	Tribe	BIA	State	County	FBI	Other (name):
Does the tribe have an independent judiciary?			Yes	No
Does the tribe have its own court that makes determinations in child welfare cases?			Yes	No	Part of an intertribal court

Additional Comments:

Child Welfare Program Services
	Yes	No
Does the tribe currently operate a child welfare program? If the tribe does not currently operate a child welfare program, please skip to Page 5-Child Welfare Staffing.
If the tribe operates a child welfare program, please check Yes or No for each service area below. If yes, also indicate whether policies and procedures are in place for that service.
	Yes	No	If yes, check if policies & procedures for this service are in place
Child protection investigations
Permanency planning
Case management
Family preservation
Child abuse & neglect prevention
ICWA
Foster/kinship care/resource family recruitment
Foster/kinship care/resource family placements
Foster care/resource family licensing by tribe
Transitional or independent living services for youth
Other services for youth (please indicate) _____________________________________ _____________________________________ _____________________________________
Kinship guardianships
Adoptions
Customary adoptions
Cultural programs
Other: _________________________________
Other: _________________________________
Other: _________________________________

	Yes	No
In addition to the tribal program, do any outside/non-tribal agencies provide child welfare services for the tribe?
If yes, which agencies provide child welfare services for the tribe (circle all that apply)	BIA	State	County	Other (name)
Service(s) provided by other agencies: ______________________________________ ______________________________________ ______________________________________ ______________________________________

Additional Comments:

Child Welfare Staffing
Instructions for this section: Please write in the staff positions of the child welfare program and indicate the number of staff currently working in each position, the number of position vacancies, and the required educational level for the position (if any).
Staff Position	# staff currently in position	# positions vacant	Required educational level

Additional Comments:

Data Management & Child Welfare Program Statistics
	Yes	No
Does the child welfare program have an electronic data management system?
If yes, what is the name of this system? _________________________________________________
If No, how does the program track and manage data? _____________________________________________ _____________________________________________ _____________________________________________
	Yes	No
If the program does not currently have an electronic data management system, is it considering obtaining one in the near future?
If yes, name of system(s) under consideration: _____________________________________________ _____________________________________________ _____________________________________________
Estimated number of children currently served by the tribal child welfare program __________
Estimated number of children currently in out-of-home placements __________	__________ Tribal __________ State or other
Current number of tribal foster/kinship/resource homes __________	Of these: # licensed by tribe __________ # licensed by state __________
Estimated number of ICWA cases in which the tribal child welfare program is actively involved __________
Estimated number of ICWA notifications received monthly __________

Additional Comments:

7