Part A—Indian Child Welfare Act Data

OMB Control No. 1076-0131

Expires: XX/XX/20XX

INDIAN CHILD WELFARE QUARTERLY AND ANNUAL REPORT

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 must complete Part A.

Part B: Only those Tribes/Grantees or BIA Agencies that operate a child protection program should complete Part B. If the Tribe’s child protection program is carried out by the State or BIA, then Part B of this form is not required by the Tribe. If the BIA is operating the child protection program for the Tribe, the BIA Agency is responsible for submitting Part B.

Note: This report captures information about services needed and provided for Indian children and families. Indian child means any unmarried person who is under age 18 and either: (1) Is a member or citizen of an Indian Tribe; or (2) Is eligible for membership or citizenship in an Indian Tribe and is the biological child of a member/citizen of an Indian Tribe. 25 CFR §23.2.

Schedule for Reporting

The Tribe/Grantee or BIA Agency completes 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 (i.e., by January 30)
Q2: Second Quarter (January 1 - March 31)	30 days after the end of Q2 (i.e., by April 30)
Q3: Third Quarter (April 1 – June 30)	30 days after the end of Q3 (i.e., by July 30)
Q4: Fourth Quarter (July 1 – September 30)	45 days after the end of Q4 (i.e., by November 14)
End of the Year Total

Reporting by Calendar Year
For reporting period:	Please submit your report by:
Q1: First Quarter (January 1 – March 31)	30 days after the end of Q1 (i.e., by April 30)
Q2: Second Quarter (April 1 - June 30)	30 days after the end of Q2 (i.e., by July 30)
Q3: Third Quarter (July 1 – September 30)	30 days after the end of Q3 (i.e., by October 30)
Q4: Fourth Quarter (October 1 – December 31)	45 days after the end of Q4 (i.e., by February 14)
End of the Year Total

PART A - INDIAN CHILD WELFARE ACT (ICWA) DATA

Tribes fill out Part A below for their ICWA program(s).

1. Official Name of Tribe: ______________________________________________

2. Name of Program: __________________________________________________________________________

3. ICWA Contract/Grant No.:____________________________________________________________________

4. BIA Region:________________________________________________________________________________

5. Identify the type of program operated through by placing a checkmark beside one of the options below:

____OSG: Tribes operating under ISDEAA Self-Governance Funding Agreements

____638: Tribes operating the under ISDEAA Title I Contracts.

_______________________________________________________________________________________

6. 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
Placement in Group Home or Residential Facility
Child Remains in Home (Family Preservation Services Provided)
Transferred to Tribal Court and Case Managed by the Tribe
Total Number of New Non-Tribal ICWA Notices “Acted On”
Total Number of ICWA Workers
7. Placement Funding Source	Q1		Q2	Q3	Q4	TOTAL
Title IV-E
BIA Child Assistance
State
D. Other (Please specify in the narrative).
Fiscal or Calendar Year:		Date:
Preparer’s Signature & Title:
Preparer’s Name (Please Print):

INSTRUCTIONS FOR PART A - INDIAN CHILD WELFARE ACT (ICWA) DATA

1.-4. Identify the Official Name of the Tribe, Name of the Program, ICWA Contract/Grant No., and the BIA Region.

5. Identify the type of program operated as either OSG (i.e., Tribes operating under ISDEAA Self-Governance Funding Agreements) or 638 (i.e., Tribes operating the under ISDEAA Title I Contracts).

6. ICWA Notifications

1. Total Number New Received – Enter the number of new ICWA notifications your Tribe received during the quarter. This number should not include duplicate counts, unless a case opened, closed and reopened again in another quarter.

2. Total Number Acted On – Enter the number of new and on-going ICWA notifications the Tribe acted on during the quarter. “Acted on” means action taken by the Tribe after receiving and processing the ICWA notification including the actions below. This Total Number Acted On will not match the total number of actions listed below.

   1. The Tribe Participated in State Hearing – Enter the number of new and on-going ICWA cases in which your Tribe participated in a state court hearing by phone or in-person.

   2. Participated in Case Planning – Enter the number of new and on-going ICWA cases in which your Tribe participated in case planning by phone or in-person.

   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 and on-going 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 and on-going 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 and on-going children placed in non-Indian/non-Tribal foster homes as of the end of the quarter.

   7. Placement in Group Home or Residential Facility - Enter the number of new and on-going children placed in a group home or residential facility as of the end of the quarter. This could mean residential substance abuse treatment, behavioral health treatment centers or medical institutions.

   8. Child Remains in Home (Family Preservation Services Provided) - Enter the number of children where a child abuse and neglect report was made, however the child remained in the home and family preservation services were provided.

   9. Number of Cases Transferred to Tribal Court and Case Managed by the Tribe -Enter the total number of cases transferred from the state court and case managed by the Tribe.

3. Total Number of New Non-Tribal ICWA Notices “Acted On”: Enter the number of new ICWA notifications regarding non-Tribal members the Tribe acted on during the quarter. “Acted on” means responded to by letter, email, or phone call 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.

4. Total Number of ICWA Workers: Enter the total number of ICWA workers/staff that respond to ICWA Notices or work on ICWA cases

(Instructions continue on next page)

7. Placement Funding Source

5. Title IV-E – Enter the number of new and on-going 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).

6. BIA Child Assistance – Enter the number of new and on-going child placements for the quarter that were paid through BIA Child Assistance.

7. State: Enter the number of new and on-going child placements for the quarter that are paid by the State.

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

The preparer (i.e., Tribe/Grantee or BIA Agency) must sign and date the form, and send it to their appropriate BIA Regional Social Worker by the due dates listed.

Please direct any questions on this form to the BIA Regional Social Worker in your respective region.

PART B – TRIBAL CHILD ABUSE AND NEGLECT DATA

Tribes or BIA Agencies fill out Part B below for their program(s).

Do not fill out if the program does not provide child protection services.

If the Tribe’s child protection program is carried out by the State and BIA, then Part B of this form is not required.

1. Official Name of Tribe : ______________________________________________

2. Name of Program: __________________________________________________________________________

3. ICWA Contract/Grant No.:____________________________________________________________________

4. BIA Region:________________________________________________________________________________

5. Identify the type of program operated through (Check One):

___ OSG: Tribes operating under ISDEAA Self-Governance Funding Agreements.

___ 638: Tribes operating the under ISDEAA Title I Contracts.

___ BIA: The BIA is providing child protection and/or child welfare services.

6. Does your program have any Tribal/State Agreements (i.e. Title IV-E Agreements, etc.) involving child welfare/assistance? ___ Yes or ___ No (Check One) Please explain the different types of agreements the Tribe has in place with the State (if any). ________________________________________________________

_________________________________________________________________________________________

7. Please identify who provides case management services (Check one): ___ Tribe ___ BIA ___ State

8. Please identify who provides child protection services (Check one): ___ Tribe ___ BIA ___ State

9. Tribal Child Abuse and Neglect Data	Q1	Q2	Q3	Q4	TOTAL
Total Reports/Referrals Received
Substantiated (court involvement)
Unsubstantiated (case closed- no action taken)
Pending (case opened for services or investigation)
Sexual Abuse
Physical Abuse
Neglect
Psychological Abuse
I. Verbal Abuse
Alcohol Involved
Drugs and/or Inhalants Involved (not listed below)
(a) Prescription Drugs Involved
(b) Methamphetamine Involved

Recurring Cases
Cases of Siblings Involved
Placement with Relative
Placement in Indian Foster Home
Placement in Non-Indian Foster- Home
Placement in Group Home or Residential Facility
R. Child Remains in Home (Family Preservation Services Provided)
S. Petition to Tribal Court
T. Human Trafficking Involved
U. Domestic Violence Involved
V. Total Number of Child Protection or Child Welfare Workers (explain child-staff ratio in narrative)
Fiscal or Calendar Year:		Date:
Preparer’s Signature & Title:
Preparer’s Name (Please Print):

INSTRUCTIONS FOR PART B – TRIBAL CHILD ABUSE AND NEGLECT DATA

1-4. Identify the Official Name of the Tribe, Name of the Program, ICWA Contract/Grant No., and the BIA Region.

5. Identify the type of program operated by placing a checkmark beside the appropriate option.

6. Identify whether your program has any Tribal/State Agreements (i.e. Title IV-E Agreements, etc.) involving child welfare/assistance in place.

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”.

7. Please identify whether the Tribe, BIA, or State provides case management services by placing a checkmark beside the appropriate option.

8. Please identify whether the Tribe, BIA, or State provides child protection services by placing a checkmark beside the appropriate option.

9. 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.

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

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

D. Pending – Enter the number of child abuse and neglects reports opened for services only (family preservation services) or investigation where the child remains in the home and the case in monitored or being investigated.

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

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

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

H. Psychological Abuse - Enter the number of child abuse and neglect reports involving psychological abuse.

I. Verbal Abuse – Enter the number of child abuse and neglect reports involving verbal abuse.

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

K. Drugs and/or Inhalants Involved – Enter the number of child abuse and neglect reports involving drugs and/or inhalants (Do not include prescription drugs or methamphetamines).

(a). Prescription Drugs Involved - Enter the number of child abuse and neglect reports involving prescription drugs.

(b). Methamphetamine Involved - Enter the number of child abuse and neglect reports involving methamphetamines.

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

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

14. Placements With Relatives – Enter the number of child abuse and neglect reports resulting in the child’s placement out of the home and with relatives.

15. Placements in Indian Foster Home – Enter the number of new and on-going placements of children in Indian foster homes as of the end of the quarter.

16. Placement in Non-Indian/non-Tribal Foster homes – Enter the number of new and on-going placements of children in non-Indian/non-Tribal foster homes as of the end of the quarter.

17. Placement in Group Home or Residential Facility – Enter the number of new and on-going placements of children in group homes or residential facility as of the end of the quarter. This could mean residential substance abuse treatment, behavioral health treatment centers, or medical institutions.

18. Child Remains in Home (Family Preservation Services Provided) – Enter the number of children where a child abuse and neglect report was made, but the child remained in the home and family preservation services were provided.

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

T. Human Trafficking Involved – Enter the number of child abuse and neglect reports where human trafficking was involved.

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

V. Total No. Of Child Protection or Child Welfare Workers – Enter the number of child protection or child welfare workers and case management 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. Explain the staff-child ratio in the narrative. For this category, no yearly total is applicable.

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The preparer (i.e., Tribe/Grantee or BIA Agency) must sign and date the form, and send it to their appropriate BIA Regional Social Worker by the due dates listed.

Please direct any questions on this form

to the BIA Regional Social Worker in your respective 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 30 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: [email protected] or Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4660, Washington, DC 20240. Do not provide your completed form to this address; instead, send your completed form to your appropriate BIA Regional Social Worker.

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