Center for Tribes (CBCT) Evaluation: Tribal Demographic Survey

PURPOSE: The Demographic Survey is used to collect information to gain a better understanding of the status of a tribal child welfare program, including funding sources, demographics of the Tribal population, child welfare services offered, and how the program tracks and manages data. Information on the Demographic Survey is collected by Center staff from any Tribal program receiving Tailored Services from the Center for Tribes.

OMB #: 0970-0XXXX

Expiration Date: XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: This form will be used to collect information on services requested by tribal child welfare programs. Public reporting burden for this collection of information is estimated to average 45 minutes including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. If you have any comments on this collection of information, please contact Roshanda Shoulders, ACF, Administration on Children, Youth and Families by e-mail at [email protected].

Capacity Building Center for Tribes

Tribal Demographic Survey

Official Tribe Name:

Date:

Contact Information

Name of Tribal Child Welfare Program _____________________________________________________________

Tribal Child Welfare Program Services
	Yes	No
Tribal/state IV-E agreement in place
If yes, Administrative reimbursement funds
If yes, Maintenance reimbursement payments
If yes, Training reimbursement funds

If Tribe has a federal IV-E planning grant:

Tribal Title IV-E Development Grant & IV-E Plan Information

Did the tribe have an adoption program in operation prior to receiving the IV-E Plan Development Grant?  Y  N

Is the tribe using an outside consultant to develop its IV-E Plan?  Y  N

Date grant activities began:

______________ / __________

month year

Has the tribe received a no-cost extension to complete grant activities?

 Y  N

Date pre-print was submitted:

______________ / __________ OR  currently in progress

month year

Date IV-E plan was approved:

______________ / __________ OR  plan awaiting approval

month year

Does the tribe have a current tribal-state IV-E agreement?

 Y  N

If Yes, with which state(s) _______________________________________

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
State(s) in which reservation/tribal communities are located
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
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: