Form Part B Part B Part B—Tribal Child Abuse and Neglect Data

Part B Form OMB Control No. 1076-0131

Expires: XX/XX/XXXX

CHILD ABUSE AND NEGLECT REPORT

Part B Form

Applicability

Tribes or Bureau of Indian Affairs (BIA) Agencies operating a child protection program under 25 CFR Part 20.402 will fill out the child abuse and neglect report.

Do not fill out the child abuse and neglect report, if the Tribe or BIA agency does not provide child protection services.

Child Protection Services (CPS) are services given by child protection program to stop or relieve the abuse or neglect of children. CPS includes making home visits to find out if abuse or neglect is or has been happening. Program case workers arrange for home living, legal action, case plans, counseling, referrals, and health care as needed.

1. Official Name of Tribe:

2. Contract No.:

Fiscal Year (FY) or Calendar Year (CY):

3. BIA Region:

4. Does your program have any Tribal/State Agreements (i.e. Title IV-E Agreements, etc.) involving child welfare/assistance?

Yes

No

Please explain the different types of agreements the Tribe has in place with the State (if any).

5. Please identify who provides case management services (Check one):

Tribe

BIA

State

6. Please identify who provides Child Protection Services (Check one):

Tribe

BIA

State

7. Is there an active Child Protection Team? (Check one)

Yes

No

8. Child Abuse and Neglect Referrals/Reports

Q1

Q2

Q3

Q4

TOTAL

Total number of child abuse and neglect cases referred to your program. The person who referred may be a community member or employee from Tribe, State, or Law Enforcement.

Recurring Cases or cases referred more than once

Cases of Siblings Involved

9. Type of Child Abuse/Neglect referral or reasons for referral

Q1

Q2

Q3

Q4

TOTAL

Child harmed sexually

Child harmed physically

Child harmed by being neglected

Child harmed emotionally

The case child case involves wine, beer, spirits, or other alcohol drinks by child or parent

Drugs and/or Inhalants Involved by parent (not listed below)

(a) Prescription Drugs Involved

(b) Methamphetamine Involved

(c) Child born drug affected Involved

(d) Opiates (Fentanyl) Involved

Domestic Violence Involved (Other family members fear harm who are living in child’s home)

Parent who cares for the child is in jail

Home is not safe or available for the child to live

10. Investigation Outcome

Q1

Q2

Q3

Q4

TOTAL

Tribal court involvement – Meets the definition of child abuse and neglect as defined by Tribes’ Law and Order Code.

Cases closed - No services required as the referral did not meet the definition of child abuse and neglect as defined by the Tribe’s Law and Order Code.

Child remains in the home (Movement to keep children at home.)

11. Placement of child(ren) if they were removed from their home

Q1

Q2

Q3

Q4

TOTAL

Child placed with Relative/Kinship

Child placed in an Indian Foster Home

Child placed in a Non-Indian Foster- Home

Child placed in a group or home living center

12. Case Plan Goal

Q1

Q2

Q3

Q4

TOTAL

Total number of cases the Tribe or BIA Agency developed case plans for

Reunification with Parent

Live with Other Relatives

Adoption

Guardianship

Emancipation

Long Term Foster Care

Missing Case Plan Goal

13. Exits from Foster Care

Q1

Q2

Q3

Q4

TOTAL

Return to parent(s).

Guardianship by Indian Family or Kinship.

Guardianship by non-Indian family.

Adoption by Indian Family or Kinship.

Adoption by non-Indian family.

Emancipation from Foster Care or child “aged out” while in Foster Care.

Child died while in Foster Care.

Child ran away from Foster Care.

14. Program Staff

Q1

Q2

Q3

Q4

TOTAL

Total Number of Child Protection or Child Welfare Workers

Preparer’s Certification

Preparer’s Name and Title (Please Print):

Date:

Preparer’s Signature

Regional Social Worker (Certification):

FORM INSTRUCTIONS

1-3. Identify the Official Name of the Tribe, Name of the Program, Contract No., fiscal year or calendar year and the BIA Region.

4. 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”.

5. Identify whether the Tribe, BIA, or State provides case management services by placing a checkmark beside the appropriate option.

6. Identify whether the Tribe, BIA, or State provides child protection services by placing a checkmark beside the appropriate option.

7. Identify whether the Tribe has an active Child Protection Team.

8. Child Abuse and Neglect Referrals/Reports-

1. Total number of child abuse and neglect cases referred to Tribe or BIA Agency - Enter the number of child abuse neglect cases referred to your program. The person who referred may be a community member or employee from Tribe, State, or Law Enforcement. Referrals may come from any reporters. Public Law 101-630, the Indian Child Protection and Family Violence Prevention Act requires that referrals that involve suspected child abuse and/or neglect will be cross reported to law enforcement, within 36 hours of receiving the referral. Do not count the same child more than once in this section. If the child was referred again, count them below in 8B. under recurring cases.

2. Recurring Cases - Enter the number of child abuse and neglect reports in which the child and/family has had more than one report made of child abuse and neglect.

3. Cases of Siblings Involved-Enter the number of cases where there are two or more siblings are involved in same case.

9. Type of Child Abuse/Neglect Referral - You may count the same child more than once in this section if the type of abuse or neglect applies to that child.

1. Child harmed sexually - Enter the number of child abuse and neglect reports involving a sexually harmed child.

2. Child harmed physically - Enter the number of child abuse and neglect reports involving a physically harmed child.

3. Child harmed by being neglected - Enter the number of child abuse and neglect reports involving a child suffering from neglect.

4. Child harmed emotionally - Enter the number of child abuse and neglect reports involving situations where the child suffered harmed emotional harm.

5. The case child case involves wine, beer, spirits, or other alcohol drinks by the child or parent - Enter the number of child abuse and neglect reports involving situations that involved wine, beer, spirits, or other alcoholic drinks by the child or parent.

6. 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.

(c) Child born drug affected Involved - Enter the number of child abuse and neglect reports involving children born drug affected.

(d) Opiates (Fentanyl) Involved - Enter the number of child abuse and neglect reports involving opiates (Fentanyl).

7. Domestic Violence Involved - Enter the number of child abuse and neglect reports involving domestic violence or where other family members are afraid to live in the home.

8. Parent who cares for the child in jail - Enter the number of children referred to the program because their caretaking parent was in jail and could no longer care for them.

9. Home is not safe or available for the child to live - Enter the number of children referred to your program due to their home living conditions and/or there was no safe home available for children to live.

10. Investigation Outcome - Do not count the same child more than once unless their case closed and opened again.

1. Tribal court involvement - Meets the definition of child abuse and neglect as defined by Tribes’ Law and Order Code. - Enter the number of child abuse and neglect reports that result in a petition to tribal court.

2. Cases closed - No services required as the referral did not meet the definition of child abuse and neglect as defined by the Tribe’s Law and Order Code. - Enter the number of child abuse and neglect reports that did not meet the definition of child abuse and neglect as defined by the Tribe’s Law and Order Code.

3. Child Remains in Home (Movement to keep children at home.) - Enter the number of children who were provided services to stay with parents. Services could be parenting classes, counseling, or providing a parent a ride, help with food, housing, or clothing.

11. Placement of child(ren) if they were removed from their home - You may count the same child more than once if they changed where they have been placed.

1. Child Placed with Relative/Kinship - Enter the number of new and ongoing children placed with the Indian child’s relative at of the end of the quarter who are not licensed.

2. Child Placed in a licensed Indian Foster Home - Enter the number of new and ongoing children placed in licensed Indian/Tribal foster homes at of the end of the quarter.

3. Child Placed in a licensed non- Indian Foster Home - Enter the number of new and ongoing children placed in non-Indian/Tribal foster homes at of the end of the quarter.

4. Child Placed in group or home living center - Enter the number of children placed in group homes or home living centers, including alcohol and drug, mental health, and medical treatment centers. The child can live in place short or long term. Do not include detention centers.

12. Case Plan Goal - You can count the same child more than once if the child’s case plan goal changed.

1. Total number of cases the Tribe or BIA Agency developed case plans for – Enter the number of case plans that were developed for the families as part of family preservation services/case management services.

2. Reunification Plan with Parent - Enter the number of children whose case plan is to live with the parent. The case plan goal of the child(ren) is to reunify the child and parent by eventually placing the child back with the parent.

3. Live with Other Relatives - Enter the number of children whose case plan goal is to place the child with a relative. The program is unable to place the child with a parent because the parent is not around due to death, jail time, or other reasons.

4. Adoption - Enter the number of children whose case plan is adoption. The case plan goal of the child is to have the child adopted (with family or others). The program is unable to place a child with a parent because a parent is not around due to death, jail time, or other reasons.

5. Guardianship - Enter the number of children who have a court order for a legal guardian. The case plan goal of the child is to have the child placed in guardianship because placement with the parent is unable to happen (Parent deceased, incarcerated, offender), and adoption is not an option.

6. Emancipation - Enter the number of children whose case plan goal is emancipation, and the child needs an independent living plan due to age. Child must have legal documentation from court to live on their own.

7. Long-Term Foster Care - Enter the number of children whose case plan goal is long-term foster care for various reasons such as the child having a disability.

8. Missing Case Plan Goal - Enter the number of children missing a case plan goal (a new case and case plan have not been developed yet or for other reasons or no case plan was developed.

13. Exit from Foster Care-Do not count the same child more than once on this section.

1. Return to parent. Enter the number of child cases closed because the child(ren) was placed back with their parent(s). 

2. Guardianship by Indian Family or Kinship. Enter the child cases closed because the child was placed in guardianship with an Indian family or Kinship.

3. Guardianship by non-Indian family. Enter the number of child cases closed because the child was placed in guardianship with a non-Indian family.

4. Adoption by Indian Family or Kinship. Enter the number of child cases that were closed because of adoption by an Indian or Kinship family.

5. Adoption by non-Indian family. Enter the number of child cases closed because of adoption by a non-Indian family.

6. Emancipation from Foster Care or child “aged out” while in Foster Care. Enter the number of child cases closed because the child emancipated from foster care or the child “aged out” in foster care. Aged out means the child is considered an adult and no longer eligible for foster care.

7. Child died while in Foster Care. The case was closed because the child died while in foster care.

8. Child ran away from Foster Care. The child ran away and could not be located. This was the reason for their exit from foster care.

14. Program Staff

1. 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 program’s child protection system. Fractions can be entered. For example, if the tribe or BIA Agency 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.

Preparer’s Certification: The preparer must sign and date the form and return the completed form to the servicing BIA Regional Social Worker. The servicing BIA Regional Social Worker must review the form to make sure it is filled out correctly and completely. The servicing BIA Regional Social Worker will sign it when it is correct and complete and send it to Central Office.

Please direct any questions on this form to the BIA Regional Social Worker in your servicing 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, 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 mailto: Information Collection Clearance Officer – Indian Affairs, Office of Regulatory Affairs and Collaborative Action, 1001 Indian School Road NW, Suite 229, Albuquerque, New Mexico 87104. 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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