Document
National Child Welfare Center for Innovation and Advancement Service Request Form
ICR 202611-0970-004 · OMB 0970-0531 · Object 174623300.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | National Child Welfare Center for Innovation and Advancement Service Request Form |
| Author | Chris King |
| Last Modified By | Writer |
| File Modified | 2026-04-21 |
| File Created | 2026-11-05 |
| Conversion State | complete |
Extracted Text
NCWCIA Service Request Form The following service request form will be available on the National Child Welfare Center for Innovation and Advancement platform and will be completed by jurisdictions requesting our services. Thank you for your interest in the National Child Welfare Center for Innovation and Advancement (NCWCIA). We partner with public child welfare agencies to provide data-driven assistance, resources, and innovative strategies to improve safety, permanency, and well-being outcomes for children and families. To reduce burden, the request process should take no more than 5 minutes to complete. The information provided will be used solely by NCWCIA to inform the resources and/or services needed. A member of our staff will respond to your request within 2 business days. If you have any questions, including those you might have while completing the form, please contact us at [email protected]. If you are interested in joining a Peer Innovation and Insight Networking Group (PIING), please complete the membership request form. Contact Information First and last name Email Phone number Jurisdiction (State or Territory) (Select from the drop-down menu) Organization Position/title Are you making this request on behalf of someone else? ☐ Yes ☐ No [If Yes] If you are answering on behalf of someone else, please enter their contact information: Primary Contact Information First and last name Email Position/title What is the reason for your request? I am requesting: (Select all that apply) ☐ More information about NCWCIA ☐ Resources ☐ Technical assistance (e.g., tailored data-driven assistance, individualized peer-to-peer connection) Please provide additional information about the reason for your request—for example, the type of technical assistance you’re interested in, what resources you would like to receive, etc. How did you hear about us? (select all that apply) ☐ Previous work with NCWCIA ☐ Another jurisdiction ☐ Regional Office ☐ Another CB-funded entity ☐ Other: [open text] Thank you! We look forward to identifying how we can work together on behalf of children and families. Jurisdiction Drop-Down Not applicable Nevada Alabama New Hampshire Alaska New Jersey American Samoa New Mexico Arizona New York Arkansas North Carolina California North Dakota Colorado Ohio Commonwealth of the Northern Mariana Islands Oklahoma Connecticut Oregon Delaware Pennsylvania District of Columbia Puerto Rico Florida Rhode Island Georgia South Carolina Guam South Dakota Hawaii Tennessee Idaho Texas Illinois Utah Indiana Vermont Iowa Virginia Kansas Washington Kentucky West Virginia Louisiana Wisconsin Maine Wyoming Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska