ICWA Annual Report

OMB Control # 1076-0131

Expires: 02/29/2008

Indian Child Welfare Act Annual Report

Check one: ( ) Calendar Year ( ) Fiscal Year Report Year: _________

Reporting Indicators	Quarter 1 Actual	Quarter 2 Actual	Quarter 3 Actual	Quarter 4 Actual	End of Year Total
A. Number of Tribal / State Child Welfare Agreements
B.1 Placements out of Home
B.2 Placements in Indian Homes
B.3 Placements in Non-Indian Homes
B.4 Placements in Homes without Notification to Tribes
B.5 Placements in Residential Facilities
C. Number of Parental Terminations Involving Indian Children
D. Number of Indian Children / Families receiving services
E. Number of Indian Children / Families eligible but not receiving services
F. Number of Indian Children / Families referred to other Agencies / Services
G. Number of Indian Children / Family referrals involving drug and substance abuse
H. Number of Children / Family reunifications
I. Totals for each quarter / year end

Report Preparer’s Signature: ________________________ Date: ___________________

Telephone Number for Signer: ______________________

Paperwork Reduction Act Statement: This information is collected to manage the Indian Child Welfare program.. The information is supplied by a respondent to obtain or retain a benefit. It is estimated that responding to the request will take an average of 30 minutes to complete. This includes the amount of time it takes to gather the information and fill out the form. If you wish to make comments on the form, please send them to the Information Collection Clearance Officer, DAS-IRM/CIO, 625 Herndon Parkway, Herndon, VA 20170. In compliance with the Paperwork Reduction Act of 1995 as amended, this collection has been reviewed by the Office of Management and Budget and assigned a control number and expiration date. The number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB clearance number.