Form 1 WBS Sampling Form

Attachment 1

OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

National Study of Children’s Bureau’s Title IV-E Child Welfare Waiver Demonstrations

Web-Based Survey Sampling Form

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

The Children’s Bureau (CB) recently announced through waiver listserv the initiation of the National Study of the 2012, 2013, and 2014 cohorts of waiver demonstrations. The Web-Based Survey (WBS) is one component of the National Study being conducted by James Bell Associates (JBA).

The WBS is focused on practice- and system-level changes as they relate to fiscal flexibility. The WBS is targeted to child welfare agency/department directors and managers in a range of positions (e.g., programs, policy, fiscal, research/evaluation). The respondents should be knowledgeable about fiscal flexibility related practice- and system-level changes in their agency/department. We anticipate that the WBS will take approximately 20 minutes to complete. In the table below, please provide the contact information for ten representatives from your waiver jurisdiction to participate in the WBS. If you have any questions, please contact Charlie Ferguson (ferguson@jbassoc.com).

NAME	TITLE	PHONE	EMAIL	ROLE IN THE WAIVER