Form 1 Practice and Systems Level Change Survey Sampling Form

Attachment 4

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

OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

Fiscal Flexibility and Practice and Systems-Level Change Telephone 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 15 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 Fiscal Flexibility and Practice and Systems-Level Change Telephone Survey (FFPSCTS) is one component of the National Study being conducted by James Bell Associates (JBA).

The FFPSCTS is focused on practice- and system-level changes as they relate to fiscal flexibility. The FFPSCTS is targeted to child welfare agency/department directors or managers in a range of positions (e.g., programs, policy, fiscal, research/evaluation). We anticipate that the FFPSCTS will take approximately 45-60 minutes to complete. In the table below, please provide the contact information for four representatives from your waiver jurisdiction to participate in the FFPSCTS. Please include one representative from each of the categories listed above, if possible. If you have any questions, please contact Charlie Ferguson (ferguson@jbassoc.com).

NAME	TITLE	PHONE	EMAIL	ROLE IN THE WAIVER