Center for Tribes Contact Form

OMB Control No.: 0970-0484

Expiration Date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 3 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.

Contact Form

Capacity Building Center for Tribes

Instructions. Please complete this form when you would like to have a Capacity Building Center for Tribes staff member contact you. For any “Not Applicable” question, please enter N/A. If this is a hard copy, please print legibly.

We encourage you to call Elizabeth Deserly, Capacity Building Coordination Specialist at [Number] should you have any questions.

Date of Request:
Tribal Organization Requesting Assistance:
Requester’s Contact Information:	Name:
	Organization
	Title:
	Address:
	City, State, Zip:
	Phone:
	Email:

What is the reason for this request? What is the need?

Who is the target audience/primary recipient of this assistance?

Example Services and Products Offered by the Capacity Building Center for Tribes:

Universal Products. Intended to increase awareness, understanding, engagement, access and use of broad target audience of child welfare professionals. Example topics include: Child welfare practice, ICWA, Kinship, foster care, and adoption, Workforce and leadership development delivered through Resources, tools, articles, reports available through Tribal Information Exchange (TIE), Web-based training module, Tribal profiles, Tribal Talks, and Tribal CW webinar series.

Constituency-based Services. Intended to increase knowledge and skills of a particular cohort of child welfare professionals on a particular topic or in a specific aspect of child welfare practice. Example topics would include: ICWA Directors/Coordinator training, and Tribal Title IV-E Assistance.

Tailored Services. Intended to increase knowledge and skills of individuals and foster improvements in organization system capacity. Consists of brief services (generally not more than 1-year in duration) and intensive services (generally more than 1-year in duration). May include work conducted offsite or onsite at your jurisdiction. Examples include: Review of specific policies and procedures, ICWA compliance for tribes and state, Tribal–state agreements, and improving data collection systems

Permanency Projects. Intended to build the capacity of tribal systems to implement and sustain systems changes that lead to improved outcomes for American Indian and Alaska Native children, including permanency and well-being. Example projects include: Developing culturally based tribal foster care and adoption programs, Improving service array for pre-and post-adoption/guardianship, and Foster care recruitment and licensing

Once you have completed this form. Please send this form to the Capacity Building Center for Tribes using the following:

• By Email: Elizabeth Deserly Elizabeth@CBC4Tribes.org

  • Please Note: If this is a hard copy form and you intend to send it by email, please scan the form and attach it to your email.

• By USPS: [what address do we want to use?]

  • Please Note: If this form is mailed to the Capacity Building Center for Tribes, please allow several days for this form to be delivered.

• By Phone: You may also telephone the Capacity Building Center for Tribes. Should you choose that option, please print and complete this form and use this form to guide your conversation when you call. The telephone number is: [what number do we want to use?]

Should you have any questions about this form, please email Elizabeth Deserly at the email address above or telephone Elizabeth Deserly at: [what number?]. Thank you!