Capacity Building Center for Tribes |
Tribal Demographic Survey |
OMB Control No.: 0970-0484 Expiration Date: XX/XX/XXXX
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THE
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting
burden for this collection of information is estimated to average 5
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.
Official Tribe Name:
Date:
Contact Information |
Program Name _____________________________________________________________ Contact ___________________________________________________________________ Title ______________________________________________________________________ Address ___________________________________________________________________ __________________________________________________________________________ Phone ___________________________________________ Email ____________________________________________ Website __________________________________________ |
Tribal Population and Location |
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# enrolled tribal members
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# or % of enrolled tribal members living on-reservation or within tribal boundaries |
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# or % of tribal population under age 18
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Approximate size (e.g., acres) of reservation or tribal communities |
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State(s) in which reservation/tribal communities are located |
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Children’s Bureau Region
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BIA Region
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Law Enforcement, Tribal Court, and Judiciary |
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Which agencies provide law enforcement for the tribe? (circle all that apply) |
Tribe |
BIA |
State |
County |
FBI |
Other (name): |
Which law enforcement agency/agencies most often assists with child welfare matters? (circle all that apply) |
Tribe |
BIA |
State |
County |
FBI |
Other (name): |
Does the tribe have an independent judiciary? |
Yes |
No |
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Does the tribe have its own court that makes determinations in child welfare cases? |
Yes |
No |
Part of an intertribal court |
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Additional Comments:
Child Welfare Program Services |
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Yes |
No |
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Does the tribe currently operate a child welfare program? If the tribe does not currently operate a child welfare program, please skip to Page 5-Child Welfare Staffing. |
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If the tribe operates a child welfare program, please check Yes or No for each service area below. If yes, also indicate whether policies and procedures are in place for that service. |
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Yes |
No |
If yes, check if policies & procedures for this service are in place |
Child protection investigations |
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Permanency planning |
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Case management |
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Family preservation |
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Child abuse & neglect prevention |
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ICWA |
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Foster/kinship care/resource family recruitment |
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Foster/kinship care/resource family placements |
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Foster care/resource family licensing by tribe |
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Transitional or independent living services for youth |
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Other services for youth (please indicate) _____________________________________ _____________________________________ _____________________________________
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Kinship guardianships |
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Adoptions |
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Customary adoptions |
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Cultural programs |
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Other: _________________________________
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Other: _________________________________
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Other: _________________________________
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Yes |
No |
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In addition to the tribal program, do any outside/non-tribal agencies provide child welfare services for the tribe? |
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If yes, which agencies provide child welfare services for the tribe (circle all that apply) |
BIA |
State |
County |
Other (name) |
Service(s) provided by other agencies: ______________________________________ ______________________________________ ______________________________________ ______________________________________
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Additional Comments:
Child Welfare Staffing |
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Instructions for this section: Please write in the staff positions of the child welfare program and indicate the number of staff currently working in each position, the number of position vacancies, and the required educational level for the position (if any). |
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Staff Position |
# staff currently in position |
# positions vacant |
Required educational level |
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Additional Comments:
Data Management & Child Welfare Program Statistics |
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Yes |
No |
Does the child welfare program have an electronic data management system? |
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If yes, what is the name of this system?
_________________________________________________
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If No, how does the program track and manage data? _____________________________________________ _____________________________________________ _____________________________________________
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Yes |
No |
If the program does not currently have an electronic data management system, is it considering obtaining one in the near future? |
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If yes, name of system(s) under consideration: _____________________________________________ _____________________________________________ _____________________________________________
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Estimated number of children currently served by the tribal child welfare program __________ |
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Estimated number of children currently in out-of-home placements __________ |
__________ Tribal __________ State or other |
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Current number of tribal foster/kinship/resource homes __________ |
Of these: # licensed by tribe __________ # licensed by state __________ |
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Estimated number of ICWA cases in which the tribal child welfare program is actively involved __________ |
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Estimated number of ICWA notifications received monthly __________ |
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Additional Comments:
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Temp |
File Modified | 0000-00-00 |
File Created | 2021-01-15 |