Identifying Information

First Name

Middle Name/Initial

Last Name

Home Address (Street):

City:

State:

ZIP Code:

Home Phone: (      )

Cellular Phone: (      )

Organization:

Title:

Work Address (Street):

City:

State:

ZIP Code:

Bus. Phone: (        )         Ext.:

Facsimile: (       )

E-mail Address:

Preferred Mailing Address: Home         Work

Emergency Contact Name:

Relationship:

Emergency Contact Daytime Phone:

Emergency Contact Evening Phone:

Emergency Contact Cellular Phone:

Ethnicity/Race

The checklist below includes Federal race and ethnic classifications as defined by the Office of Management and Budget. Responding to this section of the profile is voluntary. Please note that this information will be used solely to ensure the diversity of the child and family services review teams. Check one category under ethnicity and all that may apply under the race category:

Ethnicity

Race

Hispanic or Latino

White

Not Hispanic or Latino

Black or African American

Unknown

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Unknown

Gender

Female

Male

Language Fluency

Please indicate your ability to fluently read, speak, or write any of the languages listed below. Applicants indicating fluency in a particular language should be able to conduct interviews and/or read case records in that language. (Please check all that apply.)

Language

Read

Speak

Write

Spanish

French

Chinese

Inuit

Japanese

Vietnamese

Haitian Creole

American Sign Language

Other (please specify):

Licenses and Accreditations

Please specify in 250 characters or less.

Education

Please indicate your level of education in the following fields. Check all that apply.

Field

Degree

Bachelor's

Master's

Ph.D.

J.D.

Social Work

Human Services

Counseling

Public Administration

Other (please specify in 50 characters or less):

Experience

A minimum of 2 years of direct field experience and/or supervisory, administrative, or management experience in a public (Federal, State, or local) or private child welfare agency; or at least 2 years of direct experience working for a State Court Improvement Project or juvenile or family court dealing with child welfare cases is required to be eligible to serve as a consultant reviewer. This may include providing services or supervising, administering, or managing programs in any of the following: (1) child protective services, (2) foster care, (3) adoption, (4) family preservation, (5) family support, (6) independent living services, or (7) licensure/approval of foster and adoptive families.

From the following list, please specify in the section on the following page, the two areas in which you have the most demonstrated substantive experience. Then check the type(s) of experience you have in each area and provide a summary of the experience in the space provided below.

Areas of Experience

Type(s) of Experience

Please specify only two areas from the list above.

Check all that apply.

1.

1.  Direct Service
     Supervisory
     Management

2.

2.  Direct Service
     Supervisory
     Management

Skills

Please indicate the areas in which you have demonstrated skills. Check all that apply. If you do not have demonstrated skills in a particular area, please leave the box blank.

Interviewing children and families engaged in child welfare services

Conducting assessments of program/agency documentation

Conducting reviews of child welfare services

Facilitating group process

Interviewing community stakeholders, (including child welfare professionals)

Participating as a State Team Member in a Children's Bureau Child and Family Services Review

Computer Experience

The review process involves using computers to input data and complete forms. Please check the boxes that most accurately reflect your computer experience.

Never

Occasionally

Frequently

Daily

Based on the definitions below, please indicate your overall computer skill level.

Beginner (Basic word processing, E-mail, Internet)

Intermediate (Data entry using databases and spreadsheets in addition to Beginner skills)

Advanced (Navigating and troubleshooting problems with databases and spreadsheets in addition to Beginner and Intermediate skills)

Special Skills

Please describe any special skills or experience that you bring to the review process (in 250 characters or less, for example, experience in working with special populations or working on child welfare agency quality assurance teams).

Professional Biography

Please insert below a brief one-paragraph professional biography (please do not include personal information).

Travel/Review Week Requirements

Please indicate your travel availability.

Willing and able to travel to other States to participate in 4 day-long Child and Family Services Reviews (including a willingness to work long hours and to participate in debriefings at the end of each day).

Special Travel Needs

Please specify special travel needs, including accommodations and dietary needs.

Referral Information

Who referred you to inquire about serving as a consultant? Please provide the referrer's name and telephone number.

Referred by: (Please check one.)

	Self _______________________________________________________________
	Children's Bureau ____________________________________________________
	Children's Bureau Regional Office __________________________________________________
	National Resource Center _____________________________________________
	National Child Welfare Organization _____________________________________
	State Child Welfare Agency ____________________________________________
	Other (please specify in 50 characters or less): ____________________________ ___________________________________________________________________

Telephone Number:

Materials To Submit

Please submit the following materials by mail to the Child Welfare Reviews Project

• Consultant Reviewer Profile

• Resume

• One-paragraph Professional Biography

Child Welfare Review Projects
5515 Security Lane, Suite 800
North Bethesda, MD 20852-5007