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November 2006
(Please Type or Print Legibly)
Identifying Information |
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First Name |
Middle Name/Initial |
Last Name |
Home Address (Street): |
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City: |
State: |
ZIP Code: |
Home Phone: ( ) |
Cellular Phone: ( ) |
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Organization: |
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Title: |
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Work Address (Street): |
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City: |
State: |
ZIP Code: |
Bus. Phone: (  )   Ext.: |
Facsimile: (  ) |
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E-mail Address: |
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Preferred Mailing Address: Home Work |
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Emergency Contact Name: |
Relationship: |
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Emergency Contact Daytime Phone: |
Emergency Contact Evening Phone: |
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Emergency Contact Cellular Phone: |
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Ethnicity/Race |
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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: |
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Ethnicity |
Race |
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Hispanic or Latino |
White |
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Not Hispanic or Latino |
Black or African American |
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Unknown |
American Indian or Alaska Native |
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blank cell | Asian |
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Native Hawaiian or Other Pacific Islander |
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Unknown |
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Gender |
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Female |
Male |
Language Fluency |
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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.) |
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Language |
Read |
Speak |
Write |
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Spanish |
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French |
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Chinese |
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Inuit |
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Japanese |
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Vietnamese |
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Haitian Creole |
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American Sign Language |
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Other (please specify): |
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Licenses and Accreditations |
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Please specify in 250 characters or less. |
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Education |
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Please indicate your level of education in the following fields. Check all that apply. |
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Field |
Degree |
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Bachelor's |
Master's |
Ph.D. |
J.D. |
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Social Work |
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Human Services |
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Counseling |
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Public Administration |
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Other (please specify in 50 characters or less): |
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Experience |
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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. |
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Adoption Child Protective Services Domestic Violence Family Preservation Family Support Foster Care Independent Living Services |
Kinship Care Licensor of Foster and Adoptive Homes Mental Health Quality Assurance Residential Care Substance Abuse |
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Areas of Experience |
Type(s) of Experience |
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Please specify only two areas from the list above. |
Check all that apply. |
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1. |
1. Direct Service |
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2. |
2. Direct Service |
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Agency: ______________________________________________________________ Title: _________________________________________________________________ From (month/year): To (month/year): ________________________________________ Summary of Experience: _________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Agency: ______________________________________________________________ Title: _________________________________________________________________ From (month/year: To (month/year): ________________________________________ Summary of Experience: _________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Agency: ______________________________________________________________ Title: _________________________________________________________________ From (month/year: To (month/year): ________________________________________ Summary of Experience: _________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ |
Skills |
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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. |
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Interviewing children and families engaged in child welfare services |
Conducting assessments of program/agency documentation |
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Conducting reviews of child welfare services |
Facilitating group process |
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Interviewing community stakeholders, (including child welfare professionals) |
Participating as a State Team Member in a Children's Bureau Child and Family Services Review |
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Computer Experience |
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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 |
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Frequently |
Daily |
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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) |
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Advanced (Navigating and troubleshooting problems with databases and spreadsheets in addition to Beginner and Intermediate skills) |
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Special Skills |
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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). |
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Professional Biography |
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Please insert below a brief one-paragraph professional biography (please do not include personal information). |
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Travel/Review Week Requirements |
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Please indicate your travel availability. |
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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). |
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Special Travel Needs |
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Please specify special travel needs, including accommodations and dietary needs. |
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Referral Information |
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Who referred you to inquire about serving as a consultant? Please provide the referrer's name and telephone number. |
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Referred by: (Please check one.)
Telephone Number: |
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Materials To Submit |
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Please submit the following materials by mail to the Child Welfare Reviews Project
Child Welfare Review Projects |