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 title IV-E foster care eligibility review (FC eligibility 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

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

Social sciences (economics, sociology, business, etc.)

Public Administration

Other (please specify in 50 characters or less):

Education Equivalence

In the absence of a college degree, please indicate below whether you have 5 or more years of experience in title IV-E (or IV-A) program eligibility.

I have 5 or more years of experience in title IV-E (or IV-A) program eligibility.

I do not have 5 or more years of experience in title IV-E (or IV-A) program eligibility.

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. This may include providing services or supervising, administering, or managing programs in any of the following: (1) title IV-E eligibility, (2) foster care, (3) quality assurance, (4) program evaluation, and (5) program compliance.

From the following list, please specify in the following section the two areas in which you have the most demonstrated substantive experience. Then check the type(s) of experience that 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.

Conducting quality assurance activities

Conducting assessments of program/agency documentation

Conducting reviews of child welfare services

Participating as a team member in a Children's Bureau Child and Family Services Review (CFSR)

Determining IV-E eligibility

Participating as a team member in a Children's Bureau FC eligibility review

Review Participation

If you have participated as a team member supplementing Federal reviewers in a Children's Bureau CFSR or IV-E review, please indicate below in how many reviews you participated and the date of the last review in which you participated.

CFSRs

Number of reviews participated in:

Date of last review participated in (MM/DD/YY):

IV-E Reviews

Number of reviews participated in:

Date of last review participated in (MM/DD/YY):

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 weeklong FC eligibility reviews.

Please indicate the number of reviews that you are willing to participate in each year.

1

2

3 or more

Special Travel Needs

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

Materials To Submit

Please submit the following materials by e-mail (preferred) to cw@jbsinternational.com mail to the IV-E Review Project, Child Welfare Review Projects, 5515 Security Lane, Suite 800, North Bethesda, MD 20852-5007:

• Peer Reviewer Profile

• Resume