Center for Tribes (CBCT) Evaluation: Inquiry Form

Purpose: The Center for Tribes Inquiry Form is the first point of contact that a Tribal Child Welfare program makes with the Center for Tribes. The form is used to collect contact information, eligibility for technical assistance, and a brief amount of information on what services a Tribal program is requesting. Once reviewed, the Center for Tribes determines the best means of delivering the requested service (i.e., Universal, Targeted, or Tailored services).

OMB #: 0970-0XXXX

Expiration Date: XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: This form will be used to collect information on services requested by tribal child welfare programs. Public reporting burden for this collection of information is estimated to average 5 minutes including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. If you have any comments on this collection of information, please contact Roshanda Shoulders, ACF, Administration on Children, Youth and Families by e-mail at Roshanda.Shoulders@ACF.hhs.gov.

Integrated Services Inquiry Form

Thank you for your interest in the Capacity Building Center for Tribes, a technical assistance center funded by the Children’s Bureau, providing services to tribes that receive federal Title IV-B and/or Title IV-E funding to operate a tribal child welfare program.

Contact Information
Date of Inquiry:	Click or tap to enter a date.
Tribal Program Name:	Click or tap here to enter text.
Requestor Name:	Click or tap here to enter text.
Requestor Title:	Click or tap here to enter text. Organization: Click or tap here to enter text.
Work Phone:	Click or tap here to enter text.	Mobile Phone:	Click or tap here to enter text.
Email Address:	Click or tap here to enter text.
Program Address:	Click or tap here to enter text.	City, State, Zip:	Click or tap here to enter text.

Purpose of Request

Please tell us about your request for services. Click or tap here to enter text.

How did you hear about the Center for Tribes?

☐ Website ☐ Conference ☐ Prior Center Services

Referred by: ☐ Regional Office (RO) ☐ Another tribal program

☐ Other, Click or tap here to enter text.

Capacity Building Services Eligibility Note: Tribal funding information assists with determining eligibility for technical assistance. Targeted and tailored technical assistance is available for tribes who receive Title IV-B or Title IV-E funding.
Does your tribe receive Title IV-B (Subparts 1 and/or 2) funds?	☐ Yes ☐ No
Does your tribe receive Title IV-E funds?	☐ Yes ☐ No If yes, please indicate: ☐ Tribal-State Agreement ☐ Direct Title IV-E

Capacity Building Center for Tribes

Integrated Services Inquiry Form

V02 rev. 07-21-20