Capacity Building Collaborative, Center for States Peer Group Membership Request Form

Children’s Bureau Capacity Building Center for States

OMB Control No.: 0970-0401

Expiration Date: 06/30/2024

Peer Group Membership Request Form

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) The purpose of this information collection is to better understand the capacity building needs of child welfare jurisdictions so that the Capacity Building Center for States, a Children’s Bureau initiative can tailor and improve its services. Public reporting burden for this collection of information is estimated to average 2 minutes per respondent, 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. A Federal agency may not conduct or sponsor, and no individual or entity is required to respond to, nor shall an individual or entity be subject to a penalty or failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless that collection of information displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Beth Claxon, Children’s Bureau, by e-mail at Beth.Claxon@acf.hhs.gov.

Thank you for your interest in joining a Capacity Building Center for States (Center) peer group. Before requesting membership, please carefully read the Peer Group’s description, eligibility requirements, and approval process as shown on the Center’s website. Joining a peer group means being added to an email listserv, where you will be invited to virtual events and webinars, as well as have the opportunity to ask and answer questions via email. Emails sent over the listserv are accessible to other members of the listserv, including other state/jurisdictional staff, Center staff and consultants, and key Children’s Bureau staff.

Please use this request form to join a peer group. After you submit a request, a member of the Peer Services team will review your application, and if appropriate, forward it to the Peer Group’s Children’s Bureau Lead. After the Children’s Bureau Lead has reviewed the application, a member of the Peer Services team will email you concerning the status of your request.

If you have any questions about the form or application process, please email Becky Quinn at becky.quinn@icf.com

1. Name (first, last): ________________

2. Email address: ____________________

3. Please select your jurisdiction(s) from the list below:

Alabama	Alaska	American Samoa	Arizona	Arkansas	California
Colorado	Commonwealth of the Northern Mariana Islands	Connecticut	Delaware	District of Columbia	Florida
Georgia	Guam	Hawaii	Idaho	Illinois	Indiana
Iowa	Kansas	Kentucky	Louisiana	Maine	Maryland
Massachusetts	Michigan	Minnesota	Mississippi	Missouri	Montana
Nebraska	Nevada	New Hampshire	New Jersey	New Mexico	New York
North Carolina	North Dakota	Ohio	Oklahoma	Oregon	Pennsylvania
Port Gamble S’Klallam Tribe	Rhode Island	Puerto Rico	South Carolina	South Dakota	Tennessee
Texas	Utah	Vermont	Virgin Islands	Virginia	Washington
West Virginia	Wisconsin	Wyoming	Other [Please specify]

4. What is the name of your Agency or Organization? _____________________

5. What is your role? ___________________________

6. Select the peer group you are requesting to join from the list below:

Child and Family Services Review Round 4 Community of Practice (CFSR Round 4 CoP)	Child Welfare Training Directors	Children’s Justice Act (CJA) Grantees
Citizen Review Panels (CRP)	Continuous Quality Improvement (CQI)/Child and Family Services Review (CFSR) Managers	County-Administered State Partnership (CASP)
Diligent Recruitment	Disaster Planning, Response, and Recovery	Extended Federal Foster Care (EFFC) Programs
Family Leaders in Child Welfare (FLCW) Community of Practice	Family First Prevention Services Act (FFPSA) Prevention Plan Leads	Hotline/Intake/Screening Mangers (HISM)
In-Home Services Managers	Kinship Navigators	National Youth in Transition Database (NYTD)
Preventing and Addressing Sex Trafficking (PAST) In Child Welfare	Programmatic Data Analysts	Promoting Safe and Stable Families (PSSF) Grantees
State Adoption Managers	State Chafee and Education and Training Vouchers (ETV) Coordinators	State Foster Care Managers (SFCM)
State Liaison Officers (SLOs)	Strengthening Child Welfare Systems (SCWS) Grantees

7. The peer group you are requesting to join may use a Microsoft Teams space to communicate and share resources. Would you like to be added to the peer group Teams space in addition to the listserv?

Yes

No

Automated Submission Receipt Message
Thank you for requesting to join a Center for States Peer Group. A member of the Peer Services team will review your request and contact you via email if there are any follow up questions. If you have any questions, please email Becky Quinn at becky.quinn@icf.com

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