Demographic Data Form Pennsylvania Child Welfare Resource Center

Name: _____________________________________________ Date form completed:_______________ Email address: _____________________________________ Work Phone Number _______________ Birth date: _________________ Last four (4) digits of social security number: ____________ Gender: Male Female County of employment: _____________________ Agency Name: ___________________________________________________________________ Race:

Black/African American White/Caucasian Asian 2 or more

American Indian/Alaskan Native Native Hawaiian/Pacific Islander Hispanic/Latino Hispanic/Latino Other

Language: Are you able to provide services to children/families in a language other than English? Yes No

Current highest educational degree:Less than high school Bachelor’s Degree - other: __________(indicate Major Code)

High School Diploma or GED Master’s degree in Social Work

Associates degree _________ (indicate Major Code) Master’s Degree - other: ____________(indicate Major Code) Bachelor’s degree in Social Work Doctoral Degree

Are you currently a BSW or MSW student? Yes No IF YES… Are you a current CWEB student? Yes No Are you a current CWEL student? Yes No Are you currently pursuing an additional degree or certificate other than a BSW or MSW? Yes No

If yes, in what _________________(Please indicate Major Code) Are you a CWEB graduate? Yes No Are you a CWEL graduate? Yes No

Current Job Title: ____________(Please indicate Job Code) Effective Date of current position ___________

As part of your day-to-day work, do you provide supervision to other staff? Yes No Agency type: Public child welfare Other _______________________ Primary Work Unit (please choose one): Intake (Screening, Intake Assessment) Ongoing (In-home, Family Preservation)

Investigation/Assessment (CPS, GPS) Substitute Care (Out of home placement, foster care)

Independent Living Administrative (Manager, Director/Assistant, Administrator/Assistant, Program Specialist, Contract Monitor)

Non direct service (Clerical, Fiscal, Business) Other direct service (Homemaker, Case-aid, Family Group Coordinator/Facilitator)

School Based Generic Unit (agency does not have distinct work units)

In a “typical” month, how many families and how many children are you responsible for managing? _____ No caseload (N/A) _____ # of Families ______ # of Children Yes No Send me my ELEARN username to my email address listed above

Code Major Agency Job Title Code 1 Accounting 2 Agriculture 3 Agronomy 4 Anthropology 5 Archeology 6 Architecture 7 Arts, Fine & Applied 8 Astronomy 9 Aviation 10 Biology 11 Botany 12 Business 13 Cartography 14 Chemistry 15 Communications 16 Corrections 17 Counseling 18 Criminal Justice/Law Enforcement 19 Dietetics & Nutrition 20 Economics 21 Education 22 Electronics Technology 23 Employee/Labor Relations 24 Engineering (Any Specialty) 25 English & Literature 26 Environmental Studies 27 Epidemiology 28 Finance 29 Fish, Game & Wildlife Management 30 Food Technology & Safety 31 Foreign Language 32 Forestry 33 Geography 34 Geology 35 Geophysics 36 Health 37 History 38 Home Economics 39 Horticulture 40 Hospital Administration 41 Human Resource Management 42 Hydrology 43 Industrial Management 44 Information Technology 45 Insurance 46 International Relations 47 Journalism 48 Law 49 Law Enforcement 50 Liberal Arts/Humanities 51 Library Science 52 Management Information Systems 53 Management 54 Marketing (Facilities) 55 Marketing 56 Mathematics 57 Medical Support 58 Meteorology 59 Natural Resource Management 60 Nursing 61 Park & Recreation Management 62 Pharmacy 63 Physical Science 64 Physics 65 Political Science/Government 66 Psychology 67 Public Health 68 Public Administration 69 Public Relations 70 Purchasing 71 Real estate 72 Rehabilitation Therapy 73 Sociology 74 Statistics 75 Surveying 76 Systems Analysis 77 Theology 78 Transportation 79 Zoology 81 Other

BJJS - Director BJJS - Drug and Alcohol Treatment Specialist BJJS - Human Services Program Specialist BJJS - Human Services Program Specialist Supervisor BJJS - Manager BJJS - Other BJJS - Psychological Services Associate BJJS - Social Worker BJJS - Youth Development Aide BJJS - Youth Development Aide Supervisor BJJS - Youth Development Counselor BJJS - Youth Development Counselor Supervisor CYF - Administrator CYF - Assistant Director CYF - Case Aide CYF - Case Worker CYF - Child Care Worker CYF - Clerk/Typist CYF - Executive Director CYF - Fiscal Staff CYF - Homemaker CYF - Intern CYF - MH/MR Worker CYF - Other CYF - Program Director CYF- Resource Parent CYF - Social Service Program Analyst CYF - Social Service Program Supervisor CYF - Supervisor CYF - Training Program Staff DHS - Administrator OCYF- Program Representative 1 OCYF- Program Representative 2 OTHER - Attorney OTHER - Court Appointed Special Advocate (CASA) OTHER - Guardian Ad Litem OTHER – Judge OTHER - Legislator OTHER - Resource Parent OTHER - Youth PRI - Administrator PRI - Assistant Director PRI - Case Aide PRI - Case Worker PRI - Child Care Worker PRI - Clerk/Typist PRI - Executive Director PRI - Fiscal Staff PRI- Homemaker PRI - Intern PRI - MH/MR Worker PRI - Other PRI - Program Director PRI- Resource Parent PRI- Supervisor PRI - Social Service Program Analyst PRI - Social Service Program Supervisor PRI - Training Program Staff

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24 6

17 18 9

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