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DEMOGRAPHICS FORM

To be enrolled to take online classes at http://www.e-learn.pitt.edu, you will need to be registered for Encompass, our organization's database to track and report trainings in Child Welfare held across PA. Here you can fill out the demographics form and submit to send this electronically to our staff.

If you are a Foster Parent/Resource Parents, please use the Resource Parent Version of the form. Since you do not work for a county or private provider, you will not have to fill in as many fields of a data.

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Name:
Date Completed:
Email:
Work Phone:
Birth Date:
Last 4 Digits of SSN#:
Gender: Male Female
County of Employment:
Agency Name:
Race:
Black/African American
White/Caucasian
Asian
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Hispanic/Latino
2 or More
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
High School Diploma or GED
Associates degree (indicate Major Code)
Bachelor's degree in Social Work
Bachelor's Degree - other: (indicate Major Code)
Master's degree in Social Work
Master's Degree - other: (indicate Major Code)
Doctoral Degree
Current Education:

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? (indicate Major Code)


Are you a current CWEB graduate? Yes No


Are you a current CWEL graduate? Yes No



Current Employment: Current Job Title: (indicate Job Code)

Effective Date:


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)
Investigation/Assessment (CPS, GPS)
Independent Living
Non direct service (Clerical, Fiscal, Business)
School Based
Ongoing (In-home, Family Preservation)
Substitute Care (Out of home placement, foster care)
Administrative (Manager, Director/Assistant, Administrator/Assistant, Program Specialist, Contract Monitor)
Other direct service (Homemaker, Case-aid, Family Group
Coordinator/Facilitator)
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


E-LEARN Yes No

Send me my E-Learn username and password to the email listed above