Online Form for ADDING A NEW PERSON to E-Track.  NOTE: Do not use this form to add new E-Track
Facilitators (Trainers). 

Instructions for Completing this Online Form:

  1. Section One--all fields mandatory 
  2. Section Two--red fields mandatory, complete as many others as possible

  3. NOTE: While all fields are not required, all fields are IMPORTANT.  Please complete all fields unless they are not applicable to the person
    or it is absolutely impossible to do so.

     

     

SECTION ONE

Information on THE PERSON SUBMITTING THIS FORM (In case we have follow-up questions on the information in Section Two below):

YOUR Name: *  
YOUR RTC: *  
YOUR Phone #: *  
YOUR Email: *  

NOTE: You must complete this section even if it is redundant to information entered below.

SECTION TWO

Information on the Person Whose E-Track Record You Want Added:

Legal First Name: *    
Middle Name:    
Legal Last Name: *    
Preferred First Name:   (e.g., nickname)
Mailing Address Line 1:    
Mailing Address Line 2:    
Mailing Address Line 3:    
City:    
State/Province:    
Postal Code:    
Country:    
Preferred Phone #: *    
Fax #:    
Preferred Email: *    
UPP Status:
2-Digit Birth Month: *    
2-Digit Birth Day: *

 
Gender ID:    
Yrs. in Pub./Priv. Child Welfare:    
Current Job Effective Date:    
Supervisor:*   NOTE: If person is a caregiver and not a child welfare staff person, enter the name of their licensing specialist. If person is a private agency assessor, enter "PRIVATE ASSESSOR" for supervisor name. If person is hired only as a workshop observer, enter "WORKSHOP OBSERVER"
Secondary Supervisor:    
Staff Date Hired: *   NOTE: If person is a caregiver and not a child welfare staff person, enter the current caregiver licensure date instead.
Years Fostering:    
Level of Foster Care Licensure:    
Caseworker IV-B ID:   NOTE: For non-caseworkers, enter N/A. For caseworkers select most-appropriate option.
HIRED OBSERVER ONLY:    
UPP INTERN:    
Person Type: *   NOTE: You may select multiple Person Types by holding down the "Ctrl" key and clicking.
Region: *    
Agency: *    
Alternate Phone:    
Alternate Email:    
Additional Notes:   Use this field to enter any additional comments that will help us to better understand the information provided above.
RTC Internal Reference Info:   RTCs can use this field to reference the session information that prompted adding this individual.  (This form is returned to the RTC when the person is added.)

Please allow up to 2 BUSINESS DAYS for this form to be processed.