Nevada indian child welfare act

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The following questions are designed to assess for Indian heritage in order to apply the Indian Child Welfare Act correctly at the onset of the case. The form is meant to guide the interview to determine if the child(ren) is/are eligible for the benefits of the Indian Child Welfare Act (ICWA).

Yes No

Are you a member of or eligible for membership in an Indian/American Indian/Native American Tribe, band, or Alaska Native village or corporation or eligible for enrollment?

Yes No

Do you know your enrollment number or have a tribal membership number?

(What is the enrollment/tribal membership number?)


What is the name of the Tribe? Is there a specific band?

Yes No

Do you know the address of the Tribe?

ADDRESS: ________________________


Yes No

Is the child a member or eligible for membership in an Indian/American Indian/Native American Tribe, band, or Alaska Native village or corporation?

***If the parent and/or child states; yes to the queries, regarding membership send the notice.

Yes No

Does the child or any family members have Native American, Alaska Native, or American Indian ancestry other than you?

Yes No

If yes, what are their names? ___________________________________ (fill out ancestry chart).

Yes No

Are or were the child’s other parent, grandparents, or great‐grandparents members of a Tribe, band, or Alaska Native village or members of or hold shares in an Alaska Native corporation? (Fill out ancestry chart with this information.)

Yes No

Has the child or any members of the child’s family or extended family ever lived on an Indian reservation, Rancheria, federal trust property, Alaska Native village, or other type of predominantly Indian community?

Yes No

Has the child or any members of the child’s extended family ever received services or participated in programs primarily directed toward Native American, Indian, or Alaska Native people, such as health or dental services from an Indian health service or Tribal Temporary Assistance to Needy Families?

If the person responds with a yes, ask where _________________________.

Yes No

Has the child or the child’s parents, grandparents, or great‐grandparents or any other extended family members ever attended an Indian school or other facility primarily intended for Native Americans, Indians, or Alaska Natives?

If there is any indication that the child may be an Indian Child for purposes of the application of ICWA, the child welfare worker will make phone calls to begin and initiate the process of inquiry; which is to confirm and verify tribal affiliation. (If parent doesn’t know the answers, contact the grandparents and/or relatives for Indian heritage information.) (Any answer of yes requires a diligent search of not only the child’s relatives, but of their Tribe.) Check the federal register for the designated agent for notice and send the inquiry letter to verify tribal affiliation.



Assessing for Indian Heritage August 21, 2013 Final FPO 0504A

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