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QSR Reviewer Application

Thank you for your interest in being a Quality Service Review (QSR) Reviewer! Please provide the following information to assist us in our QSR reviewer recruitment, selection and pairing efforts.

Personal Information

First Name:*

Last Name:*

Job Title:*

Agency Name:*

Email Address:*

Mobile Phone Number:*

Mobile Carrier:

Previous QSR Reviewer Experience

Have you ever been a QSR reviewer before?

Additional Information About You

The following statements include information that will aid us in pairing you with your review partner.

Please check all that apply:

I am willing to drive myself and my partner to scheduled interviews

I am willing to travel greater than 1 hour from onsite QSR location to interview(s)

I am willing to conduct interviews in the evening, if needed

I feel comfortable interviewing children/youth

I have professional experience and/or a very good understanding of the public child welfare system

I am a non-state employee and/or a non-state contracted employee who is interested in being a potential reviewer for a QSR, but if selected for an onsite review that is over 50 miles from my residence, I may experience financial hardship because I (or the agency I represent) is not willing/able to cover the costs of lodging

I can bring a work/personal laptop (with at least one USB port) with me to be used by myself and my QSR review partner

Please summarize the reasons you are interested in being a reviewer for a Quality Service Review:

Characters Entered:

Remaining:

Please share any information you would like to share that might assist QSR Site Leads in their selection and pairing:

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Remaining:

Current Availability - Dates and Locations

How many times are you able to review from now through the end of the calendar year?

Not all the dates for the upcoming QSRs have been identified at this time. Please identify what months you will tentatively be available to be a QSR Reviewer.

Please select all months that you might be available. NOTE: We understand that your schedule might change.

Not all locations for the upcoming QSRs have been determined at this time. Please identify what counties you would be interested in going to for a QSR.

Please select all counties to which you would be willing to travel. NOTE: We understand that your ability to travel to certain locations might change.

Western Region

Central Region

Northeast Region

Southeast Region

Montgomery

Delaware

Philadelphia

Chester

Bucks

Berks

Southeast region - all counties

Please review all the information you have entered and when ready, click the SUBMIT button below. Your information will be provided to those that manage our statewide database of potential QSR reviewers and your information will be available to CQI State Site Leads who are responsible for QSR reviewer recruitment and selection.