Philadelphia Department of Human Services: Child Welfare Leadership Academy Nomination Form

Leadership Academy

Nomination Form (Please discuss with your Nominee prior to completing the form)
Nominee's Information (Supervisor to complete)
Leadership Academy Tier of Interest (select only 1 per Nominee). Sessions will be Hybrid Schedule *

Frontline Systems SupervisorsEmerging Senior Leaders
Nominee's Name*

First NameLast Name
Job Title*
Agency *
Division*
Section*
Phone Number*
E-mail*
example@example.com
Date nomination discussed with nominee*

MonthDayYear
Date
Nominee voluntarily agrees to participate in the program?*

YesNoUndecided
Nominator's Information (Supervisor's information)
Nominator's Name*

First NameLast Name
Job Title*
Email*
example@example.com
Phone Number*
In what capacity have you worked with the nominee?*
Based on the program selection criteria and your experience with the nominee, what makes this person a strong candidate for the Leadership Academy?*
Please list two ways you will support this candidate throughout their Leadership and Professional Development Journey?*
Program Contacts

DHSU.Collaboration@Phila.gov

Lisamarie Rotchford, LMSW

Social Work Supervisor

DHS University

Mobile Phone #: (267) 934-1962

Email: lisamarie.rotchford@phila.gov

Cynthia Carroll-Miles

Human Services Staff Director

Policy Development System Enhancements

Email: Cynthia.L.Carroll-Miles@phila.gov

For more information about the

Philadelphia Leadership Academy

Please visit our site at: https://www.dhsuniversity.net/Leadership_Academy/index.html
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