Grantee program staff

Instrument 2

Reach Reporting Form

(All grantees)

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

• How many youth participated in your program for at least one activity in the past program year?

Youth Served:

	# of males	# of females	Total
Age
10 or younger
11-12
13-14
15-16
17-18
19 or older
Grade
6 or less
7-8
9-10
11-12
GED program
Technical/vocational training
College
Not currently in school
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown/unreported

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX . The time required to complete this information collection is estimated to average 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

	# of males	# of females	Total
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Unknown/unreported
Language spoken at home
English
Spanish
Chinese
Other
Special populations (as applicable)
Pregnant or parenting teens
Youth in foster care
Homeless youth
Youth in the juvenile justice system
Other (describe____________________)
Total

• How many other types of clients (e.g., parents or guardians, other family members, etc.) participated in your program for at least one activity in the past program year?

Other Clients Served, including parents and guardians:

	# served
Parents/Guardians
Other Clients Served (Siblings, other Family Members, Etc.)
Total