Grantee program staff

ACYF Pregnancy Prevention Performance Measure Collection

0990-PPA_PM OMB ICR Instrument 2 Reporting Form Reach revised 2 2012

Grantee program staff

OMB: 0990-0392

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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

Unknown

--------------

---------------


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








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






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Authorewilson
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File Created2021-01-25

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