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 |
|
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | ewilson |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |