Form 3 Resource Report

OMB No. 0985-0040

RESOURCE REPORT

Complete Only One RR Form for the Entire State. Do Not Submit Sponsoring-Agency-Level or Within-State-Regional Resource Reports.

All Person Counts Should Reflect Active Counselors,Coordinators,Other Staff as of the End of Each Grant Year (31March).

The Unique Count of Counselors Attending Any Update Training During the Grant Year Cannot Exceed the Grand Total Number of Counselors.

_{12 Month Period for This Report IState Code IState Grantee Name}

^{From: 04/01/ ITo: 03/31/} I

Person Completing Report Title Telephone Number

_{( )} ^-

Section 1 All Other Section 2

Number of Active Counselors ^{State Local and Number of LocalCoordinators I Sponsors and Hours}

And Hours As of 31March Office ^{Field Sites} Total As of 31March ^Total

A. Number of Volunteer Counselors A.Number of Volunteer (Unpaid) Coordinators

B.Number of SHIP-Paid Counselors B. Number of SHIP-Paid Coordinators

C. Number of In-Kind-Paid Counselors ^{C. Number of In-Kind-Paid Coordinators}

TotalNumber of Counselors - A+B+C Total Number of Coordinators- A+B+C

D. Volunteer Counselor Hours ^{D. Volunteer (Unpaid) Coordinator Hours}

E.SHIP-Paid Counselor Hours E. SHIP-Paid Coordinator Hours F.In-Kind-Paid Counselor Hours F. In-Kind-Paid Coordinator Hours TotalCounselor Hours - D+E+F Total Coordinator Hours - D+E+F

^{Section 3 All Other} :;,ection 4- Counselor Trainings ^Total

^{Number of Other Paid and Volunteer State Localand} A. Number of InitialTrainings for New SHIP Counselors

^{Staff And Hours As of 31March Office Field Sites Total} B.Number of New SHIP Counselors Attending Initial Trainings

^{A. Number of Volunteer Other Staff} C. Total Number of Counselor Hours in Initial Trainings

^{B. Number of SHIP-Paid Other Staff} D. Number of UpdateTrainings for SHIP Counselors

^{C. Number of In-Kind-Paid Other Staff} E.Number of SHIP Counselors Attending Update Trainings

^{TotalNumber of Other Staff- A+B+C} F.Total Number of Counselor Hours in Update Trainings

^{D. Volunteer Other Staff Hours} _{NoteItem E should representthe number (unduplicated) of counselors who}

^{E.SHIP-Paid Other Staff Hours} attended atIeast oneupdate training during the full12 month period. ^{F.In-Kind-Paid Other Staff Hours} Please do not count a counselor more than once,even if he/she attended TotalOther Staff Hours - D+E+F ^{multiple updatetrainings.}

Counselor Race- Ethnicity
1	Hispanic Latino or Spanish Origin
2	White Non-Hispanic
3	Black African American
4	American Indian or Alaska Native
5	Asian Indian
6	Chinese
7	Filipino
8	Japanese
9	Korean
10	Vietnamese
11	Native Hawaiian
12	Guamanian or Chamorro
13	Samoan
14	Other Asian
15	Other Pacific Islander
16	Some Other Race-Ethnicitv
17	More Than One Race-Ethnicitv
99	Not Collected

Counselor Disability
1	Disabled
2	Not Disabled
9	Not Collected

Counselor Speaks Another language
1	Language Other Than English
2	English Speaker Only
9	Not Collected

Section 5- Number of TotalActive Counselors (SHIP-Paid,In-Kind-Paid,and Volunteer Counselors) with the Following Characteristics

Years of SHIP Service
1	Less Than 1Year
2	1Year Up to 3 Years
3	3 Years Up to 5 Years
4	More Than 5 Years
9	Not Collected

Counselor Age
1	Less Than 65 Years of Age
2	65 Years or Older
9	Not Collected

Counselor Gender
1	Female
2	Male
9	Not Collected

PRA Disclosure Statement

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