OMB No. 0581-0240
|
Grant Program Project Beneficiaries Questionnaire |
AMS values diversity and equal access to its programs and services. As such, it is helpful for us to track the impact of our Federal grant programs on a variety of communities.
This information is voluntary. The information contained herein will only be used to assist AMS with its outreach efforts.
Organization Name: Enter the Legal Name of the Organization
Employer Identification Number: Enter Organization’s EIN
Authorized Organization Representative (AOR): Enter the Name of the AOR
Please indicate any specific communities on which your grant award will have a major impact:
Ethnic Groups |
Mark All that Apply |
American Indian or Alaska Native |
☐ |
|
|
Black or African American |
☐ |
|
|
Asian |
☐ |
|
|
Hispanic or Latino |
☐ |
|
|
Native Hawaiian or Other Pacific Islander |
☐ |
Farmers and Ranchers |
Mark All that Apply |
Women Farmers or Ranchers |
☐ |
|
|
Youth Farmers or Ranchers |
☐ |
|
|
Beginning Farmers or Ranchers |
☐ |
|
|
Socially Disadvantaged Farmers or Ranchers |
☐ |
|
|
Rural Farmers or Ranchers |
☐ |
|
|
Urban Farmers or Ranchers |
☐ |
|
|
Appalachia Farmers or Ranchers |
☐ |
|
|
Certified Organic Farmers or Ranchers |
☐ |
Other Beneficiaries |
Mark All that Apply |
Low Income/Low Access Communities |
☐ |
|
|
Children |
☐ |
|
|
Youth |
☐ |
|
|
Elderly |
☐ |
|
|
Minority-Serving Institutions |
☐ |
|
|
Rural Communities |
☐ |
|
|
Urban Communities |
☐ |
|
|
American
Indian or Alaska Native (Not Hispanic or Latino)
A person
having origins in any of the original peoples of North and South
America (including Central America), and who maintain tribal
affiliation or community attachment.
Black or
African American (Not Hispanic or Latino)
A person having
origins in any of the Black racial groups of Africa.
Asian (Not
Hispanic or Latino)
A person having origins in any of the
original peoples of the Far East, Southeast Asia, or the Indian
Subcontinent, including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
Hispanic or
Latino
A person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin regardless of
race.
Native
Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A
person having origins in any of the peoples of Hawaii, Guam, Samoa,
or other Pacific Islands.
Youth Farmers
or Ranchers
Youth farmers or ranchers between the ages of 15
and 24 years.
Beginning
Farmers or Ranchers
An individual or entity that has not
operated a farm or ranch for more than 10 years and substantially
participates in the operation.
Socially
Disadvantaged Farmers or Ranchers
A farmer or rancher who is
a member of a socially disadvantaged group. A Socially Disadvantaged
Group is a group whose members have been subject to discrimination on
the basis of race, color, national origin, age, disability, and where
applicable, sex, marital status, familial status, parental status,
religion, sexual orientation, genetic information, political beliefs,
reprisal, or because all or a part of an individual's income is
derived from any public assistance program.
Rural Farmers
or Ranchers
Farmers or ranchers benefitting from the project
are located in nonmetropolitan (nonmetro) areas, defined on the basis
of counties. Nonmetro counties include some combination of: open
countryside, rural towns (places with fewer than 2,500 people), and
urban areas with populations ranging from 2,500 to 49,999 that are
not part of larger labor market areas (metropolitan areas). See ERS
Rural Classification Page:
http://www.ers.usda.gov/topics/rural-economy-population/rural-classifications.aspx.
Urban Farmers
and Ranchers
Farmers or Ranchers benefitting from the
project are located in Urbanized Areas of 50,000 or more people or
Urban Clusters of at least 2,500 and less than 50,000 people.
Appalachia
Farmers or Ranchers
Farmers or ranchers benefitting from the
project are located in the Appalachian Region,
defined in Appalachian Regional Commission’s authorizing
legislation, as a 205,000-square-mile
region that follows the spine of the Appalachian Mountains from
southern New York to northern Mississippi. It includes all of West
Virginia and parts of 12 other states: Alabama, Georgia, Kentucky,
Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania,
South Carolina, Tennessee, and Virginia. See
http://www.arc.gov/counties
for specific counties within the Appalachian Region.
Certified
Organic Farmers or Ranchers
Farmers or ranchers operations
or farms benefitting from the project are certified by a USDA
accredited certifying agent. See the USDA
National Organic Program Organic Certification & Accreditation.
Low
Income/Low Food Access Communities
Consumers or targeted
communities benefiting from the project are located in a low
income/low access census tract location as defined by one of the four
major map layers on the ERS
Food Access Research Atlas map
Children
Project
specifically benefits persons between the ages of 1 – 14.
Youth
Persons between the ages of 15 and 24 years.
Elderly
Project
specifically benefits individuals who are 60 years of age or older.
Minority-Serving
Institutions (MSI)
Project benefits colleges and
universities that provide educational opportunities to those who have
historically faced inequality in their access to higher education.
See definition at http://nifa.usda.gov/glossary#M.
Rural
Communities
Communities benefitting from the project are
located in nonmetro areas, defined on the basis of counties. Nonmetro
counties include some combination of: open countryside, rural towns
(places with fewer than 2,500 people), and urban areas with
populations ranging from 2,500 to 49,999 that are not part of larger
labor market areas (metropolitan areas). See ERS Rural Classification
Page:
http://www.ers.usda.gov/topics/rural-economy-population/rural-classifications.aspx.
Urban
Communities
Communities benefitting from the project are
located in Urbanized Areas of 50,000 or more people or Urban Clusters
of at least 2,500 and less than 50,000 people. See ERS Rural
Classification Page:
http://www.ers.usda.gov/topics/rural-economy-population/rural-classifications.aspx.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 0581-0240. The time required to complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;
fax: (202) 690-7442; or
email: [email protected].
USDA is an equal opportunity provider, employer, and lender.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | TEtzig |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |