| Instructions: AmeriCorps strives to create programs that represent and serve the full diversity of the community/our country. Information below should be self-reported by each stakeholder group/documented by Census data/etc. Please fill out every box that is yellow with information within the last twelve months. |
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| Confidentiality Statement: The information requested does not include any types of personally identifiable information. Purposes and Uses - The information requested will be collected in the aggregate for each grantee and applicant for funding. It will be used to better understand the demographic characteristics of current grantees and potential grantees to |
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| further AmeriCorps’ efforts to take into account the diversity of communities and participants in its grantmaking. Routine Uses - Routine uses may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests. The information will not otherwise be disclosed to entities outside of AmeriCorps. Effects of |
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| Nondisclosure - The information requested is mandatory in order to receive benefits. |
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| Community Awardmaking Diversity Questionnaire |
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| [Name of Organization] |
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# of People Served by Organization |
% of People Served by Organization |
# of People Served by Proposed Project (can be estimates) |
% of People Served by Proposed Project (can be estimates) |
People in Poverty in the Communities Proposed to be Served (can be estimates) |
% of People in Poverty Proposed to be Served - not a subset of column B or D (can be estimates) |
# of People on Staff |
% of People on Staff |
# of Staff in Most Senior Leadership Group |
% of Most Senior Leadership Group |
# of People on Board of Directors |
% of People on Board of Directors |
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| RACIAL/ETHNIC IDENTIFICATION |
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| African American/Black |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Asian/Asian American |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Hispanic/Latinx |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Native American or Alaska Native |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Native Hawaiian or Other Pacific Islander |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| White/Caucasian (non Hispanic) |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Two or More Races |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Not Reported |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| TOTAL |
0 |
#DIV/0! |
0 |
#DIV/0! |
0 |
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0 |
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0 |
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0 |
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| GENDER |
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| Female |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Male |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Gender Fluid/Does Not Identify as Male or Female |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Not Reported |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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| LGBTQIA+, Disability Community, Veteran/Military/Family Member |
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| Identify as a member of the LGBTQ community |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Do not identify as a member of the LGBTQ community |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Not Reported |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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| Identify as a member of the Disability community |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Does not identify as a member of the Disability community |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Not Reported |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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| Veteran |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Not a Veteran |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
| Not Reported |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |
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#DIV/0! |