| Purpose: AmeriCorps is committed to partnering with communities to alleviate poverty and advance racial equity. We are prioritizing investment in the most underserved individuals and communities. Our target over the next 5 years is that 40% of all those served by AmeriCorps members and AmeriCorps Seniors volunteers are people in poverty. AmeriCorps uses “people in poverty” as its proxy measure for “underserved,” recognizing that data shows that a higher proportion of people in poverty are people of color and other minority populations. AmeriCorps currently does not collect information about the reach of our programs to invest in underserved individuals and communities, nor does it collect information about the diversity of the community organizations that operate and support AmeriCorps programs. The information to be collected in the AmeriCorps Diversity Questionnaire Form, provided by prospective and current grantees and sponsors, will fill this data gap. Note: AmeriCorps will refer to US Census 2020 data (https://www.census.gov/) for general information about the people being served in counties in which AmeriCorps has invested resources, but those data cannot provide information specific to projects and could easily under-represent or over-represent the percentage of beneficiaries who are people in poverty and the demographic information about people served by the AmeriCorps-funded activity. |
| Usage: The information requested in the Diversity Questionnaire Form is focused on the following two populations: 1. People to be served by AmeriCorps resources. The Diversity Questionnaire asks for the total number beneficiaries to be served by the proposed project and the number of beneficiaries who are living in poverty. This poverty data will be taken into account in grantmaking and resource allocation decisions to better reach those who are underserved. The diversity questionnaire also requests demographic data of the people to be reached by the proposed project. This will not factor into grantmaking and resource allocation decisions. As AmeriCorps has never collected demographic data of beneficiaries in the past, the agency has no baseline for who is reached by its resources in terms of demographics. This will give AmeriCorps a deeper understanding of who is being served by AmeriCorps programs to inform future work. 2. Partners of AmeriCorps. AmeriCorps is seeking to expand and diversify the community organizations that successfully operate and support AmeriCorps programs. The Diversity Questionnaire will collect demographic data about staff, leadership and Board members of the organization applying for an AmeriCorps resource. It will enable AmeriCorps to better target training, technical assistance, and outreach to grantees and sponsors, in particular those who are new to AmeriCorps. This information will not be included in grantmaking and resource allocation decisions. |
| Frequency of Submission: The questionnaire will be submitted by all organizations (see "organization" under the definition tab for more information) that apply for AmeriCorps resources. Additionally, the questionnaire will be used by directly-managed programs such as NCCC as part of sponsor applicant data collection. AmeriCorps proposes to track this information across the cycle of the engagement with AmeriCorps by requesting total beneficiaries reached, disaggregated by poverty status, in the Progress Report Supplements for VISTA and AmeriCorps Seniors, the Annual Grantee Progress Report for AmeriCorps State and National, and the Project Completion report for AmeriCorps NCCC. In the future, AmeriCorps intends to collect additional disaggregated demographic data (race/ethnicity, gender, etc.) as well. |
| Confidentiality Statement: The information requested does not include any types of personally identifiable information. 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 Nondisclosure: Submission of this filled-out form is required in order to receive benefits. |
| Information Collection Burden: It is estimated that responding to the request will take an average of 5 hours to complete. This includes the amount of time it takes to gather the information and fill out the form. An agency may not request nor sponsor, and a person need not answer a request for information that does not contain a valid OMB control number. If you wish to make comments on the form, please send them to the Information Collection Clearance Officer - AmeriCorps, 250 E Street, SW, Washington, DC 20525. |
| AmeriCorps staff will provide guidance and training, upon request, to support organizations with data collection and filling out the questionnaire. |
| Instructions: There are two sections to complete: For Project and For Organization. At the top of each section, fill out basic information: - Name of Organization: Enter your organization’s exact SAM-registered legal name. This should match your organization’s legal name in eGrants. - SAM.gov Unique Entity Identifier (UEI): Effective April 4, 2022, the UEI is the authoritative entity identifier for used by AmeriCorps. If your organization has a SAM registration, then it already has a UEI. AmeriCorps will not issue awards to recipients without a valid SAM.gov UEI. - Application ID: Enter the 10-digit application ID associated with the project application. This ID, automatically generated by eGrants, is available on the application Face Sheet. The first two digits are always the abbreviated fiscal year of the application (ex. “22”). The second two digits are always letters (“SC”, “AC”, etc). The remaining six digits are always numbers. |
| For Project section: - Include the proposed/projected number of people to be served by the proposed project (e.g. anticipated reach). (At Progress Report stage, enter the actual number of people). - Under Poverty Information: Enter a numerical value (not a percentage) in every yellow box. Fill out the proposed number of people to be served who are/are not in poverty. This can be an estimate. (At Progress Report stage, enter the actual number of people served who are/are not in poverty). - Under Demographic Information: Enter a numerical value (not a percentage) in every yellow box. If you are unable to report complete information for one or more demographic categories, enter the number of individuals for which the information cannot be provided in the "Not Reported" field. - Note: Totals within each demographic category must equal the total number of people served by the proposed project. Each demographic section (e.g. race, ethnicity, etc.) is unique and must equal the total value. Each person should be counted only once in each demographic section (for example, if someone is both Asian and White, enter them only in "Two or more races" -- not in "Asian" and in "White"). |
| For Organization section: - Include the organization's number of staff, most senior leadership and Board of Directors in each of the columns. - Enter a numerical value (not a percentage) in every yellow box. If you are unable to report complete information for one or more demographic categories, enter the number of individuals for which the information cannot be provided in the "Not Reported" field. - Note: Totals within each category must equal the total value entered at the top of each column. Each demographic section (e.g. race, ethnicity, etc.) is unique and must equal the total value. |
| Information should be self-reported by each stakeholder group. Reported data should be as current as possible. Grantees and sponsors should follow their own ethical and legal internal procedures for data collection, including confidentiality. They should provide the information ‘to the best of their ability’. Note: organizations can refer to Census data (https://data.census.gov/) for the relevant community/ies in which they work, but AmeriCorps is interested in the specific reach of the project. |
| AmeriCorps Diversity Questionnaire - FOR PROJECT | ||
| What is your organization’s SAM-registered legal name? | [Name of Organization] | |
| What is your SAM.gov Unique Entity Identifier (UIE)? | [SAM registration number] | |
| What application ID is this data linked to? | [Application ID] | |
| Is the data actual or proposed? | [Explanation] | |
| How did you collect or propose to collect the information about the people to served by the Proposed Activity/Project? | [Please provide Source and Methodology of Data - a Short Description of Source of the Data Collected and the Methodology Used by the Grantee or Sponsor] | |
| For the people who will be served by the Proposed Project, please fill out their demographic data below (based on data collected by your Organization and partners) Note: if you do not currently collect this information, you can include your proposed reach. You will be requested to report on actuals of total beneficiaries reached, disaggregated by poverty status, in the Progress Report Supplements for VISTA and ACS, the Annual Grantee Progress Report for ASN, and the Project Completion report for NCCC. In the future, AmeriCorps intends to collect additional disaggregated demographic data (race/ethnicity, gender, etc.) as well. |
||
| # of People Served by Proposed Project | % of People Served by Proposed Project | |
| How many people will be served by the Proposed Project? | [Total # of People Served by Proposed Project] | |
| Poverty Information (included in funding decisions) | ||
| Poverty Status | ||
| Living in poverty | #VALUE! | |
| Not living in poverty | #VALUE! | |
| Prefer Not to Answer | #VALUE! | |
| Not Reported | #VALUE! | |
| Demographic Information | ||
| Race | ||
| American Indian or Alaska Native | #VALUE! | |
| Asian | #VALUE! | |
| Black or African American | #VALUE! | |
| Native Hawaiian and Other Pacific Islander | #VALUE! | |
| White | #VALUE! | |
| Two or More Races | #VALUE! | |
| Prefer Not to Answer | #VALUE! | |
| Not Reported | #VALUE! | |
| Ethnicity | ||
| Hispanic or Latino | #VALUE! | |
| Not Hispanic or Latino | #VALUE! | |
| Prefer Not to Answer | #VALUE! | |
| Not Reported | #VALUE! | |
| Gender | ||
| Identify as Female | #VALUE! | |
| Identify as Male | #VALUE! | |
| Gender Fluid/Do Not Identify as Male or Female | #VALUE! | |
| Prefer Not to Answer | #VALUE! | |
| Not Reported | #VALUE! | |
| LGBTQIA+ Status | ||
| Identify as a member of the LGBTQIA+ community | #VALUE! | |
| Do not identify as a member of the LGBTQIA+ community | #VALUE! | |
| Prefer Not to Answer | #VALUE! | |
| Not Reported | #VALUE! | |
| Disability Status | ||
| Identify as a member of the Disability community | #VALUE! | |
| Do not identify as a member of the Disability community | #VALUE! | |
| Prefer Not to Answer | #VALUE! | |
| Not Reported | #VALUE! | |
| Veteran Status | ||
| Veteran | #VALUE! | |
| Not a Veteran | #VALUE! | |
| Prefer Not to Answer | #VALUE! | |
| Not Reported | #VALUE! | |
| AmeriCorps Diversity Questionnaire - FOR ORGANIZATION | ||||||
| What is your organization’s SAM-registered legal name? | [Name of Organization] | |||||
| What is your SAM.gov Unique Entity Identifier (UIE)? | [SAM registration number] | |||||
| How did you collect the information about your staff and Board of Directors? | [Please provide Source and Methodology of Data - a Short Description of Source of the Data Collected and the Methodology Used by the Grantee or Sponsor] | |||||
| What year is this data from? | [Year] | |||||
| For your staff and Board of Directors, please fill out their demographic data below. | ||||||
| # 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 | |
| [Total # of People on Staff] | [Total # of Staff in Most Senior Leadership Group] | [Total # of People on Board of Directors] | ||||
| Race | ||||||
| American Indian or Alaska Native | #VALUE! | #VALUE! | #VALUE! | |||
| Asian | #VALUE! | #VALUE! | #VALUE! | |||
| Black or African American | #VALUE! | #VALUE! | #VALUE! | |||
| Native Hawaiian and Other Pacific Islander | #VALUE! | #VALUE! | #VALUE! | |||
| White | #VALUE! | #VALUE! | #VALUE! | |||
| Two or More Races | #VALUE! | #VALUE! | #VALUE! | |||
| Prefer Not to Answer | #VALUE! | #VALUE! | #VALUE! | |||
| Not Reported | #VALUE! | #VALUE! | #VALUE! | |||
| Ethnicity | ||||||
| Hispanic or Latino | #VALUE! | #VALUE! | #VALUE! | |||
| Not Hispanic or Latino | #VALUE! | #VALUE! | #VALUE! | |||
| Prefer Not to Answer | #VALUE! | #VALUE! | #VALUE! | |||
| Not Reported | #VALUE! | #VALUE! | #VALUE! | |||
| Gender | ||||||
| Identify as Female | #VALUE! | #VALUE! | #VALUE! | |||
| Identify as Male | #VALUE! | #VALUE! | #VALUE! | |||
| Gender Fluid/Do Not Identify as Male or Female | #VALUE! | #VALUE! | #VALUE! | |||
| Prefer Not to Answer | #VALUE! | #VALUE! | #VALUE! | |||
| Not Reported | #VALUE! | #VALUE! | #VALUE! | |||
| LGBTQIA+ Status | ||||||
| Identify as a member of the LGBTQIA+ community | #VALUE! | #VALUE! | #VALUE! | |||
| Do not identify as a member of the LGBTQIA+ community | #VALUE! | #VALUE! | #VALUE! | |||
| Prefer Not to Answer | #VALUE! | #VALUE! | #VALUE! | |||
| Not Reported | #VALUE! | #VALUE! | #VALUE! | |||
| Disability Status | ||||||
| Identify as a member of the Disability community | #VALUE! | #VALUE! | #VALUE! | |||
| Do not identify as a member of the Disability community | #VALUE! | #VALUE! | #VALUE! | |||
| Prefer Not to Answer | #VALUE! | #VALUE! | #VALUE! | |||
| Not Reported | #VALUE! | #VALUE! | #VALUE! | |||
| Veteran Status | ||||||
| Veteran | #VALUE! | #VALUE! | #VALUE! | |||
| Not a Veteran | #VALUE! | #VALUE! | #VALUE! | |||
| Prefer Not to Answer | #VALUE! | #VALUE! | #VALUE! | |||
| Not Reported | #VALUE! | #VALUE! | #VALUE! | |||
| Organization: Your organization’s exact SAM-registered legal name. This should match your organization’s legal name in eGrants. |
| Project: The services, activity or set of actions that you intend to provide or implement over the next 12-month period. |
| People Served by Proposed Project: beneficiaries of the service(s) that will be provided over a 12-month period by the project that is proposed in the application. This number must match the number of beneficiaries indicated in the project application narrative and/or performance measures. If the project will place members or volunteers at sites, this number should include the beneficiaries at those sites. For projects that do not directly serve people (e.g., programs that remediate public land), enter zero. |
| People on Staff: Individuals directly employed by the organization applying for/receiving AmeriCorps resources. |
| Most Senior Leadership Group: Along with the CEO, President or highest level leader in the organization, the Leadership Group is the group of 3-5 senior officers in an organization or company that help the President or CEO in directing the organization and making important strategic decisions. |
| Board of Directors: An executive committee that jointly supervises the activities of an organization, appoints the CEO and sets out the overall strategic direction of the organization. |
| Race*: |
| American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. This category includes people who indicate their race as “American Indian or Alaska Native” or report entries such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, or Nome Eskimo Community. |
| Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, India, China, the Philippine Islands, Japan, Korea, or Vietnam. It includes people who indicate their race as “Asian Indian,” “Chinese,” “Filipino,” “Korean,” “Japanese,” “Vietnamese,” and “Other Asian” or provide other detailed Asian responses such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc. |
| Black or African American: A person having origins in any of the Black racial groups of Africa. It includes people who indicate their race as “Black or African American” or report responses such as African American, Jamaican, Haitian, Nigerian, Ethiopian, or Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, Bahamian, etc. |
| Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who indicate their race as “Native Hawaiian,” “Chamorro,” “Samoan,” and “Other Pacific Islander” or provide other detailed Pacific Islander responses such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc. |
| White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicate their race as “White” or report responses such as German, Irish, English, Italian, Lebanese, and Egyptian. The category also includes groups such as Polish, French, Iranian, Slavic, Cajun, Chaldean, etc. |
| Some Other Race: Includes all other responses not included in the “White,” “Black or African American,” “American Indian or Alaska Native,” “Asian,” and “Native Hawaiian or Other Pacific Islander” race categories described above. |
| Two or More Races: Combinations of two or more of the following race categories: “White,” “Black or African American,” “American Indian or Alaska Native,” “Asian,” “Native Hawaiian or Other Pacific Islander,” and "Some Other Race" |
| Ethnicity*: |
| Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin. Origin can be viewed as the heritage, nationality group, lineage, or country of birth of the person or the person’s parents or ancestors before their arrival in the United States. People who identify their origin as Hispanic, Latino, or Spanish may be of any race. |
| Gender: Refers to one’s inner sense of one’s own gender, which may or may not match the sex assigned at birth. |
| LGBTQIA+: Refers to one's own identification of belonging to the community that brings together many different gender and sexual identities including lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, and other diverse gender and sexual identities. |
| Disability*: Difficulty with one or more of four basic areas of functioning – hearing, vision, cognition, and ambulation. May also include difficulties with selected activities from the Katz Activities of Daily Living (ADL) and Lawton Instrumental Activities of Daily Living (IADL) scales, namely difficulty bathing and dressing, and difficulty performing errands such as shopping. |
| Veteran*: A person 18 years old or over who has served (even for a short time), but is not now serving, on active duty in the U.S. Army, Navy, Air Force, Marine Corps, or the Coast Guard, or who served in the U.S. Merchant Marine during World War II. People who served in the National Guard or military Reserves are classified as veterans only if they were ever called or ordered to active duty, not counting the 4-6 months for initial training or yearly summer camps. All other civilians 18 years old and over are classified as nonveterans. |
| Living in Poverty*: Living in a household in which the total income of the householder’s family is below the appropriate poverty threshold. (For nonfamily householders, their own income is compared with the appropriate threshold.) The poverty thresholds vary depending on three criteria: size of family, number of related children, and, for 1- and 2-person families, age of householder. |
| Prefer Not to Answer: If the organization's data collection form includes the response "Prefer Not to Answer" the number of respondents should be captured in this section. |
| *Definition(s) align with the U.S. Census Bureau's American Community Survey 2020 Subject Definitions, https://www2.census.gov/programs-surveys/acs/tech_docs/subject_definitions/2020_ACSSubjectDefinitions.pdf |
| 1) Error message or warning color if the sum of the values for each category in a column does not equal the total number at the top of the column |
| 2) If any yellow-highlighted fields are blank, warning message that not all fields are completed. |
| 3) Yellow fields are restricted to numerical values (except for App ID and Organization Name) |
| 4) All non-yellow fields are locked for editing |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |