CIVIL RIGHTS DATA COLLECTION AND COMPARISON FORM For Child

civil rights data collection and comparison form for child and adult care food program sponsors this form compares racial and ethnic data

CIVIL RIGHTS DATA COLLECTION AND COMPARISON FORM
for Child and Adult Care Food Program Sponsors
This form compares racial and ethnic data of participants to the
racial and ethnic data of the county your facility is located in to
determine how effectively FNS programs are reaching potential eligible
persons and beneficiaries and to identify areas where additional
outreach is needed. The form is to be completed on an annual basis.
For sponsors of homes and centers, complete one form per facility.
Facility Name
County Name
Date
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Racial/Ethnic Data
Directions:
1.
Indicate the number of participants from each racial and ethnic
group. More than one racial category can be selected.
2.
Indicate the county percentage. This data is found on the Stats
Indiana Census Webpage under Population Estimates by Race and
Hispanic Origin. Instructions may be found here.
*
Printed attachments are acceptable as well.
Ethnic Data
Participants
Census County Data
Complete or Attach
Hispanic
A person of Cuban, Mexican, Puerto Rican, South or Central American,
or other Spanish culture or origin, regardless of race.
Non-Hispanic
Racial Data
Participants
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.
Asian
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.
Black or African American
A person having origins in any of the black racial groups of Africa.
Native Hawaiian and Other Pac. Islander
A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
White
A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.
Racial Data
Census County Data
Complete or Attach
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian and Other Pac. Islander
White
Two or More Race Groups
CIVIL RIGHTS DATA COLLECTION AND COMPARISON FORM
for Child and Adult Care Food Program Sponsors
Instructions for Completion:
1.
Enter the name of the facility
2.
Enter the county in which the facility is located
3.
Enter the date the form was completed
4.
Enter the NUMBER of participants in each ethnic and racial group.
You may select more than one racial category.
5.
Indicate the COUNTY PERCENTAGES. This data is found on the Stats
Indiana Census Webpage under Population Estimates by Race and
Hispanic Origin. Further instructions may be found here. You may
enter the percentages within the table or attach a copy of the
Stats Indiana Census Webpage data showing the county data
percentages.
Ethnic Data
Participants
Census County Data
Complete or Attach
Hispanic
A person of Cuban, Mexican, Puerto Rican, South or Central American,
or other Spanish culture or origin, regardless of race.
NUMBER
PERCENTAGE
Non-Hispanic
NUMBER
PERCENTAGE
Racial Data
Participants
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.
NUMBER
Asian
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.
NUMBER
Black or African American
A person having origins in any of the black racial groups of Africa.
NUMBER
Native Hawaiian and Other Pac. Islander
A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
NUMBER
White
A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.
NUMBER
Racial Data
Census County Data
Complete or Attach
American Indian or Alaska Native
PERCENTAGE
Asian
PERCENTAGE
Black or African American
PERCENTAGE
Native Hawaiian and Other Pac. Islander
PERCENTAGE
White
PERCENTAGE
Two or More Race Groups
PERCENTAGE
February 2021
This institution is an equal opportunity provider.