Indiana



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 | |

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 | |

This institution is an equal opportunity provider.

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 |NUMBER |PERCENTAGE |

|culture or origin, regardless of race. | | |

|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 |NUMBER |

|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, |NUMBER |

|including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, | |

|and Vietnam. | |

|Black or African American |NUMBER |

|A person having origins in any of the black racial groups of Africa. | |

|Native Hawaiian and Other Pac. Islander |NUMBER |

|A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. | |

|White |NUMBER |

|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 |PERCENTAGE |

|Asian |PERCENTAGE |

|Black or African American |PERCENTAGE |

|Native Hawaiian and Other Pac. Islander |PERCENTAGE |

|White |PERCENTAGE |

|Two or More Race Groups |PERCENTAGE |

This institution is an equal opportunity provider.

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