Evaluation of the Improving Child Welfare Outcome through Systems of Care Grant Program - Community Description Form

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Public reporting burden for this collection of information is estimated to be 2.5 hours to complete this questionnaire. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0970-0288. The control number expires on X/X/XXXX.

ommunity Description

Instructions

This form provides a “snapshot” of the geographic location and demographic make-up of your Systems of Care community. Possible sources of information for this section might include U.S. Census Data, local and state planning offices, reference librarian, State university data center, local government, Kids Count Data Book (Annie E. Casey Foundation), the Chamber of Commerce, and a recent data-driven community assessment.

1. Geographic Boundaries of Target Community: What are the specific geographic boundaries of your community (i.e. the town, city, county where your System of Care efforts will be targeted)? Specify whether the community is defined by the boundaries of a neighborhood, school district, county, township, city, tribe, or other jurisdiction.

2. Community Boundaries: Provide a list of or highlighted map with all of the counties and townships that fall entirely or partially within your target community boundaries. Specify if there are multiple municipalities/jurisdictions within your Systems of Care community.

3. Brief Community Description: Provide a brief description of some of the primary economic, social, or demographic characteristics of your target community. This description may include comments on the current economic conditions of the community, principal racial or socioeconomic groups who live in the target community, dominant cultural norms or values of community members, geographic features, major employers, recent trends, or other factors that help define your target community.

4. Community Setting: Classify your target community as urban, suburban, or rural, or describe the combination of settings targeted.

5. Total Community Population: Using the most recent data available, provide the total number of residents in your target community, including the year to which the population number refers.

6. Median Annual Household Income: Using the most recent data available, provide the median annual income for households in your target community, including the year to which the income data refer. (The median level is the dollar amount which is exactly in the middle when all the amounts are listed in order.)

7. Population percentages by Ethnic/Racial Background: For each ethnic/racial group listed, provide the population percentage in the target community of that ancestry or origin (report on only those that apply), including the year and data source to which the data refer.

Ethnic/Racial Background	Percentage
White
Black or African American
Spanish/Hispanic/Latino
Mexican, Mexican American
Puerto Rican
Cuban
Other Spanish/Hispanic/Latino
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native Hawaiian
Samoan
Other Pacific Islander

8. Other significant and descriptive community information: Please provide any additional information that would inform and create a better understanding of your Systems of Care community that has not been discussed in the above items.

Community Description Form

1. Geographic Boundaries of Target Community:

2. Community Boundaries:

3. Brief Community Description:

4. Community Setting:

5. Total Community Population:

6. Median Annual Household Income:

7. Population percentages by Ethnic/Racial Background:

Year these data reflect: _____

Data source: _________________________

Ethnic/Racial Background	Percentage
White
Black or African American
Spanish/Hispanic/Latino
Mexican, Mexican American
Puerto Rican
Cuban
Other Spanish/Hispanic/Latino
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native Hawaiian
Samoan
Other Pacific Islander

8. Other significant and descriptive community information: