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pdfOMB Approved NO. 2900-0180
Respondent Burden: 1 hour and 15 minutes
1. COMPUTATION DATE (See Instructions)
COMPLIANCE REPORT OF PROPRIETARY INSTITUTIONS
(Under Title VI Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitating Act of
1973, and the Age Discrimination of 1975)
PRIVACY ACT INFORMATION: The information requested in this report is required by law (Title VI of the Civil Rights Acts of 1964, Title
IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, The Age Discrimination Act of 1975, and Executive
Order 12250). If the information on the form was not collected VA would be unable to carry out its withdrawal of rights and responsibilities
mandated by law. Your obligation to respond is required in order to obtain or retain benefits. Failure to report may result in withdrawal of
Federal Financial Assistance. Responses may be disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the
routine uses identified in VA system of records, 37VA27, VA Supervised Fiduciary and Beneficiary Records - VA, published in the Federal
Register.
2. NAME AND ADDRESS OF INSTITUTION
3. TELEPHONE NUMBER
RESPONDENT BURDEN: We need this information to assure that VA Federally-funded programs are in compliance with equal opportunity
laws. We estimate that you will need an average of 1 hour and 15 minutes to review the instructions, find the information and complete the
form. VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB
Control Number. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can
be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html. If desired, you can call 1-800-827-1000 to
get information on where to send comments or suggestions about this form.
4. RETURN TO:
5. METHOD USED TO COLLECT DATA (Check one)
SELF-IDENTIFICATION
OBSERVER-IDENTIFICATION
SECTION I - STUDENT POPULATION DATA
TOTAL
STUDENT BODY
6. RACE/ETHNICITY
(See Instructions for
definitions)
A.
TOTAL STUDENT
BODY POPULATION
(6D+J+14L)
M
7
NUMBER OF APPLICANTS
8
NUMBER OF APPLICANTS
ACCEPTED
9
ENROLLEES DISCONTINUED
PRIOR TO COURSE
COMPLETION
10
PRESENT ENROLLMENT
11
NUMBER OF STUDENTS WHO
COMPLETED TRAINING
12
NUMBER OF STUDENTS
RECEIVED PLACEMENT
ASSISTANCE
13
NUMBER OF STUDENTS LIVING
IN FACILITY HOUSING
VA FORM
OCT 2007
20-4274
F
STUDENT BODY BY ETHNICITY
B.
SPANISH, HISPANIC,
LATINO POPULATION
M
F
STUDENT BODY BY ETHNICITY
C.
NON-SPANISH,
HISPANIC,
LATINO POPULATION
M
F
D.
TOTAL ONE RACE
(6E+F+G+H+I)
M
F
F.
BLACK OR
AFRICAN AMERICAN
E.
WHITE
M
F
EXISTING STOCK OF VA FORM 20-4274, APR 2003,
WILL BE USED.
M
F
G.
AMERICAN
INDIAN OR NATIVE
ALASKAN
M
F
I.
NATIVE HAWAIIAN
OR OTHER
PACIFIC ISLANDER
H.
ASIAN
M
F
M
F
HAWAII SCHOOLS ONLY
STUDENT BODY (TWO RACES ONLY)
This section applies to Hawaiian Schools Only whose students identify with two or more Race
Categories Listed.
14. RACE/ETHNICITY
(See Instructions for
definitions)
A.
TOTAL TWO OR MORE
RACES (14B+6C+
D+E+
F +G)
M
15
NUMBER OF APPLICANTS
16
NUMBER OF APPLICANTS
ACCEPTED
17
ENROLLEES DISCONTINUED
PRIOR TO COURSE
COMPLETION
18
PRESENT ENROLLMENT
19
NUMBER OF STUDENTS WHO
COMPLETED TRAINING
20
NUMBER OF STUDENTS
RECEIVED PLACEMENT
ASSISTANCE
21
NUMBER OF STUDENTS LIVING
IN FACILITY HOUSING
F
B.
AMERICAN/
INDIAN NATIVE
ALASKAN
& WHITE
M
F
C.
ASIAN
&
WHITE
M
D.
BLACK/
AFRICAN AMERICAN
& WHITE
F
M
F
E.
AMERICAN INDIAN/
NATIVE
ALASKAN & BLACK
M
F
F.
OTHER
2 OR MORE RACES
NOT LISTED
UNDER (14B,+ C,+ D
OR E)
M
F
G.
TOTAL NATIVE
HAWAIIAN &
PACIFIC ISLANDER
(6I+14H+I+
J+K)
M
F
H.
NATIVE HAWAIIAN &
PACIFIC ISLANDER
& WHITE
M
F
I.
NATIVE HAWAIIAN
PACIFIC ISLANDER
& ASIAN
M
F
J.
NATIVE HAWAIIAN/
PACIFIC ISLANDER
ASIAN & WHITE
M
F
K.
NATIVE HAWAIIAN/
PACIFIC ISLANDER
& ALL OTHER
COMBINATIONS NOT
LISTED UNDER
14H, I & J)
M
OTHER
L.
TOTAL UNKNOWN
OR REFUSAL
TO
PROVIDE RACE
M
F
SECTION II - COMPLAINTS OR LAWSUITS
22. HAVE ANY COMPLAINTS OR LAWSUITS ALLEGING DISCRIMINATION ON THE BASIC OF RACE, COLOR, NATIONAL ORIGIN, SEX, AGE OR DISABILITY BEEN
YES
NO
MADE AGAINST YOUR SCHOOL?
(If "YES,"furnish full details concerning the complaint on a separate sheet. Describe only complaints of discrimination based or race, color, age, national origin, age for disability and that have
been filed since the date of approval or date of last equal opportunity review, whichever is later. Include; name, race or national origin, age and sex of the complaint(s); whether the complaint
was base on race, color, national origin, age disability or sex; agency with complaint was filed; the investigating agency; results of the investigation; steps taken to resolve the issue; and whether
or not the complainant has successfully completed training. If action on the complaint is still pending, provide a statement concerning it status.
SECTION III - CERTIFICATION OF DATA
I CERTIFY THAT the information given, above is true and correct to the best of my knowledge.
23. SIGNATURE OF CERTIFYING OFFICIAL
24. NAME AND TITLE
PENALTY - A willfully false statement is punishable by law - Title 18, United States Code, Section 1001.
25. DATE
INSTRUCTIONS FOR COMPLETING COMPLIANCE REPORT OF PROPRIETARY INSTITUTIONS
PURPOSE - The report will assist the Department of Veterans Affairs (VA) determine if recipients of Federal financial
assistance are in
compliance with Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972,
Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975. These laws require that no person in the
United States shall be discriminated against because of their race, color, national origin, sex, disability and age under any
program or activity receiving Federal financial assistance.
AUTHORITY - 38 CFR Part 18, requires that you complete the report. Proprietary institutions receiving federal financial
assistance from VA or the Department of Education (ED) shall keep records and submit to VA timely, complete and accurate
compliance reports in a manner which will enable VA to ascertain the compliance status of your facility. A determination of
compliance by VA requires that not only veterans and their beneficiaries be protected against discrimination, but also all
students. The data provided in the report shall apply to the total student body in the program or activity receiving Federal
financial assistance from VA or ED. Under a delegation agreement between VA and ED, authority is delegated to VA to
conduct certain compliance activities of ED under Title VI with respect to proprietary, for profit, non-college educational
institutions. The functions delegated to VA include evaluating compliance reports, such as this report.
SUPPLEMENTARY INFORMATION - The data requested is in accordance with the Office of Management and Budget
(OMB) "Standards for Maintaining, Collecting and Presenting Federal Data on Race and Ethnicity," published in the Federal
Register on October 30, 1997.
FILING INSTRUCTIONS - Within 30 days of receipt of this report, complete and return this form to the address shown in
item 4.
Note: Only the schools in Hawaii will complete items 14F through 14K.
ITEM 1 (Computation Date) - Enter the date that is one year prior to the date this report is completed. That date is the
beginning point from which to count the number of applicants, applicants accepted, enrollees who discontinued prior to course
completion, students who completed training, students who received placement assistance and students who lived in housing
provided by the school or contracted out (items 7 through 13)
ITEM 2 and 3 - Provide the name, address of your facility and the telephone number of a facility official who can answer
questions pertaining to the information reported on the form.
ITEM 4 - Return the form to the address shown on this block.
ITEM 5 (Method Used to Collect Data) - Check only one block. The preferred and most reliable method is the
self-identification method, i.e., asking applicants/enrollees to identify their ethnicity/race. Students will first be asked to identify
themselves as "Hispanic or "Non-Hispanic" and then asked to select from one or more race categories. If obtaining data using
this method is not feasible, use the observer-identification method, i.e., obtain data by observation, without asking the
individuals to identify his/her race/ethnicity. The observer-identification method will be used as a last result.
Prior to asking for ethnicity/race, applicants/enrollees will be advised of your requirement to report ethnic/race information to
VA. If an individual refuses or elects not to provide such information, he/she will not be required to respond. The ethnicity/race
for these individuals will be reported under item "14L" as "Unknown or Refusal to Provide Race."
SECTION I - STUDENT POPULATION DATA - (Designation by race, national origin and sex).
ITEM 6 AND 14 Ethnicity/Race In Items 6B and 6C provide the ethnicity (Hispanic or non-Hispanic) of each applicant/enrollee shown in Items 7-13.
In Items 6D through 6I provide the number of applicants/enrollees in items 7-13 who identify one race only.
In Items 14A through 14F provide the number of applicants/enrollees in Items 7-13 who identify with multiple racial heritages.
Schools in Hawaii will also complete Items 14G through 14K.
The total number of the one-race-only categories will be reported in Item 6D.
The total number of the two-or-more race categories, including the total from item 14G (Hawaii schools only) will be reported in
Item 14A.
Note for Hawaiian Schools: Students in Hawaii may choose to identify with the one-race categories (6E to 6I), from
two-or-more race categories (14H to 14K) or from the two-or-more race categories specifically listed for Hawaiian schools only
(14H to 14K).
The sub total from Items 6D, 14A and 14G will be incorporate into 6A.
ITEM 14L - Total Unknown or Refusal to Provide Race: Provide the number of persons whose race is unknown or who
refuse to provide their race.
RACE CATEGORIES
ITEM 6B: Spanish, Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin.
ITEM 6C. Non-Spanish, Hispanic or Latino - A person who does not identify as being Spanish, Hispanic or Latino.
ITEM 6E. White (Only) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
ITEM 6F. Black or African American (Only) - A person having origins in any of the black racial groups of Africa.
ITEM 6G. American Indian or Alaska Native (Only) - 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..
ITEM 6H. Asian (Only) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
subcontinent including, e.g., Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
ITEM 6I. Native Hawaiian or Other Pacific Islander (Only) - A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
REPORTING CATEGORIES (Lines 7-13 and 15-21))
LINE 7. Number of Applicants: Enter the number of individuals who were accepted for admissions since the computation
date.
LINE 8. Number of Applicants Accepted: Enter the number of individuals shown on line 7 who were accepted for admissions
since the computation date.
LINE 9. Enrollees Discontinued Prior to Course Completion: Enter the number of individuals shown on line 8 whose
enrollment was discontinued for any reason other than successfully completing the program, such as voluntarily withdrawing
from school, failing to start, or being expelled for academic or disciplinary reasons.
LINE 10. Present Enrollment: Enter the number of students presently enrolled as of the date of this report. Include those who
applied or were admitted before the computation date shown in ITEM 1.
LINE 11. Number of Students Who Completed Training: Enter the number of enrollees who successfully completed their
training since the computation date. The count will include ALL individuals who completed training since the computation
date, regardless of when they applied or were admitted.
LINE 12. Number of Students Who Received Placement Assistance: Enter the number of enrollees who received placement
assistance at any time since the computation date.
LINE 13. Number of Students Living in Facility Housing: Enter the number of enrollees, as of the date of this report, living in
housing owned or operated by the school (e.g., dormitories or apartments).
SECTION II - COMPLAINTS OR LAWSUITS (Item 22):
Indicate whether any complaints or lawsuits alleging discrimination on the basis of race, color, national origin, age sex or
disability have ever been made against your school. Include ALL complaints or law suits filed since the school was opened.
SECTION III - CERTIFICATION OF DATA (Items 23 -25):
Enter the signature, name and title of the certifying official, as well as the date of the certification.
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |