Reach and Demographics

Form Approved

OMB No. 0990-0460

Exp. Date XX/XX/20XX

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0460. The time required to complete this information collection is estimated to average 10 hours 36 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Candidate Pregnancy Assistance Fund Performance Measures

FY2017-2019 Cohort

Participant Reach and Demographics

1. During the federal grant year (July 1-June 30), how many expectant and/or parenting participants did the PAF program serve within each of the following settings? Include the total number for each category:

Expectant or parenting mothers at high schools ____

Expectant or parenting fathers at high schools ____

Expectant or parenting mothers at Institutions of Higher Education ____

Expectant or parenting fathers at Institutions of Higher Education ____

Expectant or parenting mothers at community service organizations ____

Expectant or parenting fathers at community service organizations ____

Expectant or parenting mothers at other settings ____

Expectant or parenting fathers at other settings ____

Total number of expectant and parenting participants (all Settings): ____

2. During the federal grant year (July 1-June 30), how many dependent children of expectant or parenting teens, students, or young adults were served by the PAF program?

Dependent Children of an expectant or parenting student, teen, or young adult ____

3. During the federal grant year (July 1-June 30), how many extended family members of expectant and parenting participants were served by the PAF program? ____

[Extended family members are defined as other partners, spouses, Parents or guardians of expectant and parenting students, teens, youth, and young adults who were not covered in questions 1-3]

4. Indicate the number of expectant and parenting teens, students, and young adults served by the PAF program during the federal grant year (July 1-June 30) by their racial category:

White __________

African American or Black __________

American Indian or Alaska Native __________

Asian __________

Native Hawaiian/Pacific Islander __________

More than 1 Race __________

Race Unknown/Not Reported __________

5. Indicate the number of expectant and parenting teens, students, and young adults served by the PAF program during the federal grant year (July 1-June 30) by their ethnicity:

Hispanic/Latino __________

Non-Hispanic/Latino __________

Ethnicity Unknown/Not-Reported __________

6. Indicate the number of expectant and parenting teens, students, and young adults served by the PAF program during the federal grant year (July 1-June 30) by their age (as of [Insert Date]):

<14 _______

15 _______

16 _______

17 _______

18 _______

19 _______

20-24 _______

25+ _______

Unknown/not reported _____