Form 4 - Community Characteristics - Health Resources And Services Administration

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Form 4: Community Characteristics
OMB No.: 0915-0285. Expiration Date: 1/31/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOR HRSA USE ONLY
Health Resources and Services Administration
Grant Number
Application
Tracking Number
Form 4: COMMUNITY CHARACTERISTICS
Note: All information provided regarding race and/or ethnicity will be used only to ensure compliance with
statutory and regulatory governing board requirements. Data on race and/or ethnicity collected on this
form will not be used as an awarding factor.
Target
Service Area
Target
Race and Ethnicity
Service Area
Population
Percent
Population
Percent
will auto-
will auto-
Asian
calculate in EHB
calculate in EHB
will auto-
will auto-
Native Hawaiian
calculate in EHB
calculate in EHB
will auto-
will auto-
Other Pacific Islanders
calculate in EHB
calculate in EHB
will auto-
will auto-
Black/African American
calculate in EHB
calculate in EHB
will auto-
will auto-
American Indian/Alaska Native
calculate in EHB
calculate in EHB
will auto-
will auto-
White
calculate in EHB
calculate in EHB
will auto-
will auto-
More than One Race
calculate in EHB
calculate in EHB
Unreported/Declined to Report (if
will auto-
will auto-
applicable)
calculate in EHB
calculate in EHB
will auto-
will auto-
Total:
100%
100%
calculate in EHB
calculate in EHB
Target
Target
Service Area
Service Area
Hispanic or Latino Ethnicity
Population
Population
Number
Percent
Number
Percent
will auto-
will auto-
Hispanic or Latino
calculate in EHB
calculate in EHB
will auto-
will auto-
Non-Hispanic or Latino
calculate in EHB
calculate in EHB

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