Instructions: Module 5 - TheMeasurementGroup.com

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 5: Technical Assistance Summary Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Note. This module should be completed by the person(s) who provided technical assistance. The form should be completed as soon as possible after the technical assistance session occurred. This module is two pages. Items #1 through #8 are on page 1 of 2, while items #9 through #17 are on page 2 of 2. Please be sure to fill out the identification information on both pages ("Site," "Sub-Provider," etc.).

Throughout this form "TA" means technical assistance.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

TA #. Enter the three-digit code for the technical assistance session. For example, if this is the third technical assistance session that your project has had, enter "003" in these boxes.

Technical Assistance Date. Enter the numbers representing the date the technical assistance was provided in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Hour. Enter the starting time of the technical assistance as a two-digit number. Round to the nearest hour. For example, if the start time is between 10:31 am and 11:30 am, enter "11" in the boxes and darken the circle labeled "am."

Length Minutes. Enter the length of time of the technical assistance as a three-digit number. For example, if the length of time of the technical assistance is 90 minutes, enter "090."

Staff Providing Services. Enter the staff member code or codes for each of the staff providing services. The staff codes are determined by your local project. Staff codes are 3 numbers. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Language Used. Indicate the language used for the technical assistance by darkening the appropriate circle. For example, if both English and Spanish were spoken during the technical assistance, darken the circle labeled "Both E & S."

I. Topics (all that apply). Indicate which topics were presented or discussed during the technical assistance by darkening the appropriate circle(s). You may darken more than one. Use the boxes labeled "Other" to indicate topics not listed on the form.

Topics	Working Definitions
Special Populations
Adolescent/Youth	Issues related to working with adolescents and young adults (generally defined as ages 13 - 26, although local definitions may vary).
Gay/Lesbian Issues	Issues related to working with Gays and Lesbians.
HIV Sensitivity	Issues related to working with HIV-infected clients.
Immigrants/Refugees	Issues related to working with recent immigrants or refugees.
Incarcerated	Issues related to working with incarcerated clients.
Pediatric	Issues related to working with infants and children (generally defined as newborns through age 12, although local definitions may vary).
Racial & Ethnic Minority Issues/Cultural Factors	Issues related to working with racial and ethnic minorities and understanding cultural factors.
Substance Abuser	Issues related to working with substance abusing clients.
Women	Issues related to working with women clients.
Women and Reproductive Health	Issues related to working with women’s reproductive health issues.
Other	Other topics not listed on the form. Print a brief description or abbreviation of the topic in the boxes where indicated on the form.
Care-Case Management
Medical Intervention and Management-Diagnosis-Treatment	Issues related to medical services, including medical management, diagnosis and treatment.
Psychosocial Issues-Case Management	Psychosocial issues and the provision of case management.
Prevention of HIV Transmission	Issues related to the prevention of HIV infection, transmission, or retransmission.
Workplace Issues	Issues related to HIV and the workplace.
Legal Advocacy-Ethical Issues-Community Empowerment	Issues related to legal advocacy, ethical issues (such as informed consent), and community empowerment.
Personal-Interpersonal Issues	Issues related to personal or interpersonal relationships.
Technical
Computer Software	Issues related to using computer software, or with identifying software needs for individuals or organizations.
Computer Hardware	Issues related to using computer hardware, or with identifying computer equipment needs for individuals or organizations.
Information Dissemination	Issues related to disseminating information about an organization or program to others. Examples include a range of activities, such as producing newsletters or other written materials about a program, academic publications, manuals for specific treatment procedures, conferences, etc.
Instrument Development	Issues related to the development of forms for management, data collection, evaluation, or other purposes.
Data Management	Issues related to managing electronic data files for program management information systems, evaluation, and other purposes.

2. Method (all that apply). Indicate the method used for the technical assistance by darkening the appropriate circle(s). You may darken more than one.

Methods	Working Definitions
E-mail	Electronic mail delivered via computer (such as Internet, HandsNet, etc.).
Face-to-Face	Assistance provided in person, in a face-to-face work session.
Fax	Assistance provided in a written format via fax.
Lecture	A method of providing technical assistance characterized by one-way communication from the lecturer to the recipients. Usually considered formal and didactic.
Mail	Assistance provided in a written format delivered by mail (includes US Mail as well as overnight and other delivery services).
Phone	Assistance provided verbally over the telephone.
Preceptorship/ Mentorship	A method of technical assistance by a mentor or preceptor that involves intense, hands-on, one-to-one instruction or demonstration that usually takes place over a number of days or weeks.
Self-Study	A method of technical assistance characterized by an individual taking the initiative to teach him/herself.
Workshop	Technical assistance delivered in a formal training session.

3. Materials provided (all that apply). Indicate materials provided through the technical assistance by darkening the appropriate circle(s). You may darken more than one. Darken the circle next to "Other" to indicate materials provided that are not listed on the form and use the boxes to the right of "Specify" to further identify the materials.

Materials Provided	Working Definition
Articles	Newspaper, magazine, journal or copies of print media articles.
Brochures	Printed matter several pages in length.
Description of Model Programs	Printed matter descriptive of model programs.
Directories/Service Provider Lists	Printed matter listing services and/or service providers relevant to the technical assistance.
Pamphlet	Single page printed matter relevant to the technical assistance.
Recommendation to Purchase Materials	A verbal or written recommendation to purchase materials.
Technical Manual	Printed matter providing a source of reference relevant to the technical assistance.
Training Schedule	Information listing training sessions available relevant to the technical assistance.
Other	Other materials not listed elsewhere on the form. Print a brief description or abbreviation of the type of materials provided in the boxes where indicated on the form.

4. TA provided directly to (all that apply). Indicate to whom the technical assistance was provided by darkening the appropriate circle(s). You may darken more than one.

TA Provided To	Working Definition
Program Service Staff	Staff who provide direct services to clients of the program or project.
Program Support Staff	Staff providing clerical, administrative, or fiscal support to the direct service staff of the program or project.
Other Program Staff (evaluator, consultants)	Staff providing technical or other assistance to the program or project (for example, evaluators or consultants).
Program Management/Supervisor	Management or supervisorial staff.
Board	Members of the Board of Directors or Advisory Board of the agency responsible for the program or project.
Volunteers	Volunteer staff of the program or project.
Consumers	Clients or recipients of program services.
Staff-Personnel from Other Agencies	Staff or personnel from agencies not responsible for the program or project.

5. Where did the request come from (all that apply)? Indicate the source of the request for technical assistance by darkening the appropriate circle(s). You may darken more than one.

Source of Request	Working Definition
Board	The Board of Directors or Advisory Board made the request for technical assistance.
Project Officer or other Funding Official	The Project Officer or other funding official initiated the request for technical assistance.
Self (TA Recipient)	The person receiving the technical assistance made the request.
Supervisor/Manager	The request for technical assistance was made by a program manager or supervisor.
Training Session	The request was generated at a training session.
Other	The request for technical assistance came from a source not listed on the form. Do not specify what the other source was.

6. Purpose of activity (all that apply). Indicate the purpose of the technical assistance by darkening the appropriate circle(s). You may darken more than one. You may write in a purpose not listed in the boxes marked "Other."

Purpose of Activity	Working Definition
Agency Development	To increase agencies’ awareness of services and to reach agencies that may desire or need knowledge, training, or services. To expand service network and establish referral linkages.
Client Advocacy	To advocate on behalf of the client or assistance to the client to gain medical or social services, benefits, entitlements, etc. Target of advocacy is likely to include service providers. Note that technical assistance on client advocacy is typically provided to the agency or staff who would be advocating for individual clients, not to the individual client.
Computer/Technology Assistance	To assist in the development of computer skills relevant to program activities, including service delivery, management information systems, or evaluation.
Cross Training	To share skills and information within an agency, among various agencies, or among discrete populations.
Dissemination	To increase awareness, skills, and information to a larger population of service providers and/or clients.
Evaluation	Activities designed to document the efficacy of program services or functions.
Fund-Raising	To procure or elicit monetary support, resources, or other funds, or to engage in activities that lead to increasing the program’s resource base.
Grant Writing	The process of developing proposals for funding and submitting them to appropriate funding sources.
Networking	Activities designed to increase collaboration and understanding among agencies and service providers.
Organizational/Management Consulting	Activities designed to enhance the development of service provider organizations.
Policy Advocacy	To advocate for specific policy impacting a group of people or constituents. Target of advocacy may include administrators, elected officials, planning councils, and advisory boards.
Staff Development	Activities designed to increase staff skills and knowledge.
Other	Purposes not coded elsewhere. Print a brief description or abbreviation of the purpose of the activity in the boxes to the right of "Other.".

7. Style of TA (all that apply). Indicate the style of technical assistance by darkening the appropriate circle(s). You may darken both circles if the technical assistance included both styles.

Darken the circle next to "Providing expert opinion/consultation," if the technical assistance involved the provision of expert opinion or consultation. This style of technical assistance tends to provide suggestions based on the expert’s knowledge or previous experience with similar issues.

Darken the circle next to "Facilitating problem detection/solution" if the technical assistance involved facilitation of problem detection and/or solutions to problems. This style of technical assistance tends to arrive at suggestions through a group process in which the facilitator helps program staff decide what best meets their own needs.

8. What was requested and provided and actually needed now or in the future? For each of the applicable areas listed on the form, indicate whether technical assistance on that issue was requested, whether assistance was provided on the issue, and whether a need for technical assistance on the issue was identified.

For all the technical assistance areas that apply, follow these instructions:

Darken the circle(s) under "R" for each item for which technical assistance was requested.

Darken the circle(s) under "P" for each item for which technical assistance was provided.

Darken the circle(s) under "N" for each item for which the need for technical assistance was identified.

Note that the circle for "P" should be filled in if technical assistance was actually provided, whether or not it was specifically requested. Likewise, mark the circle for "N" if a need for a specific area was identified, whether or not it had been requested or provided.

Technical Assistance Area	Working Definition
Organizational development assistance
Staffing needs	Assistance with identifying the program's staff-related needs such as direct service, administrative, and other needs.
Staff recruitment	Assistance with identifying suitable applicants for agency positions.
Maximize potential of current staff	Assistance in maximizing the potential of current staff. Includes identifying training, education, and other support needed by existing program staff.
Staff supervision	Assistance with supervising program staff.
Advisory Boards and Boards of Directors	Assistance with issues related to advisory boards, board of directors, and other advisory bodies. May include topics related to recruiting individuals to serve on advisory boards, working with existing advisory groups, etc.
Consumer involvement	Assistance with maintaining or improving the involvement of service consumers in the ongoing operations of the program.
Resource allocation	Assistance with allocating resources to various program and administrative activities. Includes financial, staff, and other resources.
Internal support systems (financial, clerical)	Assistance with developing or improving administrative and support systems.
Program development assistance
Scheduling client services	Assistance with finding optimal ways to schedule client services.
Selecting program services	Assistance with selecting the best combination of services to offer and provide.
Maximize effectiveness of program component(s)	Maximizing the effectiveness of program components involves "fine-tuning" existing services to make sure they are working as well as possible. It may also include developing new program elements where appropriate.
Matching client needs to services	Assistance with assessing client needs and matching them to the most appropriate services.
Aftercare/follow-up services	Assistance with developing or maintaining services for clients who are no longer in the "active" or "main" phase of care but are seen on a continuing basis for follow-up or aftercare.
Referrals to other agencies	Assistance with making referrals for clients to other agencies, or expanding an agency’s referral network, developing networks and linkages with other service agencies.
Maintaining quality of services	Assistance with monitoring services to ensure quality; quality assurance.
Evaluating quality of services	Assistance with evaluating how effective, appropriate, and high quality services are being provided by the program.
Management information system	Assistance with developing or maintaining data systems to keep program managers and staff informed of service utilization, client information, billing, etc.
Infrastructure development assistance
Linkages with other agencies	Assistance with developing or maintaining relationships with other agencies to facilitate information sharing, referrals, funding opportunities, cross-training, and other cross-agency issues.
Linkages with government entities	Assistance with developing or maintaining relationships with local, state, and federal government entities to facilitate information sharing, funding opportunities, etc.
Cooperative-shared programming	Assistance with developing or maintaining programs that involve more than one service agency.
Client referrals	Assistance with making referrals for clients to other agencies, or expanding an agency’s referral network, developing networks and linkages with other service agencies. If marked here, this indicates helping a program to develop or maintain capacity for making referrals.
Developing memo of understanding	Assistance with formalizing agreements (memoranda of understanding) with other agencies to facilitate cooperative-shared programming or other cross-agency activities.
Community acceptance problems ("NIMBY")	Assistance with overcoming problems of community acceptance of program facilities.
Technology utilization assistance
Office systems	Assistance with developing or maintaining technology for maintaining office support activities.
Computer software	Assistance with addressing program needs for computer software, or training staff in the use of specific software applications.
Computer hardware	Assistance with addressing program needs for computer hardware, or training staff in the use of specific types of computer equipment.
Instrument development	Assistance with developing measures to be used for program clinical use, evaluation, and other purposes. Instruments are broadly defined, and may include traditional pencil-and-paper tools, as well as structured interviews, checklists, etc.
Data management	Assistance with developing or maintaining computer data systems for entering, analyzing, and reporting program data.
Information dissemination	Assistance with disseminating information about the program to others.
Resource development
Grant writing	Assistance with learning skills of grantsmanship, or in actually providing direct assistance writing a specific proposal.
Fund-raising (cash)	Assistance with procuring or soliciting monetary support, resources, or other funds, or to engage in activities that lead to increasing the program’s resource base.
Donations (materials and services)	Assistance with procuring or eliciting materials and services that could be donated to the program.
Human resources (interns, volunteers)	Assistance with identifying and maintaining people that can help the program at little cost, such as interns and volunteers. Also may involve finding ways to recruit such people to the organization.
Issues of cultural appropriateness, sensitivity, and access
Appropriateness for special populations
Language appropriateness	Assistance with issues related to whether program services are provided in a language that is appropriate for the populations being served.
Staffing to match service population	Assistance with issues related to whether program staff are appropriate to work with the populations being served.
Sensitivity for special populations
Agency issues (mission)	Assistance with issues related to whether the agency mission addresses the need for services to be provided in a sensitive manner for the populations being served.
Staff issues	Assistance with issues related to whether agency staff provide services in a sensitive manner for the populations being served.
Facility issues	Assistance with issues related to whether the program’s physical facility is designed so it meets the needs of special populations that may be served.
Printed materials (brochures, handouts, etc.)	Assistance with issues related to whether printed materials being provided by the program are sensitive to the needs of the populations being reached.
Meals, clothing	Assistance with issues related to whether meals, clothing, or other basic needs being provided by the program are sensitive to the populations being served.
Educational-prevention programs	Assistance with issues related to whether education and prevention programs provided are sensitive to the populations being served.
Treatment programs	Assistance with issues related to whether treatment and care services provided are sensitive to the populations being served.
Access
Location	Assistance with access issues related to the location of the program such as distance from clients or lack of transportation.
Physical access of facility	Assistance with issues related to whether the program’s physical facility does not pose any barriers to individuals seeking services.
"Emotional" access of facility	Assistance with issues related to whether the program’s physical facility does not pose any emotional or "psychic" barriers to individuals seeking services. This includes ensuring that the physical environment is pleasant and that there are no emotional barriers presented by the facility.
Scheduling	Assistance with issues related to whether the program’s scheduled hours of operation do not pose any barriers to individuals seeking services.
Transportation	Assistance with issues related to whether the program provides transportation or access to transportation so that this is not a barrier to accessing services.
Child-care	Assistance with issues related to whether the program provides child care or access to child care to reduce this barrier to accessing services.

Page 2 of 2 begins here.

Please make sure that the information in the shaded sections at the top of page 2 are completed so that page 1 & 2 can be matched for this TA event.

9. Settings (all that apply). Indicate the type of setting(s) by darkening one or more of the circles. Use the boxes labeled "Other" to indicate a setting not listed here.

Settings	Working Definition
Community (hotel, conference site)	Settings that are in the community, such as conference sites or hotels where training sessions take place.
Community Based Organization	Settings that are decentralized and community-based that usually provide client-centered services.
Criminal Justice	Settings that are related to or are part of the criminal justice system, such as jails, prisons, offices of probation or parole officers, or courts.
Health Care	Settings that are related to or are part of the health care system, such as clinics or hospitals. Note that physician office is coded elsewhere.
Physician Office	Office of a physician in private practice that is not within a clinic or hospital.
Religious	Settings of worship or other religious activities, such as churches, congregations, synagogues, or temples.
School/Educational	Settings for teaching and learning, such as a schools, colleges, or universities.
Social Service Agency	An agency that provides social services such as case management or public assistance.
Workplace	Settings in which people work.
Other	Other settings not coded elsewhere. Print a brief description or abbreviation of the setting in the boxes where indicated on the form.

10. Depth of TA (all that apply). Indicate the depth of the technical assistance by darkening the circle next to the most appropriate response. Darken the circle next to "Extremely In-Depth" if you feel that the technical assistance was very thorough and in-depth. Darken the circle next to "Moderately In-Depth" if you feel that the technical assistance was fairly or moderately in-depth. Darken the circle next to "Cursory" if you feel that the technical assistance was superficial or cursory in nature.

11. How will TA have impact (all that apply)? Darken the circle(s) next to the responses most appropriate for describing how the technical assistance will impact your target area.

How TA Will Have Impact	Working Definition
Facilitate Dissemination of Information	The technical assistance will help to disseminate information about the program and its concerns throughout the community.
Facilitate Evaluation of Program	The technical assistance will help the evaluation of the program.
Facilitate use of computer technology	The technical assistance will help to develop a more thorough and efficient use of computer technology to serve the program.
Facilitate use of treatment technologies	The technical assistance will help the program to use treatment technologies.
Improve Management Decisions	The technical assistance will help improve management decisions regarding the program.
Improve Organizational Functioning	The technical assistance will help improve the program’s organizational functioning.
Increase Knowledge About HIV/AIDS Content	The technical assistance will help to increase the knowledge of participants about HIV/AIDS.
Increase Knowledge About Services	The technical assistance will help to increase the knowledge of participants about services available in the community.
Increase Sensitivity Among Staff	The technical assistance will help program staff be more sensitive to the issues targeted by the technical assistance.
Increase Sensitivity To Clients	The technical assistance will help staff will be more sensitive to the program’s clients.

12. Overall Needs And Impact of TA. Using numbers from 1 (Not at All) to 5 (Very Much), respond to each of the following questions by placing a number in the box to the right of each question.

1	2	3	4	5
Not at all				Very Much

Need for TA

Overall, how much did the agency need the requested TA? (rate from 1 to 5)

Overall, how ready is the agency to receive the requested TA? (rate from 1 to 5)

Overall, how much did/does the agency need related TA that was not requested? (rate from 1 to 5)

Overall, how ready is the agency to receive the related TA that is needed but was not initially requested? (rate from 1 to 5)

Evaluation of Impact

Overall, how "open" were the TA recipients to the offered assistance? (rate from 1 to 5)

How well did the TA recipients understand/assimilate the offered assistance? (rate from 1 to 5)

Overall, how well will the TA recipients be able to implement the TA knowledge or skills into their organization without further TA? (rate from 1 to 5)

Overall, how well will the TA recipients be able to implement the TA knowledge or skills into their organization with further TA? (rate from 1 to 5)

13. What are the appropriate follow-ups for the current TA effort (all that apply)? Darken the circle(s) next to the response (s) most appropriate for describing the need for follow up to this technical assistance.

Darken the circle next to "None, TA is now complete" if no further technical assistance is required.

Darken the circle next to "Additional sessions on the issues marked in section 8" if more technical assistance is needed. Use the boxes below this question to write in the number of sessions needed. If the number is one digit precede the digit with a "0" (for example 3 additional sessions would be indicated by writing in "03").

Darken the circle next to "Telephone follow-up" if additional technical assistance can be given by telephone.

Darken the circle next to "Face-to-face follow-up" if additional technical assistance must be given in person.

Darken the circle next to "Written diagnostic report" if additional technical assistance can be given in a written report.

Darken the circle next to "Full-scale training" if additional technical assistance will require full-scale training.

Darken the circle next to "Resource materials" if additional technical assistance can be given in resource materials.

14. Was travel required to the TA (car, air, rail, other)? Darken the circle next to "Yes" if travel was required, or next to "No" if travel was not required. In the boxes located below "Distance for TA provider to TA site," write in the number of miles between the technical assistance provider and the technical assistance site. When writing in the number of miles, right justify the number (for example, if the number of miles is 12, write in "0012"). It is acceptable to provide an estimate if you do not know the exact mileage.

15. Breadth of TA. Darken the circle indicating whether the technical assistance was "General" or "Specific".

16. Participants. Indicate the types of participants by darkening one or more of the circles provided. There are two sections: "A. Primary Caregivers" and "B. Other Participant Groups". Use the boxes labeled "Other" to indicate a type of participant not listed on the form.

A. Primary Caregivers	Working Definitions
Mental Health Providers	Providers of mental health care, treatment, or services, such as psychiatrists, psychologists, counselors, and clinical social workers.
Primary Health Care Providers (Medical/ Dental)	Providers of medical or dental services focusing on the prevention of illness and the ongoing management of chronic conditions and acute health problems.
Social Service Providers	Providers of social services, such as health educators, case managers, caseworkers, health education trainers, vocational training providers, and housing specialists.
Substance Abuse Treatment Providers	Providers of substance abuse treatment, care, or services.
Support Health Care Personnel	Providers of support health care, such as nurses, nurse practitioners, physician assistants, dental hygienists, and health technicians.
Other	Other primary caregivers not coded elsewhere. Print a brief description or abbreviation of the type of provider in the boxes where indicated on the form.

B. Other Participant Groups	Working Definition
Advocates (including attorneys)	Providers that advocate on behalf of the client or give assistance to the client to gain medical or social services, benefits, entitlements, etc.
Case Managers/Case Coordinators	Providers of a range of client-centered services that link clients and other family members with health care, psychosocial services, and other services to ensure timely, coordinated access to appropriate services.
CJS Workers	Persons that work in the criminal justice system, such as probation and parole officers.
Community Services Providers	Providers of social services in the community, such as administrators of recreational and outreach programs.
Counselors	Providers of mental health or psychosocial care or services.
Employers	Persons who provide employment or jobs for client or client groups.
Family Members	Family members or relatives of client or client groups.
Grass Roots Organizations	Community organizations composed of persons interested in effecting social change, such as ACT-UP.
Peer Advocates	Non-professional activists that advocate on behalf of their peers.
Planning/Policy Makers	Persons who are involved with policy or planning, such as city planners, politicians or representatives of politicians, and other policy making groups.
Religious Leaders	Persons who are in leadership positions in churches or other religious organizations, such as priests, pastors, and rabbis.
Service Recipients Consumers/PWAs	Clients or recipients of services, such as persons with AIDS.
Teachers/Educational Leaders/ Academics	Teachers, administrators and other educational support staff.
Young Adults: 19-25 years old	Persons who are 19 to 25 years old.
Youth: 12-18 years old	Persons who are 12 to 18 years old.
Other	Other participant groups not coded elsewhere. Print a brief description or abbreviation of the type of participant in the boxes where indicated on the form.

17. Individuals served,contacted, or reached.

A. Gender: # of Males / # of Females. In the boxes provided, write the number of males and the number of females participating in this activity. If you do not have an actual count, provide an estimate. If the number is less than 100, place "0"s to the left of the number. For example, if 78 men attended the technical assistance, enter "078." Darken the circle next to "Actual Counts used" if you are using actual counts. Do not darken the circle if you are giving estimates.

B. Race/Ethnicity

% African Am-Black. Enter the percentage of total number of participants who were African American. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., "050").

% Caucasian-White. Enter the percentage of total number of participants who were Caucasian. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., "050").

% Native Am-Am Indian. Enter the percentage of total number of participants who were Native American. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., "050").

% Asian Am-Pac Island. Enter the percentage of total number of participants who were Asian American.. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., "050").

% Hispanic-Latino. Enter the percentage of total number of participants who were Hispanic or Latino/a. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., "050").

% Other-Multiracial. Enter the percentage of total number of participants who were other ethnic/racial backgrounds. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., "050").

NOTE: The total of the six race/ethnicity categories should add to 100%. Darken the circle next to "Actual %s used" if you are using actual percentages. Do not darken the circle if you are giving estimates.