2024 Racial/Ethnic Data Collection Form

Child and Adult Care Food Program and Summer Food Service Program Combined Racial/Ethnic Data Collection Form

Form to be completed by CACFP or SFSP Facility
Facility Name
Email*
example@example.com
Facility Type

CACFP Facility
Program Year Data Collected
2024
Name and Title of Person Completing Form

Full NameTitle
Total Enrollment (Enrolled programs)
Please enter your Total Enrollment
5-Day Average Attendance (Non-enrolled programs)
Average Daily Attendance
Method of Data Collection

Individual Data Form Completed by Adult Participant, Parent/Guardian (IES Form, DECAL Form, etc.)Individual Data Provided by SchoolData Collected VerballyAggregate Data (Non-enrolled programs only)
If Aggregate Data was used enter the number of individual collection responses received from Parents/Guardians
Instructions for completion:
1. In Section I, from the data collected input the total number of participants based on the two ethnic categories: a) Of Hispanic or Latinoorigin; or b) Not of Hispanic or Latino origin.
2. In Section II, from the data collected input the total; number of participants by racial category based on the six categories listed.
3. The total number of participants by ethnic category (Section I, Item D) and the total number by racial category (Section II,Item H) must be equal

Section I: Ethnic Category

	Number of Participants
A) Hispanic or Latino (Person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic" or "Latino")
B) NOT Hispanic or Latino
C) Number of Unknown Responses (Parent/guardian did not advise of an ethnic category)
D) TOTAL NUMBER OF PARTICIPANTS BY ETHNIC CATEGORY

Section II: Racial Category

	Number of Participants
A) American Indian/Alaskan Native (Person having origins in any of the original peoples on North America, and who maintains cultural identification through tribal affiliation or community recognition [includes Aleuts and Eskimo)
B) Asian (Person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent,or the Pacific Islands, for example Cambodia, China, India, Japan, Korea, the Philippine Islands, Thailand, Malaysia,Pakistan and Vietnam)
C) Black or African American (Person having origins in the Black racial groups of Africa).
D) Native Hawaiian or other Pacific Islander (Person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)
E) White (Person having origins in any of the original peoples of Europe, North Africa, or the Middle East)
F) Multiracial (Person having origins in two or more of the original peoples of Africa, Asia, Europe, Middle East,North America, or Pacific Islands).
G) Number of Unknown Responses (Parent/guardian did not advise of a racial category
H) TOTAL NUMBER OF PARTICIPANTS BY RACIAL CATEGORY

I certify to the best of my knowledge and belief that the above information is collected in accordance with USDA guidelines and is accurateand complete.
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Child and Adult Care Food Program and Summer Food Service Program Combined Racial/Ethnic Data Collection Form