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DocuSign Envelope ID: E9553E7D-3748-4C37-A9D7-602D42934ACC t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> I) Complete the Work Statement Chart to describe the work to be performed, and be sure to <br /> attach copies of all data collection tools that will be used to verify achievement of program <br /> goals and objectives. Describe who will be responsible for monitoring progress. <br /> Demographic information presented below in this application reflects those of WCOM <br /> volunteers. Lacking any means to measure them,we assume that listener demographics <br /> resemble those of Chapel Hill and Carrboro since our service is delivered free of charge. <br /> Information to Complete <br /> j.) Target Population <br /> Complete the following tables to the best of your ability. Show numbers of participants and <br /> percentages, as applicable, in each category. <br /> Please indicate whether this project/program will serve: XX❑ Persons ❑ Households ❑ <br /> Units <br /> Program: <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 45–63% 44–59% 44–57% <br /> Female 28–37% 31 –41% 33–43% <br /> Total 73 75 77 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 7- 10% 8- 11% 9- 12% <br /> American Indian or Alaska Native 1 – 1% 1 – 1% 1 – 1% <br /> Asian 2–3% 3–4% 4–5% <br /> Caucasian 63–86% 63–84% 63–82% <br /> Native Hawaiian or other Pacific <br /> Islander 0 0 0 <br /> Other 0 0 0 <br /> Total 73 75 77 <br /> Of the above, how many <br /> Hispanic/Latino 4–5% 6–7% 7–9% <br /> Of the above, how many non- <br /> Hispanic/Latino 69–95% 69–93% 70–91% <br /> Total 73 75 77 <br /> Age <br /> 0-5 years 0 0 0 <br /> 6-18 years 4-5% 4-5% 4-5% <br /> 19-50 years 40–55% 42–55% 43–55% <br /> Main Application 5/25/2016 10:00:47 AM .. of 20 <br />