Orange County NC Website
DocuSign Envelope ID: E9DE81F9-0070-4074-8F70-93DABC24ACE1 A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Program/Project Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> I) Disclosure of Potential Conflicts of Interested must be signed <br /> m) 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 /> 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: EZ Persons Households F I Units <br /> Program: Self-Sufficiency Programs <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 176 175 175 <br /> Female 603 645 645 <br /> Unknown 32 30 30 <br /> Total 811 850 850 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> • <br /> African-American 100 140 140 <br /> American Indian or Alaska Native 2 2 2 <br /> Asian 21 25 25 <br /> Caucasian 313 315 315 <br /> Native Hawaiian or other Pacific <br /> Islander 0 0 0 <br /> Other 23 25 25 <br /> Unknown 352 343 343 <br /> Total 811 850 850 <br /> Of the above, how many <br /> Hispanic/Latino 5 30 30 <br /> Of the above, how many non- <br /> Hispanic/Latino 806 820 820 <br /> Total 811 850 850 <br /> Age <br /> Main Application 1/24/2016 2:59:42 PM Page 2 4 of 58 <br />