Population Data Form
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1Attachment #12
Population Data Form
Clients Served
AGENCY NAME: ___________________________________________________________
RISK
____ % Men who have Sex with Men (Non-IDU)
____ % Men who have Sex with Men (IDU)
____ % Injection Drug Users (IDU)
____ % Substance Users (non-IDU)
____ % Heterosexual Risk
____ % Other (specify) ____________________
100 % TOTAL (must equal 100%)
RACE/ETHNICITY
____ % White, non-Hispanic
____ % Black, non-Hispanic
____ % Hispanic
____ % Asian/Pacific Islander
____ % American Indian/Alaskan Native
____ % Other (specify) ____________________
100 % TOTAL (should equal 100%)
GENDER
____ % Female
____ % Male
____ % Transgender
100 % TOTAL (should equal 100%)
AGE GROUP
____ % 0-13 years
____ % 30-39 years
____ % 13-19 years
____ % 40-49 years
____ % 20-29 years
____ % Over 50 years
100 % TOTAL (should equal 100%)
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Parent category: Business