Unduplicated Client Count by Characteristics
Quarterly Report Form

Agency:

Agency Code:

Phone Number:

Completed By:

Service Provided:

Fiscal Year:

Quarter:

 

Clients Served Qtr.

Clients Served Ytd.
1. Unduplicated Clients

2. Client by Minority Status (Unduplicated Client Count by Characteristics)
African American
Hispanic
American Indian/Native Alaskan
Asian American/Pacific Islander
Middle Eastern-Arab American
Non-Minority
Race Missing
Multi-Racial
3. Rural Clients
4. Clients in Poverty
5. Clients in Poverty/Minority