ETHNIC RACIAL DATA FORM	

Sponsor:  ________________________________________________________________

Site: ____________________________________________________________________

Address:  ________________________________________________________________

Site supervisor:  __________________________________________________________
	
Ethnic Categories	Number of
Participating Children	
Hispanic or Latino.  A 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.”		
Non-Hispanic or Latino

		
Racial Categories		
American Indian or Alaska Native.  A person having origins in any of the original peoples of North and South America, (including Central America), and who maintains tribal affiliation or community recognition.		
Asian.  A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.		
Black or African American.  A person having origins in any of the black racial groups of Africa.  Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.”
		
Native Hawaiian or Other Pacific Islander.  A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.		
White.  A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

		

Monitor's Signature	

_____________________________
	   Date       	

Instructions for Completing the Ethnic Racial Data Form

The sponsor should complete this form for each site under its sponsorship each year. Sponsors of residential camps must collect this information for each camp session.  

On May 17th, 2021, USDA released CACFP 11-2021, SFSP 07-2021 Collection of Race and Ethnicity Data by Visual Observation and Identification in the Child and Adult Care Food Program and Summer Food Service Program – Policy Recission​. Racial and ethnic data is no longer to be collected by visual observation. 

Sponsors operating SFSP are still required to collect racial and ethnic data. Instead of using visual observation, the following are options to use to collect racial and ethnic data. 
1)	If the sponsor uses free/reduced meal benefit applications, the racial and ethnic data collected on these forms can be used. All racial/ethnic application data obtained for the most recent operating year, can be used to estimate the breakdown of race/ethnicity on the racial/ethnic data form. 
2)	Use the National Center for Education Statistics website to estimate race/ethnicity on the area the site operates. Data can be found here: https://nces.ed.gov/programs/edge/TableViewer/acsProfile/2019 
Filter by school district, children, demographic data. Use the overall statistics to complete the form. 
Children must not be asked to identify their own race and ethnicity. 
All line items on this page must be answered numerically (no percentages). Do not use words such as “All” or “None”.  

The sponsor must retain racial and ethnic data for three years, plus the current year, and must safeguard this information to prevent its use for discriminatory purposes. Access to program records containing racial and ethnic data should be kept confidential and limited to authorized personnel.