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CBCAP Data Collection Form: for:______________________________________________
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Instructions: In the table below please record the total number of un-duplicated participants in CEAC activities,
meetings and events for the data collection period you selected above. Do not include participants counted in totals
previously reported within this fiscal year.
Example: John Doe attended a CEAC meeting/event in quarter 1 and was counted in that quarter’s reported numbers. He will not be counted in any
subsequent quarterly report numbers.
Data Collection Period
Q1: July to September
Q2: October to December
Q3: January to March
Q4: April to June
Participant Information
Adults 19 and Older
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Total Number
Adults 19 and Older
Child/Youth 0-18
How many had
a disability
Total Number
Child/Youth 0-18
How many had
a disability
Families
Total Number
Totals
office use only
Caucasian/White (non-latino)
0
0
0
0
0
0
Latino/Hispanic
Black/African American
Asian
Native American
Other:
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0
office use only
0
0
Total #
Recruitment
Meetings
Events
Other:
office use only
0
0
=
0
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Activities Information
Category
0
Topic/Description
Date(s)
-
-
-
-
-
-
-
-
0
Please enter total # of core CEAC members this Qtr.
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Summary/Write-up: Activity Name:________________________
Please select one of the activities from the left and provide a concise
summary. (100-200 words)