FORM G-4
Client Age, Ethnicity and Gender
Sample form for display purposes only!
Submission of this form requires data entry via the Internet!
Please complete a separate form for each service area.
*Do not enter punctuation such as commas when entering numeric values.
*Leaving this screen without saving will result in loss of changes.
Under 18
18 - 59
60 and Over
Totals
White - Not of Hispanic Origin
0
Black - Not of Hispanic Origin
0
Hispanic Origin
0
Native American
0
Asian or Pacific Islander
0
Other Ethnic Group
0
Totals
0
0
0
0
Men
Women
Groups
Total for Form G-4 should approximate the total cases reported in Forms G-3 and G-3(d).
*Please save data before printing or submitting.
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This form is for display purposes only!