* 1. Name of Organization

* 2. Where are you located (city, state)?

* 3. Date Completed

* 4. Total Number of bereaved children served annually in 2013?

* 5. What percentage of current bereaved youth served is represented by each of the following Racial/Ethnic groups?

* 6. What percentage the children and teens you serve reside in the following areas?

* 7. What percentage of the bereaved families you serve fall into each income level?

* 8. How many volunteers do you have?

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