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Custom Social Impact Report Questionnaire
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Please enable JavaScript in your browser to complete this form.
Organization Name
*
City / State
*
Area Served Today
*
Which cIty, county, state, region, etc. does your program serve?
Problem Solved
*
Describe the problem you are addressing
Population Curve
*
Describe the population curve you are looking to bend
Population Government Funding
Activity Type
*
Administration
Animals
Arts / Culture / Humanities
Civil Rights / Social Action
Community Development / Capacity Building
Crime / Legal
Disease / Medical Disciplines
Economic Development
Education
Employment
Energy / Utilities
Entertainment / Recreation
Environment
Food / Agriculture / Nutrition
Health
Housing / Shelter
Human Services
International / Foreign Affairs
Justice
Medical Research
Mental Health
Mutual / Membership Benefit
Philanthropy / Grantmaking
Professional / Scientific / Technical Services
Public Safety
Public Works
Religion / Spiritual Development
Social Impact
Social Science Research
Societal Benefit
Transportation
Youth Development
Which category of activities does your program most closely align to?
Program Description
*
Describe what your program does
Differentiator
*
What separates your program apart from the rest?
Outcomes Sought
*
Nutrition - All families and individuals have access to nutritious food and basic medical care
Water - All families and individuals have access to clean water and sanitation services
Shelter - All families and individuals have access to affordable shelter
Safety - Communities provide safety and support to families and individuals
Schools - All children have access to basic knowledge and school systems
Access - All individuals have access to information and communications
Health - All individuals lead lives which prioritize health and wellness
Environment - Communities support environmental quality and promote natural resources
Rights - All individuals are guaranteed personal rights, freedom and choice
Families - All children live in stable and supported families
Infrastructure - Communities provide adequate infrastructure and public institutions
Children - All children successfully transition to adulthood
Opportunity - All adults have economic opportunity and lead productive lives
Engagement - Families, youth, and individuals are engaged in their community's decisions and activities
Other
Hold "control" to select multiple outcomes
Other Outcomes - Write In
If selected "Other" above, elaborate here
Target Population
*
Describe your target beneficiaries' demographics
Beneficiaries Served Last 5 Years
*
Show number of beneficiaries served over the past 5 years (or whatever relevant time frame), separating each year with a comma; include full year 2025 projection fur current year
Indicators Improved
*
Write in any statistical indicators your program improves in the community (e.g., crime rate, graduation rate, unemployment rate); use specific rates of improvement where known
Program Funding
*
What is your current annual program operating budget?
% Funding from Donations
*
% Funding from Government
*
% Funding from Foundations
*
% Funding from Earned Income
*
% Funding from Other/Fees/etc.
*
Major Current Benefactors
*
Name
*
Email
*
Submit
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