Enrolled Demographics Agency NameAgency Person ReportingToday's Date MM slash DD slash YYYY Month ReportingPlease Select...JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberAGE17 and under18 - 2324 - 3031 - 4041 - 5051 - 6162 and overGENDERFemaleMaleNo Single GenderQuestioningTransgenderClient Refused/doesn't knowETHNICITYNon-Hispanic / Non-Latin(a)(o)(x)Hispanic / Latin(a)(o)(x)Client RefusedRACE (May select more than one option)American Indian, Alaska Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Pacific IslanderWhiteOtherClient refused* This element will not add to total enrolled. FunderIVRSMedicaid/MCOMHDS RegionOtherAwaiting FunderNameThis field is for validation purposes and should be left unchanged.
