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2. Welcome!
   You are receiving this form as part of your grant or contract agreement with the City of Dubuque. As a partner in community efforts to advance equity and inclusion, we are interested in the efforts you are making, the outcomes your are achieving, and ways that we can support one another. Please take a few minutes to complete this form. If you have any questions or concerns, please contact Kelly Larson at klarson@cityofdubuque.org or 563-589-4190. Thank you for working with us!
4. Please read the questions below carefully, and think about the ways in which your responses do or do not indicate successful efforts to advance equity and inclusion in the community.
6. First Name*
7. Last Name*
9. Organization/Agency/Group Name*
10. Project or Program Name*
12. Amount of City Funding Received*
13. City Department you work with*
15. Please check the primary City Council goal your project contributes toward:*

    1. Economic Prosperity
    2. Environmental/Ecological Integrity
    3. Social/Cultural Vibrancy
    4. Planned and Managed Growth
    5. Partnering for a Better Dubuque
    6. Improved Connectivity: Transportation and Telecommunications
    7. Financially Responsible City Government and High Performance Organization
17. If applicable, select Top/High Council priority your project contributes toward
    -- Select One --Arts and Culture Master PlanCentral Iowa Water Association: Direction, FundingCity Staffing Level: Evaluation, Direction, FundingFive Flags Center: Evaluation, DirectionInclusive Community: Action PlanPolice: Review Best PracticesStreet Improvement Program: FundingAnnexation: Direction on Specific ActionsEmerald Ash Borer: Policy, Program, and FundingHousing Code and Inspections: Review, Update/UpgradeIndoor Aquatic CenterPort of Dubuque Park: DevelopmentSkate ParkWorkforce Market-Rate Housing
19. Please check the location(s) or service area(s) for your project*

    1. Downtown
    2. Point Neighborhood
    3. North End
    4. South End

    1. Hill/College
    2. West End
    3. City Wide
    4. Other
21. Planning Process
    The following questions relate to the planning process used for your program.
23. Please list the agencies, organizations, or community members involved in the planning process and the role each played*
25. Targeted Planning and Outreach*

    Identify whether you were intentional in involving any of the following populations in your planning process.

    1. Ages under 18
    2. Ages 18-21
    3. Ages 22-30
    4. Ages 31-40
    5. Ages 41-50
    6. Ages 51-60
    7. Ages 61 and over
    8. American Indian/Alaskan Native
    9. Asian
    10. Bi-Sexual
    11. Black/African American

    1. College Students
    2. English Language Learners
    3. Gay
    4. Heterosexual/Straight
    5. Hispanic/Latinx
    6. Immigrants
    7. International Students
    8. Lesbian
    9. Men
    10. Middle class/income
    11. Multi-Racial

    1. Native Hawaiian/Other Pacific Islander
    2. Persons with Disabilities
    3. Refugees
    4. Trans or Transgender
    5. Unemployed/Fixed Income
    6. Upper Class/Income
    7. Veterans
    8. White/Caucasian
    9. Women
    10. Working Class/Income
    11. Our process was non-targeted
27. Identify the primary way you engaged targeted populations*
    -- Select One --Informed: provided informationConsulted: invited feedback on optionsInvolved: worked together to develop optionsCollaborated: worked together to decide all program aspectsEmpowered: co-created all aspects of the program
29. Describe the ways in which involvement of a diverse set of planners has improved your project outcomes*
31. Outreach and Marketing
    The following questions relate to the outreach and marketing conducted for your project
33. Identify the primary method used for outreach and marketing
    -- Select One --Online resources (social media, website, etc.)Information booths at eventsWritten materials (flyers, brochures, etc.)Community meetings (churches, neighborhoods, advocacy groups, etc.)Media release or advertisements (television, radio, newspaper)
35. For each type of outreach and marketing strategy you used, please describe who you were trying to reach with that strategy
37. Please describe any additional strategies used to reach a broad audience
39. Targeted Planning and Outreach*

    Identify whether you were intentional in involving any of the following populations in your marketing and outreach process.

    1. Ages under 18
    2. Ages 18-21
    3. Ages 22-30
    4. Ages 31-40
    5. Ages 41-50
    6. Ages 51-60
    7. Ages 61 and over
    8. American Indian/Alaskan Native
    9. Asian
    10. Bi-Sexual
    11. Black/African American

    1. College Students
    2. English Language Learners
    3. Gay
    4. Heterosexual/Straight
    5. Hispanic/Latinx
    6. Immigrants
    7. International Students
    8. Lesbian
    9. Men
    10. Middle class/income
    11. Multi-Racial

    1. Native Hawaiian/Other Pacific Islander
    2. Persons with Disabilities
    3. Refugees
    4. Trans or Transgender
    5. Unemployed/Fixed Income
    6. Upper Class/Income
    7. Veterans
    8. White/Caucasian
    9. Women
    10. Working Class/Income
    11. Our process was non-targeted
41. Please describe the intentional outreach efforts you made with each population checked above*
43. Participation and Feedback
    The following questions relate to participation in your program and feedback received
45. Please indicate the approximate number of people who participated in your program
47. Describe demographics of attendees
49. Check the degree to which program/event participants were reasonably representative of the demographic makeup of the community*

    1. Not representative of community demographics
    2. Slightly representative of community demographics
    3. Moderately representative of community demographics
    4. Very representative of community demographics
51. Please summarize the feedback you received regarding the program, including any feedback specifically related to equity or inclusion*
53. Describe any unexpected experiences or results that occurred due to your program
55. Describe any changes or adjustments you will make related to the attendance levels and/or feedback received*
57. The following questions relate to the degree to which you achieved your program goals
59. Based on your project goals, describe who benefitted from the program and how the individuals are better off as a result of the program*
61. Describe what was most successful and what was least successful about your program
63. Describe any lessons learned, things you could do better in the futrue, and what resources (if any) you would need to make these improvements
65. Please upload any photos, receipts, or other supporting documentation. For receipts, please include an explanation
67. The following questions relate to participation in Inclusive Dubuque and Ongoing Learning Opportunities
69. Check all of the ways in which you have participated in Inclusive Dubuque*

    1. Regularly attended Inclusive Dubuque Network partner meetings
    2. Shared monthly Inclusive Dubuque newsletters throughout your organization
    3. Actively participated in a working group
    4. Participated in Inclusive Dubuque learning events
    5. Supported employee participation in Inclusive Dubuque learning events as part of professional development
    6. Applied Inclusive Dubuque equity tools to programs and practices
    7. Shared successes and failures with other members of the Inclusive Dubuque Network
    8. Responded to the annual Inclusive Dubuque Member survey
    9. Shared progress reports on equity activities with Inclusive Dubuque
71. Indicate whether you have completed any of the following workshops*

    1. Completed an Intercultural Foundations workshop offered by the City of Dubuque
    2. Completed an Advancing Equity workshop offered by the City of Dubuque
73. A HUGE THANK YOU!
    Please note that once you submit this form, you will receive a confirmation e-mail. If you are the recipient of a community development block grant and/or an arts grant, the confirmation e-mail will contain a link to an additional form to be completed.
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