CBH Provider Diversity and Inclusion Data Collection Form

Community Behavioral Health (CBH) promotes the economic development of minority, women, and disabled-owned business enterprises (MWDSBE) through its registration program, contract review and monitoring activities, and ongoing interaction with other City departments, quasi-public agencies, and the local marketplace.

The purpose of the collection of your organization’s diversity and inclusion data is to support the City of Philadelphia’s diversity and inclusion efforts; and to document the City’s investment of taxpayers’ dollars into programs and organizations that enable and empower our diverse communities. As part of this work, we request that you use this form to submit diversity and inclusion demographic data about your executive leadership and staff, so we can better understand the diversity of your organization. Some information you’ll be asked to provide includes the demographics of your workforce, your executive staff, and your board members as well as information about your supplier diversity policies.

Before you start completing this form, please make sure you have the following documents as you will be asked to upload them.

- A list of your executive staff and their titles

- Your supplier diversity policy ( If you don’t have a supplier diversity policy, you’ll be asked to submit a document on your letterhead as to why your organization doesn’t have a supplier diversity policy)

-A copy of MWDSBE certification(s).

Organization Information

Organization Name*

Organization Federal EIN Number*

Format: XX-XXXXXXX

Organization DUNS Number

Organization Status*

Select

CBH Parent ID Number*

Total Number Of Full-Time Staff*

Total Number of Part-Time Staff*

Name Of Person Completing Form*

First and last names are required.

Title Of Person Completing Form*

Phone Number Of Person Completing Form*

Format: XXX-XXX-XXXX

Email Of Person Completing Form*

Demographic Breakdown of Workforce

Please provide the demographic breakdown of your organization’s workforce by race, ethnicity, and gender. Please submit actual numbers, not percentages.

How many full- and part-time staff of each of the following racial and ethnic backgrounds are a part of your workforce?

Black/African American*

Asian/Pacific Islander*

White*

Hispanic or Latinx*

Native American*

Race Not Listed*

How many full- and part-time staff of each of the following genders are a part of your workforce?

Male*

Female*

Transgender, Non-Binary or Third Gender*

Gender Not Listed*

Philadelphia Residency

How many Philadelphia residents are in your workforce? Please submit actual numbers, not percentages.

Full-Time Staff*

Part-Time Staff*

People with a Disability

Please use the Americans with Disabilities Act definition of “disability.” The City of Philadelphia acknowledges that some numbers provided may be based on self-identification and self-reporting. Please submit actual numbers, not percentages. How many people in your workforce have a disability?

Full-Time Staff*

Part-Time Staff*

Demographic Breakdown of Executive Staff

Please provide the demographic breakdown of your executive staff. You may use your own definition to determine who is included among executive staff. Please submit actual numbers, not percentages.

Executive Director

Race of Executive Director*

What is the racial and ethnic background of your organization’s executive director?

Select

Gender of Executive Director*

What is the gender of your organization’s executive director?

Select

Executive Team

How many people of each of the following racial and ethnic backgrounds are a part of your organization’s executive team?

Black/African American*

Asian/Pacific Islander*

White*

Hispanic or Latinx*

Native American*

Race Not Listed*

How many people of each of the following genders are a part of your organization’s executive staff?

Male*

Female*

Transgender, Non-Binary or Third Gender*

Gender Not Listed*

How many Philadelphia residents are a part of your organization’s executive team?*

How many people with a disability are a part of your organization’s executive team?*

What is the total number of executive staff in your organization?*

Demographic Breakdown of Board of Directors or Trustees

Please provide the demographic breakdown of your board of directors or trustees. Please submit actual numbers, not percentages.

How many people of each of the following racial and ethnic backgrounds are a part of your organization’s board of directors or trustees?

Black/African American*

Asian/Pacific Islander*

White*

Hispanic/Latinx*

Native American*

Race Not Listed*

How many people of each of the following genders are a part of your organization’s board of directors or trustees?

Male*

Female*

Transgender, Non-Binary or Third Gender*

Gender Not Listed*

How many Philadelphia residents are a part of your organization’s board of directors or trustees?*

How many people with a disability are a part of your organization’s board of directors or trustees?*

What is the total number of board of directors or trustees in your organization?*

Minority, Women, DisAbled Business Enterprise (MWDSBE) Certification

Is your agency MWDSBE certified?*

Select

Type of Certification

Select

Supplier Diversity

Do you have a supplier diversity policy?*

Select

Do you work with minority, woman, and/or disabled-owned business (MWDSBE) suppliers of products or services?*

Select

TOTAL ANNUAL SPENT ON MWDSBE SUPPLIERS/SUBCONTRACTORS ONLY*

Total # of MWDSBE Subcontractors/Suppliers ONLY*

TOTAL ANNUAL SPENT ON ALL SUPPLIERS/SUBCONTRACTORS*

This should include the total # of dollars spent annually for ALL suppliers/subcontractors ( MWDSBE and non-MWDSBE; To include all subcontracts)

Total # of ALL Subcontractors/Suppliers*

This is the total you contract with

Detailed MWDSBE Supplier Information

Please identify your organization’s TOP 5 minority, woman, and/or disabled-owned business suppliers of products or services, including your estimated annual expenditure(s) with each of the companies. *If you DO NOT contract with any MWDSBE suppliers, you can enter N/A for the fields in Company 1*

Company 1

At least one company is required.

Company Name*

Street Address*

City*

ST*

ZIP Code*

Phone #*

Please select company's diversity:*

Select

Company 1 MWDSBE certified?*

Select

What are the company's annual expenditures?*

Company 2

Company Name

Street Address

City

ZIP Code

Phone #

Please select company's diversity:

Select

Company 2 MWDSBE certified?

Select

What are the company's annual expenditures?

Company 3

Company Name

Street Address

City

ZIP Code

Phone #

Please select company's diversity:

Select

Company 3 MWDSBE certified?

Select

What are the company's annual expenditures?

Company 4

Company Name

Street Address

City

ZIP Code

Phone #

Please select company's diversity:

Select

Company 4 MWDSBE certified?

Select

What are the company's annual expenditures?

Company 5

Company Name

Street Address

City

ZIP Code

Phone #

Please select company's diversity:

Select

Company 5 MWDSBE Certified?

Select

What are the company's annual expenditures?

Required Attachments

Required File Attachments*

Upload a list of the people who are a part of your executive staff and their titles.
Please attach either a copy of your supplier diversity policy, or, if your organization does not have such a policy, an explanation as to why not on your organization's letterhead.
If your agency is MWDSBE certified, you must also attach a copy of the certification as verification.

Acceptable file types include pdf, doc, docx, txt, rtf.

Drag and drop files here or

By checking this box, I certify that all information I have provided on the CBH data collection form is accurate.

All information is accurate.*

Form Date Field

Send me a copy of my responses

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