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APPENDIX B - Facility Information Form

(To be completed by each facility)

Instructions: Please complete this facility information form and return it with the data collection forms. Only ONE facility information form should be completed for each participating facility. Please print your answers in the spaces provided or check the appropriate box.

3. Name of facility

4. City/Town  

5. Province (Please use a two letter abbreviation for your province)

6. Types of custody provided (Please check ALL that apply)

7. Gender (Please check the ONE box that BEST describes your facility)

Male Only Facility
Female Only Facility
Co-ed Facility

8. Description of facility (Please check the ONE box that BEST describes your facility)

Foster/Community Home
Group Home
Secure Detention/Custody Facility
Community Residential Centre
Training Centre
Treatment Centre
Boot Camp
Forest/Wilderness Camp/Ranch
Adult Facility
Other (specify) ______________________

9. Facility capacity (Please indicate the total number of permanent beds in your facility)

10. Does your facility offer cultural programming specifically for Aboriginal youth?

Yes
No

If you have any questions when completing this form please contact:

Jeff Latimer
Senior Research Officer
Research and Statistics Division
Department of Justice Canada
(613) 957-9589
jlatimer@justice.gc.ca

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