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Community Food Table Program – Pre-Survey Form
admin
2024-02-05T19:33:13+00:00
Community Food Table Program Pre-Survey Form
First Name
*
Last Name
*
Email
*
What is your employment status?
Select
Full Time (30 or more)
Part-Time
Unemployed
Disabled
Retired
Other
What age group do you belong?
Select
17 or younger
18-20
21-29
30-39
40-49
50-59
60-69
70+
What is your gender?
Select
Male
Female
Other
Prefer not to answer
What is your race?
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
Not Hispanic or Latino
Two or more
White
Other
Do you currently have a serious or chronic illness?
Select
Yes
No
Health/Risk factors:
*
Alcoholism
Allergies
Alzheimer’s disease
Amyotrophic Lateral Sclerosis (ALS)
Arthritis
Avoidant Restrictive Food Intake Disorder (ARFID)
Cancer
Depression
Diabetes
Headaches
Heart Disease
High/Low Blood Pressure
HIV/AIDS
Multiple Sclerosis
Parkinson's disease
Seizures
Stroke
Weight problems
Other
Have you used any of these food sources in the past 12 months? (Check all that apply)
*
Backpack Program
Church Donation Center
College Pantry
Farmer's Market
Food Pantry/Banks
Food Share
Mobile pantry
School Program
Senior Food Services
SNAP Services
Soup kitchen
Summer Feeding Program
Other
I don't have enough money to eat a healthy and balanced diet.
Select
Often True
Sometimes true
Never true
Prefer not to answer
I eat less than I should because I don't have enough money.
Select
Often True
Sometimes true
Never true
Prefer not to answer
I feel hungry but I did not eat because I don't have money for food.
Select
Often True
Sometimes true
Never true
Prefer not to answer
I sometimes run out of food.
Select
Agree
Somewhat agree
Somewhat disagree
Disagree
I often feel too sick/tired or both to cook a meal.
Select
Agree
Somewhat agree
Somewhat disagree
Disagree
I do not have reliable/or transportation to go grocery shopping.
Select
Agree
Somewhat agree
Somewhat disagree
Disagree
There are no grocery stores within a 5-mile radius of my home.
Select
Yes
No
What are the food groups or resources you are most interested in receiving? (Check all that apply)
*
Child Nutrition
College Food Insecurity
Food Pantry
Food Share/SNAP (also known as Food Stamps)
Hunger and Health
Meal Programs
Senior Hunger
All information is strictly confidential. Thank you for your time and participation.
Submit
Thank you for submitting your Community Food Table Program Assessment Form.
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