Community Food Table Program Pre-Survey Form

First Name

Last Name

Email

What is your employment status?
Part TimeUnemployedDisabledRetiredOther

What age group do you belong?
18-2021-2930-3940-4950-5960-6970+

What is your gender?
MaleFemaleOtherPrefer not to answer

What is your race?
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderNot Hispanic or LatinoTwo or moreWhiteOther

Do you currently have a serious or chronic illness?
YesNo

Health/Risk factors
AlcoholismAllergiesAlzheimer’s diseaseAmyotrophic Lateral Sclerosis (ALS)ArthritisAvoidant Restrictive Food Intake Disorder (ARFID)CancerDepressionDiabetesHeadachesHeart DiseaseHigh/Low Blood PressureHIV/AIDSMultiple SclerosisParkinson's diseaseSeizuresStrokeWeight problemsOther

Have you used any of these food sources in the past 12 months? (Check all that apply)
Backpack ProgramChurch Donation CenterCollege PantryFarmer's MarketFood Pantry/BanksFood ShareMobile pantrySchool ProgramSenior Food ServicesSNAP ServicesSoup kitchenSummer Feeding ProgramOther

I don't have enough money to eat a healthy and balanced diet.
Often trueSometime trueNever truePrefer not to answer

I eat less than I should because I don't have enough money.
Often trueSometime trueNever truePrefer not to answer

I feel hungry but I did not eat because I don't have money for food.
Often trueSometime trueNever truePrefer not to answer

I sometimes run out of food.
AgreeSomewhat agreeSomewhat disagreeDisagree

I often feel too sick/tired or both to cook a meal.
AgreeSomewhat agreeSomewhat disagreeDisagree

I do not have reliable/or transportation to go grocery shopping.
AgreeSomewhat agreeSomewhat disagreeDisagree

There are no grocery stores within a 5-mile radius of my home.
YesNo

What are the food groups or resources you are most interested in receiving? (Check all that apply)
Child NutritionCollege Food InsecurityFood PantryFood Share/SNAP (also known as Food Stamps)Hunger and HealthMeal ProgramsSenior Hunger