MONTHLY AGENCY SURVEY


Please submit the information requested below by the 15th day of the month following the month for which you are reporting. For example, January's information is due to us by no later than the 15th of February.

Please use one form for each county your agency serves and combine all program data on one form for each county (Ex: Brown Bag recipients, pantry recipients, etc).

Due to the important nature of this data, this form must be completed and signed by your agency's Program Director. * = Required Field.

*MONTH/YEAR:

*AGENCY ID NUMBER:

*County Served:

*Food Distribution Frequency:
5 Days A Week 1 Day A Week 1 Day A Month Other

How Frequently?

ALL AGENCIES

  1. Total number of households served during the month:
  2. Total number of children (under 18) served during the month:
  3. Total number of adults (18-59) served during the month:
  4. Total number of elderly (over 59) served during the month:
  5. Total number of people served during the month:
  6. Percentage of food that came from the food bank: %

USDA COMMODITY RECIPEINTS

  1. Number of households served with USDA commodities:
  2. Number of meals served with USDA commodities:

RESIDENTIAL PROGRAMS AND SOUP KITCHENS

  1. Total number of meals served during the month:
  2. Total number of snacks served during the month:
  3. Total number of breakfasts served during the month:
  4. Total number of lunches served during the month:
  5. Total number of dinners served during the month:
  6. Percentage of food that came from the food bank: %

By checking the box below, I declare that all information provided herein is true to the best of my knowledge and that my agency has all appropriate records on file. I am aware that all survey(s) are due by the 15th of each month and that not turning in accurately, completed and signed surveys by the deadline will result in agency suspension without further warning until all overdue reports are submitted to ASHBB.

*I accept.

*Program Director Name:


Monthly Reports may be faxed, mailed, or filed online via our website.
http://www.fightinghunger.org/agency.html
Fax: (850) 562-6176 / Phone: (850) 562-3033