organization search result
 
 

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research, Nutrition and Analysis, Room 1014, (0584-0474), Alexandria, VA 22302. Do not return the completed form to this address. OMB NO. 0584-0474 EXPIRATION DATE: 09/30/2015

 
 

Contact Information
Format: 555-555-5555
 
Do you want this to be the main email contact?
 
 
 
 

Organizational Details
 
 
How would you classify your organization by type? (Please select all that apply)
 
  Notes (Please use this space to provide more specific information about your organization type, i.e. USDA, B-Corporation, etc.)
 
 
 
Which emergency food services do you provide, if any? (Please select all that apply)
 
 
 
 
What services do you provide for food assistance, if any? (Please select all that apply)
 
 
 
 
 
What services do you provide for healthy foods, if any? (Please select all that apply)
 
 
 
 
 
What programs or services does your organization provide? (Please select all that apply)
 
  Notes
 
 
 
 
What government programs or services do you help provide access/enrollment to? (Please select all that apply)
 
  Notes
 
 
 
 
What area does your organization serve? (Please select all that apply)
 
  Notes
 
 
 
 
What is the audience demographic that your organization serves? (Please select all that apply)
 
 
Number of People Served Annually
 
  Notes