This survey is voluntary, anonymous and confidential.  Your participation will help us to improve our programs.

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* 1. zip code

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* 2. In the last year, how often have you or your family received food from:

  Often Sometimes  Never
Food Pantry
WIC
SNAP (food stamps)
Community meals (provided by faith communities, civic groups, etc.)
Meals through Senior Centers
Free or reduced school lunch
Weekend back pack/meal programs
Fresh Connect
Commodity supplemental food program (CSFP) Senior food boxes
Farm to Families
Meals on Wheels
MANNA (medically tailored meals)
Do you have trouble getting transportation to any of the services listed above?

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* 3. Ethnicity

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* 4. What is your sex?

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* 5. Total Number of People Living in your household

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* 6. Number of Children under 17

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* 7. Number of Adults 18-59

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* 8. Number of Seniors 60+

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* 9. Is anyone in your household currently employed

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* 10. What is your annual household income

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* 11. In the last week, how often did you eat the following foods?

  Never 1-2 times 3-4 times 5-6 times 7 or more times
Fruit (examples:  apples, mangoes, bananas)
Starchy Vegetables (examples:  corn, potatoes)
Non-Starchy Vegetables (examples:  green beans, broccoli)
Lean Meats (examples:  chicken, fish, pork, lean beef)
Processed Meats (examples: hotdogs, lunch meats)
Non-Meat Proteins (examples: peanut butter, beans, soy)
Whole Grain Items (examples: whole wheat bread, brown rice)
Refined Grain Items (examples:  white bread, pasta, white rice)
Sugary Drinks (examples: soda, sports drinks, fruit juice)
Pre-Packed Meals (examples: frozen entrees, lunchables)
Fast/Convenience Foods (examples:  McDonalds, Turkey Hill, Burger King)

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* 12. When combining all of your food resources (including SNAP, cash, pantries, etc.) are you:

  Strongly Disagree (never) Disagree (most likely no) Neutral (unsure) Agree (most likely yes) Strongly Agree (always)
Able to get the quantity of food you need to feed your family?
Able to get the quality of food you want to feed your family?

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* 13. Are you able to obtain these foods easily with the help available to you?

  Strongly Disagree (never) Disagree (most likely no) Neutral (unsure) Agree (most likely yes) Strongly Agree (always)
Fresh Fruit
Fresh Vegetables
Dairy
Proteins such as meat, peanut butter, tuna, canned chicken, beans

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* 14. Please rate the following statements on the scale below:

  Strongly Disagree (never) Disagree (most likely no) Neutral (unsure) Agree (most likely yes) Strongly Agree (always)
Most days, I feel healthy
Most days, I feel energetic
Help with food, like SNAP, pantries, etc. reduces my stress/worry about providing food for myself and my family

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* 15. Do you or does anyone in your household have a chronic medical condition such as diabetes, high cholesterol or high blood pressure?

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* 16. Has your health care provider recommended a special diet?

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* 17. If yes, are you able to follow your special diet with the foods available to you?

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* 18. DURING THE LAST MONTH, did any of these apply to the food situation in your home?

  Often Sometimes  Never
Did you worry about running out of food?
Did anyone in your household skip or eat smaller meals because there wasn't enough food?
Has anyone in your household gone for a whole day in the last month without eating due to lack of food?
Were you able to eat a healthy, balanced meal three times a day?

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