Agency Retail Survey - 2015 Question Title * 1. List your contact information Agency Agency Account # Agency Contact Email Phone Address City Zip Code County Question Title * 2. On monthly basis, what is number of clients your agency serves? Number of client visits? Number of meals served? On monthly basis, what is number of clients your agency serves? Less 100 101-500 501-1,000 1,001-2,500 2,501-5,000 5,000-10,000 10,000 On monthly basis, what is number of clients your agency serves? Number of client visits? menu None 101-500 501-1,000 1,001+ On monthly basis, what is number of clients your agency serves? Number of meals served? menu Other (please specify) Question Title * 3. Does your agency have a retail partnership? NTFB Organized Retail Partnership Retail Partnership not organized by NTFB Type of Retail Partnership Yes No Type of Retail Partnership NTFB Organized Retail Partnership menu Yes No Type of Retail Partnership Retail Partnership not organized by NTFB menu Other (please specify) Question Title * 4. If your agency currently has a NTFB coordinated retail partnership, list names of NTFB organized retailers. 1 2 3 4 5 6 Question Title * 5. If your agency has a retail relationship with a local store not yet an official NTFB retail partner, list store name to help us ensure your agency maintains partnership. 1 2 3 Question Title * 6. List your agency transportation capacity, access to vehicle type Box Truck (Refrigerated) Box Truck (Non- Refrigerated) Trailer enclosed Trailer open Pick Up Van SUV Other Other (please specify) Question Title * 7. What is your desired weekly retail volume (in pounds)? Less 100 101-500 501-1,000 1,001-1,500 1,501-2000 2,001 + Other (please specify) Question Title * 8. What is your donation Pick up Availability (minimum 3 times a week)? 3 4 5 6 List preferred Days (Mon, Tues, Wed, Thurs, Frid, Sat.) of Week for Pick Up Question Title * 9. What is your refrigeration/ capacity? 1 2 3 4 5 None Refrigeration Capacity (select quantity) Refrigeration Capacity (select quantity) 1 Refrigeration Capacity (select quantity) 2 Refrigeration Capacity (select quantity) 3 Refrigeration Capacity (select quantity) 4 Refrigeration Capacity (select quantity) 5 Refrigeration Capacity (select quantity) None Freezer Capacity (select quantity) Freezer Capacity (select quantity) 1 Freezer Capacity (select quantity) 2 Freezer Capacity (select quantity) 3 Freezer Capacity (select quantity) 4 Freezer Capacity (select quantity) 5 Freezer Capacity (select quantity) None Other (please specify) Question Title * 10. List the priority of your most desirable food needs? Very High High Medium Low Non Priority Dairy Dairy Very High Dairy High Dairy Medium Dairy Low Dairy Non Priority Meat/Fish Meat/Fish Very High Meat/Fish High Meat/Fish Medium Meat/Fish Low Meat/Fish Non Priority Other Protein (peanut butter) Other Protein (peanut butter) Very High Other Protein (peanut butter) High Other Protein (peanut butter) Medium Other Protein (peanut butter) Low Other Protein (peanut butter) Non Priority Produce Produce Very High Produce High Produce Medium Produce Low Produce Non Priority Cans Cans Very High Cans High Cans Medium Cans Low Cans Non Priority Other Other Very High Other High Other Medium Other Low Other Non Priority Other (please specify) Question Title * 11. Does your agency have the following supplies? Yes No Pallet Blanket Pallet Blanket Yes Pallet Blanket No Standard bathroom or table top scale Standard bathroom or table top scale Yes Standard bathroom or table top scale No Agency ID Badge or Name Tag Agency ID Badge or Name Tag Yes Agency ID Badge or Name Tag No Other (please specify) Done
