More Than a Meal Phase 2 Data Availability Survey

Please fill out the survey below regarding your interest in the second phase of our More Than a Meal (MTAM) research study. As such, we are conducting this survey to determine if your program has key pieces of information on file that will be needed to pursue this new study.

This survey is brief and should only take a few minutes of your time. Thank you!

Question Title

1. Which of the data points below would you be able to provide for the clients you served between 2010 and 2013:

	2010	2011	2012	2013
Date of birth	Date of birth 2010	Date of birth 2011	Date of birth 2012	Date of birth 2013
Gender	Gender 2010	Gender 2011	Gender 2012	Gender 2013
Street address	Street address 2010	Street address 2011	Street address 2012	Street address 2013
9 Digit zip code	9 Digit zip code 2010	9 Digit zip code 2011	9 Digit zip code 2012	9 Digit zip code 2013
Zip code	Zip code 2010	Zip code 2011	Zip code 2012	Zip code 2013
Race/ethnicity	Race/ethnicity 2010	Race/ethnicity 2011	Race/ethnicity 2012	Race/ethnicity 2013
Meals, delivered daily (5 days a week)	Meals, delivered daily (5 days a week) 2010	Meals, delivered daily (5 days a week) 2011	Meals, delivered daily (5 days a week) 2012	Meals, delivered daily (5 days a week) 2013
Meals, limited delivery (less than 5 days per week)	Meals, limited delivery (less than 5 days per week) 2010	Meals, limited delivery (less than 5 days per week) 2011	Meals, limited delivery (less than 5 days per week) 2012	Meals, limited delivery (less than 5 days per week) 2013
Activities of Daily Living	Activities of Daily Living 2010	Activities of Daily Living 2011	Activities of Daily Living 2012	Activities of Daily Living 2013
Instrumental Activities of Daily Living	Instrumental Activities of Daily Living 2010	Instrumental Activities of Daily Living 2011	Instrumental Activities of Daily Living 2012	Instrumental Activities of Daily Living 2013
Living alone	Living alone 2010	Living alone 2011	Living alone 2012	Living alone 2013
Service start date	Service start date 2010	Service start date 2011	Service start date 2012	Service start date 2013
Service end date	Service end date 2010	Service end date 2011	Service end date 2012	Service end date 2013
Homeboundness	Homeboundness 2010	Homeboundness 2011	Homeboundness 2012	Homeboundness 2013
Food insecurity	Food insecurity 2010	Food insecurity 2011	Food insecurity 2012	Food insecurity 2013
Ability to shop	Ability to shop 2010	Ability to shop 2011	Ability to shop 2012	Ability to shop 2013
Ability to prepare meals	Ability to prepare meals 2010	Ability to prepare meals 2011	Ability to prepare meals 2012	Ability to prepare meals 2013

Question Title

2. Does your database include information on other formal support services that were provided during this time frame (such as homemaker, transportation, home health care, case management)?

	Yes	No
Transportation	Transportation Yes	Transportation No
Homemaker	Homemaker Yes	Homemaker No
Transportation	Transportation Yes	Transportation No
Home health care	Home health care Yes	Home health care No
Case management	Case management Yes	Case management No

Question Title

3. Between 2010 and 2013, did you collect any additional data during client intake and reassessment than what is included above? If so, please describe below.

Question Title

4. Would you be able to transmit this information to us electronically via a secure file transfer platform?

Yes

Question Title

5. In what format is all this client information in?

Access Database

Excel Database

SQL Database

CSV Database

Other (please specify)

Question Title

6. Please enter your contact information below.

Name: *

Organization Name: *

City/Town:

State: *

Email Address: *

Thank you very much for participating in this survey! We look forward to working with you this Fall to implement the More Than a Meal Phase 2 project.