VA Farms Intake

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* 1. Intake Date

Date

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* 2. VA FARMS Partner

GRuB Victory Garden

Veterans Ecological Trades Collective (VETC)

Veterans Farm at Orting

Growing Veterans

Viva Farms

Tatley Outpost

Vets on the Farm

Enterprise for Equity

Washington State University Cultivating Success

Farm to Farmer ( WA Farmland Trust Farmland Access)

Other (please specify)

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* 3. Client ID number ( VA Farms partner then Client number example for Veterans Affairs client number 1, VA001)

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* 4. County of residence

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* 5. Zip code

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* 6. Age

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* 7. Gender

Male

Female

Transgender

Prefer not to Say

Other (please specify)

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* 8. E-Mail

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* 9. Ethnic/Racial Background

American Indian or Alaska Native

Asian, Asian-American

Black, African-American, Other African

Native Hawaiian or Pacific Islander

White or Caucasian

Hispanic, Latino

Other

Multi-Racial (2+ identified)

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* 10. VA Farms enrollment type, select all that apply

Incubator Farms Participant

Internship

E4E Business Planning Program

Cultivating Success

Viva Farms Practicum

Farm to Farmer (WA Farmland Trust Farmland access)

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* 11. Is Veteran Homeless

Yes

Other (please specify)

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* 12. If homeless, how many times in past three years ?

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 13. If yes, how long in days this most recent time?

183

365

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 14. Gained Employment in agriculture NOT related to VA Farms

Paid temporary

Paid permanent

Non-paid (volunteering, unpaid internships, etc.)

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* 15. Veteran Education Level

Less than High School grad

High School Diploma or GED

Some College – no degree or cert

Certificate

Associate Degree

Bachelor’s Degree or above

Unknown

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* 16. Currently Active Duty

Yes

If no date of discharge:

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* 17. Currently Enrolled in VA Health Care

Yes

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* 18. If currently enrolled in VA Health Care what facility?

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* 19. Period of Service (indicate which period(s) of service the veteran served):

WWII – December 7, 1941 to December 31, 1946

Desert Storm – Persian Gulf War

Korean Conflict – June 27, 1950 to January 31, 1955

GWOT (OIF, OEF, ONE)

Vietnam Era – August 5, 1964 – May 7, 1975

Other:

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* 20. Type of Discharge (check one):

Honorable

Dishonorable Uncharacterized

General Under Honorable Conditions

Uncharacterized

Other than Honorable

Veteran Doesn’t Know

Bad Conduct

Veteran Refuses to Provide

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* 21. What best characterizes the type of referral made, select all that apply?

No Referral Made, Does not apply

Substance Abuse

Counseling

Psychiatric Services

VA Health Care services

Community based health care services

Child Care

Veterans Benefits (eg. Educational, Social Security, Cemetary etc...)

Food Assistance (eg. SNAP, WIC, Food Banks, Pantries)

Housing (eg. HUD VASH, Residential transitional)

Legal Aid (eg. Veterans Justice Court)

Transportation

Vocational Rehabilitation

Other (please specify)

VA Farms Intake

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* 1. Intake Date

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* 2. VA FARMS Partner

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* 3. Client ID number ( VA Farms partner then Client number example for Veterans Affairs client number 1, VA001)

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* 4. County of residence

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* 5. Zip code

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* 6. Age

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* 7. Gender

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* 8. E-Mail

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* 9. Ethnic/Racial Background

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* 10. VA Farms enrollment type, select all that apply

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* 11. Is Veteran Homeless

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* 12. If homeless, how many times in past three years ?

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* 13. If yes, how long in days this most recent time?

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* 14. Gained Employment in agriculture NOT related to VA Farms

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* 15. Veteran Education Level

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* 16. Currently Active Duty

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* 17. Currently Enrolled in VA Health Care

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* 18. If currently enrolled in VA Health Care what facility?

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* 19. Period of Service (indicate which period(s) of service the veteran served):

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* 20. Type of Discharge (check one):

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* 21. What best characterizes the type of referral made, select all that apply?

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* 22. Comments