Service Insights Initiative Application

Agency Contact Information

Agency name*

Primary agency town/city/township*

Agency address*

Street Address Address Line 2 City State ZIP Code

Agency Staff Representative

Name*

Role at agency*

Phone number*

Email address*

Please help us understand your agency's capabilities

Indicate the type of programs that are available at your agency.

Which of these programs are currently collecting data during client intake?*

Clothing Assistance
Food Pantry
Grocery or Meal Delivery
Meal Programs
Soup Kitchen
SNAP Application Assistance
Other

Please describe your selection of other

For programs where data is not currently being collected, is your agency interested in collecting data for which of the following programs?*

Clothing Assistance
Food Pantry
Grocery or Meal Delivery
Meal Programs
Soup Kitchen
SNAP Application Assistance
Other

Please describe your selection of other

When does this agency distribute food?

(e.g. 1st Saturday of the month from 9 a.m. to 12 p.m. or every M-W-F from 10 a.m. to 2 p.m., etc.)

What, if any, concerns do you have about implementing a software system at your site?

Please describe your agency's current process for intake

(e.g. by appointment, patrons check-in with staff/volunteer at open distribution for one-on-one intake, no process, etc.)

How does your agency currently log information about patrons?

Paper and pencil
Microsoft Excel
Microsoft Access
Google Docs
Electronic Software
Other

(Check all that apply)

Please describe your selection of electronic software

Please describe your selection of other

Does your agency have a current database that you would like imported into the new software system?

Yes, and very important to import our data
Yes, but not sure if we should import
We do not need to import data
No

Please note we cannot guarantee data imports will be supported.

What type of data do you currently collect from the individuals you serve during intake?

Name
Date of birth
Address
Household members with ages
Health status or dietary considerations
Employment status or income
Other

Please describe your selection of other

What data would you like to collect from the individuals you serve in the future?

Agency Characteristics

What is the current number of staff and volunteers who help or could help with intake?

Number of staff assisting with intake:

Number of volunteers assisting with intake

How many individuals (not households) does your agency serve?

Monthly?

At an average single distribution?

What types of technology and how many devices does your agency currently have available that could be used for intake?

Tablets
Laptops
Desktop computers
Smartphone
Other

Check all that apply and list the number of devices below.

Please describe your selection of other

Number of devices available

Does your agency have wireless internet access at your distribution site?

Yes
No

Other than English, what percentage of the people you serve identify one of the following as their primary language?

Spanish

French

Arabic

Somali

Other

Please indicate if your agency receives TEFAP, CSFP, or any other federal program with reporting requirements?

TEFAP
CSFP
Other

Check all that apply.

Please describe your selection of other

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