Nutrition Consortium

Of New York State

Data Collection Form

Agency Name:

Quarter:

Date:

Agency Name:

Data Analysis

Please specify the number of households you assisted in each category this quarter

  1. First Time Food Stamp Program Applicants:Yes No
  2. Households with Earned Income: Households with Unearned Income:
  1. Households with Unemployment: Households with No Income:
  2. Households with Dependent Care Costs:Kinship Care Households:
  3. Households assisted with Online Application:

Please specify the number of individuals you assisted in each category this quarter

  1. Ethnicity

African American: Caucasian: Native American:

Hispanic: Asian: Multi-Ethnic: Other:

  1. Immigrants: 8. Homeless: 9. College Students:

10. Disabled: 11. Veterans:

12. Farmers*: 13. Military Families*:

(*Include all individuals in the household)

  1. Seniors(by age)

60-64: 70-74: 80+:

65-69: 75-79: Unknown:

  1. Children(by age)

0-5: 13-18:

6-12: Unknown:

  1. Individuals assisted by Zip Code

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

** Additional Zip Code entry on final page of report

Agency Name:

Outreach Analysis

  1. Number of Households that contacted NOEP for Food Stamp Program Information:
  1. Indicate how these Households heard about the NOEP and provide the number of Households that contacted the NOEP due to each: (Check all that apply)

Outreach Materials / Promotional Items:

Presentations:

Health Fairs / Community Events:

Referral from Other Agencies:

Walk-ins:

Word of Mouth:

Website:

Unknown:

Other (Specify): :

Client Assistance Analysis

Please specify the number of households assisted this quarter

  1. How many households did you provide Application Assistance to:

(Example: providing and/or filling out application, copying documents, etc…)

  1. Did you conduct Home Visits this quarter? Yes No
  1. Did you provide Translation Services this quarter? Yes No

Agency Name:

Referral Analysis

Please specify the number of referrals you made to other Nutrition Assistance Programs and Community Resources this quarter:

WIC:

HEAP:

Social Security:

Health Insurance Programs:

Crisis Intervention:

Home Care:

Early Intervention Programs:

Senior Assistance Programs:

Soup Kitchens:

Food Pantries:

Summer Food Programs:

Other::

Other::

Other::

Other::

Other::

Retention Analysis

  1. How many households did you assist in continuing to receive Food Stamp Assistance:
  1. Please specify how these households were assisted and include the number for each category:

Assisted with Recertification Process:

(Example: filling out recertification application and/or contacting LDSS/HRA)

Verified Correct Allotment of Food Stamp Benefits:

Assisted Household with Replacement Benefits:

Agency Name:

Face-to-Face Contacts

Outreach Event & Description / Completion Date / Number of
Face-to-Face Contacts
Total Contacts
Outreach Event & Description / Completion Date / Number of
Face-to-Face Contacts
Total Contacts

Additional Zip Codes

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :

Zip Code: : Zip Code: : Zip Code: :