Food Intake Form

Name*

Phone*

Email

Date of Birth*

Gender*

Male
Female

Address*

Ethnicity*

Hispanic or Latino
Not Hispanic or Latino

Race (check all that apply)*

White
Asian
Pacific Islander or Native Hawaiian
American Indian or Alaska Native
Black or African American

Please list the names, birthdates, genders, ethnicity, and race of ALL the people living in your household

Please don’t include yourself

1

Date of birth

Gender

Hispanic (Y/N)?

Race

2

Date of birth

Gender

Hispanic (Y/N)?

Race

3

Date of birth

Gender

Hispanic (Y/N)?

Race

4

Date of birth

Gender

Hispanic (Y/N)?

Race

What is your household's total monthly income?*

Include income from all members of the household and all types of income: wages, social security, disability, etc.).

Within the past 12 months have you worried that your food would run out before you got money to buy more?*

Yes
No

Within the past 12 months did the food that you bought just not last and you didn't have money to get more?*

Yes
No

Have you or anyone in the household ever applied for SNAP (Food Stamps) benefits?*

Yes
No

If you or anyone in the household has ever applied for Food Stamps, are they currently receiving benefits?

Yes
No

Is anyone in the household a Military Veteran or active Military?*

Yes
No

Does anyone in the household currently have health coverage?*

What type of health coverage do the household members have? (Check all that apply)*

Private Insurance
Medicare/Medicaid
Veteran’s Benefits
Indian Health Service
Disability
N/A

Do you or anyone in your household receive food assistance from any of these programs? (Check all that apply)

Senior Nutrition Program(s)
Other Food Pantries
Soup Kitchen
School Breakfast/Lunch
Kids Summer Meals
WIC (Women’s, Infant’s & Children’s Program)
Tribal Commodities
N/A

How has COVID-19 impacted your food needs?*

Not at all
Somewhat
A lot

Consent*

I agree to the privacy policy and self-certification.

I understand that I am self-certifying my income eligibility for this program. I understand that my basic, identifying, and non-confidential service transactions/information will be shared in an electronic shared case database administrated by the Food Bank of Northern Nevada called “Oasis Insight” and may be shared with California Health and Human Service Agencies who provide our food.

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