Welcome to Tampa Bay Harvest

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AGENCY QUESTIONNAIRE

Name of Organization: ____________________________________________________________________________

Location Address: ________________________________________________________________________________

Mailing address: __________________________________________________________________________________

Director’s Name: __________________________________________________________________________________

Name of Primary Contact: ___________________________________________Title: _________________________

Name of Alternate Contact: _________________________________________ Title: _________________________

Name of Emergency/After Hours contact: ______________________________ Title: ______________________

Contact name for correspondence_____________________________________Title:_________________________

Email: __________________________________________________________ Fax: ______________________________

Type of organization: Food Pantry ___, Shelter ___, Soup Kitchen ___. If other, or combination, please

describe:___________________________________________________________________________________________

What is your program’s mission? ___________________________________________________________________

____________________________________________________________________________________________________

Funded by: ________________________________________________________________________________________

____________________________________________________________________________________________________

Geographic Area Served: ___________________________________________________________________________

If a food pantry, how frequently in a 3-month period can a client receive food: _________________________

How long is that food supposed to last? _____________________________________________________________

If a Soup Kitchen, what hours and days do you serve meals? _________________________________________

Aside from the food aspect of your program, do you provide other services? Please describe these services.

____________________________________________________________________________________________________

Are your clients infants _____, children ______, men _______, women _______ or families _______?

Number of Clients served per day _________, or per week_______ or per month _________________

Meals served: Brkfst __Lch ___ Din ___ Sun ___ Mon ___ Tue ___ Wed ___ Thurs ___ Fri ___ Sat ___

# of refrigerators: _____________________ Sizes: ________________________________________________________

# of freezers: _______________________ Sizes: __________________________________________________________

Do you have any Scale to weight incoming food? _______________________________________ (mandatory)

Hours of operations for TBH deliveries: ______________________________________________________________

Where are the deliveries made, i.e., front door, West Side of bldg. ______________________________________

____________________________________________________________________________________________________

Hours of operation for clients: _______________________________________________________________________

Name of person certified in safe food handling: _______________________________________________________

Our facility can handle the following types of food: (please check those that apply)

Non perishable only: __, frozen: ____, bread & packaged bakery: ___,

fresh produce: ___, prepared foods: _____,