Childhood Nutrition Collaborative: Goal 1 Reporting Form 2019
This form intends to capture all activities in Tompkins County that advance Goal 1 "Increase the percentage of households with children (0-24) in Tompkins who are food secure."

Nine objectives have been identified as proxies for food insecurity because they are both measurable and meaningful. They fall under 4 broad categories: availability, access, education, and sovereignty.

Please use this form to report on each of the activities you facilitate that advance Goal 1.

This is a pilot form, you have the opportunity to provide input on this form!
Email address *
Full name (first & last): *
Your answer
Organization: *
If you are unsure or not affiliated with an organization, please enter "N/A" below.
Your answer
Collaborators (all organizations and/or individuals): *
If you did not collaborate with anyone outside of your organization, please enter "N/A" below.
Your answer
Activity name: *
Activities include but are not limited to events, projects, and programs.
Your answer
Activity description: *
Your answer
Select the purpose of this activity: *
Choose up to 3 objectives.
Required
First activity date (in 2019): *
MM
/
DD
/
YYYY
Last activity date (in 2019): *
MM
/
DD
/
YYYY
Activity frequency: *
Select the location of this activity (Tompkins County town): *
If the activity occurred at multiple site, select the location of the main site (headquarters, distribution center, etc.).
Number of activity participants from each town (include all ages): *
0 (or unsure)
1-5
6-10
11-50
51+
Caroline
Danby
Dryden
Enfield
Groton
City of Ithaca
Town of Ithaca
Lansing
Newfield
Ulysses
How many young people (prenatal to 24 years old) participated in this activity? *
Please provide your best estimate if the exact total is unavailable.
Your answer
How many adults (ages 25+) participated in this activity? *
Please provide your best estimate if the exact total is unavailable.
Your answer
**The questions below are optional, but encouraged.**
How do you define success for this activity?
Your answer
How do you measure success (outcomes you are working toward)?
If you are currently unsure or unable, please indicate that below.
Your answer
Please share any recent measureables that are available below.
Your answer
What is working well for this activity?
Your answer
What is challenging for this activity?
Your answer
Who else, beyond the participants, is impacted by this activity?
Your answer
Any other comments/feedback?
Your answer
A copy of your responses will be emailed to the address you provided.
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