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Harvest for the Hungry/ United Way resource survey
This survey is to help Harvest for the Hungry better assist the communities we support through a referral system set up by United Way.
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Email
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Your email
Produce pick- ups are scheduled on Wednesday mornings from 9-12. If this does not workout for you, maybe we can work out a set pick-up time. below let us know about your needs and how us or others can possibly assist you.
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Your answer
Date of birth
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MM
/
DD
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YYYY
Address
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Your answer
Gender
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Male
Female
Other:
Phone number
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Your answer
How would you prefer your authorization be sent to you
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Via SMS
Via Email
1. Do you have a valid government issued ID?
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YES
NO
2. Do you eat less than you feel you should because there’s not enough food ?
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YES
NO
I Don't Know
3. Are you worried that in the next few months, you may not have safe housing that you own, rent or share?
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YES
NO
I Don't Know
4. In the past year, have you had a hard time paying your utility company bills?
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YES
NO
I Don't Know
5. Are you in need of clothing to meet your daily needs?
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YES
NO
I Don't Know
6. Are your finances covering your living costs?
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YES
NO
I Don't Know
7. Do you have a dependable way to get to work or school and your appointments?
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YES
NO
I Don't Know
8. Do you think completing more education or training, like finishing a GED, going to college or learning a trade would be helpful to you?
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YES
NO
I Don't Know
9. Do you have a job or other steady source of income?
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YES
NO
I Don't Know
10. Do you have a usual source of medical care?
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YES
NO
I Don't Know
11. Do you have medical insurance?
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YES
NO
I Don't Know
12. Does getting childcare make it hard for you to work, go to school or study?
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YES
NO
I Don't Know
13. Do you have people in your life that you feel supported by?
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YES
NO
I Don't Know
14. Have you experienced a time when finances got in the way of being able to cover your costs for your prescriptions?
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YES
NO
I Don't Know
15. Would you like to receive assistance with any of these needs?
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YES
NO
I Don't Know
16. Are any of your needs urgent? For example, I don’t have food tonight or I don’t have a place to sleep tonight?
YES
NO
I Don't Know
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