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Welcome to the Food Survey
Thank you for taking the time to fill out and submit this form.
18
Questions
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Language
English (US)
Spanish (Latin America)
1
We want to know what your experience is around food!
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2
How many people are your responsible for feeding?
1 if it's just yourself
1
2
3
4
5
6
7
8
9
10 or more
Someone else is responsible for the majority of my meals
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3
Which of the following best represents your yearly household income?
Less than $5,000
$10,000-19,999
$20,000-29,999
$30,000-39,999
$40,000-49,999
$50,000-59,999
$60,000-69,999
$70,000+
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4
During the last 12 months...
*
This field is required.
Strongly Agree
Agree
Some
Very Little
Not At All
I have been worried about having enough food to eat
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Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
I have been unable to eat healthy/nutritious meals
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Row 1, Column 3
Row 1, Column 4
I have only been able to eat a few kinds of meals
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I have been worried about having enough food to eat
I have been unable to eat healthy/nutritious meals
I have only been able to eat a few kinds of meals
Strongly Agree
Row 0, Column 0
Agree
Row 0, Column 1
Some
Row 0, Column 2
Very Little
Row 0, Column 3
Not At All
Row 0, Column 4
Strongly Agree
Row 1, Column 0
Agree
Row 1, Column 1
Some
Row 1, Column 2
Very Little
Row 1, Column 3
Not At All
Row 1, Column 4
Strongly Agree
Row 2, Column 0
Agree
Row 2, Column 1
Some
Row 2, Column 2
Very Little
Row 2, Column 3
Not At All
Row 2, Column 4
1
of 3
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5
During the last 12 months...
*
This field is required.
Strongly Agree
Agree
Some
Very Little
Not At All
I ate less than I thought I should
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
I have had to skip a meal
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
I went without eating for the whole day
Row 2, Column 0
Row 2, Column 1
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I ate less than I thought I should
I have had to skip a meal
I went without eating for the whole day
Strongly Agree
Row 0, Column 0
Agree
Row 0, Column 1
Some
Row 0, Column 2
Very Little
Row 0, Column 3
Not At All
Row 0, Column 4
Strongly Agree
Row 1, Column 0
Agree
Row 1, Column 1
Some
Row 1, Column 2
Very Little
Row 1, Column 3
Not At All
Row 1, Column 4
Strongly Agree
Row 2, Column 0
Agree
Row 2, Column 1
Some
Row 2, Column 2
Very Little
Row 2, Column 3
Not At All
Row 2, Column 4
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of 3
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6
During the last 12 months...
*
This field is required.
Strongly Agree
Agree
Some
Very Little
Not At All
My household ran out of food
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
I have been hungry but did not eat
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Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
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My household ran out of food
I have been hungry but did not eat
Strongly Agree
Row 0, Column 0
Agree
Row 0, Column 1
Some
Row 0, Column 2
Very Little
Row 0, Column 3
Not At All
Row 0, Column 4
Strongly Agree
Row 1, Column 0
Agree
Row 1, Column 1
Some
Row 1, Column 2
Very Little
Row 1, Column 3
Not At All
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1
of 2
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7
In General...
Strongly Agree
Agree
Some
Very Little
Not At All
I eat food to fill my needs and not for any other purpose
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Row 0, Column 1
Row 0, Column 2
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Row 0, Column 4
I enjoy the meals I eat
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
I often find myself eating my meals alone
Row 2, Column 0
Row 2, Column 1
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Row 2, Column 3
Row 2, Column 4
I prefer to eat my meals with others or in a group
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
I prefer to have a grab and go mealΒ
Row 4, Column 0
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I have the time to prepare and cook a mealΒ
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I eat food to fill my needs and not for any other purpose
I enjoy the meals I eat
I often find myself eating my meals alone
I prefer to eat my meals with others or in a group
I prefer to have a grab and go mealΒ
I have the time to prepare and cook a mealΒ
Strongly Agree
Row 0, Column 0
Agree
Row 0, Column 1
Some
Row 0, Column 2
Very Little
Row 0, Column 3
Not At All
Row 0, Column 4
Strongly Agree
Row 1, Column 0
Agree
Row 1, Column 1
Some
Row 1, Column 2
Very Little
Row 1, Column 3
Not At All
Row 1, Column 4
Strongly Agree
Row 2, Column 0
Agree
Row 2, Column 1
Some
Row 2, Column 2
Very Little
Row 2, Column 3
Not At All
Row 2, Column 4
Strongly Agree
Row 3, Column 0
Agree
Row 3, Column 1
Some
Row 3, Column 2
Very Little
Row 3, Column 3
Not At All
Row 3, Column 4
Strongly Agree
Row 4, Column 0
Agree
Row 4, Column 1
Some
Row 4, Column 2
Very Little
Row 4, Column 3
Not At All
Row 4, Column 4
Strongly Agree
Row 5, Column 0
Agree
Row 5, Column 1
Some
Row 5, Column 2
Very Little
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Not At All
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1
of 6
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8
Do you or your family π§πππππ«π food aid (SNAP, EBT, etc.)?
Yes
No
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9
Do you or your family πͺπ¨π food aid (SNAP, EBT, etc.)?
Yes
No
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10
What transportation options are available to you?
Walking
Train
Driving
Uber/Lyft
Bus
Other
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11
How far do you travel for food and meals?
Please Select
Less than 5 minutes
5-10 minutes
10-20 minutes
20-30 minutes
More than 30 minutes
Please Select
Please Select
Less than 5 minutes
5-10 minutes
10-20 minutes
20-30 minutes
More than 30 minutes
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12
Do you (have you) accessed a food bank or pantry to meet nutritional needs?
Yes
No
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13
To what extent do you identify with the following statements:
If you answered NO
Strongly Agree
Agree
Some
Very Little
Not At All
I feel uncomfortable or anxious with the idea of accessing a food bank or pantry
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
My community helps me access food for my family
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
I don't know how to access or get started with a food bank or pantry
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
I feel (have felt) isolated from peers who do not get food aid
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
I have attended events only to access free or discounted food
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
I feel uncomfortable or anxious with the idea of accessing a food bank or pantry
My community helps me access food for my family
I don't know how to access or get started with a food bank or pantry
I feel (have felt) isolated from peers who do not get food aid
I have attended events only to access free or discounted food
Strongly Agree
Row 0, Column 0
Agree
Row 0, Column 1
Some
Row 0, Column 2
Very Little
Row 0, Column 3
Not At All
Row 0, Column 4
Strongly Agree
Row 1, Column 0
Agree
Row 1, Column 1
Some
Row 1, Column 2
Very Little
Row 1, Column 3
Not At All
Row 1, Column 4
Strongly Agree
Row 2, Column 0
Agree
Row 2, Column 1
Some
Row 2, Column 2
Very Little
Row 2, Column 3
Not At All
Row 2, Column 4
Strongly Agree
Row 3, Column 0
Agree
Row 3, Column 1
Some
Row 3, Column 2
Very Little
Row 3, Column 3
Not At All
Row 3, Column 4
Strongly Agree
Row 4, Column 0
Agree
Row 4, Column 1
Some
Row 4, Column 2
Very Little
Row 4, Column 3
Not At All
Row 4, Column 4
1
of 5
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14
To what extent do you identify with the following statements:
If you answered YES
Strongly Agree
Agree
Some
Very Little
Not At All
I have felt welcomed when accessing a food bank or pantry
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
I have felt respected when accessing a food bank or pantry
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
I have felt safe when accessing a food bank or pantry
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
My community helps me to access food for my family
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
I access food aid as little as possible
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
I feel uncomfortable accessing a food bank or pantry
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
I feel (have felt) anxious when accessing a food bank or pantry
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
I feel (have felt) isolated from peers who do not access food aid
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
I have attended events only to access free or discounted food
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
I have felt welcomed when accessing a food bank or pantry
I have felt respected when accessing a food bank or pantry
I have felt safe when accessing a food bank or pantry
My community helps me to access food for my family
I access food aid as little as possible
I feel uncomfortable accessing a food bank or pantry
I feel (have felt) anxious when accessing a food bank or pantry
I feel (have felt) isolated from peers who do not access food aid
I have attended events only to access free or discounted food
Strongly Agree
Row 0, Column 0
Agree
Row 0, Column 1
Some
Row 0, Column 2
Very Little
Row 0, Column 3
Not At All
Row 0, Column 4
Strongly Agree
Row 1, Column 0
Agree
Row 1, Column 1
Some
Row 1, Column 2
Very Little
Row 1, Column 3
Not At All
Row 1, Column 4
Strongly Agree
Row 2, Column 0
Agree
Row 2, Column 1
Some
Row 2, Column 2
Very Little
Row 2, Column 3
Not At All
Row 2, Column 4
Strongly Agree
Row 3, Column 0
Agree
Row 3, Column 1
Some
Row 3, Column 2
Very Little
Row 3, Column 3
Not At All
Row 3, Column 4
Strongly Agree
Row 4, Column 0
Agree
Row 4, Column 1
Some
Row 4, Column 2
Very Little
Row 4, Column 3
Not At All
Row 4, Column 4
Strongly Agree
Row 5, Column 0
Agree
Row 5, Column 1
Some
Row 5, Column 2
Very Little
Row 5, Column 3
Not At All
Row 5, Column 4
Strongly Agree
Row 6, Column 0
Agree
Row 6, Column 1
Some
Row 6, Column 2
Very Little
Row 6, Column 3
Not At All
Row 6, Column 4
Strongly Agree
Row 7, Column 0
Agree
Row 7, Column 1
Some
Row 7, Column 2
Very Little
Row 7, Column 3
Not At All
Row 7, Column 4
Strongly Agree
Row 8, Column 0
Agree
Row 8, Column 1
Some
Row 8, Column 2
Very Little
Row 8, Column 3
Not At All
Row 8, Column 4
1
of 9
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15
Do you or your family members routinely attend any of the following?
Check all that apply
School (K-12)
College Campus
Religious Institutions
Clinics
Other
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16
Do you (would you) attend events with any of the following features?
Check all that apply
Movie Showing
Tabled Picnic Space
Live Music
Food
Physical sport or Yard Games
Tabletop Board Games
Face Painting
Balloon Animals
Cooking Classes
Craft Workshops
Magician
Information or Education Sessions
Other
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17
What food sources would you like to see more of in your neighborhood?
A new or better supermarket
Ethnic/specialty restaurants
Vegan/vegetarian options
Convenience stores
A community garden
Food trucks
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18
Your Zip Code:
Or city/state
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19
Would you be open to providing further details about your personal experience with food aid?
Yes
No
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20
Contact information (email, number, etc.)
To provide further details
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