Service Insights - Setup assessment

Service Insights - Setup assessment

In order to successfully implement the software system, NTFB is interested in learning more about your agency capabilities. Please complete this form as soon as possible to start the process.
Agency Name*
Agency account no.*
Point of Contact for Service Insights*

First NameLast Name
Email*
example@example.com
What is your timeline on fully implementing platform?*
Tell us more about your distribution style*

Walk up and drive through onlyAll client choice, inside buildingMixed: client choice inside building and drive thru distributionBy appt only or assigned day
Please describe your agency's current process for intake (e.g. one-on-one, welcome/waiting room, no process)*
How many neighbors does your agency serve?
Monthly? blanks*
At an average single distribution blank*
Do you qualify your neighbors based on TEFAP requirements?*

YesNo
How does your agency currently log information about neighbors? (Check all that apply)*

Paper and pencilExcelMicrosoft AccessGoogle DocsOther
What type of data do you currently collect from the neighbors you serve during intake?*

NameDate of birthAddressRelationship to Household MembersHealth Status or Dietary considerationsEmployment Status or IncomeOther
Tell us about how you plan to roll out the intake platform to your neighbors. Give as much detail and include things that you will need to consider on what new data you would like to collect, new intake process, how many staff/volunteers you will have devoted to the process and what your goal in implementing the platform.*
Please provide us at least 3 zip codes you serve. *
Do you have more than one location that will be utilizing platform?*

YesNo
In this section, we would like to know about the users that NTFB will set up for you. Please consider who will be the admin user. NTFB will review in training how to set up additional users.
- Admin: will have an administrative role and will set up any additional users that will handle primarily the intake of your neighbors. This role will also be primarily responsible for any additional setup, managing accounts, reporting, and serving as support to your team and our main point of contact.
Admin user*

First NameLast Name
Email*
example@example.com
Best contact number to reach Admin*
Please enter a valid phone number.
What is the current number of staff and volunteers who help with client intake?
Number of staff assisting with intake blanks*
Number of volunteers assisting with intake blank
Should be Empty: