CHW/SNAP Pre-Screener Form

CHW/SNAP Pre-Screener Form

The Foodbank, Inc.
CHW FORM Name

First NameLast Name
Birth Date

MonthDayYear
Preferred Language:

Email
Please make sure it is a working email.
Address (If homeless, please mark as N/A)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
What type of assistance do you need in your household? Check all that apply.

Alcohol/Substance AbuseChildcareClothingDomestic Violence/Mental HealthEducationFinancial AssistanceFood (Do you receive SNAP Benefits?) Y or N (If NO, go to SNAP section below.)HousingInsuranceEmployment/Low IncomeLegalMedical/Medication AssistanceTransportationPregnancyOther
SNAP BENEFIT PRE-SCREENING SECTION
What is your household size?

1-45-77-910+
Does your household include someone 60 years or age or older or disabled?

YesNo
Are you a U.S. Citizen?

YesNo
Do you receive TANF benefits?

YesNo
Are you employed at least 20 hours a week?

YesNo
Do you participate in a federally funded work study program?

YesNo
Are you assigned to enroll in an employment and training program?

YesNo
Do you care for a dependent under the age of 6?

YesNo
Are you a single parent with a child under 12?

YesNo
School Enrollment Status

Part-TimeFull-TimeN/A
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