CSFP Program Report
Agency Name
*
Agency ID
*
Distribution Month/Year Date
*
CSFP Program
Total Number of Seniors Served Monthly
*
How many Seniors did you deliver to this month?
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How many no shows did you have this month?
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How many Seniors did you serve through temporary certification this month?
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Did you have CSFP Boxes that were not distributed?
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Yes
No
If yes, how many?
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How many seniors are on your waiting list?
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Dates of Distributions
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Please provide the numbers for each Race/Ethnicity for this month’s distribution.
American Indian or Alaska Native
Number of Hispanic?
Asian
Number of Hispanic?
Black or African American
Number of Hispanic?
Native Hawaiian or other Pacific Islander
Number of Hispanic?
White
Number of Hispanic?
Participants that Marked Two Races
American Indian or Alaska Native American and White
Asian and White
Black or African American and White
Native Hawaiian or other Pacific Islander and White
Name
*
First Name
Last Name
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Title
*
Signature
*
Please verify that you are human
*
Submit
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