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?
*
How many no shows did you have this month?
*
How many Seniors did you serve through temporary certification this month?
*
Did you have CSFP Boxes that were not distributed?
*
Yes
No
If yes, how many?
*
How many seniors are on your waiting list?
*
Dates of Distributions
*
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
Date
Title
*
Signature
*
Please verify that you are human
*
Submit
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