Agency Monthly CSFP Program Report

Agency Monthly 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?*

YesNo
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 NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Title*
Signature*
Please verify that you are human*
Should be Empty:

Participants that Marked Two Races