NYS FAM Coalition - Food Supplier Survey

NYS FAM Coalition - Food Supplier Survey

for Food Banks/Private Wholesalers/Food Suppliers
Are you a wholesaler/food supplier for food as medicine interventions such as:
- Medically Tailored or Clinically Appropriate Home Delivered Meals
- Medically Tailored or Nutritionally Appropriate Food Prescriptions
- Fresh Produce and Non-Perishable Groceries (Pantry Stocking)?
We are building a resource list of food banks/private wholesalers/food suppliers to share with the Coalition.

Please respond to this survey to be added to our Coalition Food Supplier resource list.
Organization/Company Name:*
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
1. Please select the NYS Counties in which you provide services (select all that apply)*

AlbanyAlleganyBronxBroomeCattaraugusCayugaChautauquaChemungChenangoClintonColumbiaCortlandDelawareDutchessErieEssexFranklinFultonGeneseeGreeneHamiltonHerkimerJeffersonKingsLewisLivingstonMadisonMonroeMontgomeryNassauNew YorkNiagaraOneidaOnondagaOntarioOrangeOrleansOswegoOtsegoPutnamQueensRensselaerRichmondRocklandSaratogaSchenectadySchoharieSchuylerSenecaSt. LawrenceSteubenSuffolkSullivanTiogaTompkinsUlsterWarrenWashingtonWayneWestchesterWyomingYates
2. For which of the following services are you able to supply food?*

Medically Tailored Home Delivered Meals (approved by Registered Dietitian)Clinically Appropriate Home Delivered Meals (approved by Registered Dietitian)Medically Tailored or Clinically Appropriate Food Prescription - Food Boxes (approved by Registered Dietitian)Medically Tailored or Clinically Appropriate Food Prescription - Food VouchersPantry Stocking (Fresh Produce and Non-Perishable Grocery Items)Culturally Tailored MealsCulturally Tailored Food BoxesFood Pantry
2A. Do you offer direct to home delivery?

YesNo
2B. Do you offer wholesale delivery to FAM providers?

YesNo
3. Please indicate the dietary accommodations you are able to provide (check all that apply)*

VegetarianVeganGluten-FreeLow FODMAPKosherHalalDairy-FreeNut-FreeOther
4. What is your service frequency? (if you offer multiple service frequencies, select all that apply)*

DailyWeeklyEvery Other WeekMonthlyOther
5. Do you offer in-person services, delivery services, or both?*

In-PersonDeliveryBoth
6. What percentage of your seasonal food is NYS grown/produced or grown/produced within a 400-mile radius?*

80-100%60-80%40-60%20-40%0-20%
Are you certified in NYS as a Minority or Women-Owned Business Enterprise? (MWBE)*

YesNo
Organization/Company Website
7. If there are any informational or marketing materials you wish to share, please upload them here:

Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
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