Monthly Program Distribution Report

Monthly Distribution Report

Please submit this form to report distributions for the reporting month. Partners are required to submit distributions reports by the 5th of each month for the month prior.
Please select the program that you are reporting for:*

Partner Backpack (I provide backpacks to schools)School Backpack (I work at a school)School/Campus PantryCSFPSenior ServingsHealthcare Clinics
Partner Backpack Monthly Report

Please contact Isaac Muly at imuly@okfoodbank.org if you have any questions or difficulties.
Email*
example@example.com
Agency ID Format: 5 digit agency number, the dash, and the 2 digit program number. Do not put 0092p in front of your number.

Ex.) 15004-01
Backpack Program Agency ID*
Auto BP Agency ID
Partner BP Agency Name*
Reporting Month*
Counties Served (can select multiple)*
Person Completing Report:*

First NameLast Name
Total Number of Packs/Sacks Distributed:*
List number of Schools / Sites served in your program by grade category. (0, if none)*
How many recipients participated in your program this month? (0,if none)*
How many recipients participated in your program this month? (0,if none)*
What percentage of the food you distributed this month was obtained from the Food Bank of Eastern Oklahoma? (your best estimate, 0, if none)*
School Backpack Monthly Report

Please contact Isaac Muly at imuly@okfoodbank.org if you have any questions or difficulties.
SBP Email*
example@example.com
Agency ID Format: 5 digit agency number, the dash, and the 2 digit program number. Do not put 0092p in front of your number.

Ex.) 15004-01
School Backpack Program Agency ID*
Auto SBP Agency ID
SBP School Name*
SBP Reporting Month*
SBP Counties Served (can select multiple)*
SBP Person Completing Report*

First NameLast Name
SBP Total Number of Boxes Received This Month*
SBP Total Number of Sacks Distributed This Month*
School / Campus Pantry Monthly Report

Please contact Isaac Muly at imuly@okfoodbank.org if you have any questions or difficulties.
Email*
example@example.com
Program Type*

School Pantry (Middle School and High SchoolsCampus Pantry (Colleges, Technical Schools, High Education Sites)
Reporting Month*
County*
SPCP Program Agency ID*
Agency Name*
Person Completing Report*

First NameLast Name
How many times did you distribute food products/hygiene items to students this month? (count every time a student received products from the pantry, including repeat students)*
How many students were served by the pantry this month? (count each student only once)*
How many of the students served were NEW to the pantry program this month? (new to the program this school year)*
How many children, age 0-17 live in the households of students you served this month? (include student in count) (must be greater than or equal to the number of students you served this month)*
How many adults age 18-54 live in the households of students you served this month?*
How many adults age 55 and above live in the households of students you served this month?*
Healthcare Pantry Monthly Report Form

Please contact Joe Mercer @ jmercer@okfoodbank.org if you have any questions or difficulties.
Healthcare Program Agency ID*
Auto HLTH Agency ID
Agency Name*
Reporting Month*
Person Completing Report*

First NameLast Name
Email*
example@example.com
How many boxes of food did you distribute this month? (Count every time a patient received food from the pantry, including repeat patients.) *
How many of the patients were served by the pantry this month? (Count each patient only once. Do not include family member.) *
How many of these patients were new to the pantry program? (Have not received food from the program this year.)*
How many children ages 0-17 live in the households of the patients you served this month? (Include patient if applicable)*
How many adults ages 18-54 live in the households of the patients you served this month? (Include patient if applicable)*
How many adults ages 55 and above live in the households of the patients you served this month? (Include patient if applicable)*
CSFP Monthly Distribution Report

Please contact Taryn Watson at taryn.watson@okfoodbank.org if you have any questions or difficulties.
CSFP Program Agency ID*
Auto CSFP Agency ID
Agency Name*
Distribution Date*

MonthDayYear
Date
Distribution County*
Total number of boxes distributed this month*
How many EXTRA boxes do you have on hand after distributing this month?*
Recipient Sign-In Sheets

Cancelof
Individuals to remove from recipient list
please send a copy of each person's Notice of Denial or Discontinuance
Notices of Denial or Discontinuance

Cancelof
Individuals to add to recipient list
Please send a copy of each person's signed application
Recipient List Applications

Cancelof
Individuals to add to Waitlist
Please send a copy of each person's signed application
Waitlist Applications

Cancelof
Updated Applications

Cancelof
Name of Site Representative*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Questions or Comments
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) Mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW, Washington, D.C. 20250-9410;

(2) Fax: (202) 690-7442; or

(3) Email: program.intake@usda.gov.

This institution is an equal opportunity provider.
Senior Servings Monthly Distribution Report

Please contact Taryn Watson at taryn.watson@okfoodbank.org if you have any questions or difficulties.
Senior Servings Agency ID*
Auto Senior Servings Agency ID
Agency Name*
Distribution Month*
Total number of boxes distributed this month (# of seniors served)*
How many Seniors are on your waitlist?*
Name of Site Representative*

First NameLast Name
Auto SPCP Agency ID
Questions, comments, and Concerns
Should be Empty:

Monthly Distribution Report

Partner Backpack Monthly Report

School Backpack Monthly Report

School / Campus Pantry Monthly Report

Healthcare Pantry Monthly Report Form

CSFP Monthly Distribution Report

Senior Servings Monthly Distribution Report