Agency Member Survey Form Month*Select…JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Agency Name*Agency IDCounty*Select…Adams CountyAllen CountyDeKalb CountyHuntington CountyLaGrange CountyNoble CountySteuben CountyWells CountyWhitley CountyAgency Type (check all that apply)DaycareCommunity Cupboard Voucher ProgramPantry ProgramResidential / TransitionalShelterSoup KitchenYouth ProgramOtherGross Total of Individuals ServedNumber of MalesNumber of FemalesDo you track ethnicity? (if “Yes”, fill in the additional breakdown belowYesNoAfrican AmericanCaucasianHispanicAsianOtherChildren Age Group (0 – 18 years old)Adult Age Group (19 – 59 years old)Senior Age Group (60+ years old)Do you track income? (if “Yes”, fill in the additional breakdown below)YesNoExtremely LowLowModerateOtherLast month did your agency serve…More ClientsAbout the Same Number of ClientsFewer ClientsNo ClientsWere there any clients you were unable to serve?YesNoIf “Yes”, how many?Reason you were unable to serve? (select all that apply)Lack of VolunteersLack of FundingLack of ProductClient exceeded number of visitsClient lived outside of service areaOtherIf “Other”, please specifyForm Completed By (full name)*Date Completed*Checking this box means that you affirm that the above information is accurate to the best of your knowledge and that you will provide any subsequent requested documentation or follow-up information in a timely manner?*Submit Please enable JavaScript in your browser to submit the form
