Community Food Assessment

This is a Draft Assessment Tool that Kathy Jett is creating. Please e-mail klj27@cornell.edu for your feedback. Thanks! ~ Kathy

1. Are You::

Male

Female

3. Is English you primary language?:

Yes

4. How old are you?:

Under 25

25 - 45

45 - 65

65+

6. Do you have access to a vehicle?:

Always

Often

Sometimes

Never

9. How many adults live with you?:

If unemployed, how many months?:

11. Do you receive any of the following benefits?:

Public Assistance

SSD / SSI

Retirement income / pension

Veterans income

12. What is your total annual household income?:

13. Do you or anyone in your household receive Food Stamps / EBT?:

Yes

If No, why not?:

I / We can cover food costs without EBT

Do not qualify

Too long and difficult to apply

Don't know where to go / who to contact

Others need it more

Other reason::

If Yes, Amount per Month?:

Is this enough to by groceries for: :

Entire month

Three (3) Weeks

Two (2) Weeks

One (1) Week

What is your experience with food stamps::

14. Is anyone in your household enrolled in WIC?:

Yes

If not, why?:

I / We can cover food costs without WIC

Do not qualify

Too long and difficult to apply

Don't know where to go / who to contact

Others need it more

Any other reason no?:

Yes - WIC benefits are most helpful in covering costs for::

Infants to age (1) one

From age (1) one up

WIC Comments::

15. Do you receive / use the WIC FMNP coupons to shop at the Farmers Markets?:

Yes

If not, why would that be?:

Didn't know about coupons

Don't like going to the markets

Don't know when the markets operate

Can't get to markets (Work, Transportation)

Not interested

Other reason no market::

16. If there are children in your household do they receive free or reduced price lunches at school?:

Yes

Beside school lunch, do children eat meals at::

Other ways children eat?:

How often do they eat meals outside your home?:

Never

Once a week

A few times a week

Every day

17. Do you get any of your monthly food supplies from food pantries?:

Yes

Which food pantry do you visit?:

How often do you visit a food pantry?:

Multiple times per week

Once a week

A few times per month

Some months, but not others

Do food pantries have foods you want to eat?:

Yes

What items do you wish they had?:

18. Do you / your household ever get meals at::

Loaves & Fishes

Salvation Army

Community Centers / Churches

Other places to get meals::

How often do you go there for meals?:

In general, do you like the meals being served?:

Usually

Usually NOT

What would you prefer instead?:

19. Do you or anyone in your household: (Check all that apply):

Grow a fruit / vegetable garden

Shop at farm stands

Buy meat or other products from area farmers

Hunt for food

Fish for food

Can or freeze foods

Buy in bulk and store large amounts of food

Receive extra food from friends / neighbors

20. Do you ever go to Farmers' Markets?:

Yes

If yes, which one (s)?:

If not, could you say why?:

Do you know you can shop with food stamps at farmers' markets?:

Yes

21. Where do you usually shop for groceries?:

Why do you shop there? (Check all that apply):

Location / convenience

Price

Quality

Have products I like

Other reasons::

When you go to the store, do you shop::

For the Day

For the Week

For the Month

Does your usual store accept::

Food Stamps

WIC checks

How far away is your usual grocery store?:

How do you typically get to your grocery store? (Check all that apply):

Other items not mentioned::

22. How often do you (your household) eat at restaurants?:

23. How often do you (your household) eat at fast food outlets?:

24. Do you have cooking facilities where you live?:

Yes, including: (Check all that apply):

microwave

stovetop / oven

refrigerator

cookware

If you cook, how often per week?:

Every day

Almost every day

2 - 3 days a week

Once a week

When you cook, do you...:

Start from scratch

Use pre-cooked foods

List other monthly costs that affect "eating well"::

26. Which of these statements best describes your household in the last 12 months::

Enough of the kinds of food we want to eat

Enough food but not always waht we like

Sometimes not enough to eat

Often not enough to eat

27. If getting enough food is a challenge for your household, what are the reasons?:

28. Has accessing healthy / nutritious foods gotten easier or more difficult for you in recent years?:

29. What would make accessing food easier?:

30. Other comments regarding food access and food security for your household. :

1a. "The food that (I We) bought just didn't last, and (I/We) didn't have enough money to get more.":

A. Often True

B. Sometimes True

C. Never True

D. Don't Know

2a. "(I/We) couldn't afford to eat balanced meals.":

A. Often True

B. Sometimes True

C. Never True

D. Don't Know

3a. In the last 12 months, did (you/or other adults in your householdl) ever cut the size of your meals or skip meals?:

A. Yes

B. No (Skip #4)

C. Don't Know (Skip #4)

Because there wasn't enough money for food?

4a. How often did this happen?:

A. Almost every month

B. Some months but not every month

C. Only 1 or 2 months

D. Don't know

5a. In the last 12 months, did you ever eat less than you felt you should because thee wasn't enough money for food?:

A. Yes

B. No

C. Don't Know

6a. In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food?:

A. Yes

B. No

C. Don't Know

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Community Food Assessment