FNS-543 National Hunger Clearinghouse Database Form

NATIONAL HUNGER CLEARINGHOUSE DATABASE FORM

Facilitating the exchange of information, resources, and ideas

among organizations fighting hunger and poverty.

OMB Control Number: 0584-0474. 

Please complete this form and return it to WHY (World Hunger Year).

Date: _______________

Organization Name: _______________________________________________________________________

Address: _____________________________________County/Counties Served: ______________________

City: ____________________________ State: ________________________Zip code: __________________

Phone: ____________________________ext: __________ Fax: ____________________________________

Hours of Service: ______________________________ Website: __________________________________

Email: __________________________ Do want this to be the main email contact? YES NO

Contact’s Name: ______________________________ Title: _____________________________________

Phone: ________________________ ext: _______ Email: _____________________________________

Would you like to receive our monthly newsletter, the Clearinghouse Connection by:

Fax ______ Email ______ Do not want to receive it ________

Year Founded: ______ Number of Full Time Staff: _______ Number of Part time staff: _______

Number of Volunteers: _______ National or Regional Affiliation: ______________________________

Annual Budget (select one)

• $0 - $49,999

• $50,000 - $99,999

• $100,000 - $499,999

• $500,000 - $999,999

• $1,000,000 +

How would you classify your organization? (select all that apply)

• Advocacy

• Coalition

• Direct Services

• Education Institution

• Emergency Food Provider

• Funder

• Labor

• Religious

What is your organization’s target population? (select all that apply)

• Families

• Homeless

• Immigrants

• Senior Citizens

• Youth

• Other __________

Where does your organization provide services?

• Business

• Child Care Center

• College University

• Community Center

• Correctional Facility

• Detention Center

• Extension Service

• Farm

• Health Care Facility

• Home/Residence

• Organizational Offices

• Public Housing

• Religious Institution

• School

• Senior Citizen Center

• Shelter

• Soup Kitchen/Food Pantry

What area does your organization serve?

• County

• International

• National

• Neighborhood

• Regional

• Rural

• State

• Suburban

• Urban

AGENCY SERVCIES- PLEASE MARK ALL THAT APPLY Page 2

Children Services:

• After school

• Day care/Childcare

• Foster Care/Adoption

• Other ________________

Counseling:

• Case Management

• Crisis Hotline

• Domestic Violence

• Drug and Alcohol

• Family Support

• Individual

• Referral Services

• Sexual Assault

• Other ______________

Education:

• ESL

• Head Start

• Nutrition Education

• Prison Re-entry Program

• Other______________

Food Assistance:

• Community Support Agriculture

• Farmer’s Markets

• Food Bank

• Food Delivery

• Food Pantry

• Kids Cafe

• Meals on Wheels

• Soup Kitchens

• Other________________

Government Programs:

• Child & Adult Care Food Program

• CSFP

• Earned Income Tax Credit

• FEMA/Disaster Relief

• Food Stamp Program

• Home Energy Assistance

Government Programs (cont.)

• Senior Farmer’s Mkt Nutrition

• Summer Feeding Program

• TEFAP

• TANF

• WIC

• WIC/FMNP

• SFMNP

• Other _________________

Health Care

• Health Clinic

• Prescription Assistance

• Other _________________

Homeless Services:

• Drop In Center

• Emergency Shelter

• Halfway House

• Transitional Housing

• Voice Mail

• Other__________________

Housing:

• Appliances/ Furniture

• Home Repairs

• Rent Subsidy

• Utilities Assistance

• Weatherization

• Other_______________

Jobs:

• Career Counseling

• Job Placement

• Job Readiness

• Job Training

• Other_______________

Other Services:

• Clothes

• Hunger Hotline

• Thrift Shop

Do you do advocacy work? If so, please indicate what kind. ­­­­­­­­_________________________

Do you provide transportation services? Yes ____ No ____

Do you provide transportation vouchers? Yes ____ No ____

Do you accept food donations? Yes ____ No ____

Do you provide seasonal services? (i.e. Christmas baskets) Yes ____ No ____

Mission Statement: ___________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

***Please write or attach a description of your organization’s background and programs***

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0584-0474.  The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  This collection of information expires 07/31/2009.

Form FNS-543

National Hunger Clearinghouse- WHY (World Hunger Year)

5 05 Eighth Avenue, Suite 2100 New York, NY 10018 *

tel: 1-866-3 HUNGRY * fax: 212.-465-9274 * email: NHC@worldhungeryear.org