• Title *

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• Phone *

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• Email *

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RDN On Staff *

Yes

No

Choose one option.

Meals Made From Scratch In Your Own Kitchen *

Yes

No

Choose one option.

Client Referrals Via Medical Referral Form *

All

Some

No

Choose one option.

Nutritional Assessment By RDN*

All

Some

No

Choose one option.

Medical diagnoses served

HIV/AIDS

Cancer

Congestive Heart Failure

Hypertension/Stroke

Diabetes

Chronic kidney Disease

Rental Failure

COPD

Other    

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HIPPA Compliant *

Yes

No

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Organization Name *

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Website *

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Address *

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General Organization Contact Email *

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General Organization Contact Phone Number *

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Contact Name *

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• Title *

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• Phone *

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• Email *

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Type Of Organization *

Select Option 501(C)(3) CBO 501(C)(3) intermediary Healthcare system Insurance Co Integrated delivery system Other Please select one option.

Implementing Partners *

FQHC

Community Health Center

Hospital (public/private)

Department of Health

Insurance Co

Retail Food supplier

Non profit food bank/pantry

Schools

Other    

Please select at least one option.

Index Patient Screening Questions *

Food insecurity - please confirm how you are identifying

SDOH Assessment – please confirm the tool you are using

Current Produce consumption

Current assessment of healthy eating (rating scale)

Number of household members

Insurance

SNAP

SSDI

Please select at least one option.

Insurance type(s) accepted *

Medicare

Medicaid

Commercial/Employer sponsored plan

No insurance

Please select at least one option.

Require established primary care provider *

Yes

No

Choose one option.

Metrics collected on patient/recipient *

HbA1c

Height and Weight

BMI

Blood pressure

Blood glucose (ongoing)

Triglycerides

LDL

Tobacco use

Other    

Please select at least one option.

Qualitative Metrics collected on patient/recipient(check all that apply) *

Satisfaction

Fruit and veg consumption

Personal well being

Physical activity

Overall household health

Other    

Please select at least one option.

Metrics collected from provider – utilization(check all that apply) *

Emergency room usage

Admissions/Readmission rates

Care gap compliance (compliance with preventive care exams)

Overall utilization

Other    

Please select at least one option.

Program criteria *

Food insecurity

Established Provider

Income documentation

Established patient

Targeted conditions

Other  

Please select at least one option.

Nutrition education *

Select Option Offered Highly encouraged Mandatory for participation Please select one option.

Type of education available *

Meal Planning/Budget planning

Healthy Weight Goals

Cooking demonstrations/classes

Exercise/physical activity

Registered dietician or CDE support

Evidence based chronic condition management programming

Other   

Please select at least one option.

Clinical oversight of the program and education *

Medical provider

RD

RN

Health Coach

Other    

Please select at least one option.

Clinical oversight provided on site or in conjunction with a clinical partner *

Yes

No

Choose one option.

Education Delivery (check all that apply) *

In person

Virtual

Telephonic

Hybrid

Please select at least one option.

Average length of time people are in the program *

Select Option 6-month 9-month 12-month Other Please select option.

Average number of clinical visits during intervention *

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Food distribution *

Select Option Weekly Biweekly Monthly Other Please select option.

Food provision per distribution (per person in the household) *

Pounds

OR    

Servings

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Redemption (Check all) *

Food Retailer

Farmers Market

CSA

Food Bank

Online Delivery

Other    

Please select at least one option.

Food type (check all) *

Premade meals

Grocery/prep needed

Please select at least one option.

Produce offerings (check all that apply) *

Fresh

Frozen

Canned-unadulterated

Please select at least one option.

How much produce is provided (Percent of total per person) *

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Additional foods offered *

This field is required.

If additional foods offered, do you consistently follow ADA/AHA criteria *

Yes

No

Choose one option.

Documented clinical improvements *

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Publications (max 3) *

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Certifications (max 5) *

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Awards/recognition (max 5) *

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Organization Name *

Website *

Address *

Enter the location to display on the map

General Organization Contact Email *

General Organization Contact Phone Number *

Contact Name *

• Title *
• Phone *

  This field is required.
• Email *

  This field is required.

Type Of Organization *

Select an option 501(C)(3) CBO 501(C)(3) intermediary Clinic Other Please select one option.

Primary Funding Sources(include up to two selections) *

Large Private Donor

Insurance Company (corporate)

Healthcare provider(corporate)

Municipal

GuSNIP/FINI (Federal)

Other Federal Funding

Crowd-funded from fundraising efforts

Self Sustained / Self Supported

Other   

Please select at least one checkbox.

Clinical Implementation Partners (Check all that apply)*

FQHC

Community Health Center

Hospital (public/private)

Department of Health

Rural Community Health Centers

None

Other   

Please select at least one checkbox.

Other Program Partner(s) Types (Check all that apply) *

Government / Municipal

Health Insurance

Value-based Care / Managed Care (ACO)

Foundation

Corporation

Non-profit or CBO

University

Farmer’s Market

Farm

None

Please select at least one checkbox.

Eligibility (check all that apply) *

Medicare

Medicaid/MediCal

SNAP

Please select at least one checkbox.

Data Collection Type (check all that apply)

Demographic

Income

Other   

Enrollment Data Captured (Check all that apply) *

HIV/AIDS

Obesity

Cancer

Heart Disease

Pregnancy

Unspecified Diet-Related Chronic Disease

Food insecurity

Produce consumption

Diabetes / Pre-Diabetes

Please select at least one checkbox.

Other social factors (check all that apply) *

Low Income

Veteran Status

Other   

Please select at least one checkbox.

Patient Age Population (Check all that apply) *

Pediatric (0 - 12)

Adolescent (13 - 17)

Adult (18 - 64)

Older Adult (65+)

Please select at least one checkbox.

Biometrics

Select Option Yes None Yet – Need funding None Yet – Need capacity None – Not interested

Type of Patient/Recipient Metrics (check all that apply)

HbA1c

Height and Weight/BMI

Blood pressure

Blood glucose (ongoing)

Hypertension

FV consumption

FV knowledge

Type of Provider-Utilization Metrics Collected (check all that apply)

Emergency room usage

Readmittance

Overall utilization

Prescription Amount (dosage)

per day

per month

per patient

Household members included?

Yes

No

Mode of Transaction (Check all that apply) *

Vouchers/coupons/Tokens

SNAP / EBT Card

Mobile App

Produce Box / CSA subscription

Retailer Loyalty Card

Other  

Please select at least one checkbox.

Redemption Site (Check all that apply) *

Food Retailer

Farmers Market

CSA Box

Food Bank

Online Delivery

On-site produce distribution

Mobile Market

Other  

Please select at least one checkbox.

Type of produce *

Local

Regional

Fresh

Other foods offered  

Please select at least one checkbox.

Nutrition/cooking education

Yes

No

Type of Nutrition Education (check all that apply)

Meal planning

Healthy weight goals

Cooking classes, live

Cooking content

Nutrition content

SNAP Ed

Other  

Education provider

RDN

CBO

Third party

Duration (select one) *

6-month

9-month

12-month

Other  

Please select one option.

Frequency of biometric data collection / interaction with program operators

Additional Factors to Consider (limit 100 characters)

Please copy the URL of the image you want to upload and paste it in the URL field. Here’s how to do it

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Organization Name *

This field is reqired.

Website Address *

This field is reqired.

Address *

Enter the location to display on the map
This field is reqired.

General Organization Contact Email *

This field is reqired.

General Organization Contact Phone Number *

This field is reqired.

Contact Name *

This field is reqired.

• Title *

  This field is reqired.
• Phone *

  This field is reqired.
• Email *

  This field is reqired.
• TKC Member? *

  Yes

  No

  
  Choose YES or No.

What is the principal purpose of your teaching kitchen (Select up to three)? *

Student education (i.e. college, university, k-12 schools)

Improving health outcomes

Equity/social justice

Improving culinary skills (teaching cooking/baking)

Generating a profit from products or services sold

Reducing health care costs of trainees/employees

Other    

Please check at least one checkbox.

How is your teaching kitchen funded? (select all that apply) *

Corporate sponsorship

Philanthropy

Volunteer based

Government

In-kind donations

Client paid

Insurance coverage

Other    

Please check at least one checkbox.

Type of facility *

Hospital/medical center

Academic Institution (K-12 school, college, university)

Culinary School

Non-profit, Community-based program

Corporate/ For-profit program

In-home, personal kitchen

Other    

Please check at least one checkbox.

Kitchen facilities are *

Rented

Owned

In-kind space use

Please check at least one checkbox.

Physical Kitchen Structure *

Pop-up

Mobile

Built in demonstration only

Built in demonstration and hands on stations for participants

Virtual

Please check at least one checkbox.

Licensed Team members include: check all that apply *

Registered Dietitian

MD

ND

NP/RN

Certified Chef

Chef Educator

Health Coach

Certified Nutritionist

Other licensed team members    

Please check at least one checkbox.

Do Participants (Check all that apply) *

Listen To Lectures

Watch Demos

Cook Along with Instructor

Please check at least one checkbox

Teaching Fundamentals *

Culinary Education

Nutrition Education

Exercise/Movement Education

Mindfulness Education

Health Coaching/Motivational Interviewing

Other    

Please check at least one checkbox

Tell us about your teaching kitchen curriculum: check all that apply *

We currently use a curriculum that we purchased or license

We developed our own curriculum

Please check at least one checkbox

What is the average number of participants you typically teach in a month? *

This is field is required

What is the average number of participants you typically teach in a year? *

This is field is required

Populations Served (Check all that apply) *

Adults

Children

K12 Students

Culinary Trainees (Chefs)

College or University Students

Persons with Disabilities

Low Income/food insecure

Clients

Patients

Employees

Retirees

Veterans

Active Military (And Families)

Other    

Please check at least one checkbox

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Organization Name *

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Website Address *

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Address *

Enter the location to display on the map
This field is reqired.

General Organization Contact Email *

This field is reqired.

General Organization Contact Phone Number *

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Contact Name *

This field is reqired.

• Title *

  This field is reqired.
• Phone *

  This field is reqired.
• Email *

  This field is reqired.

What is the name of the program you offer? *

This field is reqired.

Is your program associated with a USDA Gus Schumacher Nutrition Incentive Grant Program (GusNIP) and/or Food Insecurity Nutrition Incentive (FINI) award?

Yes

No

Choose one option.

If “Yes”, what is the name of the primary awardee of the GusNIP or FINI award? *

This field is required.

Would you describe your firm as farm direct (farmers markets, mobile markets, farm/produce stands, CSA's, etc.) or brick and mortar ? (grocery stores, corner stores, etc.) *

Farm Direct

Brick and Mortar

Choose one option.

Program Operation

Year-round

Seasonal

Choose one option.

If you answered “Seasonal” to the previous question, please check all that apply *

Winter

Spring

Summer

Fall

Please check at least one checkbox

Allowable SNAP purchases that trigger incentives at your firm? Select the best fit for your program (i.e., What can a customer purchase with their EBT card to earn the incentive?) *

all SNAP eligible items

all Fruits + Vegetables (FV) (fresh, cut, dried, canned, frozen with no added sugar, salt, oil, etc.)

only fresh FVs

only fresh and frozen FVs

only state and regionally grown FVs

only organic grown FVs

Other    

Please check at least one checkbox

Which fruit and vegetable products are eligible for incentives at your fi rm? (e.g., What can a customer purchase with their incentive?) Select all that apply *

all fresh FVs

canned FVs (no added salt/sugar)

frozen FVs (no added salt/sugar)

dried FVs (no added salt/sugar)

dried herbs and spices

plants that produce herbs and FVs

seeds that produce herbs and FVs

only state and regionally grown FVs

only organic grown FVs

Other    

Please check at least one checkbox

In what form(s) are SNAP incentives provided to customers at this firm? Select all that apply *

coupon

token

frozen FVs (no added salt/sugar)

paper

EBT card

loyalty card – unique ID/phone number

loyalty account – plastic card

loyalty account – mobile application

discount

Other    

Please check at least one checkbox

Ratio of SNAP dollars to SNAP incentive. Select all that apply. (Ex: For every $1 spent on SNAP, customer will earn $1 in incentive, up to $20, daily. RATIO is 1:1. A ratio of 2:2 is equivalent to 1:1) *

1:1

2:1

3:1

4:1

5:2

25% off

50% off

Other    

Please check at least one checkbox

Maximum daily incentive amount. (Ex: For every $1 spent on SNAP, customer will earn $1 in incentive, up to $20, daily. Maximum is 20) If your firm does not have cap, enter "0" *

$

This field is reqired.

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