Add Your FIM Program To The Map
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RDN On Staff *

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Meals Made From Scratch In Your Own Kitchen *

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Client Referrals Via Medical Referral Form *

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Nutritional Assessment By RDN*

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Medical diagnoses served


   
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HIPPA Compliant *

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Please copy the URL of the image you want to upload and paste it in the URL field. Here’s how to do it
Your logo (paste image URL)
You can add up to 5 extra photos (paste image URL)




Enter the location to display on the map
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Please copy the URL of the image you want to upload and paste it in the URL field. Here’s how to do it
Your logo (paste image URL)
You can add up to 5 extra photos (paste image URL)




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Enter the location to display on the map
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  • Choose YES or No.
What is the principal purpose of your teaching kitchen (Select up to three)? *
   
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How is your teaching kitchen funded? (select all that apply) *
   
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Type of facility *
   

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Kitchen facilities are *

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Physical Kitchen Structure *

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Licensed Team members include: check all that apply *
   
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Do Participants (Check all that apply) *

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Teaching Fundamentals *
   
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Tell us about your teaching kitchen curriculum: check all that apply *
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Populations Served (Check all that apply) *
   
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Please copy the URL of the image you want to upload and paste it in the URL field. Here’s how to do it
Your logo (paste image URL)
You can add up to 5 extra photos (paste image URL)




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What is the name of the program you offer? *
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Is your program associated with a USDA Gus Schumacher Nutrition Incentive Grant Program (GusNIP) and/or Food Insecurity Nutrition Incentive (FINI) award?

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

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Program Operation

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

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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?) *
   
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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 *
   
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In what form(s) are SNAP incentives provided to customers at this firm? Select all that apply *
   
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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) *
   
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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" *
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Please copy the URL of the image you want to upload and paste it in the URL field. Here’s how to do it
Your logo (paste image URL)
You can add up to 5 extra photos (paste image URL)




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