Form

Fresh Connect Partner Intake Form

Email*

First name*

Last name*

Job title*

Company name*

Company type*

State/Region*

Current Program Model

(e.g., paper/voucher-based food Rx program, food box delivery, grocery store gift card, etc.). Note: Feel free to leave blank if you do not have a program.

Target population

(e.g., diabetic patients, high-risk pregnant patients, families that have screened positive for food insecurity)

Target service Area

(where do participants live)?

Target start date*

Month/Day/Year

Overall addressable population

Considering the population you would like to reach, about how many people are 'eligible'? Note: This is not how many people you will ultimately target/how many people you might have funding for; it is the estimated prevalence of the condition/environment/factors you seek to impact)

Target/pilot population size*

This question relates to the target/pilot population. To start, how many people will be invited to enroll in your Fresh Connect program? Note: This could be less than the overall addressable population and is usually guided by your budget, capacity, and/or research design.

The minimum program enrollment period for a Fresh Connect program is six months. Will that work for your program design? *

yes

maybe

Do you have known program success metrics? If yes, please summarize.

(e.g., change in food insecurity measured by the Hunger Vital Signs, change in HbA1c, no missed pre-natal appointments, etc.)?

Do you have funding for a Fresh Connect program?*

yes

Not yet (recently applied, or in process)

Funding Source

(e.g., Medicaid, federal grant, private philanthropy, internal operation's budget, etc.)