Form FNC-543 The National Hunger Clearinghouse Database Form

Clearinghouse Database Form

Page 1 of 5

The National Hunger Clearinghouse
Database Form
To be included in the National Hunger Clearinghouse, please complete the following database survey form.

PURPOSE
The National Hunger Clearinghouse is administered by World Hunger Year (WHY) under contract from the
U.S. Department of Agriculture's Food and Nutrition Service. The purpose is to foster connections and
information sharing among thousands of groups working on hunger, food, nutrition and other agricultural
issues by compiling information in one central location. To accomplish this, the Clearinghouse is asking
organizations and businesses to fill out this simple database form. Information from this form will be entered
into the Clearinghouse's national database and will be available free of charge by phone, fax, or the Internet.
Because of the diversity of organizations, all categories may not apply to your group.

INSTRUCTIONS
1.
2.
3.
4.
5.
6.

If you're using Web browsing software capable of handling forms, the information you enter into the
spaces below will be sent to us by email when you click the Submit Form button at the bottom of this
page.
Complete all questions relevant to your organization. You may have multiple entries in a category.
Take as much space as you need to explain your program or mission in the last entry block.
Send additional information about your organization -- brochures, publications, fact sheets,
newsletters, etc. -- by postal mail; our address is listed at the end of the form.
Add the National Hunger Clearinghouse to your mailing list and fax list.
Return the form by clicking Submit Form below after you've filled in all the blocks.

OMB Control No. 0584-0474
Approval Date: 02/07/2000
Expiration Date: 02/28/2003

Organization Name:
Street Address:

City:
State:

Zip:

Zip+4:

Phone: (

)

-

Fax: (

)

-

Salutation:
(Mr./Mrs./Ms./Dr./Etc.)
First Name:
Last Name:
National, State or
Regional Affiliation
(optional):
E-Mail Address:

http://www.worldhungeryear.org/forms/nhc_form.asp

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Clearinghouse Database Form

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WWW Address: http://www.
SECTOR (check all that apply):

g Nonprofit
c
d
e
f

g Other
c
d
e
f

g Commercial/Business f
c
d
e
f
g Government f
c
d
e
g Indian Reservation
c
d
e

TYPE OF ORGANIZATION (check all that apply):

c Direct Service
d
e
f
g

c Cooperative g
d
e
f
g
c Educational
d
e
f

c Coalition
d
e
f
g

c Religious
d
e
f
g

c Labor
d
e
f
g

c Association g
d
e
f
g
c Network
d
e
f

c Funder
d
e
f
g

c Incorporated
d
e
f
g

AREA SERVED (check all that apply):

g Urban
c
d
e
f

g City
c
d
e
f

g Rural
c
d
e
f

g County
c
d
e
f

g Suburban
c
d
e
f

c State
d
e
f
g

c Regional
d
e
f
g

c Neighborhood
d
e
f
g

c National
d
e
f
g

c International
d
e
f
g

FOOD DISTRIBUTION (check all that apply):

c Food Bank
d
e
f
g

c Food Rescue/Gleaning
d
e
f
g

c Transportation/Trucki
d
e
f
g

c Food Pantry
d
e
f
g

c Farmers Market Nutrition Program
d
e
f
g

c TEFAP
d
e
f
g

c Warehouse
d
e
f
g

c Commodities/Food Donation
d
e
f
g

c Other
d
e
f
g

g Soup Kitchen
c
d
e
f

g School Lunch
c
d
e
f

g Group Meals
c
d
e
f

c School Breakfast
d
e
f
g

c Meals on Wheels
d
e
f
g

c Summer Feeding
d
e
f
g

g Kids Cafe
c
d
e
f

g Other Programs
c
d
e
f

g Café (Nonprofit)
c
d
e
f

c Commercial/Business
d
e
f
g

c After School
d
e
f
g

PREPARED FOODS (check all that apply):

FOOD PRODUCTION and PROCESSING: (check all that apply):

c Farm
d
e
f
g

c Processor
d
e
f
g

c Community Garden
d
e
f
g

c Packer
d
e
f
g

c Manufacturer
d
e
f
g

c Other
d
e
f
g

Type: (check all that apply):

c Family Owned
d
e
f
g

c Sustainable Agriculture
d
e
f
g

c Hydroponics
d
e
f
g

c Organic
d
e
f
g

c Aquaculture
d
e
f
g

c Land Trust/Land Link
d
e
f
g

c Community Supported Agriculture
d
e
f
g

c Other
d
e
f
g

FOOD SALES (check all that apply):

c Farmer's Market
d
e
f
g

c Wholesaler
d
e
f
g

c Terminal Market
d
e
f
g

c Food Coop
d
e
f
g

c Neighborhood Market
d
e
f
g

c Food Buying Club
d
e
f
g

c Grocery Store/Supermarket
d
e
f
g

c Prepared Food
d
e
f
g

c Other
d
e
f
g

GLEANING and FOOD RESCUE: (check all that apply):
Type of Food:

g Prepared Food
c
d
e
f

g Produce
c
d
e
f

http://www.worldhungeryear.org/forms/nhc_form.asp

g Fish/Meat
c
d
e
f

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Clearinghouse Database Form

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c Other
d
e
f
g

c Dairy
d
e
f
g

Source of Food: (check all that apply):

c Restaurant
d
e
f
g

c Processor
d
e
f
g

c Farm/Orchard
d
e
f
g

c Food Store
d
e
f
g

c Caterer
d
e
f
g

c Packer
d
e
f
g

c Farmers' Market
d
e
f
g

c Cafeteria/Food Service
d
e
f
g

c Hotel
d
e
f
g

c Manufacturer
d
e
f
g

c Wholesaler
d
e
f
g

c Other
d
e
f
g

c Hospital
d
e
f
g
ADVOCACY/POLICY/RESEARCH (check all that apply):

c Food
d
e
f
g

c Hunger
d
e
f
g

c Farm
d
e
f
g

c Food Security
d
e
f
g

c Labor
d
e
f
g

c Legislation
d
e
f
g

c Agriculture
d
e
f
g

c Hunger Hotline
d
e
f
g

c Sustainable Agricultu
d
e
f
g

c Food Systems
d
e
f
g

c Grass Roots Organizing
d
e
f
g

c Economic
d
e
f
g

c Nutrition
d
e
f
g

c Poverty
d
e
f
g

c Welfare
d
e
f
g

c Other
d
e
f
g

c Homelessness
d
e
f
g

EDUCATION (check all that apply):

c Agricultural
d
e
f
g

c Team Nutrition
d
e
f
g

c Academic/Continuing
d
e
f
g
Education

c Budgeting/Shopping
d
e
f
g

c Cooking/Culinary/Food Preparation
d
e
f
g

c Food Handling/Safety
d
e
f
g

c Nutrition
d
e
f
g

c Menu Planning/Recipes
d
e
f
g

c Job Training/Vocation
d
e
f
g

c Other
d
e
f
g

c After School
d
e
f
g

SERVICE SITES (check all that apply):

c School (Preschool-12)
d
e
f
g

c Child Care Center
d
e
f
g

c Correctional Facility
d
e
f
g

g College/University
c
d
e
f

g Community Center
c
d
e
f

g Religious Institution
c
d
e
f

c Extension Service
d
e
f
g

c Organizational Offices
d
e
f
g

c Shelter
d
e
f
g

g Public Housing
c
d
e
f

g Business
c
d
e
f

g Soup Kitchen
c
d
e
f

c Health Care Facility
d
e
f
g

c Reservation
d
e
f
g

c Home/Residence
d
e
f
g

g Other
c
d
e
f
OTHER PROGRAM AREAS (check all that apply):

c Emergency/Disaster Assistance
d
e
f
g

c Family Services
d
e
f
g

g Children/Teens/Youth
c
d
e
f

g International Assistance
c
d
e
f

g Homeless
c
d
e
f

c Personal Services
d
e
f
g

c Economic Development
d
e
f
g

c Women
d
e
f
g

g Arts/Culture
c
d
e
f

g Housing
c
d
e
f

g Legal Services
c
d
e
f

c Health Care
d
e
f
g

c Seniors
d
e
f
g

c Environment
d
e
f
g

http://www.worldhungeryear.org/forms/nhc_form.asp

c Community
d
e
f
g
Development

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c Low-Income
d
e
f
g

c Financial Services
d
e
f
g

c Substance Abuse
d
e
f
g

c Gay/Lesbian
d
e
f
g

c Employment
d
e
f
g

c Literacy
d
e
f
g

c HIV/AIDS
d
e
f
g

c Disabled
d
e
f
g

c Other
d
e
f
g

FULL-TIME STAFF:

j None
k
l
m
n

j 1-9
k
l
m
n

j 10-24
k
l
m
n

j 25-49
k
l
m
n

j 50-99
k
l
m
n

j 100+
k
l
m
n

YEAR FOUNDED:
NUMBER of
VOLUNTEERS:
Do You Need Additional Volunteers:

j Yes
k
l
m
n

j No
k
l
m
n

Do You Offer Internships?

j Yes
k
l
m
n

j No
k
l
m
n

ANNUAL BUDGET:

j $0 - $49,999
k
l
m
n

j $50,000 - $99,999
k
l
m
n

j $100,000 - $499,999
k
l
m
n

j $500,000 - $999,999
k
l
m
n

j $1,000,000+
k
l
m
n
Are You Willing To UPDATE Your Clearinghouse Information Annually?

j Yes
k
l
m
n

j No
k
l
m
n

Do You Own A Computer?

j Yes
k
l
m
n

j No
k
l
m
n
Please attach a one-paragraph description of
your organization's mission and/or programs.

Also, please mail us additional literature
(brochures, newsletters, etc.), and add
the Clearinghouse to your mailing list.

http://www.worldhungeryear.org/forms/nhc_form.asp

6/13/2007

Clearinghouse Database Form

Page 5 of 5
Submit This Form

Reset

The National Hunger Clearinghouse is made possible by a contract administered by the Food and Nutrition
Service of the United States Department of Agriculture. For further information please contact the
Clearinghouse:
USDA National Hunger Clearinghouse at World Hunger Year
505 Eighth Avenue, 21st Floor * New York, NY 10018-6289
Phone: 1-800-GLEAN-IT or (212) 629-8850 * Fax: (212) 465-9274
Clearinghouse Email: [email protected]
World Wide Web: www.worldhungeryear.org/nhc
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, gather the
data needed, and complete and review the information collection. Send comments regarding this burden
estimate or any aspect of this collection of information, including suggestions for reducing the burden, to the
U.S. Department of Agriculture, Clearance Officer, OIRM, Ag Box 7630, Washington, D.C. 20250.
Form FCS-543 (5-96)

http://www.worldhungeryear.org/forms/nhc_form.asp

6/13/2007