Form FNS-543 NATIONAL HUNGER CLEARINGHOUSE DATABASE FORM

OMB NO. 0584-0474
EXPIRATION DATE: XX/XX/XXXX

NATIONAL HUNGER CLEARINGHOUSE DATABASE FORM
Facilitating the exchange of information, resources, and ideas
among organizations fighting hunger and poverty.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research, Nutrition and Analysis,
Room 1014, (0584-0474), Alexandria, VA 22302. Do not return the completed form to this address.
Please complete this form and return it to WHY (World Hunger Year).
Date:
Organization Name:
Address:

County/Counties Served:

City:

State:

Phone:

ext:

Zip code:
Fax:

Hours of Service:

Website:

Email:

Do want this to be the main email contact?

Contact's Name:

Yes

No

Title:

Phone:

ext:

Email:

Would you like to receive our monthly newsletter, the Clearinghouse Connection by:
Fax
Email
Do not want to receive it
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
Education Institution
Coalition
Emergency Food Provider
Direct Services
Funder

Labor
Religious
Government

What is your organization's target population? (select all that apply)
Families
Immigrants
Homeless /Unemployed
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
National
Neighborhood

Regional
Rural
State

Suburban
Urban

National Hunger Clearinghouse-part of WHY's Grassroots Action Network
505 Eighth Avenue, Suite 2100 New York, NY 10018*
tel: 1-866-3 HUNGRY *fax: 212-465-9274 *email: [email protected]
www.whyhunger.org

FORM FNS-543 (04-12) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 9.1 Version

Page 2

AGENCY SERVICES PLEASE MARK ALL THAT APPLY

Children Services:
After School
Day Care/Childcare
Foster Care/Adoption
Other

Government Programs (cont.):
Senior Farmer's Mkt Nutrition
Summer Feeding Program
TEFAP
TANF
WIC
Other

Counseling:
Case Management
Crisis Hotline
Domestic Violence
Drug and Alcohol
Family Support
Individual
Referral Services
Sexual Assault
Other

Health Care:
Health Clinic
Prescription Assistance
Other
Homeless Services:
Drop In Center
Emergency Shelter
Halfway Home
Transitional Housing
Voice Mail
Other

Education:
ESL
Head Start
Nutrition Education
Prison Re-entry Program
Other

Housing:

Food Assistance:
Community Support Agriculture
Farmer's Markets (EBT)
Food Bank
Food Delivery
Food Pantry
Kids Cafe
Meal on Wheels
Soup Kitchens
Other

Jobs:

Government Programs:
Child & Adult Care Food Program
CSFP
Earned Income Tax Credit
FEMA/Disaster Relief
SNAP
Home Energy Assistance
Do you do advocacy work? If so, please indicate what kind.
Do you provide transportation services?
Do you accept food donations?
Do you provide seasonal services? (i.e. Christmas baskets)

Appliances/Furniture
Home Repairs
Rent Subsidy
Utilities Assistance
Weatherization
Other
Career Counseling
Job Placement
Job Readiness
Job Training
Other

Other Services:
Clothes
Hunger Hotline
Thrift Shop

Yes
Yes
Yes

No
No
No

Mission Statement:

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

National Hunger Clearinghouse-part of WHY's Grassroots Action Network
505 Eighth Avenue, Suite 2100 New York, NY 10018*
tel: 1-866-3 HUNGRY *fax: 212-465-9274 *email: [email protected]
www.whyhunger.org