Food Security Initiative

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Centering Food Security Initiative

For easier online submission we have set character limits of 3000 characters for each open question.

aId*

Account ID - This field will be HIDDEN to users

cId*

Contact ID - This field will be HIDDEN to users

Notice

Form submissions require a unique URL which contains information used to identify your practice. If you were forwarded a URL from someone else your submission may not be associated with your practice. Please check the portal dashboard or contact a member of our Practice Services team to obtain your unique URL.

Practice Information

Site Name*

Site License #*

Practice Setting *
Select all that apply

Birth Center

Community Health Center

FQHC Designation or Lookalike

Health Department Clinic

Hospital-Based Clinic

Indian Health or Tribal Clinic

Integrated Health System

Military Treatment Facility

Mobile Unit

Private Practice

Rural Health Clinic

Centering models offered *
Select all that apply

CenteringPregnancy Offered

CenteringPregnancy

# of prenatal patients per year*

CenteringParenting Offered

CenteringParenting

# of patients per year*

CenteringHealthcare Offered

CenteringHealthcare

Other Offered

Other

Please Specify*

How is Centering currently delivered?*

In-person Virtual A mix of both

When do you anticipate returning to in-person groups?* Characters remaining:

3000/3000

Do you stay connected with Centering families after a group series has completed?*

Yes No

How?* Characters remaining:

3000/3000

e.g. Centering reunion, CenteringParenting groups continue beyond year 24 months

Site Demographics - Race

Please use the sliders below to indicate the percentage of each race represented in your patient population.

Total must equal 100%

Unknown

American Alaska Native

Asian

Black African American

Native Hawaiian Pacific Islander

White

Other

Race Total*

Total Percentage Must be 100%

Error: Total percentage for population cannot be greater than 100%

Site Demographics - Ethnicity

Please use the sliders below to indicate the percentage of each ethnicity represented in your patient population.

Total must equal 100%

Hispanic / Latino / Spanish Origin

Not Hispanic / Latino / Spanish Origin

Unknown

Ethnicity Total*

Total Percentage Must be 100%

Error: Total percentage for population cannot be greater than 100%

Patient Demographics - Insurance Type

Please use the sliders below to indicate the percentage of each payer represented in your patient population.

Total must equal 100%

Indian Health Services

Medicaid

Military/Tricare

Private Insured

CHIP (Children’s Health Insurance Program)

Uninsured

Other

Payer Total*

Total Percentage Must be 100%

Error: Total percentage for population cannot be greater than 100%

Food Security Information

Does your clinic have a food distribution program?*

Yes No

Do you have the structure in-place to support food distribution to Centering families?* Characters remaining:

3000/3000

What are your programs’ needs beyond the current level of investment?* Characters remaining:

3000/3000

Do the families you care for have access to state or federal programs like WIC or a community food program?*

Yes No

Please describe Characters remaining:

3000/3000

Do you already integrate nutrition into Centering?*

Yes No

How would funding enhance this?* Characters remaining:

3000/3000

How would funding allow for nutrition integration?* Characters remaining:

3000/3000

Please indicate which factors are affecting food security for your patients *
Select all that apply

Factors: Funding

Lack of funds for healthy food

Factors: Access

Lack of access (food desert)

Factors: Availability

Lack of availability of quality food

Factors: Other

Other risk factors

Please Specify | Other risk factors* Characters remaining:

3000/3000

What is your plan for food distribution?* Characters remaining:

3000/3000

What types of foods, vehicle for distribution, timeline? Potential vehicles could include in-clinic pantry/shelf, enhanced group session snacks/meals, grocery bags of healthy food at each session, via local delivery, local produce market gift cards, food pharmacy and local farmers’ markets delivery to group sessions.

How would you get input from families around what types of foods would be welcome? * Characters remaining:

3000/3000

How many Centering families do you anticipate reaching and how many distributions per family?* Characters remaining:

3000/3000

Amount Requested* $

Please include a simple budget for your proposed food distribution program.*

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