Monthly Statistical Report for Shared Harvest Foodbank

For the Month of 20
Complete appropriate Statistical Sections. Reports must be submitted to the foodbank no later than the 15th of the month following the month to which the report pertains.
Name of Agency:
New Information Available
Name of Person Completing Form:
Food Pantry: A part of a foodbank network that distributes food and grocery products to low-income households, including food from sources other than USDA, to relieve situations of emergency and distress. It is housed in a standing facility that distributes commodities, among other food and grocery products, on a regular basis.
Check one box:
Full Service
All food is available to clients
Partial Service
Bakery or surplus food available to clients
Food Pantry Statistical Section Households Total
A. Number of Households
With Minor Children Without Minor Children
B. Number of Seniors Served (age 60 & older)
C. Number of Adults Served (age 18 & 59)
D. Number of Children Served (birth to 17)
E. Total Number of People (B+C+D)
Meal Site: Provides meals to people in need.
Shelter: Provides nights of shelter to homeless people, run away children or victims of abuse.
MEAL SITE and/or SHELTER Statistical Section
A. Number of People (head count) Served:
B. Number of Meals (plate count) Served:
CONGREGATE and/or RESIDENTIAL MEALS Statistical Sections*
A. Number of People (head count) Served:
B. Number of Meals (plate count) Served:
Congregate or Residential Meals: Primary service is not food distribution; but meals are included as part of the services provided, including Residential Treatment Facilities, Child or Adult Day Care, Senior Citizen Center, Group Home, Youth Program, Summer Camp, etc.
Thanks for All You Do!

Mail To: Shared Harvest Foodbank, 5901 Dixie Highway, Fairfield, Ohio 45014-4207
FAX To: 513-874-0152
OR CALL: Sarah at 800-352-3663 or 513-874-0114