Tips for Filling
Out this Form

How to report Regular Service: This is an unduplicated number. Each household counted here should be different. Therefore, only count a family's first visit this month in this section.

How to report Extra Service: If you serve the same family more than once this month, report their additional visits here. For instance, if the same family comes three times this month, record their last two visits in this section.

How to report Pounds and Vouchers: Everything that you distribute to a family during their food pantry visit should be reported here. That includes food and non-food products and cash or product vouchers redeemable at a store. All food and non-food items should be weighed on a scale if possible. For vouchers, you may use the formula: 1 dollar = 1 pound.

How to report First Visits by Individuals: This is the number of people served this month for the first time this year. For example, if a mother comes for the first time in February and she has three children, enter four. If she visits in subsequent months, include her only in the Regular or Extra Service area but NOT in the First Visits by Individuals field.

All agencies are required to fill out a monthly Service Statistics Report Form.
Reports are due the 10th of the following month (i.e. April's is due by May
10th). If you serve food (regardless of where it is obtained) you must submit a
report. If you did not serve any food, a zero report may be submitted.

Monthly Food Pantry Stats Form

If you are unsure of how to record your statistics or you have any questions, please call us at 715-835-9415.

Statistics are for the month of:

  

Agency Name

Agency ID

Contact Name

Contact Phone

Email

Street Address

Regular Service (1st Visit this Month)

Individuals
(Ages 0-17)

Individuals
(Ages 18-59)

Individuals
(Ages 60+)

Households

Pounds/Vouchers

Extra Service (2nd+ Visit this Month)

Individuals
(Ages 0-17)

Individuals
(Ages 18-59)

Individuals
(Ages 60+)

Households

Pounds/ Vouchers

Total for this Month

Individuals
(Ages 0-17)

Individuals
(Ages 18-59)

Individuals
(Ages 60+)

Households

Pounds/Vouchers

Are the weights exact measurements or estimations?

 The weights are exact.

 The weights are estimated.

First Visits by Individuals

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