Mobile Distribution Form - Central Pennsylvania Food Bank

Mobile Distribution Statistics Report

Site representative, please complete this form within 5 business days following each distribution. If you must cancel your delivery, provide notice asap! After you complete the form, you will get a thank you message. If you do not see the thank you message, please reopen the form and fix any errors. Thank you!

Delivery Site*
Types of Distribution*
- Fresh Express
- MilitaryShare
Date*
MM slash DD slash YYYY
Agency Reference Number*
Order Number*
Agency Representative Name*
First Last
Email*
Phone*
Please provide the Number of HOUSEHOLDS/ NEW HOUSEHOLDS served on this day.
Number of TOTAL HOUSEHOLDS served on this date:*
Number of NEW HOUSEHOLDS served on this date:*
Please provide the Number of INDIVIDUALS/ NEW INDIVUDUALS served on this day.
Number of TOTAL INDIVIDUALS served on this date:*
Number of NEW INDIVIDUALS served on this date:*
Please provide the Number of INDIVIDUALS / Number of NEW INDIVIDUALS in the following age groups served on this date:
Total 0 - 17 years*
New 0 - 17 years*
Total 18 - 59 years*
New 18 - 59 years*
Total 60+ years*
New 60+ years*
Staff / Volunteer Hours: Please complete this information on your volunteer or staff support for this distribution.
Number of volunteers / staff*
(X) Number of hours*
= Total number of volunteer hours for today*

Questions or concerns? Please email mdinfo@centralpafoodbank.org