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Hot Bread Kitchen Program Intake Survey

Please complete the following survey. The survey should take 10-15 minutes to complete.

We are asking for this information because:
1) We want to get to know you better; and
2) We want to continuously improve our programs and ensure they are responsive to your needs. 

Your response is confidential and we will never share personal identifiable information. 

If you have any questions about this survey, please contact a Hot Bread Kitchen staff member. Thank you!

Hot Bread Kitchen will NOT exchange information included in this intake with any third-party organization or entity outside of this organization.




Please note: We do not currently have employer partnerships in Long Island.




Emergency Contact Information
Please list a person we can contact in case of emergency during your program.


(Mother, brother, spouse, partner, cousin, etc)

Demographic Information







Family/Household Composition and Housing 






enter "0" if none
Please list the number of children in your household who are in each of the following age groups:
Enter "0" if none
Enter "0" if none
Enter "0" if none
Enter "0" if none
Enter "0" if none

Household Finances


Household income includes earned income (such as from a job or pension) and public benefits (including cash assistance, food stamps, social security, unemployment, disability, etc). If you need assistance with this question, please ask a HBK staff member.

Household Income
2023 Household Income for Household of 1
Household Size: 1

2022 Annual Household Income: $112,080
2023 Household Income for Household of 2
Household Size: 2

2022 Annual Household Income: $128,160
2023 Household Income for Household of 3
Household Size: 3

2022 Annual Household Income: $144,120
2023 Household Income for Household of 4
Household Size: 4

2022 Annual Household Income: $160,080
2023 Household Income for Household of 5
Household Size: 5

2022 Annual Household Income: $172,920
2023 Household Income for Household of 6
Household Size: 6

2022 Annual Household Income: $185,760
2023 Household Income for Household of 7
Household Size: 7

2022 Annual Household Income: $198,600
2023 Household Income for Household of 8+
Household Size: 8 or more

2022 Annual Household Income: $211,320

Household income includes earned income (such as from a job or pension) and public benefits (including cash assistance, food stamps, social security, unemployment, disability, etc).


Employment History




Select 'Yes' if you currently have a job

Current / Last Employment Information
Please answer the following questions about your current job (if you are employed) or your last job (if you are not currently employed). 





Small Business


Small Business



New Business

Existing Business

Leave blank if your business does not have a name yet


This can be an estimate if you do not know the exact revenue figure.











Food businesses operating under the Department of Health must register with the New York State Department of Taxation and Finance







To what extent do you agree or disagree with the following statements:



Examples of a major unexpected expense could be an unplanned medical bill, home or car repair bill, etc.


To what extent do you agree or disagree with the following statements: