Hot Bread Kitchen Program Intake Survey

Please select your language.

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.

Contact Information

First Name

Last Name

Where do you live?

BronxBrooklynManhattanQueensStaten IslandNew JerseyOtherPlease note: We do not currently have employer partnerships in Long Island.

Cell Phone

Home Phone

Date of Birth

Emergency Contact Information

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

Name of Emergency Contact

Relationship to You

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

Emergency Contact's Phone Number

Demographic Information

Country of Birth

What is your native or first language?

Gender Identity: How do you publicly self-identify?

WomanManGender nonbinary/Genderqueer/ Gender nonconformingOtherDecline to state

Please specify your gender

Race & Ethnicity: How do you publicly self-identify?

Asian American/Pacific Islander/AsianBlack/African American/AfricanHispanic/Latino/Latina/LatinxNative American/American Indian/IndigenousWhite/Caucasian/EuropeanMulti-racial/Multi-ethnic (two or more races or ethnicities)Different identity (please specify)Decline to state

Please specify your race

What is the highest level of education you have completed?

Family/Household Composition and Housing

What is your current marital status?

How many people currently live in your household, including yourself?

Are you a parent or legal guardian?

YesNo

Are you currently responsible for the care of any children?

YesNo

How many children do you have or are you responsible for?

enter "0" if none

Please list the number of children in your household who are in each of the following age groups:

Less than 2 years old

Enter "0" if none

2-5 years old

Enter "0" if none

6-10 years old

Enter "0" if none

11-14 years old

Enter "0" if none

15-17 years old

Enter "0" if none

Are you currently responsible for the care of any other family members? (such as a parent, grandparent, aunt/uncle, cousin)

YesNo

Household Finances

What is your household income? (An estimate is fine if you aren't sure).

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.

What is the time frame for your income estimate above?

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

Is your annual household income (before taxes) less than or equal to the number above?

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

Which public benefits do you receive? Select all that apply:

Unemployment InsuranceCash assistanceSNAP Benefits / Food StampsSocial Security InsuranceWIC BenefitsSocial Security Disability InsuranceMedicare/MedicaidPublic Housing/Section 8None

Do you have health insurance?

YesNo

Employment History

Are you currently authorized to work in the US?

YesNoMy work authorization application is in process

Do you currently have a job?

YesNo

Have you been employed at any point in the last 27 weeks (approximately 7 months)?

YesNoSelect 'Yes' if you currently have a job

Do you have a Food Protection Certificate or Food Handler's License?

YesNo

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).

Job Sector/ Industry

How would you categorize your work schedule at this job?

Less than part time / IrregularPart timeFull time

What is/was your hourly wage at this job?

Does / Did your employer offer health insurance?

YesNo

Did you enroll in health insurance?

YesNo

Small Business

Do you currently own or hope to start a small food business? (This includes catering or selling food from your home.)

YesNo

Small Business

What stage are you currently at in starting your food business?

Starting a food business is just an idea I am considering.I have decided to start a food business, but don't yet have a business plan or a product.I am already operating a food business and generating some revenue.I have fully launched my food business and consistently generate revenue.

What type of food business do you own or want to start?

BakeryBeveragesPackaged GoodPastryPrepared FoodRestaurantOther

Other: Please Describe

New Business

Is your long term goal to turn this food business into a full-time job, if not already?

YesNoI don't know

Existing Business

Business Name

Leave blank if your business does not have a name yet

Does your food business have an existing website or social media page? If so, please share the link below:

Revenue earned over the past 12 months ($)

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

What kind of facility are you using to produce your products?

Stand-alone Brick and MortarShared Commercial KitchenAt HomeGuest of a Kitchen SpaceFood Truck or CartOther

Other: Where are you currently producing your products?

Where do you currently sell most of your products?

Traditional Service RestaurantFriends and familyFarmers MarketLocal grocery storesLarge vendor(s)WholesaleOnlineOther

Other: Please describe

*CPG Products Only* Do you plan to eventually co-pack/co-manufacture your product?

YesNoI don't know

Is this business your full-time job?

YesNo

Is your business incorporated?

YesNoI don't know

What is your business structure?

Sole proprietorshipPartnershipC-CorpS-CorpLLCCooperativeNon-ProfitOtherUnknownNot yet formed

Do you have employees?

YesNo

How many employees do you have?

Do you have a Certificate of Authority?

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

Is your business certified as a M/WBE?

YesNo

Financial Wellbeing

Do you have a bank account?

YesNo

Are you currently saving money?

YesNo

How often are you saving money?

DailyWeeklyEvery 2 weeksMonthlyYearlyOther / When I canI don't know

For what period of time would your savings cover your immediate needs?

Less than 1 week1-3 weeks1-2 months3-5 months6 months or moreI don't know

Which of the following statements best describes how your household has paid its bills over the last 12 months?

Pay all of our bills on timePay nearly all of our bills on timePay most of our bills on timePay some of our bills on timePay none of our bills on time

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

I am unable to save because I am always spending money on things I need.