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A. Site Information
Organization Name:Lauren
Address123 Main Street
Hackensack, New Jersey 07601
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Location TypeFQHC
Estimated number of guests served weekly100
Estimated number of guests served annually:5200
Estimated number of unique guests served annually: (Unique= First time guest)2500
Please enter the estimated number of guests in each age range below
0-18 19-34 35-50 51-64 65+
500 1000 2000 1600 100
Please enter the estimated number of guests per year in each race category below
White/Caucasian Hispanic Black/African American Asian Middle East/North African
500 3000 1500 150 50
Please enter the estimated number of guests per year in each income range below
0-$14,999 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+
500 3000 1500 150 50 0
Please enter the estimated number of guests per year who qualify for income-based assistance under the following programs
SNAP WIC Other
500 300 200
What percentage of guests you consider low income? (%)80
How do you measure low income?

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B. Baseline Readiness
Does your site currently display any diabetes-related materials?Yes
How confident are staff in discussing diabetes with guests?
Very ConfidentConfidentSomewhat ConfidentSlightly ConfidentNot Confident
Does your site currently refer guests for diabetes testing or care?Yes
Approximately how many guests are referred each month?1-5
What challenges do staff currently face when providing diabetes-related information or referrals?

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C. Social Determinants of Health (SDOH) Screening
Income0
Education0
Unemployment0
Food Insecurity5200
Housing, Basic Amenities (including build environment)0
Early Childcare Development0
Access to Affordable Health Service0
Transportation0
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