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Manual Request Form
  1. Building Farmacies: A Guide for Implementing a Farmers’ market at a Community Health Center Dissemination Survey

    Thank you for your interest in the Building Farmacies manual. Please answer the following questions to help us learn more about the people and groups interested in this manual, and help us plan for future training programs related to forming farmacies. Upon completion of this form, we will email you a copy of the manual. Thanks again for your interest in this manual!
  2. What is your email address? (This is where the manual will be emailed. We will not share your email address with anyone.)(*)
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  3. What is your job title?
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  4. In what state and county is your organization or agency located?
  5. State:
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  6. COUNTRY
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  7. ____________________________________________________________________________________

  8. What type of organization or agency are you affiliated with? Use the dropdown to choose YES to all that apply.

  9. Federally qualified health center (FQHC)
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  10. Community health center
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  11. Hospital
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  12. Private medical practice
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  13. School or university
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  14. Daycare
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  15. Faith-based
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  16. Recreation
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  17. Farmer's market
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  18. Farm or agriculture
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  19. Government
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  20. Other, specify:
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  21. ____________________________________________________________________________________

  22. Which geographic setting best describes the location of your organization or agency? Pick one.
  23. Region
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  24. Other, specify:
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  25. ____________________________________________________________________________________

  26. Why are you interested in receiving a copy of the Building Farmacies: A Guide for Implementing a Farmers’ market at a Community Health Center manual?
  27. Invalid Input
  28. ____________________________________________________________________________________

  29. Does your organization or agency address any of the following issues? Use the dropdown to choose YES to all that apply.
  30. Diet-related chronic diseases (e.g., obesity, diabetes)
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  31. Health disparities
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  32. Poverty
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  33. Food insecurity/hunger
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  34. Sustainable agriculture
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  35. Economic development
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  36. Community development
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  37. Environmental justice
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  38. Labor and workforce development
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  39. Housing
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  40. Education
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  41. ____________________________________________________________________________________

  42. Does your organization or agency currently have any of the following food programs onsite? Use the dropdown to choose YES to all that apply.

  43. Farmer's market
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  44. Mobile market
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  45. Community garden
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  46. Food pantry or food bank
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  47. Feeding programs (e.g. Meals on Wheels)
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  48. Grocery
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  49. Food coop
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  50. Restaurant
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  51. SNAP/WIC distribution
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  52. Other, specify:
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  53. ____________________________________________________________________________________

  54. Does your organization or agency have plans to start an onsite farmers’ market? (check only one)
  55. Choose one:




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  56. ____________________________________________________________________________________

  57. How much do you agree or disagree with the following statements related to forming a farmers’ market at your organization or agency?
    Use the dropdown to choose: STRONGLY DISAGREE DISAGREE NEUTRAL AGREE STRONGLY AGREE
  58. We have institutional support for forming an onsite farmers’ market.
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  59. We are connected to community partners who would help us with our farmers’ market.
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  60. People in my organization believe that farmers’ markets would help solve one or more community problems.
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  61. We have space at my organization to have an onsite farmers’ market.
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  62. We have financial resources to establish and sustain an onsite farmers’ market.
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  63. ____________________________________________________________________________________

  64. On a scale from 1-10. 1 BEING - NOT AT ALL INTERESTED TO 10 BEING -VERY INTERESTED How interested are you in attending a training to develop a farmacy at your organization or agency?
  65. NOT AT ALL INTERESTED ------------------------VERY INTERESTED
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  66. ____________________________________________________________________________________
  67. How do you plan to use the Building Farmacies manual?
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  68. ____________________________________________________________________________________
  69. Please type the characters on the right into the box below. Click "refresh" if you want to see a different set of characters.
    Please type the characters on the right into the box below. Click "refresh" if you want to see a different set of characters.
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