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Food Insecurity Questionnaire Form Template

Assess food security needs in your community effectively

Understanding food insecurity is crucial for supporting those in need. This Food Insecurity Questionnaire Template helps organizations and communities gather essential data on hunger and food access. With it, you can identify areas that require support, raise awareness, and allocate resources effectively, all while ensuring WCAG-aligned accessibility features. Start using this live template to develop a customized survey that meets your goals.

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Full name
Phone number
Email address
Postal code
Total number of people in your household
Are there any children under 18 in your household?
Yes
No
Within the past 12 months, we worried our food would run out before we got money to buy more.
Often true
Sometimes true
Never true
Prefer not to say
Within the past 12 months, the food we bought just did not last, and we did not have money to get more.
Often true
Sometimes true
Never true
Prefer not to say
In the past 30 days, did you cut the size of meals or skip meals because there was not enough money for food?
Yes
No
How many days in the past 30 days did you cut the size of meals or skip meals due to not having enough money for food?
Not applicable
1-2 days
3-5 days
6-10 days
More than 10 days
Prefer not to say
Which food support programs or resources are you currently using?
What type of support would be most helpful right now?
Food pantry locations
Emergency groceries
Prepared meals
SNAP application help
WIC information
Home delivery options
Nutrition education
Other
Please Specify:
If you selected Other, please describe the support you need.
Do transportation or mobility issues make it hard to access food?
Yes
No
Sometimes
Prefer not to say
Do you have any dietary restrictions or allergies we should know about?
How soon do you need assistance?
Today
Within 3 days
Within 1 week
Within 2-4 weeks
Not urgent
Prefer not to say
Preferred way to receive information about resources
Phone call
Text message
Email
In-person at a partner site
No preference
Do not contact me
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
If you prefer to self-describe your gender, please share here.
If Other language, please specify
Primary language
English
Spanish
Chinese
Vietnamese
Arabic
French
Prefer not to say
Other
Please Specify:
May we contact you with information about free food resources?
Yes
No
Type your full name to acknowledge your responses are accurate and to authorize follow-up (if applicable).
Date
Anything else you would like us to know?
Do you consent to share your information with trusted partner organizations to connect you with resources?
Yes
No
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Paper art illustration depicting a food insecurity questionnaire form with various sections and graphics related to food access.

When to use this form

This form helps you screen for household food needs during intake, outreach, or follow-up. Use it in clinics, schools, food banks, campus pantries, or home visits to spot risk early and prioritize support. It is ideal before enrollment in benefits, at discharge, or during telehealth check-ins. You can act on results right away: schedule deliveries or pantry pickups with the Meal order form, and record dietary needs with the Food preferences survey form. When trends emerge, share de-identified data with partners to guide funding and program design. The outcome: you identify who needs help, match services faster, and track change over time.

Must Ask Food Insecurity Questionnaire Questions

  1. In the past 12 months, were you ever worried that food would run out before you had money to buy more?

    This flags worry, which is an early sign of risk even before food actually runs out. It helps you prioritize follow-up and plan referrals sooner.

  2. In the past 12 months, did the food you bought not last, and you did not have money to get more?

    This measures real shortages, not just concern. Clear yes/no data guides immediate aid and resource allocation.

  3. How often did you cut meal size or skip meals because there was not enough money for food?

    Frequency shows severity and helps you right-size support, such as number of meals, vouchers, or delivery cadence. It also reveals patterns that may need budget or benefits counseling.

  4. In the past 12 months, did any child in your household not eat enough because you could not afford food?

    Child hunger signals acute risk and the need for faster response and targeted services. Pair with the Food evaluation form to monitor the quality of meals offered through your program.

  5. Do you have any dietary restrictions or allergies we should consider when providing food assistance?

    Allergies and restrictions inform safe, culturally appropriate options. This reduces waste and improves the fit and impact of the support you provide.

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