Neighbor Experience Form

Neighbor Experience
Please use this form to share your experience with visiting a Food Bank of Central New York partnered food program.

We love to hear from our neighbors about their experience, good and bad. The information provided will help us collaborate with our partner programs to improve our services continually.
Please share the type of feedback you would like to provide.

Food ProductsSite or Service Experience
Do you believe the experience at the partnered food program amount to a form of discrimination covered by the Civil Rights Act*

YesNo

Neighbor Experience
Are you completing this form for someone else?

YesNo
Who are you completing this form for?

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Please indicate which Food Bank partnered program you visited.
The program I visited is not listed
What is the name and address of the program you visited?

Site Name

Street Address

CityState / Province

Postal / Zip Code
What county is this program in?
Please share your experience.
Product
Please share your experience with the product noted above.
Do you wish to remain anonymous? If yes, your name will not be shared with the Food Bank partnered program.

Yes
Name and Contact of Person Completing this Form.

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Do you wish to speak with a representative of the Food Bank about your experience? (if yes, you will need to complete the contact information).

Yes

Neighbor Experience
Does your complaint fall under any of the following protected categories?

RaceColorSex (including gender identity and sexual orientation)AgeNational OriginDisabilityReprisal or retaliation for prior civil rights activity
When you continue below, you will be directed to the USDA's Program online Discrimination Complaint Form, away from the Food Bank of Central New York's website.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

To file a program discrimination complaint, a Complainant should complete Form AD-3027, USDA Program Discrimination Complaint Form, which can be obtained online at https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or

Fax: (833) 256-1665 or (202) 690-7442; or
Email: Program.Intake@usda.gov

This institution is an equal opportunity provider.

Thank you for sharing your experience. The Food Bank of Central New York and our staff work closely with community-based partner organizations. We take your experiences seriously as we collaborate with these organizations to provide a dignified experience.

By continuing, you will be directed to the United States Department of Agriculture's Online Discrimination Complaint Form. You will be taken away from the Food Bank of Central New York's website and platforms. Food Bank of Central New York staff are not able to answer questions about ongoing Civil Rights complaints.

To officially file a complaint please follow the following steps:

To file a program discrimination complaint, a Complainant should complete Form AD-3027, USDA Program Discrimination Complaint Form, which can be obtained online at https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or

Fax: (833) 256-1665 or (202) 690-7442; or
Email: Program.Intake@usda.gov
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