Healthy Steps Diaper Bank – Data Collection (to be submitted after diapers are picked up) Staff Name* First Last Work Location CountyColumbiaCumberlandJuniataLebanonMifflinMontourNorthumberlandPerrySnyderSomersetUnionCHILD PID #* Date of Birth* MM slash DD slash YYYY Child Weight (lbs)Gender* Female Male Race*Select OneAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesRace Not ReportedHispanic/Latino* Yes No Military Status* Active Duty Veteran Non-Veteran Residence Zip Code* ZIP Code First Time Receiving Diapers* Yes No Potty Training Yes No Diaper Type* Diaper Training Pants Size* Quantity* Date Received Diaper* MM slash DD slash YYYY FAMILY FID #* Relationship to Child:* Notes:
