1 

2018 Grantee

Increasing Choice Through a 

Flexible, Technology-Driven 

Meal Program in New York

Summary:

To modernize its congregate dining program, the Albany County 

Department for Aging and the Erie County Department of Senior 

Services partnered with local restaurants to give participants 

more flexibility in how and where they dine. Adults 60 and older 

could eat at any participating restaurant at a time of their choice. 

The study had a number of positive outcomes, including 

decreasing feelings of social isolation in older adults. The study 

also demonstrated the need for more progressive, self-driven 

services for older adults.
2 

Table of Contents

Vendor Contract Sample.......................................................... 3

Vendor Contract Terms and Conditions Sample.......4

Customer COVID-19 Survey.....................................................5

Diners Guide.....................................................................................6

Focus Group Questions.............................................................. 7

General Meal Requirements ...................................................8

Go and Diner Customer Satisfaction Survey.................9

Isolation Survey ............................................................................ 10

Participant Registration.............................................................11

Tech Survey .................................................................................... 12
3 

Vendor Contract Sample

Sample contract between grantee and partner 

restaurant.
SCHEDULE E-Remuneration Schedule

Administration for Community Living Innovations in Nutrition Programs and Services Capstone Series. Organization: Erie County Department of 

Senior Services. The Albany County Department for Aging (ACDFA) and Erie County Department of Senior Services (ECDRS) Will Initiate a 

Technology Driven Congregate Dining Program Including a Restaurant Dining Program to Current Service Models.

Restaurant Dining Program

Go & Dine

It is understood by both parties that the County of Erie shall not be obligated in any way to 

utilize the services of the Agency at any time during the term of this agreement.

If the County utilizes the services of the Agency during the term of this agreement, all payments 

shall be based on the per meal rate as agreed upon by County and Agency. 

Agency will be paid $10 per Breakfast meal served, and $12 per Lunch meal served to 

registered County Go & Dine program participants per specifications in Schedule A of this 

agreement.

Payments: Any and all requests for payment to be made per specifications in Schedule A of 

this agreement. Except as otherwise expressly stated in the Agreement, no payment shall be 

made by the County to the Agency for out-of-pocket expenses or disbursements made in 

connection with the contract services to be performed hereunder. 
Fiscal Reporting: Agency agrees to establish and maintain separate accounting records for this 

contractual agreement in accordance with generally accepted accounting principles. 

Refund by the Agency: If, upon the expiration of this Agreement, the amount received by the 

Agency, exceeds the authorized expenditures pursuant to this Agreement, Agency shall remit to 

the County the amount of such excess within ten (10 ) days upon separate request of the County. 

The Agency's obligation under this Section shall continue beyond the expiration or termination 

of this Agreement.

Final Payment by the County: If, upon the expiration or termination of this agreement, the 

County owes the Agency for contract services, the Agency shall submit an invoice within thirty 

(30) days after the termination date, in such form and supported by such documentation and 

certification as the County may require, and the County shall pay the Agency the appropriate 

amount. The County's obligation under this Section shall continue beyond the expiration or 

termination of this contract. 

This project was supported, in part by grant number 90PPNU0001 from the U.S. Administration 

for Community Living, Department of Health and Human Services, Washington, D.C. 20201.
4 

Vendor Contract Terms 

and Conditions Sample 

Sample statement of services for partner 

restaurant.
1 

Administration for Community Living Innovations in Nutrition Programs and Services Capstone Series

Organization:

Erie County Department of Senior Services

The Albany County Department for Aging (ACDFA) and Erie County Department of Senior Services 

(ECDSRS) will initiate a technology driven congregate dining program including a restaurant dining

program to current service models.

SCHEDULE A

STATEMENT OF SERVICES

Erie County Department of Senior Services Restaurant Dining Program:

Go & Dine 2019 

To the fullest extent applicable, Agency hereby makes the representations and agrees to the 

terms and conditions set forth in this Schedule: 

Services, Terms and Conditions

1) Erie County is contracting with the Agency to (A.) Prepare and serve meals to participants of the 

Erie County Department of Senior Services Restaurant Dining Program: Go & Dine (B.) Evaluate 

their performance to ensure that all program criteria is met; and (C.) Meet reporting requirements to 

County as specified herein. 

2) Agency is responsible for following written policies and procedures concerning all aspects of the 

program. 

3) The obligation of the County shall be limited to reimbursement for the price per meal as set forth in 

Schedule E of this Agreement. The County shall not be responsible for payments to the Agency for 

any Agency expenditures in violation of this provision. 

4) Agency will comply with all applicable Federal State and Local laws, rules and regulations (“Law”), 

including, but not limited to those promulgated by the United States Department of Health and 
2 

Human Services Administration on Aging, the New York State Office for the Aging, the New York 

State Department of Health (including Hazardous Analysis Critical Control Points (“HACCP”) 

procedures) and the Erie County Department of Health, in the performance of this Agreement, 

including but not limited to the procurement, storage, handling, preparation, cooking, heating, and 

chilling of meals.

5) Agency undertakes and agrees that any program or services facility provided hereunder shall be in 

full compliance with all applicable laws, regulations, and ordinances respecting health, sanitation, 

and fire protection, and will supply the Commissioner of Senior Services with proof of such 

compliance upon request. If said facilities should be cited for violations under these applicable laws, 

regulations, and/or ordinances, the Agency will be responsible for the correction of such violations 

as soon as possible after notification and within the period specified in the citation(s). Agency shall 

forward all notices of violations to the Commissioner of Senior Services within 24 hours of receipt 

of such violation. Agency represents that all required fire and sanitation inspections have been made 

and that it has adequately planned for the safety needs of the elderly who are to be beneficiaries of 

service under this Agreement, and which service is within the contract of the Agency. The Agency 

agrees from time to time to satisfy the County that adequate provision for such safety needs are in 

effect. The Agency agrees to procure and keep in effect all necessary licenses, permits and food 

handler cards required by law, and the Agency agrees to post such licenses, permits, and cards in a 

prominent place within the site location(s), as required. 

6) All equipment supplied by the County under this Agreement shall be deemed to be the property of 

the County and shall be used as far as practical by the Agency, for the purpose of carrying out the 

extent of the Agreement, and shall not be available for general use by the Agency outside of this 

Agreement. All such equipment shall be identified in a suitable manner. Upon the termination of this 

Agreement, if not renewed, Agency shall submit a final inventory of all such equipment on hand 

within thirty days after completion of the services to be performed under this Agreement. 

Disposition of the inventoried property shall be made in accordance with applicable provisions of the 

law under the direction of the County. Agency shall reimburse the County for any loss or damage of 

said equipment due to fire, theft, or any cause other than from normal use. 

7) The County and Agency will collaborate during the contract period to evaluate the program and 

discuss ways to best serve the seniors of the community. 

8) Appropriate Agency and County staff will meet or teleconference as needed, to review quality 

control procedures, and make appropriate adjustments in the meal service, food preparation, recipes, 

or menu. 

9) Agency is encouraged to attend the quarterly project meeting with County and Congregate site 

representatives.
3 

10) Agency is responsible for performance and compliance of the following: 

A. Prepare and Serve Meals to Go & Dine Participants

1.Agency will prepare and serve meals to Go & Dine Program participants.

2.Participants will be registered by Erie County Department of Senior Services staff. 

3.Participants will be issued a program key tag and a minimum of four (4) meal 

vouchers per month. 

a) Key tag and voucher have matching participant numbers 

b) Participants may use their vouchers at any Go & Dine restaurant site 

c) Voucher issuance and use may be phased out in the future, and number of 

meals available to participant stored in key tag data. Agency will be notified 

in advance if and when this change occurs. 

4.Participants will be provided a menu and program guidelines: 

a) Participants must present their voucher and key tag when ordering 

1. Agency must verify that the key tag and voucher numbers match 

b) “Take out” orders are not permitted 

c) Go & Dine meals are only for program participants; if a meal is claimed for 

another, participant may be removed from the program. 

d) Voluntary contributions to County Nutrition services are not to be collected at 

the restaurant 

1. If Participant asks about contributing, they should be advised to call 

Senior Services Information and Assistance at (716) 858-8526 

i. All County Nutrition program participants are given 

information about voluntary contributions which help sustain 

and expand these programs 

5.Participants may choose one meal per visit from the menu devised collaboratively by 

County and Agency. 

a) Meal is at no cost to the Go & Dine participant 

1. If participant orders any additional menu item, participant is 

responsible for that charge out of pocket. 

2. The County does not provide a gratuity through this program. Any 

gratuity provided is the sole responsibility of the program participant. 

b) When “cashing out” a participant, Agency must scan the barcode provided by 

the County first, then scan the Participant’s key tag 

c) Participant must hand in a Go & Dine voucher 

1. Agency must write the name of the Restaurant and the date of the 

transaction on the voucher 

2. Vouchers must be submitted to the County with weekly invoices (see 

reporting section below).
4 

6.General Meal Requirements:

a) Meals are provided based on menus developed by the County and Agency. 

b) Each complete meal will meet or exceed, at least one-third the recommended 

daily allowance for adults 60 years of age or older and include a good source 

of Vitamin C every serving day, a good source of Vitamin A three times per 

week, and 3oz. high biological value edible protein every day. 

c) All menu substitutions must be approved by the County Registered Dietitian. 

All menu substitutions must be of equal nutritive value. 

d) Agency guarantees that all meals will conform to the requirements of the 

program. This includes the provision that each complete meal must provide 

1/3 of the Recommended Daily Allowance for adults 60 years of age and 

older, as specified by the Food and Nutrition Board, National Academy of 

Science and the National Research Council. The meal must include a good 

source of Vitamin C every day, a good source of Vitamin A three times per 

week, and 3 oz. high biological value edible protein every day. 

e) Meals must be moderate in sodium (~1500 mg. /meal or less), saturated fat 

and sugar levels. No salt may be used in the cooking process. Low sodium 

products are to be used in gravies, soups, sauces, etc. 

f) All meals must be of the highest quality standards and conform to USDA 

requirements. Meals must be prepared in a manner to preserve optimum 

flavor, color, texture, size, shape and appearance while retaining nutrients and 

food value. Agency must ensure entrée tenderness. Agency must sample food 

items to ensure high quality and entrée tenderness prior to serving. 

g) Agency must provide specific recipe information to the county dietitian as 

required by NYSOFA, as needed, to complete nutritional analysis of all items 

served for all menus. 

h) Agency shall keep full and accurate sales and procurement records related to 

meals provided to the Agency for purposes of this Agreement. All such 

records shall be kept on file for a minimum of six years after the end of the 

federal fiscal year to which they pertain or such longer period as the 

Administration on Aging, NYSOFA or the County may from time to time 

reasonably designate in writing. 

7. Food Safety and Sanitation: 

a) The location where the food is prepared, processed, and/or packaged shall be 

maintained and operated in compliance with Law, including but not limited to 

Local and/or State Department of Health regulations. 

b) Agency is required to comply with all applicable HACCP procedures and to 

maintain such records as required by the New York State, Department of 

Health and to provide such records to the County upon request. The County 

reserves the right to inspect all aspects of the Proposer’s food preparation, 
5 

storage and delivery and to require that food that does not meet HACCP 

guidelines be discarded. 

c) Agency is required to abide by staff hygiene and safe food handling practices 

per Exhibit A herein. 

d) All food preparation, storage and distribution facilities, appliances and 

equipment shall at all times be kept and maintained in a clean and sanitary 

condition as required by Law and that kitchen appliances and other equipment 

are kept at all times in good repair for satisfactory operation as required by 

Law.

B. Monitoring and Evaluation: 

1.Quality Assurance: 

a) Agency is required have routine quality assurance processes in place to ensure 

that food is prepared and served in accordance with requirements set forth 

herein. 

2.Quality Improvement: 

a) Agency is required to work with the County on quality improvement efforts. 

Client feedback will be collected on a regular basis through a variety of 

appropriate means including, but not limited to, surveys and focus 

groups/interviews with program participants and/or their caregivers. 

3.Agency will work in conjunction with the County to inspect and monitor meal 

preparation, to ensure that food safety, quality, portion control, logistics, as well as all 

documentation as it relates to food production is in compliance with this agreement. 

4.The County is responsible for evaluation of the Go & Dine Program and all services 

provided in connection with it. The Agency shall cooperate with the County in the 

conduct of such evaluations that are deemed appropriate from time to time. 

5.The ECENS program is committed to ensuring a high level of participant satisfaction 

with the quality and variety of the food that is served, and with other aspects of 

service that is provided. Participants are surveyed on a regular basis to assess 

satisfaction with the program. Agency must assist in the distribution and collection of 

paper surveys. 

6.Agency must partner with the County to review and address issues related to 

participant satisfaction. 

7.Agency should anticipate site visits by the Erie County Department of Senior 

Services to review such efforts. 

C. Reporting

1.Erie County Department of Senior Services staff will exchange scanners, and pick up 

vouchers and invoices once per week. 

2.Agency will be provided a receipt stating the date, Agency name, and number of 

vouchers received that week. 
6 

3.Payment will be issued to the Agency approximately 2-3 weeks after invoices are 

submitted. 

4.In addition to the aforesaid reports, Agency shall provide such written reports to the 

county as may be required by Law and/or as the County may reasonably request in 

writing with respect to specific issues or questions regarding the services provided 

pursuant to this agreement.

This project was supported, in part by grant number 90PPNU0001 from the U.S. Administration for 

Community Living, Department of Health and Human Services, Washington, D.C. 20201
5 

Customer COVID-19 

Survey

Survey on the impact of COVID-19 on participants’ 

lives and participation in the program.
Go & Dine COVID-19 CUSTOMER 

SURVEY

Thank you so much for participating in the Go & Dine program. We like to hear from our customers about how the program is working 

for them. Please take a few minutes to complete this survey and let us know how you were impacted by the COVID-19 pandemic so 

that we could better serve you should a similar event occur in the future. All answers are COMPLETELY CONFIDENTIAL and 

will have no bearing on your services going forward. Thank you for your input. Please complete both sides of the survey.

1. How has COVID-19 and NYS PAUSE impacted your participation in the Go & Dine program?

2. How has COVID-19 and the NYS PAUSE impacted your socialization with friends and family?

3. What has your biggest concern been during the COVID-19 pandemic and NYS PAUSE?

4. Has the Go & Dine program eased any of your concerns during this time?

$ Yes $ No

5. If yes, please explain?

6. How have you been able to interact with loved ones during this time? Select all that apply.

$ Telephone $ Email $ Face Time $ Zoom $ Facebook $ Skype

6 6

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664 Page 1
Go & Dine COVID-19 CUSTOMER 

SURVEY

TURN OVER

7. Would you be comfortable using a virtual meeting/web based platform/or other method to connect to others over a meal?

$ Yes $ No

8. If yes, what methods would you be comfortable using?

$ iPhone $ Smartphone $ Tablet $ PC/Laptop

9. How comfortable would you be returning to a restaurant or congregate dining site once they are able to reopen?

$ Uncomfortable $ Cautious $ Comfortable

10. What activities would you be comfortable participating in while practicing safe social distancing? Select all that apply.

$ Attending movies standard and drive in $ Mall

$ Restaurants $ Social activities (themed nights)

$ Bingo $ Card games

$ Exercise clubs $ Other_______________________________________

OFFICIAL USE ONLY

A E

$ $ 

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6 

Diners Guide

Guidelines, participating restaurants, and menus.
Mark Poloncarz

COUNTY EXECUTIVE
 Erie County Senior Services 

 GO & DINE program guidelines 

1. Participants must be 60 years or older, and a resident of Erie County.

2. A registration form must be FULLY COMPLETED by the participant in order to 

participate in the Go & Dine Restaurant Program. 

3. The costs of the approved meals are covered by Erie County. All gratuities and costs 

of any additional menu are the responsibility of the participant.

4. Meals are required to be consumed at the restaurant. No take-out is allowed. 

Leftovers may be taken home.

5. The meal is for the participant of the Go & Dine Program only. Participants may NOT 

to use their vouchers to cover any meal other than their own. Participants who are caught 

violating this policy will be removed from the program.

6. Participants are required to present both their assigned key tag and voucher at the 

beginning of each dining experience. 

7. Participants will be asked to answer short surveys about the program, full 

participation in these surveys is encouraged so that we may improve and maintain the 

program.

8. Vouchers for meals will be sent monthly. With each monthly supply of vouchers, 

participants will also receive nutritional education information as well as a self-addressed 

envelope to send in a voluntary contribution. These contributions will help sustain the 

program. Contribution should be made by check. DO NOT SEND CASH. Please make the 

check payable to the Erie County Department of Senior Services, and put Go & Dine in the 

memo.
West Side Bazaar

25 Grant Street (corner of Grant and Ferry)

Buffalo, NY 14213

(Parking in lot off of West Ferry)

HOURS:

Tuesday-Thursday: 11am – 7pm

Friday & Saturday: 11am – 8pm

Sunday & Monday: Closed

VENDORS (4)
Abyssinia Ethiopian Cuisine – (716) 563-6602

Senior Veggie Combo – Veggie Combo, with Beets, Lentils, Split Peas, Stewed 

Spinach, Cabbage, Potato, Carrots, Green Beans, Injera or Rice

Senior Abyssinia Combo – Chicken or Beef with Veggies and Hard-Boiled Egg, 

Injera or Rice

Gufuma – Ethiopian Spices, Corkscrew Pasta, Red and Green Peppers, Onions, 

and Choice of Chicken or Beef

M Asian Halal Food – (716) 533-8558

Senior Veggie Platter – Chana Masala (ceci beans and masala seasoning) with 

Eggplant, White Rice, and a Veggie Samosa

Senior Butter Chicken – Butter Chicken Curry with White Rice and small side of 

Naan 

Senior Goat Curry – Curry Spices, Goat, and Tomato with White Rice or Naan

Thang’s Family Japanese Ramen – (716) 715-5053

Vegetable Ramen – Miso, Bok Choy, Napa Cabbage, Mushroom, Broccoli, 

Carrot, Bean Sprouts, Zucchini, Yellow Squash, Snow Peas, Ramen

Yaki Udon – Buckwheat Noodles stir fried with Chicken, Octopus, Squid, 

Prawns, Egg, Snow Peas, Carrots, Onion, Sesame Seeds, Yaki Sauce

Senior Katsu Ramen – Fried Chicken, Ramen, Chives, Mushrooms, Egg, Milk, 

Scallions, Sesame Seeds ,Special Sauce
007 Chinese Food – (716) 951-2535

007 Dim Sum Combo 1 – Char Siu Pau (bbq pork steam bun), Shumai (pork, 

shrimp, carrot dumplings), Black Bean Bau (black bean paste steam bun)

007 Dim Sum Combo 2 – Sayo Pau (jicama, carrot, mushroom steam bun), 

Corn-O Dumpling (corn, shrimp pork), Sweet Pea Dumpling (sweet pea, shrimp, 

pork)

**All meals come with milk and dessert du jour
Kiosko Latino (formerly at West Side Bazaar)

345 W Ferry St

Buffalo, NY 14213

(716) 424-2000

Hours:

Tuesday – Thursday: 11:30am – 6pm

Friday & Saturday: 11:30am – 7pm

Sunday & Monday: Closed

Lunch & Dinner

Senior Pernil or Pollo Guisado – Roasted Pork or Chicken with Rice and small 

Side Salad

Enchilada Combo – White Corn Tortilla, Sauce, Cheese, choice of protein 

(beef/chicken/pork), Refried Beans with Rice and a small Side Salad

Three Taco Combo – Mexican Rice with three Rolled Tacos, Beef, Refried 

Beans, and small Side Salad

**All meals come with milk and dessert du jour
Cozy Corner

690 East Main Street

Springville, NY 14141

(716) 592-9545

Hours:

Monday – Thursday: 6am – 2pm

Friday: 6am – 8pm

Saturday: 6am – 2pm

Sunday: 8am – 2pm
Breakfast (No breakfast after 11am on FRIDAYS):

2 Eggs – Cooked to your liking, with Bacon, Toast, Home Fries

2 Pancakes – served with Syrup, Bacon, Home Fries

2 Egg Vegetable Omelet – with Cheese, Mushroom, Tomato, Onion, Green 

Pepper, and served with Home Fries, Toast

Lunch & Dinner

Cozy Cheeseburger – with Macaroni Salad or Coleslaw

Soup and half Sandwich – (ham, turkey, salami or bologna)

Tuna Melt – with Macaroni Salad or Coleslaw

Grilled Ham & Cheese – with Macaroni Salad or Coleslaw

Greek Chicken Salad

Julienne Salad

Cold Plate – Macaroni Salad, Potato Salad, Coleslaw, Meat and Cheese 

Liver and Onions – with Mashed Potatoes and Gravy, a side Salad and Bread

Ham Steak – with Mashed Potatoes and Gravy, a Side Salad and Bread

Open Meatloaf – with Mashed Potato and Gravy, side Salad, and Bread

**All meals come with milk and dessert du jour
Peg’s Place

4046 Lake Shore Rd

Hamburg, NY 14075

(716) 627-7800

Hours:

Monday – Saturday: 7am – 8pm

Sunday: 7am – 2pm
Breakfast

2 Eggs – cooked to your liking with your choice of Ham, Bacon or Sausage, 

Toast, Home Fries, Juice, Apple Sauce

1 Waffle – served with Syrup, your choice of Ham, Bacon or Sausage, Toast, 

Home Fries, Juice, Apple Sauce

2 Egg Vegetable Omelet – with Cheese, Mushroom, Tomato, Onion, Green 

Pepper and served with Apple Sauce, Home Fries and Toast

Lunch & Dinner

1/4 Pound Burger – with Cheese, Lettuce, Tomato, Onion; Potato Salad

Roasted Turkey Breast – on a Pita or Wrap with Lettuce, Tomato, Onion; Cup 

of Soup

Tuna or Egg Salad – on Toast with Lettuce and Tomato; Cup of Soup or Chili; 

Applesauce

Chicken or Steak Souvlaki – served with Pita Bread

Chef Salad – served with Grilled Chicken

Bourbon Chicken – served with Mashed Potato and Vegetable Medley, Bread

Salisbury Steak – with Mashed Potato, Vegetable, Applesauce, Bread

Liver and Onions – with Baked or Mashed Potato, Vegetable, Dinner Roll

Spaghetti and Meatballs– served with side Salad, Breadstick, Applesauce

**All meals come with milk and dessert du jour
Billygans Cafe

38 Niagara St.

Tonawanda, New York

(716) 692-2700

Hours: 

Wednesday – Sunday: 8AM – 2PM

Breakfast

(2) Eggs any style – with Home Fries, (2) Bacon or Sausage, Toast, small Orange 

Juice, small 1% Milk, and Fresh Fruit Cup

(1⁄2) Eggs Benedict with Orange Hollandaise & Tomatoes – (2) Potato Pancakes, 

small Orange Juice, small 1% Milk, and Fresh Fruit Cup

(2) Slices of French Toast – (2) Bacon or Sausage, small Orange Juice, small 1%

Milk, and Fresh Fruit Cup 

Egg & Cheese Breakfast Sandwich – Your choice of Ham, Bacon or Sausage on 

Bread of your choice with Home Fries, small Orange Juice, small 1% Milk, and

Fresh Fruit Cup

Fiesta Scramble – (2) Eggs with Cheddar Cheese, Homemade Salsa & Sour 

Cream, Home Fries, small Orange Juice, small 1% Milk, and Fresh Fruit Cup
Lunch

Tiki Turkey Sandwich – Provolone, Lettuce, Tomato, Onion & Mango Spread, 

Choice of Bread, Salad of the day, small 1% Milk, Cookie

Cup of Homemade Soup of the Day & 1⁄2 Sandwich Special – Choice of Bread, 

Lettuce, Tomato & Onion, Salad of the day, small 1% Milk, Cookie

Bacon Cheddar Burger – with Lettuce, Tomato, Onion, Salad of the day, small 

1% Milk, Cookie

Grilled Swiss & Coleslaw on Kaiser (Vegetarian) – Salad of the day, small 1% 

Milk, Cookie

Chicken Souvlaki (Wrap or Salad) – Marinated Chicken, fresh Lettuce, Tomato, 

Onion, Feta Cheese & Special Dressing, small 1% Milk, Cookie

Salad of the Day – Coleslaw, Cucumber & Tomato Salad, Potato Salad

Soup of the Day – New England Clam, Italian Clam, Chili
 

Candy Apple Cafe

81 Buell St.

Akron, New York 14001

(716) 542-4155

Hours: 

Open Everyday

7am-7pm

Breakfast

(2) Eggs any style – with Home Fries, (2) Bacon or Sausage, Toast, small Orange 

Juice, small 1% Milk, and Fresh Fruit or Apple Sauce

Vegetable Omelet (tomato, onion, mushroom, pepper, broccoli, & 

cauliflower) – Home Fries, small Orange Juice, small 1% Milk, and Fresh Fruit or 

Applesauce

Western Breakfast Sandwich on a Hard Roll – Home Fries, small Orange Juice, 

small 1% Milk, and Fresh Fruit or Applesauce

(2) Pancakes with – Your choice of Ham, Bacon or Sausage, Home Fries, small 

Orange Juice, small 1% Milk, and Fresh Fruit or Applesauce
Lunch/Dinner

Little Ben’s Big Burger – w/Lettuce, Tomato, Onion, Potato Salad, small 1% 

Milk, & Cookie

Cheryl’s Favorite Pita Pocket (choice of Tuna, Chicken or Roast Beef) –

w/Lettuce, Tomato & Onion, Coleslaw, small 1% Milk, & Cookie

Tuna or Chicken Salad Plate – w/Cottage Cheese, Egg, Cucumber, Chef Salad, & 

Dressing, small 1% Milk, & Cookie

Homemade Meatloaf – w/Mashed Potato & Gravy, Vegetables du Jour, Roll 

w/Butter, small 1% Milk, & Cookie

Baked Chicken Parmesan – w/Pasta & Tomato Sauce, Vegetable du Jour, Chef 

Salad w/Dressing, small 1% Milk, & Cookie

Country Grilled Ham Steak – w/Baked Potato, Vegetable du Jour, Roll 

w/Butter, small 1% Milk, & Cookie

Sautéed Liver & Onions – w/Mashed Potatoes & Gravy, Vegetable du Jour, Roll 

w/Butter, small 1% Milk & Cookie

 
 

17 Main Street

Hamburg, New York 14075

(716) 648-5779

HOURS:

Sunday: 9:00am – 3:00pm

Mon. – Sat.: 8:00am – 7:00 pm

Breakfast

Includes: tropical fruit and milk

Quiche – crustless cheesy egg casserole, side of toast, choice of ham, bacon, or 

sausage and 100% juice

Oatmeal & Yogurt – served with milk and brown sugar and a side of low-fat 

vanilla yogurt with mixed berries

Vegetarian Breakfast Scramble – egg, peppers, onion, hash brown, cheese, 

side of toast

Western Omelet – egg, ham, salsa, fried onion, roasted red pepper and 

cheddar cheese, side of toast

Cheese Omelet – egg with melted cheese, side of toast and 100% juice

Bacon Mushroom Omelet – egg, crumbled bacon, sautéed mushrooms, Swiss 

cheese, side of toast
Lunch/Dinner

Includes: tropical fruit, milk and your choice of a cup of soup or side salad

Chicken Club Wrap - chicken breast, bacon crumbles, lettuce, tomato, ranch 

dressing 

Deluxe Tuna Wrap – tuna salad, cheddar cheese, roasted red peppers, spinach 

LTM Panini - lettuce, tomato, mayo, choice of turkey/ham/or tuna salad

Three Cheese Panini - cheddar, American, and Swiss cheese grilled together

Veggie Delight Panini – avocado, roasted red pepper, tomato, spinach, red 

onion, cheddar cheese

Comfort Caprese Melt – mozzarella, tomato, pesto mayo, balsamic glaze

Swiss Florentine Quiche – crustless baked egg casserole topped with fresh 

spinach and Swiss cheese

Tomato and Cheddar Quiche – crustless baked egg casserole topped with 

cheddar cheese and tomato

Salads

Includes: tropical fruit, milk and your choice of a cup of soup or Deep River chips

Mediterranean Delight – mixed greens, banana peppers, black olives, chick 

peas, feta cheese, sundried tomato basil vinaigrette

CZ Indulgence Salad – mixed greens, chicken breast, cheddar cheese, walnuts, 

craisins, mandarin oranges, croutons, sweet and sour Riviera dressing
 

Fuji Grill Japanese Restaurant

736 Maple Road

Williamsville, New York

(716) 688-6199

Hours: 

Mon – Thurs: 11am – 10pm

Fri – Sat: 11am – 11pm

Sunday: Noon – 10pm

Lunch/Dinner

BENTO BOX

Choice of One: Beef, Chicken, Salmon, Shrimp, or Tofu

Choice of Sauce: Teriyaki, Spicy, or Plain

with Assorted Stir-Fry Vegetables

Served With:

Seasoned White Rice

Shumai (Dumpling)

Edamame

Green Salad with Homemade Ginger Dressing

Milk

Mochi Ice Cream (Assorted Flavors)
7 

Focus Group Questions

Survey of participant experiences.
Page 1 

FOCUS GROUP QUESTIONS

Thank you so much for participating in the Go & Dine Program. We like to hear from our customers about how 

the program is working for them. Please take a few minutes to complete this questionnaire to let us know your 

opinions about the overall program so that we can better serve you in the future. All answers are COMPLETELY 

CONFIDENTIAL and will have no bearing on your services going forward. Thank you for your input. Please 

complete both sides of the questionnaire.

1. How long have you been a participant in the Go & Dine program?

2. What has your overall experience been while participating in the Go & Dine program? What do you like? 

3. Have you recruited anyone to join the Go & Dine program? If so, who? 

 

4. Has the program enabled you to enjoy meals with friends or family members that you may not have been

able to previously? 

5. Has the ability to use vouchers of the program provided you an opportunity to spend discretionary dollars

elsewhere? 

6. Did you attend a traditional congregate dining site before participating in the program? If no, what barriers

did you encounter?
Page 2 

7. As a participant of the Go & Dine program what do you receive from the Go & Dine sites/venues that you

don’t believe you get from traditional congregate? Please explain. 

8. Have you received any other services as a result of participating in the Go & Dine Program? If so, what are

they? 

9. Have there been any barriers that have not allowed you to use all of your vouchers to get to restaurants 

monthly? If so, what are they?

10. How has the COVID-19 pandemic affected your ability to utilize the Go & Dine Program?

11. Do you feel that the service level at the participating sites/venues was the same as prior to COVID-19? 

12. Do you feel comfortable returning to a congregate site that adheres to proper safety precautions? 

13. Should there be a resurgence of the COVID-19 pandemic do you feel that the congregate sites are better 

prepared to handle the pandemic?

Thank you! 
8 

General Meal 

Requirements

Nutritional requirements restaurants must follow.
General Meal Requirementsfor New York State

• Each complete meal meets or exceeds one-third the recommended daily allowance 

for adults 60 years of age or older. 

• It includes a good source of vitamin C (30mg) and vitamin A (300 mcg) and at least 

3oz of high biological value edible protein. 

• Meals provide 3 oz protein, 1⁄2 cup vegetable, 1⁄2 cup starchy vegetable or fruit, 1 

serving bread, dessert, 8 oz dairy. 
9 

Go and Diner Customer 

Satisfaction Survey

Survey on the impact of the program.
Go & Dine Customer Satisfaction 

Survey

Thank you so much for participating in the Go & Dine program. We like to hear from clients about how the program is working for 

them. Please take a few minutes to complete this survey and let us know what we are doing well and where and how we can improve 

the program for the future. All answers are COMPLETELY CONFIDENTIAL and will have no bearing on your services going 

forward. Thank you for your input.

1. How many of your vouchers do you use a month?

$ 1 $ 2 $ 3 $ 4

2. Has the Go & Dine program encouraged you to go out and eat a nutritious meal with family and friends?

$ Yes $ No

3. With whom do you usually participate in the Go & Dine program with? 

$ Alone $ Spouse $ Sibling $ Child $ Grand Child

$ Relative $ Significant Other $ Friend

4. Have there been any barriers that have not allowed you to use all of your vouchers or get to restaurants monthly?

$ Yes $ No

5. If yes, please explain.

6. Do you feel since joining the Go & Dine Program that you have been able to see your family and friends more often?

$ Strongly Disagree $ Disagree $ Neutral $ Agree $ Strongly Agree

7. Do you feel since joining the Go & Dine Program that you have been able to get out of your house more often?

$ Strongly Disagree $ Disagree $ Neutral $ Agree $ Strongly Agree

8. Do you feel since joining the Go & Dine Program that you are eating more nutritious foods?

$ Strongly Disagree $ Disagree $ Neutral $ Agree $ Strongly Agree

9. How do you feel we could improve the Go & Dine Program?

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Go & Dine Customer Satisfaction 

Survey

10. Have you ever participated in the StayFit Dining program provided by Erie County Senior Services?

$ Yes $ No

11. If not, would you like information about the program sent to you?

$ Yes $ No

12. Have you ever heard of NY Connects Information and Assistance Hotline?

$ Yes $ No

13. If not, would you like information about the program sent to you?

$ Yes $ No

xxxxx

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10

Isolation Survey

Survey evaluating participant feelings of isolation.
Go&Dine Isolation Survey

Please indicate how often each of these statements below is descriptive of you. The answers given to this survey 

are COMPLETELY CONFIDENTIAL and will have no effect on your services going forward. The 

information gathered in this survey will only be used to determine whether the Go&Dine has had positive 

effects on those who use it.

1. I am unhappy doing so many things alone.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

2. I have nobody to talk to.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

3. I cannot tolerate being so alone.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

4. I lack companionship.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

5. I feel as if nobody really understands me.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

6. I find myself waiting for people to call or write.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

7. There is no one I can turn to.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

8. I am no longer close to anyone.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

9. My interests and ideas are not shared by those around me.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

10. I feel left out.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

11. I feel completely alone.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

12. I am unable to reach out and communicate with those around me.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

Turn Over

Russell, D. (1996). UCLA Loneliness Scale (Version 3): Reliability, validity and factor structure. Journal of 

Personality Assessment, 66, 20-40.

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Go&Dine Isolation Survey

13. My social relationships are superficial.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

14. I feel starved for company.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

15. No one really knows me well.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

16. I feel isolated from others.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

17. I am unhappy being so withdrawn.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

18. It is difficult for me to make friends.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

19. I feel shut out and excluded by others.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

20. People are around me but not with me.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

Thank you for your feedback!

Official use only:

xxxx

$ Baseline $ 6 Months $ 12 Months

$ Erie $ Albany

Russell, D. (1996). UCLA Loneliness Scale (Version 3): Reliability, validity and factor structure. Journal of 

Personality Assessment, 66, 20-40.

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11

Participant Registration 

Form for collecting participant demographics and 

calculating nutritional score.
_______

Go & Dine

NUTRITION SITE and NUMBER: CLIENT NO:

DATE: Gender: Male Female DOB: Veteran: Yes No

Last Name: First Name: Mid Init 

Address:

City: State: Zip:

Phone: Frail\Disabled: Yes No

Emergency Contact: Relationship: Phone:

Living Status: Alone, With Spouse Only, With relatives, With non-relatives, With Spouse and others, Others

Marital Status: Married Widowed Divorced Never Married Domestic Partner or

Significant Other 

Number in 

Race: White Black American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander

Other Race 2 or More Races White (Alone) Hispanic

Ethnicity: Hispanic Non-Hispanic

1 person monthly income: less than $1012 Between $1013 $1265 Between $1266 $1518 Greater than $1519

2 person monthly income: less than$1372 Between $1373 - $1715 Between $1716 $2058 Greater than $2059

Read the statements below. Circle the number in the "YES" column for those that apply to you.

Circle Number below if YES (if NO leave blank)

I have an illness/condition that made me change the kind/amount of food I eat. 2

I eat fewer than 2 meals a day. 3

I eat few fruits or vegetables, or milk products. 2

I have 3 or more drinks of beer, liquor or wine almost every day. 2

I have tooth or mouth problems that make it hard for me to eat. 2

I don't always have enough money to buy the food I need. 4

I eat alone most of the time. 1

I take 3 or more different prescribed or over-the-counter drugs a day. 1

Without wanting to, I have lost or gained 10 pounds in the last 6 months. 2

I am not always physically able to shop, cook and/or feed myself. 2

Total

A score of 0-2 means Good. You could recheck at six months.

A score of 3-5 means you are at moderate nutritional risk. You could see what you can do to improve eating habits and 

make life-style changes.

A score of 6 or more means you are at a high nutritional risk. You could take the checklist to a doctor, dietitian or 

qualified health or social service professional and talk to them. Ask for definite ways to improve your nutritional health.

Rev 3/2018 pg 1 of 2

2020 NEW: ____________

UPDATE: ____________

REGISTRATION FORM

Household:

Total your nutritional score and compare below.
Informed Consent to Capture and Record Personal Information 

I hereby consent to my personal information contained in this Registration Form being saved in the 

Client Data System maintained by the New York State Office for the Aging and used by the local Office 

for the Aging. I understand that my information will not be shared with other agencies without my 

permission. 

I understand that the information on this form may be sent to the State and federal government, and is 

used to improve the services offered and better meet my needs. 

_______________________________ ______________ 

Signature Date 

_______________________________ 

Print 

ATTESTATION 

To be completed by worker 

I attest that informed consent, as indicated, was obtained from the above individual, who provided 

his/her signature above. All appropriate processes were followed, and consent was provided 

voluntarily. 

_________________________________________ _____________________ 

Worker Signature Date

_______________________ 

Worker Name (Print) 

_________________________________________ 

Congregate Site 

Revised 3/2018 pg 2 of 2 
12

Tech Survey

Survey for meal providers on the effectiveness of 

scanners and keytags. 
Innovations in Nutrition Technology 

Survey

The following questions pertain to the use of the handheld scanners and key tags that are used in the congregate 

dining and restaurant dining programs within your county. As a provider of one of the two programs which use 

them, we would like to know how the implementation of them has impacted you as a provider. This input will 

help us report back to the Administration on Community Living, on how using technology has impacted 

providers within our network.

1. How would you rate the effectiveness of the scanners in terms of tracking client units?

$ Poor $ Fair $ Good $ Very Good $ Excellent

2. Do you feel that the scanners were a user friendly device to assists in capturing clients meal units?

$ Strongly Disagree $ Disagree $ Neutral $ Agree $ Strongly Agree

3. Did you have any challenges arise with implementing the use of the scanners for you and your staff?

$ Yes $ No

4. If yes, what were some of the challenges?

5. Would you implement any changes in the way the scanners or other technology are used to track client 

service units and data?

$ Yes $ No

6. If yes, what would you like to see changed?

For Congregate Sites:

7. Do you feel that the implementation of scanners has helped to reduce the amount of staff time in terms of 

data collection and entry on a daily, weekly or monthly basis?

$ Strongly Disagree $ Disagree $ Neutral $ Agree $ Strongly Agree

Complete questions on other side

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Innovations in Nutrition Technology 

Survey

8. How has the feedback from staff and clients been in terms of using the scanners and key tags to track 

attendance?

$ Poor $ Fair $ Good $ Very Good $ Excellent

9. Could you provide additional feedback on the implementation and use of the scanners and key tags?

For Go & Dine Providers:

10. Are you aware of any technology available that may interface with your POS system better?

$ Yes $ No

11. If yes, what is the name and how would it be used?

12. Could you provide additional feedback on the implementation and use of the scanners and key tags?

Thank you!

OFFICIAL USE ONLY

13. Provider type

C G

$ $ 

14. County:

A E

$ $ 

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