Food Stamp Nutrition Connection Resource Sharing Form (Private)

Food Stamp Nutrition Connection:

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Food Stamp Nutrition Connection Resource Sharing Form
Tell us about your nutrition education materials by completing the form below. We review each item
submitted. Materials that meet the scope and criteria of the Food Stamp Nutrition Connection are
included in the resource system. When you have finished completing the form, click on the "submit"
button at the bottom of the page. You may also print a copy (DOC|45 KB) of this form and return it
by mail.
If you would like to donate a copy of a new resource for us to review, please address it to:
Food Stamp Nutrition Connection
Food and Nutrition Information Center
National Agricultural Library
10301 Baltimore Avenue, Suite 105
Beltsville, MD 20705

Part I. About You
Please provide your contact information in case we have questions about this resource. View our
Privacy Policy.
1. Your name:
2. Your e-mail address:
3. Which best describes your relationship to the resource you are submitting?
I developed this material (complete sections I-III).
I distribute or handle ordering for this material (complete sections I, II and IV).
I use this resource but I am not the developer or distributor of this material
(complete sections I and II).
Part II. Resource Information
Please tell us about the material you are submitting.
1. Resource Title:
2. Developer/Author(s):
3. Primary Author's Affiliation:
4. Publication/Revision Date:

Edition:

5. How is this material used?
Consumer Education
Staff Training
Background Information/Research
6. What languages are available:
7. If this resource is available online, please provide the web site address (URL):
8. Briefly, describe your resource:

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9. How do we contact the publisher/distributor:
Publisher name:
Street address:
City/State/Zip:
Telephone:
E-mail:
Part III. Author/Developer Information
Please share information about how this material was developed.
1. Please describe the target audience.

2. If you used a readability formula to test this material, please provide the following:
Name of formula used:
Score/grade level:
3. Please describe any pilot studies conducted:

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4. Does this material include a validated evaluation tool?
Yes

No

5. What is the funding source for the development of this material:

Comments:

Part IV. Publisher/Distributor Information
How can this material be ordered or accessed?
1. ISBN number (if applicable):
2. Please indicate how this material may be used by other educators:
May copy for educational purposes without prior permission
Permission needed to copy

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May not copy.
3. How can educators order this material?

4. What is the cost of this material? (price/unit)
5. Can this material be ordered in quantity?
Yes

No

6. Describe any bulk discounts available.

Comments

Submit

Reset

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
person is not required to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0518-0031. The time required to
complete this information will vary based upon ones relationship to the resource being submitted. It
is estimated to take 19 minutes to complete the entire survey. This includes time for reviewing

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instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. If you need help with this form, please
contact us.

Last Modified: Tuesday, 24-Jul-2007 09:23:17 EDT
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