Business Respondents: Grantees and Administrators/ Retailers/Local Community Org. Staff

Appendix AD.1

Quarterly Core Program Data Form

English Only

Evaluation Technical Assistance for the
Food Insecurity Nutrition Incentive Grant Program

_{APRIL – JUNE 2015 FINI QUARTERLY CORE PROGRAM DATA TEMPLATE}

ABOUT YOUR OUTLET AND FINI PROJECT What is the outlet’s name? What is the outlet’s address? ADDRESS 1: ADDRESS 2: CITY: STATE: ZIP CODE: What is your outlet type? Large Chain Grocery Store/Supermarket 1 Discount Superstore 2 Convenience Store 3 Small Store or Corner Store 4 Farmers Market 5 Direct Farm 6 Farm Stand 7 Mobile market at single location 8 Mobile market at multiple locations 9 CSA 10 In what year did this outlet receive its SNAP authorization? ____ ____ ____ ____ What is your SNAP authorization number?

Is the incentive program at this outlet: (Mark all that apply.) New 1 Continuation of an existing program 2 Expansion of an existing program (serve more SNAP customers) 3 Modification of an existing program (Change in incentives or other services but no change in number of SNAP customers) 4 What was your source of funding to establish the incentive program? (Mark all that apply.) FINI Grant 1 Matching Grant 2 Other 3 (SPECIFY) How much money was spent on the incentive program? (Include funding from all sources). ____________________________ What was the money spent on? (Mark all that apply.) Purchase equipment 1 Purchase token, scrip, etc. 2 Hire new staff 3 Train staff 4 Outreach activities 5 Education activities 6 Pay outlet 7 Other 8 (SPECIFY) How many paid staff and volunteers were involved in establishing the incentive program? Paid Staff: ______________ Volunteers: ___________

11. Do SNAP participants receive the incentive when they purchase …

Any SNAP eligible item 1 (SKIP TO 12)

Specific SNAP eligible item 2

11a. Which of the following SNAP eligible items are to purchase by SNAP participants to receive the incentive? (Mark all that apply.)

	Fresh	Frozen	Canned	Dried
Fruit
Fruit Juice
Potatoes
Legumes (beans, peas, lentils)
Vegetables (excluding potatoes and legumes)
Vegetable juice
Other, please specify: __________________
Other, please specify: __________________
Other, please specify: __________________
Other, please specify: __________________

12. Are incnetives redeembale on purchase of

Any SNAP eligible item 1 (SKIP TO TO 13)

Specific SNAP eligible item 2

12a. Which of the following SNAP eligible items can SNAP participants purchase with the incentive? (Mark all that apply.)

	Fresh	Frozen	Canned	Dried
Fruit
Fruit Juice
Potatoes
Legumes (beans, peas, lentils)
Vegetables (excluding potatoes and legumes)
Vegetable juice
Other, please specify: __________________
Other, please specify: __________________
Other, please specify: __________________

13. Is the incentive provided to the customers in the form of:

YES NO

a. A token 1 2

b. Scrip (certificate

of money) 1 2

c. Electronic format 1 2

d. Some other form 1 2

(SPECIFY)

13. What is the minimum denomination for the incentive? (e.g. $2 tokens, $0.50 scrip)

13. Is this incentive limited to:

YES NO

a. Organic produce 1 2

b. Local produce 1 2

13. What is the ratio of SNAP spending to incentive match offered to the customer? (e.g. for $10 SNAP purchase, offer $5 incentive)

17. What is the frequency of incentive offered to the customer?

Daily (each shopping visit) 1

Weekly 2

Monthly 3

Seasonal 4

Other 5

(SPECIFY)

17. Is there a maximum incentive limit per customer?

Yes 1

No 2 → (SKIP TO Q21)

17. What is the maximum incentive limit in dollars per customer?

____________________________

17. How is the maximum incentive set?

Per day 1

Per week 2

Per month 3

Per season 4

Other 5

(SPECIFY)

INCENTIVE IMPLEMENTATION THIS QUARTER Was the outlet open this quarter? Yes .1 No 2 (SKIP TO 37) In what months in this quarter did this outlet operate? (Mark all that apply.) April 1 May 2 June 3 On how many total days did the outlet operate in the current quarter? ____ ____ days On what days did this outlet usually operate during this quarter? (Mark all that apply). Monday 1 Tuesday 2 Wednesday 3 Thursday 4 Friday 5 Saturday 6 Sunday 7 In the current quarter, what is the average number of hours the outlet was open each day of operation? ____ ____ hours per day What time of day did the outlet typically operate in the current quarter? AM only 1 PM only 2 Both AM and PM 3 Does the outlet’s operating schedule vary…? By week 1 By month 2 Does not vary 3 How many SNAP transactions at this outlet were processed in the current quarter? ______________________________ What is the value of SNAP reimbursements made to vendors at this outlet in the current quarter? $______________________________

What is the average incentive value redeemed at this outlet in the current quarter? $ ______________________________ What is the value of incentives issued at this outlet in the current quarter? $______________________________ What is the value of incentives redeemed at this outlet in the current quarter? $______________________________ Was the incentive offered on all operating days this quarter? Yes 1 No 2 ↘ (IF NO:) How many days was the incentive offered? ____ ____ How many people from the outlet were involved in administration (e.g. promotion, outreach, operation) of the incentive program? ________ 34a. Of these, how many were paid? ____ ____ 34b. Of these, how many were volunteers? ____ ____ Did the outlet redeem benefits from other nutrition assistance programs in the current quarter? (Mark all that apply.) No 1 Yes, WIC Farmers Market Nutrition Program 2 Yes, WIC Cash Value Vouchers 3 Yes, Senior Farmers Market Nutrition Program 4 Other 5 (SPECIFY)

Which of these education activities were offered by the outlet in the current quarter? (Mark all that apply). Federally funded SNAP-Ed nutrition programs and activities 1 EFNEP and/or Education extension offered nutrition education/ activities 2 Other 3 (SPECIFY)

CONTACT INFORMATION What is the name, title, email address and phone number of the person completing this form? NAME: ________________________________ TITLE: _________________________________ EMAIL: ________________________________ PHONE NUMBER: _______________________

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