Grantees and Administrators (SLT Gov) Respondents

Appendix AE.1

Annual Core Program Data Form

English Only

Evaluation Technical Assistance for the
Food Insecurity Nutrition Incentive Grant Program

_{Fall 2015 FINI ANNUAL CORE PROGRAM DATA TEMPLATE}

APRIL 1, 2015 – MARCH 31, 2016

What is the grantee’s name? What is the name of the incentive program? (e.g., double up coupons, fresh bucks, etc.) Is the incentive program: new, continuation of existing program, expansion of existing program (same incentive structure, but serve more SNAP customers), or a modification of existing program (change in incentives or other services but no change in SNAP customers)? (Check all that apply). New 1 Continuation of an existing program. 2 Expansion of an existing program 3 Modification of an existing program 4 What is the organizational or management structure for the incentive program? (Please attach a written description and include organizational chart if available). At what type of outlets was the incentive program offered? (Check all that apply). 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

How many outlets did your organization operate (include outlets that offer and don’t offer FINI incentives)? ____ ____ ____ 4a. At how many of these outlets was the incentive offered? ____ ____ ____ What tracking systems were used by the outlets to monitor SNAP and incentive distribution and redemption? (Check all that apply). Manual 1 Excel or other computer program. 2 Web based form 3 Other 4 (SPECIFY) _________________________ How is the incentive provided to SNAP customers? (Check all that apply). Provided at SNAP office 1 Provided at outlet 2 Mailed to participants at home 3 Added to electronic benefit transfer (EBT) card 4 Added to electronic incentive card 5 Other 6 (SPECIFY) _____________________________ What was your source of initial funding to establish the incentive program? (Check all that apply). FINI grant 1 Matching grant 2 Other 3 (SPECIFY) ___________________________ Between April 1, 2015 and March 31, 2016, how much money was spent by your organization to operate the incentive program (include funding from all streams; do not include costs incurred by the outlet) $______________

What was this money spent on? (Check all that apply). Purchase equipment 1 Purchase token, scrip, etc. 2 Hire Staff 3 Train Staff 4 Outreach activities 5 Education activities. 6 Pay outlet staff 7 Other 8 (SPECIFY) How many people were involved in the administration (management) of the incentive program? (Include grantee staff who work at the outlets to assist them in operating the program). ____ ____ 3a. Of these, how many were full time? _____ 3b. Of these, how many were part-time? _____ 3c. Of these, how many were volunteers? _____

Contact information of the person completing this form: NAME: ________________________________ TITLE: _________________________________ EMAIL: ________________________________ PHONE NUMBER: _______________________