U_Master Pilot Costs Workbook

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Overview

Instructions
A. Your Agency
B. Staff
C. Service Provider Contracts
D. Facilities
E. Services
F. Gen. Supplies & Equipment
G. Volunteers
H. Miscellaneous
DROPDOWN LISTS

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Sheet 1: Instructions

If you have any questions about this workbook or how to complete it, please contact [assigned cost-benefit liaison] at [phone] or [email].
OMB Control No.:	0584-####]
Exp. Date:	[X/XX/20XX]
Supplemental Nutrition Assistance Program Employment & Training Costs Workbook
[Grantee Agency Workbook / Service Provider Workbook]
Introduction and Instructions
The cost-benefit analysis component of the Evaluation of the Supplemental Nutrition Assistance Program (SNAP) Employment & Training (E&T) Pilot will provide Congress and other stakeholders with information about the overall, per participant, and per component costs of providing pilot services, and whether the benefits of each pilot exceed its costs. This workbook collects information about the cost of implementing your SNAP E&T pilot to inform these analyses. The evaluation team will also collect information on pilot benefits through other sources.
What is this workbook about?
This workbook is for SNAP E&T pilot [specify: grantees, their selected partners, and service providers]. It asks questions about the costs of implementing the SNAP E&T pilot [specify treatment/control as appropriate]. This workbook is intended to gather information on total pilot costs, including costs that are paid with SNAP E&T funds, costs that are paid with funds from other funding sources, and the monetary value of donations (e.g., donated facilities or volunteer labor). This purpose of this workbook is not to monitor pilot grant spending; collected data are for research purposes only.
How is the workbook organized?
The workbook is divided into eight (8) sections, labeled A through H. Each section asks questions about the costs of specific resources, such as staff, facilities, and payments for services, and appears in a separate tab in this workbook. You can access each section by clicking on the tabs at the bottom of this page. You should complete the questions in all sections. Please save this file after completing each section. [Note: This section will require some customization based on which tabs of the workbook are sent to which respondent type.]
What time period does the workbook cover?
Please report costs for the most recently completed quarter, [specify reporting period], when completing the workbook.
What information should I use to complete the workbook?
You will need information about agency use of resources (such as facilities and equipment), and payments made to use these resources, to complete the workbook. Please use actual payment records rather than budgets to complete workbook questions. It may be helpful to review the entire workbook before starting to identify the kinds of information that are required.
Who from my organization should complete the workbook?
A person familiar with the costs of pilot resources and agency and accounting records should have primary responsibility for completing the workbook. This person may need to consult with other people in the agency to gather information required to address some questions.
What do I do after I complete the workbook?
Please complete the workbook within two (2) weeks of receiving it. When you have completed the workbook, please save the file, and submit via the evaluation File Transfer Protocol site using the instructions provided.
How will the information that I provide be used?
Information gathered through this workbook will be secure to the extent permitted by law. Only members of the research team will have access to workbook information. The study team will generate estimates of overall pilot costs to each grantee, the costs of different pilot components and activities, and costs per pilot participant. The research team will compare these cost estimates to measured pilot impacts on participant outcomes as part of a cost-benefit analysis.
Thank you for your participation in this important study.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-xxxx. The time required to complete this information collection is estimated to average 120 minutes including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Support, Food and Nutrition Service, USDA, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302.

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Sheet 2: A. Your Agency

OMB Control No.:

[0584-####]

WORKSHEET A: YOUR AGENCY [to be completed by all respondents]

Exp. Date:

[X/XX/20XX]

This worksheet requests basic information about your agency.

1)

What is the official name of your agency?

[Click here and start typing.] Study team will pre-fill after first round of data collection.

2)

Please provide contact information for the person primarily responsible for completing this workbook.

Name

[Click here and start typing.] Study team will pre-fill after first round of data collection.

Title

Email

Phone

3)

If any unusual circumstances may have affected pilot costs during the reporting period, [specify reporting period] (e.g., unusually high turnover or changes in agency operations), please use the space below to describe them.

[Click here and start typing.]

PLEASE SAVE AND CONTINUE TO THE NEXT SECTION.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average 120 minutes including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Support, Food and Nutrition Service, USDA, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302.

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Sheet 3: B. Staff

WORKSHEET B1: STAFF [to be completed by all respondents]

This worksheet requests information about the staff from your agency who worked on the SNAP E&T pilot during the reporting period, [specify reporting period].

1)

Using the table below, please provide information about salaries and fringe benefits for those staff from your agency who did work for the SNAP E&T Pilot during the reporting period, [specify reporting period]. List all staff who worked on the pilot (last name, first initial), including those staff whose salaries are paid with funds from other funding sources (i.e., staff that provide in-kind services to the pilot). You'll provide information about volunteers in another tab.

�ØUse the dropdown list to indicate each person's primary responsibility or responsibilities on the SNAP E&T pilot.

ØEnter their salary or wage, and use the dropdown list to indicate if the amount entered is a hourly, weekly, monthly, or annual amount.

�ØIndicate the value of payroll taxes and fringe benefits that your organization paid for each person, either as a dollar amount of a percentage of their salary or wage. Scroll down to item 2 of this worksheet for a list of what these benefits and taxes might include.

�ØIndicate the approximate percentage of each person's salary or wage that is paid for with SNAP E&T pilot funds.

�ØSpecify each person's pilot start date and the number of hours they work in a typical week (some people might work more hours per week than scheduled). Note the approximate percentage of each person's time that they spent doing work for the SNAP E&T pilot during the reporting period, [specify reporting period]. Estimate the % of each person's pilot time that was spent on evaluation-related activities.

�ØUse the dropdown list to note whether the person's status on the SNAP E&T pilot has changed during the reporting period (e.g., if they are new staff, or if they left the project). You will explain any status changes in item 3 of this worksheet. [Not asked during first round of data collection; asked as part of all subsequent cost data collections.]

Title

Primary SNAP E&T Pilot Responsibilities

Salary/Wage

Time During Reporting Period

Changes to SNAP E&T Pilot Status

Primary Responsibility #1

Primary Responsibility #2

Salary/Wage

Salary/Wage is per..

Value of Payroll Taxes and Fringe Benefits

% of Annual Salary/Wage Funded with SNAP E&T Pilot Grant

Pilot Start Date

Hours Worked per Week

% of Time Spent on Pilot

% of Pilot Time Spent on Evaluation Activities

% of Salary

or

$ Amount

Study team will pre-fill after first round of data collection.

[Click here and select from list.] Study team will pre-fill after first round of data collection.

[Click here and select from list.] Study team will pre-fill after first round of data collection.

Study team will pre-fill after first round of data collection.

[Click here and select from list.] Study team will pre-fill after first round of data collection.

Study team will pre-fill after first round of data collection. Cell formatted to collect % not #.

or

Study team will pre-fill after first round of data collection.

Study team will pre-fill after first round of data collection.

Study team will pre-fill after first round of data collection.

Study team will pre-fill after first round of data collection.

Study team will pre-fill after first round of data collection.

[Click here and select from list.]

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2)

Please indicate which payroll taxes and benefits are included in the fringe figures reported in the table above.

Social Security (FICA)

[Click here and select from list.] Study team will pre-fill after first round of data collection.

Unemployment Insurance

Health Insurance

Life Insurance

Pension/Retirement

Workers Compensation

Disability

Other

3)

If any unusual circumstances may have affected staffing or staff costs during the reporting period, [specify reporting period], please describe these in the box below.

[Click here and start typing.] [After the first round of data collection, will ask about changes (staff transitions or turnover) indicated in the above staff table. Respondent will be asked to note which, if any, staff transitioned on to or off of the SNAP E&T pilot and the reason for the transition or to otherwise explain their reason for noting a change in a person's SNAP E&T status in the above table.]

PLEASE SAVE AND CONTINUE TO THE NEXT SECTION.

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Sheet 4: C. Service Provider Contracts

WORKSHEET C: SERVICE PROVIDER CONTRACTS [to be completed by grantee agency respondents only]
	This worksheet requests information about entities that your agency contracts with to implement the SNAP E&T pilot.
	1)	Did your agency contract with one or more entities to provide SNAP E&T pilot services during the reporting period, [specify reporting period]?
			[Click here and select from list.] Study team will pre-fill after first round of data collection.
	2)	If you answered YES to the above question, please use the table below to enter information on the entities that your agency contracted with to provide SNAP E&T pilot services during the reporting period, [specify reporting period].
			�ØList service providers.
			�ØBriefly note which services the entity is contracted to provide.
			�ØReport the amount that you paid to the service provider during the reporting period, [specify reporting period]. Note: this column asks for actual amount paid, not value of services provided.
			�ØUse the dropdown list to indicate whether the provider's status has changed during the reporting period, [specify reporting period] (e.g., if they are a new SNAP E&T provider, or they are no longer providing SNAP E&T pilot services). You will explain any status changes in the next section of this worksheet. [Not asked during first round of data collection; asked as part of all subsequent cost data collections.]
			Name of Service Provider	Services Provided	$ Amount Paid to Service Provider	Changes to SNAP E&T Pilot Status
			[Click here and start typing.] Study team will pre-fill after first round of data collection.	[Click here and start typing.] Study team will pre-fill after first round of data collection.	[Click here and start typing.]	[Click here and select from list.]
3)	Please use the space below to describe what, if any, unusual circumstances may have affected service provider contracts during the reporting period, [specify reporting period].
			[Click here and start typing.] [After the first round of data collection, will ask about changes to individual service provider contracts during the reporting period and for the respondent to otherwise explain their reason for noting a change in a contract in the above table.]
		PLEASE SAVE AND CONTINUE TO THE NEXT SECTION.

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Sheet 5: D. Facilities

WORKSHEET D: FACILITIES USED TO PROVIDE SNAP E&T PILOT SERVICES

This worksheet requests information about the facilities used by your agency to provide SNAP E&T pilot services during the reporting period, [specify the reporting period].

1)

Please use the table below to report information about the facilities regularly used by your agency to provide SNAP E&T pilot services during the reporting period, [specify reporting period], including facilities that are donated or that you do not pay to use. For each:

�ØProvide the facility's name. A "facility" is any space used to provide SNAP E&T pilot services; this might include a building or a portion of a building (e.g., an office suite).

�ØUse the dropdown list to indicate the type of facility (e.g., administrative office building, American Job Center, etc.).

�ØIndicate whether your agency rents, leases, or owns the facility, or if it is donated / your agency does not pay to use it.

�ØReport the total facility cost during the reporting period, [specify reporting period]. Use dropdown list to indicate if the cost is weekly, monthly, etc.

��ØIndicate the percentage of each facility's cost that was paid for with SNAP E&T pilot funds.

�ØApproximate the percentage of the facility's total space that was used by the SNAP E&T pilot during the reporting period, [specify reporting period].

�ØUse the dropdown list to indicate how many months the facility was used by the SNAP E&T pilot during the reporting period, [specify the reporting period].

��ØUse the dropdown list to indicate whether there has been a change in your agency's use of the facility to implement the SNAP E&T pilot during the reporting period, [specify reporting period] (e.g., if you started to use the facility to implement the pilot during the reporting period, or stopped using the facility during the reporting period). You will explain any status changes in the next section of this worksheet. [Not asked during first round of data collection; asked as part of all subsequent cost data collections.]

Facility

Type of Facility

Facility is…

Facility Costs

Facility Usage

Changes to SNAP E&T Pilot Status

Total Facility Cost

Reported Cost is…

% of Cost Paid for with SNAP E&T Pilot Funds

Approximate % of Facility Used by SNAP E&T Pilot

Months Used by SNAP E&T Pilot

Study team will pre-fill after first round of data collection.

[Click here and select from list.] Study team will pre-fill after first round of data collection.

[Click here and select from list.] Study team will pre-fill after first round of data collection.

[Click here and select from list.]

Study team will pre-fill after first round of data collection.

[Click here and select from list.]

[Click here and select from list.]

2)

Please use the table below to report the utility costs for the facilities listed in the table above during the reporting period, [specify reporting period]. �Indicate the total costs of:

�Øphone, internet, and other telecommunications utilities

�Øheat, water, and electricity

�Øall other utilities

�Report the % of these utility costs that were paid for with SNAP E&T pilot grant funds.

Facility

Total $ Amount Paid for Utilities

% of Cost Paid for with SNAP E&T Pilot Funds

Phone / Internet / Other Telecom.

Heat / Water / Electricity

Other Utilities

Will autofill as the above table is completed.

3)

Please use the space below to describe what, if any, unusual circumstances may have affected facilities costs during the reporting period, [specify reporting period].

[Click here and start typing.] [After the first round of data collection, will ask about changes to facilities / facility costs during the reporting period and for the respondent to otherwise explain their reason for noting a change in the table above.]

PLEASE SAVE AND CONTINUE TO THE NEXT SECTION.

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Sheet 6: E. Services

	WORKSHEET E: SERVICES [to be completed by service providers only]
		This worksheet requests information about the non-labor costs associated with some of the services that your agency provides to SNAP E&T pilot customers.
	1)	Supportive Services: If your agency provided supportive services to SNAP E&T pilot customers during the reporting period, [specific reporting period], please complete the table below. If you did not provide supportive services to pilot customers, skip to item 4 below.
			�List each supportive service provided by your agency to SNAP E&T pilot customers during the reporting period, [specify reporting period] (e.g., transportation, childcare).
			�Report the total cost of each service during the reporting period. This cost might include payments made directly to customers (through vouchers or gift cards), or payments made to third-party service providers to provide the service, etc. This DOES NOT include labor costs incurred by your agency, which were recorded in tab B. Staff.
			�Report the total number of SNAP E&T pilot customers that received the service during the reporting period, [specify reporting period].
			�Indicate the approximate percentage of the reported cost that was paid for with SNAP E&T pilot funds.
					Type of Supportive Service	Total Cost of Service During Reporting Period	# of SNAP E&T Customers that Received Service	% of Cost Paid for with SNAP E&T Pilot Funds
					[Click here and start typing.]	[Click here and start typing.]	[Click here and start typing.]	[Click here and start typing.]
		2)	Other Services: Please complete the table below, which requests information about other services that your organization might provide to SNAP E&T pilot customers during the reporting period, [specify reporting period]. For each of these services that your agency provided:
			�Report the total cost of providing each service during the reporting period, [specify the reporting period]. See examples of what these costs might include listed alongside each service. This DOES NOT include labor costs incurred by your agency, which were recorded in tab B. Staff.
			�Briefly describe the costs you reported; i.e., indicate if they were for the purchase of any materials or supplies, payments to third-party service vendors, etc.
			�List the approximate percentage of the reported costs that were paid for with SNAP E&T pilot funds.
			�Report the number of SNAP E&T pilot customers that received the service during the reporting period, [specify the reporting period].
			Service			Costs Incurred During Reporting Period, [specify reporting period]					# of Customers that Received Service During the Reporting Period
						Total Cost	Brief Description of Costs			% of Costs Paid for with SNAP E&T Pilot Funds
			1)	Formal Assessments			[Click here and start typing.]
				Ø	Assessments of customers' skills, aptitudes, and interests
				Ø	E.g. TABE, CareerScope, or WorkKeys, etc.
				Ø	Costs might include: purchase of testing materials (e.g., test booklets) and/or payment of licensing fees/agreements (required for some computer-based assessments, etc.)
			2)	Structured Group Activities			[Click here and start typing.]
				Ø	Workshops or other structured group activities / seminars
				Ø	E.g. job readiness workshop series, resume or interviewing workshops, financial assistance seminars, job clubs, etc.
				Ø	Costs might include: purchase of workbooks or curricula, payments to third-party vendors to provide the service, etc.
			3)	Education (non-training)			[Click here and start typing.]
				Ø	Remedial education focused on things like reading, literacy and math
				Ø	E.g. ABE, GED, ESL
				Ø	Costs might include: purchase of workbooks or curricula, payments to third-party vendors to provide the service, etc.
			5)	Vocational Skills Training			[Click here and start typing.]
				Ø	Classroom-based training on the skills required to obtain employment in a particular industry or occupation
				Ø	Costs might include: purchase of workbooks or curricula to directly provide training; payments to customers (in the form of vouchers); payments to third-party training providers.
			6)	Work-Based Learning			[Click here and start typing.]
				Ø	Education or training received at the work place or on the job
				Ø	E.g. on-the-job training (OJT), apprenticeship, internships, paid work experience, etc.
				Ø	Costs might include: subsidized wages paid, payments to employers, etc.
		3)	If your agency provided Structured Group Activities to SNAP E&T pilot customers during the reporting period, [specify reporting period], please answer the following questions.
			a)	Approximately how many structured group activities (e.g., workshops) did you provide to SNAP E&T pilot customers during the reporting period? Include in this count multiple sessions of the same activity.
			b)	How long (hours) was a group activity, on average?
			c)	How many customers attended each activity, on average? If the activities were also attended by customers from other programs, please include them in the count provided.
			d)	How many staff provided each workshop?
		4)	Please use the space below to describe what, if any, unusual circumstances may have affected service costs during the reporting period, [specify reporting period].
			[Click here and start typing.]
				PLEASE SAVE AND CONTINUE TO THE NEXT SECTION.

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Sheet 7: F. Gen. Supplies & Equipment

WORKSHEET F: GENERAL SUPPLIES & EQUIPMENT/CAPITAL ASSETS [to be completed by all respondents]
	This worksheet requests information about general office supplies and durable equipment and capital assets used by your agency to implement the SNAP E&T pilot.
	1)	Using the table below, please indicate the cost or estimated value of general office supplies and materials used by your agency's SNAP E&T pilot program. For the purposes of this worksheet, supplies and materials are [need to add examples; would include purchase of MIS systems].
			ØList the supply or material, including supplies and materials that have been donated to your agency. DO NOT list any service-specific materials or supplies already listed in the previous worksheet (E. Services).
			ØIndicate the cost (purchase price) or replacement value of each material or supply.
			ØReport the approximate percentage (%) of the cost that was paid for with SNAP E&T pilot funds. Note "0%" from the list if the item was donated.
			Type of Supply / Material	Purchase Price or Estimated Value	% of Cost Paid for with SNAP E&T Pilot Funds
	2)	Please use the table below to report information about equipment/assets used by your SNAP E&T pilot during the reporting period, [specify the reporting period]. For the purposes of this workbook, durable equipment and capital assets are items with an expected useful life of more than one year; this might include [specify examples]. Please indicate:
			�ØThe type of equipment/asset.
			�ØThe year the equipment/asset was purchased (if available).
			�ØThe original purchase price or estimated value of the equipment/asset.
			�ØThe equipment/asset's expected useful life, in years.
			�ØThe percentage of the equipment/asset's purchase price that was paid for with SNAP E&T grant funds.
		Type of Equipment		Primary Use	Year Purchased	Purchase Price or Estimated Value	Expected Useful Life (Years)	% of Purchase Price Paid with SNAP E&T Pilot Funds
		Study team will pre-fill after first round of data collection.		Study team will pre-fill after first round of data collection.	Study team will pre-fill after first round of data collection.	Study team will pre-fill after first round of data collection.	Study team will pre-fill after first round of data collection.	Study team will pre-fill after first round of data collection.
	3a)	Did your agency rent or lease any equipment for use by the SNAP E&T pilot during the reporting period, [specify reporting period].
			[Click here and select from list.]
	3b)	If you answered YES to question 3a, please complete the table below with information about rented or leased equipment used by the SNAP E&T pilot during the reporting period, [specify reporting period].
			Type of Equipment	Total Rent / Lease Costs During the Reporting Period	% of Costs Paid with SNAP E&T Pilot Funds
4)	Please use the space below to provide any explanatory notes about the materials, supplies, or equipment listed in the tables above.
		[Click here and start typing.]
		PLEASE SAVE AND CONTINUE TO THE NEXT SECTION.

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Sheet 8: G. Volunteers

WORKSHEET G: VOLUNTEERS [to be completed by service providers only]
	This worksheet requests information about the value of any labor donated to the SNAP E&T during the reporting period, [specify reporting period].
1)	Did volunteers help your agency to provide SNAP E&T pilot services during the reporting period, [specify reporting period]?
		[YES/NO]
2a)	If you answered YES to question 1, please use the table below to estimate the value of the labor donated by the volunteers that helped your agency provide SNAP E&T Pilot during the reporting period, [specify reporting period]. For each volunteer, please enter:
		�ØTheir position (job title)
		�ØEach volunteer's primary responsibility or responsibilities on the SNAP E&T pilot.
		�ØThe number of hours they volunteered per week.
		�ØThe number of months they volunteered during the reporting period, [specify reporting period].
		�ØThe estimated hourly wage for a paid employee in each position.
	Position		Primary SNAP E&T Pilot Responsibilities		Time		Estimated Hourly Wage for Paid Employee
			Primary Responsibility #1	Primary Responsibility #2	Hours Worked per Week	Months Worked
	Study team will pre-fill after first round of data collection.		[Click here and select from list.] Study team will pre-fill after first round of data collection.	[Click here and select from list.] Study team will pre-fill s first round of data collection.		Study team will pre-fill after first round of data collection.
2b)	Please describe the source of your estimates for hourly wages.
		[Click here and start typing.]
3)	Please use the space below to enter any explanatory notes on the information provided in this section.
		[Click here and start typing.]
		PLEASE SAVE AND CONTINUE TO THE NEXT SECTION.

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Sheet 9: H. Miscellaneous

WORKSHEET H: MISCELLANEOUS COSTS [to be completed by all respondents]

This worksheet requests information about other costs incurred by your agency in implementing the SNAP E&T pilot that are not already recorded in the other tabs of this workbook.

1)

INDIRECT COSTS: Did your agency calculate an indirect cost rate for the SNAP E&T pilot during the reporting period, [specify reporting period]?

[Click here and select from list.]

a)

If you answered YES to question 1, indicate whether the indirect cost rate was an established rate (e.g., federally negotiated) or if your agency calculated the rate some other way.

[Click here and select from list.]

b)

If you answered YES to question 1, please enter the indirect cost rate (%) that your agency used during the reporting period, [specify reporting period].

[Enter percentage (%).]

c)

If you answered YES to question 1, please report the $ amount paid for indirect costs during the reporting period, [specify reporting period].

[Enter $ amount.]

d)

If you answered YES to question 1, please list the expenses to which the indirect cost rate is applied?

[Click here and start typing.]

2)

TRAVEL: Complete the table below if your agency paid the SNAP E&T pilot-related travel of any staff during the reporting period, [specify the reporting period].

ØIndicate the type of travel expense (e.g., gasoline reimbursement for travel to job sites, etc.).

ØReport your expenses ($) for each type of travel during the reporting period, [specify reporting period].

ØReport the approximate percentage (%) of the expense that was paid for with SNAP E&T pilot funds.

Type of Travel Expense

Expense Cost

% of Cost Paid with SNAP E&T Pilot Funds

[Click here and start typing.] Study team will pre-fill after first round of data collection.

3)

OTHER COSTS: Using the table below, please enter the cost or estimated value ($) of any items purchased by or donated to your agency for use by the SNAP E&T pilot during the reporting period, [specify reporting period], that are not already listed in this workbook.

ØList the type of each item.

ØReport the item's cost (e.g., purchase price) or estimated value ($).

ØReport the approximate percentage (%) of the cost that was paid for with SNAP E&T pilot funds. Note "0%" if the item was donated.

Type of Item or Service Purchased for / Donated to the SNAP E&T Pilot

Cost or Estimated Value ($)

% of Cost Paid with SNAP E&T Pilot Funds

[Click here and start typing.] Study team will pre-fill after first round of data collection.

END OF WORKBOOK. THANK YOU FOR YOUR PARTICIPATION. PLEASE SAVE AND SUBMIT VIA THE EVALUATION FTP SITE USING THE INSTRUCTIONS PROVIDED.

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Sheet 10: DROPDOWN LISTS

Worksheet B1: Staff (Salary)
Primary Responsibilities	Salary is per	SNAP E&T Pilot Status	Payroll Taxes and Fringe Benefits
[TBD; will vary by pilot]	hour	no change	YES
[TBD; will vary by pilot]	week	changes (explained below)	NO
[TBD; will vary by pilot]	month
[TBD; will vary by pilot]	year
Worksheet C: Service Provider Contracts
Contracts	SNAP E&T Pilot Status
YES	no change
NO	changes (explained below)
Worksheet D: Facilities
Type of Facilitiy	Facility is…	Reported cost is…	Months Used	SNAP E&T Pilot Status
[TBD; will vary by pilot]	owned	weekly	1	no change
[TBD; will vary by pilot]	leased	monthly	2	changes (explained below)
[TBD; will vary by pilot]	rented	annual	3
[TBD; will vary by pilot]	donated		4
Worksheet F: Gen. Supplies & Equipment
Rent/Lease
YES
NO
Worksheet G: Volunteers
Primary Responsibilities
[TBD; will vary by pilot]
[TBD; will vary by pilot]
[TBD; will vary by pilot]
[TBD; will vary by pilot]
Worksheet H: Misc.
Indirect Rate	Established Rate
YES	YES
NO	NO