Worksheet FNS 759 OMB# 0594 formerly 0542

Form Approved OMB No. 0584-0594
Expiration Date: XX/XX/XXXX

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Supplemental Nutrition Assistance Program Education (SNAP-Ed)
Education and Administrative Reporting System (EARS) Form
OMB 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 0584-0594. The time to complete this information
collection is estimated to average 60 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Unless otherwise noted, the following applies to all items in this form:
1) Population refers to SNAP-Ed participants (individuals participating in or exposed to SNAP-Ed activities, which
consists of direct education; social marketing; and policy, systems, and environmental change (PSE) interventions).
Indirect education will be captured within the social marketing and PSE sections.
2) Reach is defined as the audience that experiences the intervention or encounters an improved environment on a
regular (typical) basis and is assumed to be influenced by it.
3) Actual counts are counts that can be collected with a high degree of certainty. Estimated counts are only
appropriate when enough information to provide actual counts is not available, as may be the case for statistics
representing the reach of PSEs.
4) Fields providing totals for data will be automatically calculated.
5) Key points are noted throughout the form to assist with reporting.

FNS-759 (02/16) Previous Editions Obsolete.

SBU

Electronic Form Version Designed in Adobe 10.0 version

ITEM 1

Data on SNAP-Ed

State:

Federal Fiscal Year:

An implementing agency is an organization that has a contract or formal agreement with the State Supplemental Nutrition Assistance
Program (SNAP) to develop and deliver nutrition education and obesity prevention activities. If your State directly administers
programs, then your State Agency must complete this form. Use one form per implementing agency.
Implementing Agency Name:

ITEM 2

Direct Education - information on participation by age and sex

Number of SNAP-Ed participants (unduplicated) by age group and sex:
Reporting an unduplicated count means providing the number of unique individuals, regardless of the number of sessions he/she has
participated in a direct education intervention.
A row may have both actual counts and estimated counts. Actual counts should be used whenever possible. Estimated counts are
appropriate in certain cases, such as when single presentations are given to families at school events.
Age

Female

Male

Actual
Count

Estimated
Count

Less than 5 Years
5-17 Years
18-59 Years
60 Years or Older
Total

Explanation of Estimation Method(s) - 500 Word Limit

For any estimated counts, please describe the methods used to determine the number of participants.

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Total

ITEM 3

Direct Education - information on participation by race and ethnicity

Number of unduplicated SNAP-Ed participants by race and ethnicity:
As in Item 2, a row may have both actual counts and estimated counts. Actual counts should be used whenever people self-identify.
Estimated counts are appropriate in certain cases, such as when individuals do not identify with a specific race and are assigned one
or more than one for reporting purposes.

Actual Count of
Estimated Count of
SNAP-Ed Participants SNAP-Ed Participants
Ethnicity

Hispanic/Latino
Non-Hispanic/Latino

Race (Select One or More)

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Total

ITEM 4

Direct Education - characterizing education session format, delivery, time, and use of interactive media

Programming Details:
Interactive multimedia integrates text, audio, graphics, still images, and moving pictures into one computer-controlled, multimedia
product that provides an individualized educational experience based on a participant's input.

Format

A. Number
Delivered

1. Single Session
2. Series of 2 to 4 Sessions
3. Series of 5 to 9 Sessions
4. Series of 10 or More Sessions

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B. Time Range
per Session
(in minutes)

C. Number of Sessions
Delivered Using
Interactive
Multimedia

Note: The remaining items in this form collect data on all three types of interventions, specifically direct education (denoted by DE), social marketing (denoted by
SM), and policy, systems, and environmental changes (denoted by PSE).

ITEM 5

Interventions - characterizing implementation, indirect education, reach, and expenditures

Codes for this item are provided on the previous pages.
Indirect education is captured in Column I, and you can leave the column blank (have no codes for it) if indirect education is not used.

A. Name or
Descriptive Title
for the
Intervention

B. Intervention
Types(s)
(DE, SM
and/or PSE)
(Select All
That Apply)

C. Year

D.
E. Priority
Implementation Population(s)
Stage
(Use Codes)
(Use Codes)

F. Estimated
G. Data H. Intervention I. Indirect
J.
Number of
Sources
Settings
Intervention Intervention
SNAP-Ed
(Select All (Use Codes)
Channels
Topic(s)
Participants That Apply) and Number (Use Codes)
Reached
of Sites Per
Setting

Explanation of Reach Calculations and Any Assumptions Made - 1000 Word Limit

Please provide a brief description of the estimated reach for each intervention, including methods used and any assumptions made.

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Codes for Item 5
For Column C, enter the year of the intervention (for the year on which you are reporting) out of the projected lifespan, while including
planning and development phases. If an intervention, such as a PSE, will be an ongoing program, do not include an end year.
Example: If you are reporting on the first year of a three-year social marketing campaign, record “1 out of 3.”
For Column D, use the following codes (select all that apply):
P = Planning (for social marketing, this includes market and formative research)
D = Developing (for social marketing, this includes campaign/materials design and consumer testing)
I = Implementing
T & E = Tracking and Evaluation
For Column E, enter all of the appropriate codes describing the priority population (target audience) for the intervention.
Ethnicity: H/L = Hispanic/Latino
N = Hispanic/Latino

Sex: F = Female
M = Male

Race: AI/AN = American Indian or Alaska Native
A = Asian
B = Black or African American
NH/PI = Native Hawaiian or Other Pacific Islander
W = White

Age: A = All ages
<5 = Less than 5 years of age
5-17 = 5 to17 years of age
>18 = 18 to 59 years of age
>60 = 60 years of age or older

For Column F, interventions that only consist of direct education do not require a response here. Item 2 data will be used.
For Column G, for each type of communication channel and event, enter all of the applicable codes for the source(s) of the data used
to tabulate the estimate.
C = commercial market data on audience size
S = survey of target audience
V = visual estimate
O = other
For Column H, use the intervention setting codes and follow it with the number of sites per setting.
Example: If an intervention was carried out in 2 congregate meal sites, you would report “A, 2.”
For Column I, use all of the codes corresponding to the indirect intervention channels used in each campaign
A = Articles
B = Billboards, bus/van wraps, or other signage
C = Calendars
E = Electronic materials (e.g. email and electronic newsletters or mailings/text messaging)
H = Hard copy materials (e.g. fact sheets, flyers, pamphlets, activity books, posters, banners, postcards, recipe cards, or
newsletters for mailings)
N = Nutrition Education Reinforcement Items (NERI) (e.g., pens, pencils, wallet reference cards, magnets, door hangers, and
cups with nutrition messages)
P = Point-of-sale or distribution signage (e.g., displays or window clings in retail stores)
R = Radio public service announcement
S = Social media (e.g., Facebook, Twitter, Pinterest, and blogs)
T = TV public service announcement
V = Videos (includes CD, DVD, and online video sites like YouTube)
W = Website
O = Other – please specify:
For Column J, use the intervention topic codes and select all that apply.

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Setting Codes for Item 5
Type of Setting by Domain
Eat
A.
B.
C.
D.
E.
F.

Congregate Meal Sites/Senior Nutrition Centers
Fast Food Chains
Mobile Vending/Food Trucks
Restaurants
Soup Kitchens
USDA Summer Meals Sites
Other - please specify:
Learn

G.
H.
I.
J.
K.
L.
M.
N.
O.
P.

Adult Education, Job Training Sites,TANF Sites, & Veterans Services
Adult Rehabilitation Centers
Afterschool Program Sites (Includes Boys and Girls Clubs)
Family Resource Centers
Head Start Facilities
Libraries
Mobile Education Sites
Schools (Preschool)
Schools (K-12, Elementary, Middle, and High)
Schools (Colleges and Universities)
Other - please specify:
Live

Q.
R.
S.
T.
U.
V.
W.

Child Care Centers
Emergency Shelters and Temporary Housing Sites
Faith-based Centers/Places of Worship
Family Daycare Homes
Indian Reservations
Individual Homes
Public Housing Sites
Other - please specify:
Play

X.
Y.
Z.
AA.
BB.
CC.

Bicycle and Walking Paths
Community Centers
County Fairgrounds
Gardens (Community/School)
Parks and Open Spaces
Recreation Centers (Includes YMCAs )
Other - please specify:
Shop

DD.
EE.
FF.
GG.

Farmers Markets
Food Assistance Sites, Food Banks, and Food Pantries
Small Food Stores (≤3 registers)
Large Food Stores and Retailers (4+registers)
Other - please specify:
Work

HH.
II.
JJ.
KK.
LL.
MM.

Extension Offices
Health Care Clinics and Hospitals
Military Bases
SNAP Offices
WIC Clinics
Worksites
Other - please specify:
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Intervention Topic Codes for Item 5
Individual knowledge and skills
A. My Plate food groups and portions for a healthy eating pattern
B. Food shopping and resource management
C. Food preparation/cooking and food safety
D. Promoting and maintaining a healthy weight
E. Prevention of obesity, diabetes, and other chronic diseases
Other – please specify:
Individual behaviors
Food and beverage consumption:
F. Fruits and vegetables
G. Whole grains
H. Dairy (including low-fat/fat-free milk and/or fortified soy beverages)
I. Protein foods (including seafood, lean meats and poultry, eggs, nuts, seeds, and soy products)
J. Healthy fats and oils
K. Fiber-rich foods
L. Water
M. Limiting added sugars
N. Limiting saturated fats
O. Limiting sodium
Engagement in physical activity
P. Active commuting (e.g., walking and bicycling)
Q. Participation in sports and recreational activities (e.g., tennis and swimming)
R. Reducing sedentary activities and screen time (e.g., playing computer games and TV viewing)
Other – please specify:

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ITEM 6

Partnerships - entities that receive no direct SNAP-Ed funding but are involved in SNAP-Ed programs
A. Number of
Partners You
Work With this
Reporting Year

Partner Title

B. Assistance
Received
If Applicable
(Use Codes)

C. Assistance
Provided
If Applicable
(Use Codes)

D. Intervention Type(s)
With Partner's
Involvement (DE, SM,
and/or PSE)
(Select All That Apply)

N/A

N/A

N/A

Agricultural Organizations (Includes Farmers Markets)
Chefs/Culinary Institutes
City and Regional Planning Groups
Child Day Care Centers
Early Care and Education (Includes Head Start)
Faith-based Groups
Food Banks/Food Pantries
Food Stores (Convenience Stores, Grocery Stores, Supermarkets, Etc.)
Foundations/Philanthropy Organizations/Nonprofits
Government Program/Agency (Federal, State, Local, Etc.)
Hospitals/Healthcare Organizations (Includes Health Insurance Companies)
Human Services Organizations
Indian Tribal Organizations
Labor/Workforce Development Groups
Media/Advertising Groups
Parks and Recreation Centers
Public Health Organizations
Restaurants
Schools (Preschools, K-12, Elementary, Middle, and High)
Schools (Colleges and Universities)
Transportation Groups
Worksites
Other (please specify):

Total
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Codes for Item 6
For Column B, enter one or more of the following codes that describe the type of assistance received from partner entities.
For Column C, enter one or more of the following codes that describe the type of assistance provided to partner entities.
Note that there is a category for “Other” types of support not covered.
A = Advertising (includes marketing)
C = Consulting
D = Development
E = Evaluation and tracking
F = Funding
H = Human resources (*staff or staff time)
I = Program implementation (e.g. food and beverage standards)
M = Materials (publications, supplies, etc.)
P = Planning
R = Recruitment (includes program outreach)
S = Space (e.g., facility or room where programs take place)
T = Technical services (e.g. a videographer producing videos for local SNAP offices)
O = Other - please specify:
*Staff members include professionals, paraprofessionals, and volunteers when applicable.

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