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

Evaluation of Food Insecurity Nutrition Incentives (FINI)

Appendix AE.1 Annual Core Program Data Form - English only

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

OMB: 0584-0616

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Appendix AE.1


Annual Core Program Data Form


English Only

Shape1

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

  1. What is the grantee’s name?


  1. What is the name of the incentive program? (e.g., double up coupons, fresh bucks, etc.)



  1. 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



  1. What is the organizational or management structure for the incentive program? (Please attach a written description and include organizational chart if available).


  1. 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




  1. 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? ____ ____ ____


  1. 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) _________________________


  1. 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) _____________________________


  1. 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) ___________________________


  1. 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)

$______________




  1. 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)


  1. 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? _____


  1. Contact information of the person completing this form:

NAME: ________________________________


TITLE: _________________________________


EMAIL: ________________________________


PHONE NUMBER: _______________________


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleFINI Grantees Template
AuthorChandria Jones
File Modified0000-00-00
File Created2021-01-21

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