Fns 886 Snap-ed Toolkit Intervention Submission Form

SNAP-Ed Toolkit Submission Form and Scoring Tool

Appendix 2 Intervention Submission Form FNS-886

State, Local and Tribal Agencies

OMB: 0584-0639

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UNITED STATES DEPARTMENT OF AGRICULTURE

OMB APPROVED NO. 0584-XXXX
Expiration Date: MM/DD/YYYY

Food and Nutrition Service
SNAP-ED TOOLKIT INTERVENTION SUBMISSION FORM
This submission form will be used in the review of your intervention. All items marked with an asterisk (*) are required. Make sure to
check all relevant categories for each field. Responses must fit within the space provided. Guidance is provided regarding what should
be addressed for questions which are answered in narrative format. You may not be able to complete all of the optional questions if
your intervention is considered an emerging intervention. This does not mean it will be excluded from consideration for the SNAP-Ed
Toolkit.
Up to 5 documents may be attached to provide additional information. Attached documents should be summary and/or evaluationoriented publications or reports.
SECTION I. INTERVENTION NAME, CONTACT INFORMATION, AND COST:
1. Strategy/Intervention/Program name (brand):*
2. Developer(s)/Author(s) and credentials:*
3. Developer(s)/Author(s) Organization(s):
4. Contact name:*
5. Contact email:*
6. Contact phone:*
7. Funding source(s):*
8. Organization Website (URL):
9. Publication/Revision year:*
10. Are the intervention and evaluation materials available at no cost?:*

11. If there is a cost for materials, please describe:

12. Is this material available to order?:*

Yes

No

a. If yes to question 12, how are materials ordered?:
b. If ordering website is different from question 8, please provide website link:

Form Approved OMB No. 0584-NEW | 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 5 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA
22302, ATTN: PRA (0584-xxxx*). Do not return the completed form to this address. Expiration date: XX/XX/XXXX
FNS-886 (12-17) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 Version

Intervention:
Date submitted:
13. Describe the intervention materials available (maximum 500 characters):*
Provide a summary of the available intervention materials. It could be helpful here to include a bulleted list of intervention materials
with corresponding links to more information.

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Intervention:
Date submitted:
SECTION II. INTERVENTION OVERVIEW:
14. Check all relevant categories for each field:*
Field
Intervention
Approach(es)/Type(s)

Categories
Direct Education
Policy, Systems, and Environmental (PSE) Change
Social Marketing

Target Behavior(s)

Breastfeeding

Healthy Eating

Physical Activity and Reducing Screen Time
Food Insecurity/Food Assistance
Other:
15. Primary Intervention Objectives:*
-

Add Objective
16. Provide a brief overview of the intervention in paragraph form that describes how it works, how it addresses PSE change, social
marketing and/or direct education, and other key features (maximum 2,000 characters):*
The [Intervention name, acronym] is a [intervention type] designed to [intervention objective(s)]. Include another 2-4 sentences
providing additional intervention details, such as basic information on how it works, how it addresses SNAP-Ed outcomes
(including PSE), and other important features critical to successful implementation.

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Intervention:
Date submitted:
We have used the RE-AIM framework to facilitate the review and discussion of interventions. To learn more about RE-AIM, please visit
http://re-aim.org/.1
SECTION III. REACH:
17. Check all relevant categories for the field:*
Field

Categories

Available language(s)

Cambodian

Chinese

Creole

English

Hmong

Korean

Lao

French

Russian

Spanish

Vietnamese

Other:
18. Check all relevant categories for each field:*
Field
Target audience(s)

Ethnicity
Race

Categories
Hispanic/Latino
Non-Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Other

Preschool (<5 years old)
Middle School

Elementary School

High School

Homeless/Food Pantry Clients
Pregnant/Breastfeeding Women
Parents/Mothers/Fathers

Adults

Older Adults

Other:
19. Describe how the intervention reaches the intended population or SNAP-Ed Audience Segment (maximum 1,000 characters):*
How does the intervention specifically address the needs of the target audience? Explain what steps were taken during
development to ensure it is appropriate for the audience it serves and the setting in which it is intended to be held.

1

Additional resources to help you understand RE-Aim can be found online at
http://web1.sph.emory.edu/DTTAC/planningFundamentals/docs/Mod5-7REAIMFramework.pdf

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Intervention:
Date submitted:
SECTION IV. EFFECTIVENESS:
To help you understand the outcomes of interest for SNAP-Ed, please review the The Supplemental Nutrition Assistance Program
Education (SNAP-Ed) Evaluation Framework: Nutrition, Physical Activity, and Obesity Prevention Indicators: Interpretive Guide to the
SNAP-Ed Evaluation Framework. For detailed information about indicators, please visit the interactive SNAP-Ed Toolkit. To understand
what is used for the numerator and denominator for each indicator, please see Appendix D., p. 362–391 of the PDF version of the
Interpretive Guide.
20. Describe any target audience or community partner involvement in the development of your intervention (500 character limit):*
Explain what partners were involved and how they contributed to the development of your intervention.

21. Were instruments used in developing, testing, and evaluating this intervention with educators, intervention participants, and
stakeholders to assess the acceptability (how well it serves the target audience and fits into the intended setting) of the
intervention?*
Yes

No

a. If “Yes” to question 21, please describe how they were used to assess and improve your intervention (1,000 character limit):
Explain how the tools were used, the results collected, and (if they were used) how they were used to update or improve your
intervention. Provide links to tools, if available. If reports are available, it is highly suggested that they are included as an
attachment to your submission.

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Intervention:
Date submitted:
22. What intended outcomes were achieved and to what extent (this includes health, behaviors, environmental, policy/practice
outcomes)?* If applicable, for each Indicator of the SNAP-Ed Evaluation Framework that this intervention addressed, which
metric(s) from the companion Interpretive Guide changed?
-

Outcome/Indicator:
Outcome Measure(s) addressed:
Extent achieved:
-

Numerator (if applicable):

-

Denominator (if applicable):

(Please insert additional outcomes if necessary.)
Add Outcome
23. Please describe what unintended/unexpected outcomes occurred and to what extent (1,000 character limit).
In addition to unintended benefits, describe any challenges, lessons learned, or recommendations that may be useful to future
users of this intervention.

24. Choose the appropriate evidence-based approach for your intervention (choose only one option):*
To accurately determine the appropriate evidence-based approach for your intervention, please review the
Checklist for Evidence Based Approaches.
Research-tested

Practice-tested

Emerging

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Intervention:
Date submitted:
25. For your evidence-based approach, please indicate the supporting evidence which you are providing to support your intervention.*
CDC.gov provides additional information about types of evaluation. Check all relevant categories for each field:
Field
Type of Evaluation

Categories
Case study

Cost analysis

Cost-benefit analysis

Cost-effectiveness evaluation

Cost-utility analysis

Economic evaluation

Evaluability assessment

Evaluation report

Formative research (such as audience testing)
Impact evaluation

Logic model

Needs Assessment

Objectives-based evaluation

Outcome evaluation
Peer-reviewed publication(s)
Pilot testing results

Program monitoring

Process evaluation
Supporting research for theoretical framework
Other (please describe):

26. Please describe the evidence findings included in your submission (1,000 character limit):*
Please include links to online materials, if available. Include examples showing change in behavior, environmental settings, sectors
of influence, or population results, as appropriate. Attaching supporting documents which substantiate evidentiary claims made
here is highly recommended.

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Intervention:
Date submitted:
27. Are evaluation materials provided for your intervention:*
Yes

No

a. If yes to question 27, Please describe the provided evaluation materials (500 character limit):
Please include links to formative or process evaluation materials such as surveys, interview or focus group questions, and output
or outcome data collection tools, if available.

b. If no to question 27, please describe the recommended evaluation materials (500 character limit):
Please include links to appropriate evaluation materials, if available.

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Intervention:
Date submitted:
SECTION V. ADOPTION:
28. Check all relevant categories for each field:*
Field
Primary intended setting(s)

Categories
Community

Early childcare & education

Faith-based

Farmers markets

Gardens

Healthcare

Indian Tribal Organizations

Food retail

Food pantries

Schools

USDA program sites (not National School Lunch Program)
Worksites
Other (please describe):
29. Describe the primary setting(s) the intervention was designed for and degree of adoption (500 character limit):*
Include settings not listed above. If available, indicate the number and proportion of eligible sites/settings/partners that completed
the intervention and the number and proportion of the target audience that was reached. These may be estimates. If available,
explain how sites were able to continue the intervention without assistance.

30. Briefly describe how partners/settings selected in 28 contributed to the success of the intervention (1,000 character limit)*
Describe resources provided (volunteers, physical space, technical services, etc.) and how they were used.

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Intervention:
Date submitted:
31. Check all relevant categories for each field:*
Field

Categories

Check all relevant potential
intervention partners/settings

Agricultural organizations (includes farmers markets)
Chefs/culinary professionals

City/regional planning

Early child care & education facilities
Faith-based groups

Food banks/pantries

Government programs

Healthcare

Labor/workforce development
Parks and recreation

Food retail
Indian Tribal Organizations

Media/advertising groups

Nonprofits

Restaurants

Schools (colleges, universities, vocational)

Schools (K-12)

Worksites

Other (please specify):
32. Has the intervention been implemented in the past with a low-income audience?*
Yes

No

a. If yes to question 32, what state(s) was it used in?:
33. Describe any examples where partners/settings expressed an unsolicited interest in participating in the intervention, and the factors
that contributed to their interest (1,000 character limit):
Describe the type of partners/settings and the intervention role of interest, such as referring clients, acting as a setting, or receiving
or providing resources. Explain what reasons the group provided for their interest in participating in the intervention, and how this
facilitated your intervention’s effectiveness, if applicable.

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Intervention:
Date submitted:
SECTION VI. IMPLEMENTATION:
34. Describe the main intervention components (i.e., critical features of the intervention’s intent and design that should be kept intact
when the intervention is implemented) (1,000 character limit):*
[Intervention acronym] includes [main intervention components]. These intervention components provide [specific aims or goals of
the components]. Describe which components are core components and which may be modified or omitted. Include additional
sentences that help describe how these components address the target behavior(s), any basic steps required to implement the
intervention and a timeline for implementation, points of coordination among partners or settings for delivery, and ongoing tracking
and evaluation points.

35. Are staff/partner/volunteer training materials available for your intervention?*
Yes

No

a. If yes to question 35, Please describe the provided training materials (500 character limit):
Please include links to training materials, if available.

36. Describe methods used and data collected to ensure the intervention was implemented with fidelity (500 character limit):*
Include materials that define the steps to plan implementation, role delineation and resource allocation; feedback systems to
monitor operations, consumer response, and partner/setting acceptance; benchmarks to track progress; and the resource
commitments, both in-house and through new resource acquisition. Include budget estimates for implementation and oversight. It
is highly recommended that any of the materials listed above are included as intervention material attachments.

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Intervention:
Date submitted:
SECTION VII. MAINTENANCE:
37. How long has this intervention been implemented in the field?*
38. Has this intervention been adopted independently by partners/in settings not directly supported by SNAP-Ed?*
Yes

No

39. Describe the ongoing resources needed to maintain the quality of this intervention (1,000 character limit):*
Describe resources such as physical materials, staff FTE’s and ongoing training, and costs associated with tracking and evaluation.

40. Describe any adaptations or modifications made to your intervention over time (1,000 character limit):
If applicable, explain how process evaluation was used to inform adaptations and modifications. Please include adaptation in
different settings or communities than those for which it was originally intended. Modifications may be made to move interventions
from pilot projects to full scale, or to make adaptations to changes in conditions such as partner/setting interest, policy priorities,
updated standards, personnel changes, economic conditions, etc.

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Intervention:
Date submitted:
41. What effect, if any, have the modifications described above changed the adoption, implementation, or outcomes achieved by the
intervention (500 character limit)?
If applicable, describe changes to number or type of sites, how implementation was improved, and what outcomes were achieved
and to what extent.

42. What sustainability concerns must be addressed by organizations who wish to utilize this intervention? (500 character limit)*
Consider staffing and funding needed for implementation, as well as intervention complexity. Describe any steps taken or
modifications to the intervention to address these issues.

43. Describe partnerships or diversified funding mechanisms which may address the concerns above (500 character limit):
Describe any efforts that have successfully addressed sustainability such as demonstrating return on investment, social enterprise,
partnership with non-profit or private partners, or successfully awarded grant funding.

SECTION VIII. INTERVENTION ATTACHMENTS:
44. Please attach and list below: intervention materials (such as training manuals or sample lessons) and any evaluation tools (such as
environmental assessments or participant surveys) for review.
-

(Please insert additional items as necessary.)
Add Item

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Intervention:
Date submitted:
SECTION IX. EVALUATION ATTACHMENTS:
45. Please attach and list below up to 5 supporting documents that are summary and/or evaluation-oriented publications or reports.
1)
2)
3)
4)
5)

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File Typeapplication/pdf
File TitleFNS-886
SubjectSNAP-ED TOOLKIT INTERVENTION SUBMISSION FORM
File Modified2017-12-27
File Created2017-12-27

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