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

Evaluation of Food Insecurity Nutrition Incentives (FINI)

Appendix X.2. Outlet characteristics form.xlsx

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

OMB: 0584-0616

Document [xlsx]
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Overview

Instructions
outlet level dataform


Sheet 1: Instructions

INSTRUCTIONS
We would like you to list all FINI outlets that your organization operated in 2015 and projections for 2016 and 2017 on the next tab titled "outlet level dataform." We asking you to provide the following information for each outlet:



Variable Explanation Response Options
FNS Authorization Number FNS Authorization Number assigned to that outlet. This should be unique per outlet.
Outlet Name Outlet Name
Outlet Address Number Location of the outlet, which we will use to map all FINI outlets in a state.
Outlet Street
Outlet City
Outlet State Code
Outlet Zip
Outlet Zip4
Outlet Type Outlet Type Large Chain Grocery Store/Supermarket
Discount Superstore
Convenience Store
Small Store or Corner Store
Farmers Market
Direct Farm
Farm Stand
Mobile market at single location
Mobile market at multiple locations
CSA
Incentive Match Rate Incentive Match Rate a = <1:1
b = 1:1
c = >1:1
d = a and b above
e = a and c above
f = b and c above
g = all of the above
Incentive Offered in 2015? Incentive was offered in 2015? Yes; No; Don't Know
Incentive offered in 2016? Will this outlet offer FINI incentive in 2016? Please make an attempt to predict what will happen in 2016 if you are still planning. Yes; No; Don't Know
Incentive offered in 2017? Will this outlet offer FINI Incentive in 2017? Please make an attempt to predict what will happen in 2017. Yes; No; Don't Know
Open year round in 2017? Open year round in 2017? Yes; No; Don't Know
Incentive offered February 2017? Incentive offered February 2017? Yes; No; Don't Know
Incentive offered March 2017? Incentive offered March 2017? Yes; No; Don't Know
Incentive offered April 2017? Incentive offered April 2017? Yes; No; Don't Know
Incentive offered May 2017? Incentive offered May 2017? Yes; No; Don't Know
Incentive offered June 2017? Incentive offered June 2017? Yes; No; Don't Know
Incentive offered July 2017? Incentive offered July 2017? Yes; No; Don't Know
Incentive offered August 2017? Incentive offered August 2017? Yes; No; Don't Know
Incentive offered September 2017? Incentive offered September 2017? Yes; No; Don't Know
























According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number. The time required to complete this information collection is estimated to average 60 minutes 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.

Sheet 2: outlet level dataform

FNS Authorization Number Outlet Name Outlet Address Number Outlet Street Outlet City Outlet State Code Outlet Zip Outlet Zip4 Outlet Type Incentive Match rate Incentive Offered in 2015? Incentive offered in 2016? Incentive offered in 2017? Open year round in 2017? Incentive offered February 2017? Incentive offered March 2017? Incentive offered April 2017? Incentive offered May 2017? Incentive offered June 2017? Incentive offered July 2017? Incentive offered August 2017? Incentive offered September 2017?
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