Fns 886 Snap-ed Toolkit Intervention Scoring Tool

SNAP-Ed Toolkit Submission Form and Scoring Tool (FNS 885 and FNS 886) w/ Screenshots

Appendix 2.1 FNS 886 Final Draft 10-6-2021.rtf

State, Local and Tribal Agencies

OMB: 0584-0639

Document [rtf]
Download: rtf | pdf


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UNITED STATES DEPARTMENT OF AGRICULTURE

Food and Nutrition Service

OMB APPROVED NO. 0584-0639

Expiration Date: XX-XX-XXXX


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 10 documents may be attached to provide additional information. Attached documents should be summary and/or evaluation-oriented publications or reports.


SECTION I. INTERVENTION NAME, CONTACT INFORMATION, AND COST:


  1. Strategy/Intervention/Program name (brand):*


  1. Developer(s)/Author(s) and credentials:*


  1. Developer(s)/Author(s) Organization(s):


  1. Contact name:*


  1. Contact email:*


  1. Contact phone:*


  1. Funding source(s):*


  1. Organization Website (URL):


  1. Publication/Revision year:*


  1. Are the intervention and evaluation materials available at no cost?:* Yes No



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



  1. Shape18 Shape19 Is this material available to order?:* Yes No

    1. If yes to question 12, how are materials ordered?:


    1. If ordering website is different from question 8, please provide website link:









Form Approved OMB No. 0584-0639 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 [0584-0639]. 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, 1320 Braddock Place Alexandria, VA 22314

ATTN: PRA (0584-0639). Do not return the completed form to this address. Expiration date: XX-XX-XXXX



FNS-886 Version 2 (4-21) Previous Editions Obsolete

SBU Electronic Form Version Designed in Adobe 10.0 Version




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SECTION II. INTERVENTION OVERVIEW:

  1. 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 3,000 characters):*

For example: The [Intervention name, acronym] is a [intervention type] designed to [intervention objective(s)].

Include 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.

Consider adding the following details for each appropriate intervention approach:

  • Direct Education: Number of sessions, length of each session, age of participants, preferred settings, etc

  • PSE Change: Description of PSE change, targeted settings, key stakeholders to engage, training and/or technical assistance provided, etc.

  • Social Marketing: Channels used (e.g. mass media, social media), message(s) promoted, targeted segment of the SNAP- Ed eligible audience, target behavior(s) addressed, etc.



  1. Shape24 Shape25 Shape26 Check all relevant categories for each field:*


Field

Categories

Intervention Approach(es)/Type(s)

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


  1. Please select the evidence-based approach that best describes your intervention:*

  • Research-tested: significant effects on individual behaviors, food/physical activity environments, or policies shown with findings published in peer-reviewed literature or external evaluation report

  • Practice-tested: positive effects on individual behaviors, food/physical activity environments, or policies shown

  • Emerging: based on underlying theory or logic with potential for obesity prevention but has not yet been formally evaluated

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  1. 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

Categories

Type of Evaluation

Case Study Cost analysis

Cost-effective evaluation

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):




  1. Shape29 Primary Intervention Objectives:*

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  1. Describe the intervention materials available (maximum 500 characters):*

Provide a summary of the available intervention materials. It could be helpful here to It could be helpful here to reference the appendices and/or to include a bulleted list of intervention materials with corresponding links to more information.

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:

  1. Shape35 Shape36 Shape37 Shape38 Shape39 Shape40 Shape41 Shape42 Check all relevant categories for the field:*


Field

Categories

Available language(s)

Cambodian Chinese Creole English

Hmong Korean Lao French Russian Spanish Vietnamese

Other:

  1. Shape43 Shape44 Shape45 Shape46 Shape48 Shape49 Shape50 Shape51 Shape52 Shape53 Shape54 Check all relevant categories for each field:*


Field

Categories

Target audience(s)

Ethnicity

Hispanic/Latino Non-Hispanic/Latino

Race

American Indian or Alaskan Native Asian

Black or African American

Native Hawaiian or Other Pacific Islander White

Other

Preschool (<5 years old) Elementary School

Middles School High School Homeless/Food Pantry Clients

Pregnant/Breastfeeding Women


Parents/Mothers/Fathers Adults Older Adults

Other:



  1. Shape55 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.

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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


SECTION IV. EFFECTIVENESS:

To help you understand the outcomes of interest for SNAP-Ed, please review SNAP-Ed Evaluation Framework. For detailed information about indicators, please visit the interactive SNAP-Ed Toolkit

.


  1. 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.

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

Shape59 Shape60 Yes No


    1. If “Yes” to question 23, please describe which instruments were used in developing, testing, and evaluating this intervention to assess the effectiveness of the 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. Reference appendices and/or provide links to tools, if available. If reports are available, it is highly suggested that they are included as an attachment to your submission.


  1. Which instruments were used in developing, testing, and evaluating this intervention to assess the effectiveness of the intervention? (500 character limit)*

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  1. What intended outcomes were achieved and to what extent (this includes health, behaviors, environmental, policy/practice outcomes)?*

For the Outcome field, provide specifics when describing the outcome measure. For the SNAP-Ed Evaluation Framework Indicator and Measure field, select the relevant indicator and measure from theSNAP-Ed Evaluation Framework if applicable (e.g., MT5: Nutrition Supports , MT5b: Total number of policy changes ). Describe how the outcome was achieved in the Extent Achieved field and what instruments were used to measure the outcome in the How Outcome was Measured field.



o Outcome


SNAP-Ed Evaluation Framework Indicator and Measure

(If applicable):

Extent achieved:

- How Outcome was Measured

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(Please insert additional outcomes if necessary.)


  1. 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.

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  1. Please describe the evidence findings included in your submission (2, 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 and referencing the appendices here is highly recommended.


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  1. Shape70 Shape71 Are evaluation materials provided for your intervention:* Yes No

    1. If yes to question 28, please describe the provided evaluation materials (500 character limit):

Please include links to and/or reference appendices with formative or process evaluation materials such as surveys, interview or focus group questions, and output or outcome data collection tools, if available.


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    1. If no to question 28, please describe the recommended evaluation materials (500 character limit):

Please include links to and/or reference appendices with appropriate evaluation materials, if available.

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SECTION V. ADOPTION:

  1. Shape74 Shape75 Shape76 Shape77 Shape78 Shape79 Shape80 Shape81 Shape82 Shape83 Check all relevant categories for each field:*


Field

Categories

Primary intended setting(s)

Community Early childcare & education

Faith-based Farmers markets Food retail Food pantries Gardens Healthcare

Indian Tribal Organizations Schools

USDA program sites (not National School Lunch Program) Worksites

Other (please describe):


  1. Shape84 Shape85 Shape87 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.

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  1. Briefly describe how partners/settings selected in 29 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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  1. Shape90 Shape91 Shape92 Shape93 Shape94 Shape95 Shape96 Shape97 Shape98 Shape99 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 Food retail


Government programs Healthcare Indian Tribal Organizations


Labor/workforce development Media/advertising groups Nonprofits


Parks and recreation Restaurants


Schools (colleges, universities, vocational) Schools (K-12) Worksites


Other (please specify):

  1. Shape100 Shape101 Shape102 Shape103 Shape104 Shape105 Shape106 Shape107 Shape108 Shape109 Shape111 Has the intervention been implemented in the past with a low-income audience?* Yes No

c. If yes to question 33, what state(s) was it used in?:


  1. 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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SECTION VI. IMPLEMENTATION:

  1. 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.

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  1. Shape115 Shape116 Are staff/partner/volunteer training materials available for your intervention?* Yes No


36a. If yes to question 36,�please describe the training needed to implement your intervention (e.g. online versus in-person training, number of training sessions, who delivers the training, who receives the training, evaluation of the training, etc.) (500 character limit): Please reference training materials provided as appendices and/or link to training materials online, if available.

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  1. Describe methods used and data collected to ensure the intervention was implemented with fidelity (500 character limit):*

Shape118 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.



SECTION VII. MAINTENANCE:

  1. How long has this intervention been implemented in the field?*


  1. Shape120 Shape121 Has this intervention been adopted independently by partners/in settings not directly supported by SNAP-Ed?* Yes No

  2. 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.

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  1. 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. Describe how these modifications addressed any sustainability concerns.

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  1. 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.

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  1. 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.

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SECTION VIII. INTERVENTION ATTACHMENTS:

  1. Please attach and list below up to 5 (Appendix A - E) intervention materials (such as training manuals or sample lessons) Please name files with short (<150 characters), descriptive names, including the appendix letter. For example,

Appendix A_Training Manual. If possible, reference the attachments (e.g. As shown in Appendix A,...) throughout your submission form

to help reviewers quickly find the appropriate information.


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-


-

(Please insert additional items as necessary.)

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SECTION IX. EVALUATION ATTACHMENTS:

  1. Please attach and list below up to 5 supporting documents (Appendix F-J) that are summary and/or evaluation-oriented publications or reports. You may also consider including evaluation tools, like environmental assessment or pre-post surveys, in this section.


Please name files with short (<150 characters), descriptive names, including the appendix letter. For example, Appendix F_FY19 Eval Report.

If possible, reference the attachments (e.g. as shown in Appendix F...) throughout your submission form to help reviewers quickly find the appropriate information.


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File Typetext/rtf
File TitleFNS-886
SubjectSNAP-ED TOOLKIT INTERVENTION SUBMISSION FORM
AuthorProctor, Jakira - FNS
File Modified2021-10-06
File Created2021-09-20

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