Appendix C FNS 886 Intervention Submission Form

SNAP-Ed Intervention Submission Form

OMB APPROVED NO. 0584-0639
Expiration Date: XX-XX-XXXX
United States Department of Agriculture
Food and Nutrition Service
SNAP-Ed Intervention Submission Form
INSTRUCTIONS
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 character limits. Guidance is provided regarding what should be addressed
for questions which are answered in narrative format. Up to 10 documents may be attached to
provide additional information. Attached documents should be summary and/or evaluationoriented publications or reports.

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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 5.5 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.
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Section I. Intervention Name and Contact Information

1. Strategy/Intervention/Program name*:
________________________________________________________________
________________________________________________________________

2. Developer(s)/Author(s) and credentials*:
________________________________________________________________

3. Developer(s)/Author(s) Organization(s):
________________________________________________________________

4. Contact name*:
________________________________________________________________

5. Contact email*:
________________________________________________________________

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 5.5 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.
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6. Contact phone*:
________________________________________________________________

7. Funding source(s)*:
________________________________________________________________

8. Organization Website (URL):
________________________________________________________________

9. Publication/revision year*:
________________________________________________________________

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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 5.5 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.
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Section II. Intervention Overview

10. Provide a brief overview of the intervention in narrative form that describes how it works,
how it addresses Policy, System, and Environment (PSE) change, social marketing and/or
direct education, and other key features (3,000 character limit):* For example: The [Intervention
name, acronym] is a [intervention strategy] designed to [intervention objective(s)].
Include additional intervention details, such as basic information on how it works, which SNAPEd Evaluation Framework indicators it addresses, how the intervention serves underserved
populations, 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.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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 5.5 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.
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11a. Intervention Strategies (check all relevant categories)*

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Direct Education (1)
Policy, Systems, and Environmental (PSE) Change (2)
Social Marketing (3)

11b. Target behaviors (check all relevant categories)*

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Healthy Eating (1)
Physical Activity and Reducing Screen Time (2)
Food Resource Management (3)
Other: (4) __________________________________________________

12. What are the primary objectives of the intervention?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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 5.5 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.
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13. What are the available languages for the intervention? Check all relevant categories.*

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Cambodian (1)
Chinese (2)
Creole (3)
English (4)
Hmong (5)
Korean (6)
Lao (7)
French (8)
Russian (9)
Spanish (10)
Vietnamese (11)
Other: (12) __________________________________________________

14. Who is the intended audience for this intervention? Check all relevant categories for each
field:*

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 5.5 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.
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Race and/or Ethnicity

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American Indian or Alaska Native (1)
Asian (2)
Black or African American (3)
Hispanic or Latino (4)
Middle Eastern or North African (5)
Native Hawaiian or Other Pacific Islander (6)
White (7)
Other: (8)
No racial group priority (9)

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 5.5 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.
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Age / Population Group

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Preschool (1)
Elementary School (2)
Middle School (3)
High School (4)
Parents/Caregivers/Guardians (5)
Adults (6)
Older Adults (60 years and older) (7)
Community Wide (8)
Pregnant/Breastfeeding (9)
People experiencing homelessness (10)
Tribal Nations (11)
Refugees/Asylees or Immigrants (12)
Veterans (13)
People with intellectual and developmental disabilities (14)
Other: (15)

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 5.5 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.
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15. Describe the main or core 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):*
For example: [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 methods for delivery, and ongoing
tracking and evaluation points.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page Break

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 5.5 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.
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Section III. Intervention Development

16. Describe how the intervention addresses the needs of the intended audience or SNAP-Ed
audience segment (1,000 character limit):*
How does the intervention specifically address the cultural needs, preferences, language,
reading levels, and accessibility needs of the intended audience? Explain steps taken during
development to ensure it is appropriate for the intended audience and the settings
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

17. Describe any priority population and community partner involvement in the development of
your intervention (500 character limit):*
Explain why each partner was involved and how they contributed to the development of your
intervention.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
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 5.5 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.
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18a. Were SNAP-Ed educators, intervention participants, partners and/or stakeholders involved
in testing the acceptability (how well it serves the intended audience and fits into the intended
setting) of the intervention?*

o Yes (1)
o No (2)
18b. Please describe the tools and instruments that were used in developing, testing, and
evaluating this intervention for acceptability with the intended audience, partners, and
stakeholders.
Explain how the tools and instruments were used, the results collected, and (if they were used)
how they were used to update or improve your intervention. Reference attachments in Section
VIII. Evaluation Attachments and/or provide links to tools, if available. If reports are available,
include as an attachment to your submission.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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 5.5 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.
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18c. Are MyPlate materials used in this intervention?*

o Yes (1)
o No (2)
Display This Question:
If 18c. Are MyPlate materials used in this intervention?* = Yes

Please describe the MyPlate materials used and any adaptations made to the materials.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page Break

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 5.5 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.
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Section IV. Evaluation and Outcomes
For SNAP-Ed outcomes and indicators, see the SNAP-Ed Evaluation Framework.

19. Please select the evidence-based approach that best describes your intervention:*
Note, emerging strategies should not be submitted to the SNAP-Ed Clearinghouse until they
have been evaluated for effectiveness. States and implementing agencies are able to continue
submitting "emerging" interventions in their annual SNAP-Ed State plans.

o 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 (1)

o Practice-tested: positive effects on individual behaviors, food/physical activity
environments, or policies shown (2)

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 5.5 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.
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20. For your evidence-based approach, please indicate the supporting evidence which you are
providing to support your intervention.* Up to five supporting documents can be attached in
Section VIII. Evaluation Attachments.
The Centers for Disease Control and Prevention (CDC) provides additional information about
evaluation.
Check all relevant categories:

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Case Study (1)
Economic Evaluation (2)
Evaluability Assessment (3)
Evaluation Report (4)
Formative research (such as audience testing) (5)
Impact Evaluation (6)
Objectives-based evaluation (7)
Outcome evaluation (8)
Peer-reviewed publication(s) (9)
Pilot testing results (10)
Process evaluation (11)
Supporting research for theoretical Framework (12)

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 5.5 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.
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▢
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Traditional knowledge and Indigenous approaches (13)
Other (please describe): (14)

21. Please describe the behavior change theory(ies) used in the development of your
intervention and evaluation and how they were used. (1,000 character limit)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

22. What and to what extent were intended outcomes achieved (this includes health, behaviors,
environmental, policy/practice outcomes)?*
• For the Intended Outcome field, provide specifics when describing the outcome
measure. Add additional Intended Outcomes as needed. If there are more than 5,
include as an attachment in Section VIII. Evaluation Attachments.
• For the SNAP-Ed Evaluation Framework Indicator and Measure field, select the relevant
indicator and measure from the SNAP-Ed Evaluation Framework if applicable (e.g.,
MT5: Nutrition Supports, MT5b: Total number of policy changes).
• For the Extent Achieved field, describe how the outcome was achieved and the extent
achieved.
• For the How Outcome was Measured field, describe what instruments were used to
measure the outcomes and include the name of the instrument.

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 5.5 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.
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Intended Outcome #1

o Outcome (1)
__________________________________________________

o SNAP-Ed Evaluation Framework Indicator and Measure (2)
__________________________________________________

o Extent achieved (300 character limit) (3)
__________________________________________________

o How outcome was measured (300 character limit) (4)
__________________________________________________

Add another outcome

o Click Here (1)
Display This Question:
If Add another outcome = Click Here

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 5.5 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.
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Page 16 of 36

Intended Outcome #2

o Outcome (1)
__________________________________________________

o SNAP-Ed Evaluation Framework Indicator and Measure (2)
__________________________________________________

o Extent achieved (300 character limit) (3)
__________________________________________________

o How outcome was measured (300 character limit) (4)
__________________________________________________

Display This Question:
If Add another outcome = Click Here

Add another outcome

o Click Here (1)
Display This Question:
If Add another outcome = Click Here

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 5.5 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.
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Intended Outcome #3

o Outcome (1)
__________________________________________________

o SNAP-Ed Evaluation Framework Indicator and Measure (2)
__________________________________________________

o Extent achieved (300 character limit) (3)
__________________________________________________

o How outcome was measured (300 character limit) (4)
__________________________________________________

Display This Question:
If Add another outcome = Click Here

Add another outcome

o Click Here (1)
Display This Question:
If Add another outcome = Click Here

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 5.5 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.
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Page 18 of 36

Intended Outcome #4

o Outcome (1)
__________________________________________________

o SNAP-Ed Evaluation Framework Indicator and Measure (2)
__________________________________________________

o Extent achieved (300 character limit) (3)
__________________________________________________

o How outcome was measured (300 character limit) (4)
__________________________________________________

Display This Question:
If Add another outcome = Click Here

Add another outcome

o Click Here (1)
Display This Question:
If Add another outcome = Click Here

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 5.5 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.
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Page 19 of 36

Intended Outcome #5

o Outcome (1)
__________________________________________________

o SNAP-Ed Evaluation Framework Indicator and Measure (2)
__________________________________________________

o Extent achieved (300 character limit) (3)
__________________________________________________

o How outcome was measured (300 character limit) (4)
__________________________________________________

23. Please describe the evaluation findings included in your submission (2,000 character limit):*
Include examples showing change in behavior, environmental settings, sectors of influence, or
population impacts, as appropriate. Attaching supporting documents which substantiate
evidentiary claims made and referencing the attachments here is highly recommended. Up to
five supporting documents can be attached in Section VIII. Evaluation Attachments.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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 5.5 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.
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24. Which instruments and outcomes were used in evaluating this intervention to assess the
effectiveness (performance under real world settings) of the intervention? (500 character limit)*
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

25. Please describe if there were any unintended/unexpected outcomes (1,000 character
limit).
In addition to unintended outcomes, include unintended/unexpected benefits, challenges,
lessons learned, or recommendations that may be useful to future users of this intervention.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

26. Describe methods used and data collected to ensure the intervention was implemented with
fidelity (intervention was delivered as conceived and planned) (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
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 5.5 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.
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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 in Section VII. Intervention Attachments.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page Break

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 5.5 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.
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Section V. Implementation
27. What are the primary settings for the intervention. Check all relevant categories*:

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Community (1)
Early child care & education (2)
Faith-based (3)
Farmer’s markets (4)
Food retail (5)
Food pantries (6)
School gardens (7)
Community gardens (8)
Healthcare (9)
Indian Tribal Organizations (10)
Schools (11)
Colleges/Universities (12)
USDA program Sites (13)
Worksites (14)

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 5.5 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.
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▢
▢

Senior Centers (15)

Other (please describe): (16)
__________________________________________________

28. Describe the primary setting(s) the intervention was designed for and how the settings
contributed to the success of the intervention (1,000 character limit):*
Include settings not listed above. If available, indicate the number of eligible
sites/settings/partners that completed the intervention and the number of the intended audience
that was reached. These may be estimates. If available, explain how sites were able to continue
the intervention without assistance and any sustainability efforts for the intervention. Describe
resources provided (volunteers, physical space, technical services, etc.) and how they were
used.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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 5.5 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.
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29. Select the partners involved in the intervention? Check all relevant intervention partners:*

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Agricultural organizations (includes farmers’ markets and farmers) (1)
Chefs/culinary institutes (2)
City and regional planning and transportation groups (3)
Colleges and universities (4)
Early care and education facilities (includes childcare centers, daycare homes,
Head Start, preschool, and prekindergarten programs) (5)
Faith-based groups (6)
Food banks/food pantries/food recovery organizations (7)
Food stores (convenience stores, grocery stores, supermarkets, etc.) (8)
Foundations/philanthropic organizations/nonprofits (9)
Government nutrition assistance programs/agencies (Federal, State, local, etc.)
(10)
Hospitals/healthcare/public health organizations (includes health insurance
companies) (11)
Human services organizations (12)
Tribal Organizations (13)

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 5.5 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.
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▢
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Labor/workforce development groups (14)
Low-income housing organizations (includes housing for seniors and people with
disabilities) (15)
Media/advertising groups (16)
Organizations that work with people with disabilities (other than housing) (17)
Parks and recreation centers (18)
Restaurants (19)
Schools (K–12, elementary, middle, and high) (20)
Senior centers and organizations (21)
State nutrition and obesity prevention organizations and collaboratives (22)
Worksites (23)
Other (please describe): (24)

30. How long has this intervention been implemented in the field?
________________________________________________________________

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 5.5 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.
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31. Describe the ongoing resources needed to maintain the quality of this intervention (1,000
character limit):*
Describe resources such as physical materials, full-time employees and ongoing training, and
costs associated with tracking and evaluation.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

32a. Describe any adaptations or modifications made to your intervention over time (1,000
character limit):*
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.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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 5.5 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.
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32b. Describe the feasibility of adapting to other settings/communities than those in which the
intervention was developed (500 character limit).
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

33. What effect, if any, have the modifications described in the previous question 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.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

34. Describe how the intervention will be sustained in the future. Describe partnerships or
diversified funding mechanisms which may address any potential sustainability concerns (500
character limit):
Describe any efforts that have successfully addressed sustainability such as demonstrating
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 5.5 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.
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return on investment, social enterprise, partnership with non-profit or private partners, or
successfully awarded grant funding.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page Break

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 5.5 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.
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Section VI. Training, Materials, and Resources

35. Are there costs associated with using the intervention and evaluation materials?

o Yes (1)
o No (2)
Display This Question:
If 35. Are there costs associated with using the intervention and evaluation materials? = Yes

36. If there is a cost for some or all of the materials, please describe:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

37. Are the materials available to order?*

o Yes (1)
o No (2)

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 5.5 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.
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Display This Question:
If 37. Are the materials available to order?* = Yes

Specify which materials are available to order:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Display This Question:
If 37. Are the materials available to order?* = Yes

How are materials ordered?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page Break

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 5.5 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.
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Display This Question:
If 37. Are the materials available to order?* = Yes

Please provide website link or contact information for ordering materials:
________________________________________________________________

38. Describe the intervention materials available (500 character limit):*
Provide a summary of the available intervention materials. If helpful, reference attachments
included in Section VII. Intervention Attachments and/or include a bulleted list of intervention
materials with corresponding links to more information.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

39. Are staff/partner/volunteer training materials available for your intervention?

o Yes (1)
o No (2)

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 5.5 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.
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40a. Are evaluation materials provided for your intervention?*

o Yes (1)
o No (2)
Display This Question:
If 40a. Are evaluation materials provided for your intervention?* = Yes

40b. Please describe the provided evaluation materials (500 character limit):
Please include links to and/or reference attachments included in Section VIII. Evaluation
Attachments with formative or process evaluation materials such as surveys, interview or focus
group questions, output or outcome data collection tools, if available, and reliability and/or
validity testing completed for the tools.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Display This Question:
If 40a. Are evaluation materials provided for your intervention?* = No

40c. Please describe the recommended evaluation materials (500 character limit):
Please include links to and/or reference appropriate evaluation materials, if available.
________________________________________________________________
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 5.5 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.
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________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

41. Please describe the training needed to implement your intervention (e.g. online versus inperson 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 attachments in Section VII. Intervention Attachments
and/or link to training materials online, if available.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Page Break

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 5.5 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.
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Section VII. Intervention Attachments

42. Please list below up to 5 (Attachment A - E) intervention materials (such as training
manuals or sample lessons). Please name files with short (<150 characters), descriptive names,
including the attachment letter. For example, Attachment A_Training Manual. If possible,
reference the attachments (e.g. As shown in Attachment A,...) throughout your submission form
to help reviewers quickly find the appropriate information. All attachments should be submitted
along with this form as described in the accompanying instructions.
Please note, you can only upload one file per question. File size cannot exceed 50MB. If you
need to submit files that are large and exceed the limit, compress the files into a ZIP file prior to
uploading.

Intervention Attachment A

Intervention Attachment B

Intervention Attachment C

Intervention Attachment D

Intervention Attachment E

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 5.5 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.
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Section VIII. Evaluation Attachments

Please list below up to 5 supporting documents (Attachment F-J) that are summary and/or
evaluation-oriented publications or reports. Please do not upload any raw data files with your
submission. You may also consider including evaluation tools, like environmental assessment or
pre-post surveys, in this section. Please ensure evaluation attachments do not contain any
personally identifiable information (PII). Please name files with short (<150 characters),
descriptive names, including the attachment letter.

Evaluation Attachment F

Evaluation Attachment G

Evaluation Attachment H

Evaluation Attachment I

Evaluation Attachment J

End of Survey
Thank you for submitting your intervention to the SNAP-Ed Clearinghouse. Your response has
been recorded.

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 5.5 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

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