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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:

Strategy/Intervention/Program name (brand):*

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

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

Contact name:*

Contact email:*

Contact phone:*

Funding source(s):*

Organization Website (URL):

Publication/Revision year:*

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

If there is a cost for materials, please describe:

Is this material available to order?:*	Yes	No
If yes to question 12, how are materials ordered?:

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

SECTION II. INTERVENTION OVERVIEW:
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.

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	

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

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):	

Primary Intervention Objectives:*
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Add Objective

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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:
Check all relevant categories for the field:*

Field	Categories	
Available language(s)	Cambodian	Chinese	Creole	English
Hmong	Korean	Lao	French Russian	Spanish	Vietnamese
Other:	
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:	

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

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
.

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.

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?*
Yes	No

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.

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

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  	

Add Outcome

(Please insert additional outcomes if necessary.)

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.

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.

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

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.

SECTION V. ADOPTION:
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):	

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.

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.

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):	
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?:

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.

SECTION VI. IMPLEMENTATION:
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.

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.

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.

SECTION VII. MAINTENANCE:
How long has this intervention been implemented in the field?*

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

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.

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.

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:
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.)

Add Item

SECTION IX. EVALUATION ATTACHMENTS:
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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