| Assessment of the Administrative Costs of Electronic Healthy Incentives Projects (eHIP) |
| State Administrative Cost Templates |
OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
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| Table of contents |
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| Tab |
Description |
| Table of Contents |
List of worksheets with descriptions |
| Quarterly Expenses |
Quarterly summary of eHIP project expenses, not including incentives |
| Activities |
Descriptions of eHIP activities for reporting personnel hours and breakdown of other costs |
| Personnel Hours by Activity |
Hours or percent of FTE by personnel category/person, eHIP activity, and period |
| Salaries |
Personnel salaries by salary component |
| Non-Personnel Costs by Activity |
Other direct costs, broken down by type of cost and activity |
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| This information is being collected to provide the Food and Nutrition Service (FNS) with key cost information on Electronic Healthy Incentives Projects conducted by SNAP State agencies. This is a voluntary collection, and FNS will use the information to examine costs of Electronic Healthy Incentives Projects for SNAP. This collection requests personally identifiable information under the Privacy Act of 1974. 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-NEW. The time required to complete this information collection is estimated to average 7 hours (420 minutes) per response. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN: PRA (0584-NEW). Do not return the completed form to this address. If you have any questions, please contact the FNS Project Officer for this project, Kathleen Patton, at [email protected] or 703-305-2813. |
| Quarterly Summary of eHIP Project Expenses |
OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
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| INSTRUCTIONS: Please enter total quarterly project expenses, by the payment source for that expense. Please include administrative and incentive expenses. Contractual expenses should include only expenses for eHIP work. Contractual expenses to retailers may include payments for retailer startup costs. List expenses that are not already specified in the rows under "Other expenses"; please add only one "other" expense per row. The Notes column can be used to add additional detail describing expenses or explanation of how the expenses were determined and/or limitations of the data. Please specify the sources of other funds below the line totalling all expenses. |
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| State: |
[insert state name in Quarterly Expenses tab] |
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| Year: |
[insert year in Quarterly Expenses tab] |
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| Quarter (specify months): |
[specify months in Quarterly Expenses tab] |
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| Type of expense |
Grant funds amount |
SNAP funds amount |
State funds amount |
Other funds amount (specify below total) |
Notes on what expenses cover, how they were determined, limitations of the data: |
| Personnel |
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| Regular (full- or part-time state employee) |
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| Temporary or contracted employee |
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| Subtotal, personnel |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
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| Fringe benefits (e.g., health insurance, other benefits) |
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| Contractual expenses (for eHIP work) |
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| Retailers |
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| EBT processor |
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| State MIS (include interagency payments) |
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| Technical assistance to retailers by contractor |
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| Other (specify): |
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| [e.g., payments to farmers] |
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| Subtotal, contractual |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
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| Materials, postage and other communications |
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| Travel |
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| Other expenses (list below, not including incentives) |
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| Subtotal, other expenses not listed elsewhere |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
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| Incentives redeemed (exclude incentives earned but not redeemed) |
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| Indirect expense (based on standard percentage or cost per FTE for overhead or general administration, or cost allocation plan - explain method in notes) |
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| Total, all expenses |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
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| Instructions: list sources of funds other than FNS and State grantee below and provide total for each source. (Optional) Add notes to explain the specific uses of the funds, how the amount was estimated etc. |
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| Other sources of funds |
Total funds expended |
Notes (use of funds, basis for estimates etc.) |
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| Total of other funds |
$- |
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| This information is being collected to provide the Food and Nutrition Service (FNS) with key cost information on Electronic Healthy Incentives Projects conducted by SNAP State agencies. This is a voluntary collection, and FNS will use the information to examine costs of Electronic Healthy Incentives Projects for SNAP. This collection requests personally identifiable information under the Privacy Act of 1974. 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-NEW. The time required to complete this information collection is estimated to average 7 hours (420 minutes) per response. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN: PRA (0584-NEW). Do not return the completed form to this address. If you have any questions, please contact the FNS Project Officer for this project, Kathleen Patton, at [email protected] or 703-305-2813. |
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| Activities |
OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
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| INSTRUCTIONS: This sheet describes project activities. Please use these description of activities to help you fill out the "Personnel Hours by Activity" and "Other Direct Costs by Activity" tabs. The "Project Phase" column indicates when the activities are expected to occur. |
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| Project phase |
eHIP activities |
Description |
| Implementation |
eHIP promotion |
Publicity, mailings, social media, outreach, posters, contacts with community organizations for eHIP. Does not include minimal time spent by local offices or others handing out flyers, brochures, etc. |
| Implementation |
EBT systems changes for eHIP |
Design, development, testing of changes to EBT system and SNAP MIS for eHIP |
| Implementation |
Farmers market recruiting, equipment assistance, and startup support for eHIP |
Outreach and negotiating agreements with farmers' markets and farmers, planning for implementation, providing assistance with equipment and payment applications, other technical and operational support during startup, other farmers' market/farmer liaison for eHIP. |
| Implementation |
Retailer recruiting and startup support for eHIP |
Outreach and negotiating agreements with retailers (not including farmers' markets), plans for implementation, other retailer liaison for eHIP |
| Implementation |
Retailer system changes for eHIP |
Technical and financial assistance to retailers and their service providers for POS system changes for eHIP. |
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| Implementation, Operations |
Project management for eHIP |
General eHIP project management not specific to (or not separable from) other activities. Includes progress and financial reporting to FNS and evaluation, meetings with FNS and evaluation, contract negotiation and management. |
| Implementation, Operations |
Settlement and accounting of eHIP incentives and grant funds |
Reconciliation, settlement, financial reporting activities related to eHIP incentives and grant funds |
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| Operations |
Customer service for eHIP |
Assistance to participants regarding eHIP incentives via SNAP hotline, EBT processor hotline, local/county office; resolution of related disputes |
| Operations |
Farmers' market support for eHIP |
Answering questions, trouble-shooting, resolving disputes involving farmers' markets and farmers regarding eHIP incentives. |
| Operations |
Fraud prevention and detection for eHIP |
Reviewing reports of eHIP activity, conducting related investigations, implementing penalties on retailers or participants to prevent, detect, and punish trafficking and other fraudulent activity involving eHIP incentives |
| Operations |
Retailer support for eHIP |
Answering questions, trouble-shooting, resolving disputes involving retailers other than farmers' markets and farmers regarding eHIP incentives. |
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| This information is being collected to provide the Food and Nutrition Service (FNS) with key cost information on Electronic Healthy Incentives Projects conducted by SNAP State agencies. This is a voluntary collection, and FNS will use the information to examine costs of Electronic Healthy Incentives Projects for SNAP. This collection requests personally identifiable information under the Privacy Act of 1974. 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-NEW. The time required to complete this information collection is estimated to average 7 hours (420 minutes) per response. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN: PRA (0584-NEW). Do not return the completed form to this address. If you have any questions, please contact the FNS Project Officer for this project, Kathleen Patton, at [email protected] or 703-305-2813. |
| Personnel Hours by Activity |
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OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
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| INSTRUCTIONS: Please enter personnel hours for all staff that worked on eHIP in the quarter. Hours should be reported by activity (see "Activities" tab); if staff worked on multiple activities, staff may be listed multiple times, with each listing corresponding to one activity. Please give staff hours if available, or percent of FTE if hours are not available. If reporting FTEs, specify number of hours per FTE per quarter (13 weeks). Estimates are acceptable if exact hours are not available. Report numbers with the same precision as in the source of the information: for example, estimates may be whole numbers while actual time may be tracked in .25 hour increments. Incidental time spent on eHIP does not need to be included (e.g., if someone not working on eHIP attends a meeting where eHIP is discussed, that individual's time does not need to be included). Hours for multiple personnel in the same category can be combined into a single row reflecting the total time for that category. See examples for alternative ways to report. |
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| State: |
[insert state name in Quarterly Expenses tab] |
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| Year: |
[insert year in Quarterly Expenses tab] |
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| Quarter (specify months): |
[specify months in Quarterly Expenses tab] |
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| Hours per FTE per quarter: |
[specify number of hours per FTE per quarter (13 weeks)] |
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(Report hours or % of FTE) |
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| Personnel category/title |
Activity (see list) |
Period (week, month, quarter) |
# of periods worked in quarter |
Avg. Hours per period |
% of FTE |
Source of Funds |
Notes (source of hours, clarifications etc.) |
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| [Example: Project director] |
Project management for eHIP |
Quarter |
1 |
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50% |
Grant funds |
Estimated percentage; full-time on project. |
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EBT systems changes for eHIP |
Quarter |
1 |
42.5 |
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Grant funds |
From timesheets |
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| [Example: retailer liaison] |
Retailer recruiting and startup support for eHIP |
Month |
3 |
40 |
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State funds |
Estimate. |
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eHIP promotion |
Week |
13 |
10 |
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Other funds (describe in notes) |
5 managers x 1 hour meeting x 2 meetings /week |
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| [insert rows as needed] |
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| Total hours, all personnel [if available - can be computed by evaluation staff] |
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| This information is being collected to provide the Food and Nutrition Service (FNS) with key cost information on Electronic Healthy Incentives Projects conducted by SNAP State agencies. This is a voluntary collection, and FNS will use the information to examine costs of Electronic Healthy Incentives Projects for SNAP. This collection requests personally identifiable information under the Privacy Act of 1974. 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-NEW. The time required to complete this information collection is estimated to average 7 hours (420 minutes) per response. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN: PRA (0584-NEW). Do not return the completed form to this address. If you have any questions, please contact the FNS Project Officer for this project, Kathleen Patton, at [email protected] or 703-305-2813. |
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| Salaries |
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OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
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| INSTRUCTIONS: Please enter the titles/personnel categories and pay rates for all staff who worked on eHIP in this quarter. All staff categories listed in "Personnel Hours by Activity" should be listed here as well. Please provide EITHER the pay rate, basis paid, fringe benefits rate, and overhead/indirect cost rate OR the loaded hourly rate. Pay rate should be amount paid per period as specified in "Basis Paid". In "Basis paid" column, select yearly, monthly, biweekly, weekly, or hourly. For "Basis of fringe rate" select one method: percentage or dollar amount per pay period. For loaded rate enter $ per hour including pay rate, fringe rate, and overhead/indirect. If the specific pay rate or loaded rate is unavailable, please provide the midpoint in the salary range for that job category/title. |
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| State: |
[insert state name in Quarterly Expenses tab] |
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| Year: |
[insert year in Quarterly Expenses tab] |
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| Quarter (specify months): |
[specify months in Quarterly Expenses tab] |
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For each, provide either (1) pay rate, fringe benefits rate, and overhead/indirect cost rate OR (2) loaded hourly rate inclusive of pay, fringe benefits, and overhead/indirect cost (if applicable). |
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Option 1: Provide pay rate, basis paid, fringe benefits rate, overhead/indirect cost rate |
Option 2: Provide loaded hourly rate |
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| Personnel category/title |
Pay rate ($ per period) |
Basis paid |
Fringe benefits rate (%) |
Basis of fringe rate |
Overhead/indirect cost rate (% of direct cost) |
Loaded rate ($ per hour) |
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| This information is being collected to provide the Food and Nutrition Service (FNS) with key cost information on Electronic Healthy Incentives Projects conducted by SNAP State agencies. This is a voluntary collection, and FNS will use the information to examine costs of Electronic Healthy Incentives Projects for SNAP. This collection requests personally identifiable information under the Privacy Act of 1974. 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-NEW. The time required to complete this information collection is estimated to average 7 hours (420 minutes) per response. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN: PRA (0584-NEW). Do not return the completed form to this address. If you have any questions, please contact the FNS Project Officer for this project, Kathleen Patton, at [email protected] or 703-305-2813. |
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| Non-Personnel Costs by Activity |
OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
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| INSTRUCTIONS: Please enter non-personnel costs by activity below. Please include all project direct costs, whether funded by the eHIP grant or by other sources. Refer to the "Activities" tab for information on the activities. Expenses that cover multiple activities can be allocated to activities by estimate. Use the "Notes" tab to provide any additional information for interpreting the figures, including the basis for computations or estimates of share of costs by activity (if applicable). Add rows for other contractual expenses and other direct expenses not listed elsewhere as needed. |
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| State: |
[insert state name in Quarterly Expenses tab] |
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| Year: |
[insert year in Quarterly Expenses tab] |
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| Quarter (specify months): |
[specify months in Quarterly Expenses tab] |
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Activities |
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Retailer recruiting and startup support |
EBT systems changes |
Retailer systems changes |
eHIP promotion |
Customer service |
Accounting |
Project management |
Total, all activities |
Notes |
| Contractual expenses |
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| EBT processor |
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$- |
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| Payments to retailers |
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$- |
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| State MIS (include interagency payments) |
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$- |
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| Technical assistance to retailers by contractor |
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$- |
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| Other (specify) |
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$- |
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$- |
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$- |
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| Subtotal, contractual expenses |
$- |
$- |
$- |
$- |
$- |
$- |
$- |
$- |
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| Materials, postage and communications (paid by State; include expenses incurred by contractors above) |
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$- |
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| Travel |
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$- |
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| Other direct expenses not listed elsewhere (list below and specify) |
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$- |
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$- |
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| Subtotal, other direct expenses |
$- |
$- |
$- |
$- |
$- |
$- |
$- |
$- |
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| Indirect or overhead expenses |
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$- |
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| Total, all expenses |
$- |
$- |
$- |
$- |
$- |
$- |
$- |
$- |
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| This information is being collected to provide the Food and Nutrition Service (FNS) with key cost information on Electronic Healthy Incentives Projects conducted by SNAP State agencies. This is a voluntary collection, and FNS will use the information to examine costs of Electronic Healthy Incentives Projects for SNAP. This collection requests personally identifiable information under the Privacy Act of 1974. 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-NEW. The time required to complete this information collection is estimated to average 7 hours (420 minutes) per response. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN: PRA (0584-NEW). Do not return the completed form to this address. If you have any questions, please contact the FNS Project Officer for this project, Kathleen Patton, at [email protected] or 703-305-2813. |
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