| Assessment of the Administrative Costs of Electronic Healthy Incentives Projects (eHIP) |
|
|
|
|
|
|
|
|
|
|
| Incentive Report Template |
|
|
|
|
|
|
|
|
|
|
OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
|
|
|
|
|
|
|
|
|
|
|
| Table of contents |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Tab |
Description |
|
|
|
|
|
|
|
|
|
|
| Retailer list |
List retailers, store type, location, implementation method, and whether participating in GusNIP, Healthy Fluid Milk Incentive, or other incentive -- for all participating eHIP retailers |
|
|
| Summary |
Summary monthly incentive figures |
|
|
| Retailer-level incentives |
Incentive transactions at the retailer and outlet level (if available) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| 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. |
|
|
|
|
|
|
|
|
|
|
| Summary |
|
OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
|
|
|
| INSTRUCTIONS: Please provide the monthly summary figure for each item. Shaded items are desirable but not necessary. Additional detail should be provided in the Notes column if needed to clarify the data (for example, if there are any limitations or cautions about the data). If data are by cardholder instead of by household, please indicate this in the Notes column. |
|
|
|
|
|
| State: |
Washington |
|
|
| Year: |
2025 |
|
|
| Month: |
June |
|
|
|
|
|
|
|
Count OR $ total OR Average number OR Average $ |
Notes (limitations, clarifications, etc.) |
|
| Eligible food purchases with SNAP (Optional - please provide any available data) |
|
|
|
| Number of purchases with eligible foods |
|
|
|
| Total $ of eligible foods purchased |
|
|
|
| Number of households with eligible foods purchases (trying to earn incentives) |
|
|
|
| Number of retailers with eligible foods purchases |
|
|
|
|
|
|
|
| Incentive earnings |
|
|
|
| Number of purchases earning incentives |
|
|
|
| Total $ of eligible foods in purchases earning incentives (gross amount before refunds) (Optional - provide if available) |
|
|
|
| Total $ of incentives earned on approved purchases (gross amount before refunds) |
|
|
|
| Number of households earning incentives |
|
|
|
| Average $ of incentives earned per household* (Optional - provide if available) |
|
|
|
|
|
|
|
| Refunds (Optional but preferred - provide if possible) |
|
|
|
| Number of refunds with incentives deducted from customer balance |
|
|
|
| Total $ of refunds of eligible food purchases that earned incentives |
|
|
|
| Total $ of incentives deducted from customer balance due to returns |
|
|
|
|
|
|
|
| Expunged incentives |
|
|
|
| Total $ Incentives expunged |
|
|
|
| Number of households with incentives expunged |
|
|
|
|
|
|
|
| Outstanding Liability for unredeemed incentives (Optional) |
|
|
|
| Total value of household incentive balances at the end of the month. |
|
|
|
| Number of households with incentive balances at the end of the month. |
|
|
|
|
|
|
|
| *Per household averages are only for the households with relevant activity (e.g., for incentive earnings, denominator is number of households earning incentives). |
|
|
|
|
|
|
|
| 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. |
|
| Retailer-level incentives |
OMB Number: 0584-NEW
Expiration Date: MM/DD/20YY |
|
|
|
|
|
|
|
| INSTRUCTIONS: Please provide information on incentive transactions by retailer, and outlet if available. Use one line for each retailer outlet if available, or one line for each retailer if outlet-level information is not available. The retailer total line is only needed if outlet-level data is available. Identify outlets by the Outlet ID on the Retailer List worksheet. For the dollar values, please report net amounts after deducting refunds and the associated incentives. |
|
|
|
|
|
|
|
|
| State: |
Washington |
|
|
|
|
|
|
| Year: |
2025 |
|
|
|
|
|
|
| Month: |
June |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SNAP purchases w/eligible foods (reporting optional) |
SNAP purchases earning incentives |
| Retailer/outlet |
FNS Store ID (should match Retailer list) |
Number of purchases with eligible foods |
$ of eligible foods purchased |
Number of purchases earning incentives |
$ of eligible foods in purchases earning incentives |
$ of incentives earned |
Number of households earning incentives (optional) |
| eHIP Retailer 1 |
|
|
|
|
|
|
|
| Outlet 123456 (if available) |
|
|
|
|
|
|
|
| [additional outlets] |
|
|
|
|
|
|
|
| Retailer 1 total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| eHIP Retailer n |
|
|
|
|
|
|
|
| Outlet 456789 (if available) |
|
|
|
|
|
|
|
| [additional outlets] |
|
|
|
|
|
|
|
| Retailer n total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| eHIP retailer total |
|
0 |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
| 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. |
|
|
|
|
|