State and Local Government

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Overview

Report review
Task time worksheet
Salary information
ODC worksheet
Other funding

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Sheet 1: Report review

Worksheet for eHIP administrative cost reports review
OMB Number: 0584-NEW Expiration Date: MM/DD/20YY
Organization:
Respondent:	Cost Components
	INTERVIEWER: Fill in ahead of time before interview. Enter F if fully covered by administrative cost report, P if partially covered, U if not covered
Activity	Salaries and wages	Fringe benefits	Contrac-tual expenses	Supplies	Printing & comms	Other direct costs	Indirect costs
Retailer agreements
Systems changes
eHIP promotion
Customer service
Accounting
Project management
Fraud prevention and detection
Other funding
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 1.5 hours (90 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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Sheet 2: Task time worksheet

Time estimation worksheet for eHIP stakeholder interviews
OMB Number: 0584-NEW Expiration Date: MM/DD/20YY
Respondent:
Organization:
Activity:
Sub-activity:
INTERVIEWER: If necessary, complete one worksheet for each sub-activity that contributes to an activity.
Step #	Step description	Worker type	Frequency of step	Per month, quarter, year?	Time to do step once	Total time per period	Notes
1
2
3
4
5
6
7
8
9
10
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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Sheet 3: Salary information

eHIP evaluation
Salary Worksheet
OMB Number: 0584-NEW Expiration Date: MM/DD/20YY
COMPLETE ONE WORKSHEET PER ACTIVITY OR PER SUBACTIVITY
Staffing position (include each staff position listed in time log)	Pay rate (dollars)	Basis paid (select from list)	Fringe benefit percentage /amount	Fringe benefits calculated as:	Notes
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
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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Sheet 4: ODC worksheet

Worksheet for estimating unreported non-personnel costs for eHIP
OMB Number: 0584-NEW Expiration Date: MM/DD/20YY
COMPLETE ONE WORKSHEET PER ACTIVITY OR SUBACTIVITY
Organization:
Respondent:
Activity:			INTERVIEWER: Fill in as needed to estimate total
Cost component	Time period	Estimated total	Unit cost	Unit type	Number of units	Basis of estimates/other notes
Fringe benefits
Contractual expenses
Supplies
Printing & comms
Other direct costs
Indirect costs
Examples: for fringe benefits, unit cost may be percentage of salaries and wages, and number of units then would be cost of salaries and wages.
For printing and mailing, unit cost may be per piece and number of units may be number of flyers printed and mailed.
Indirect costs may be a percentage of some/all direct costs, dollars per FTE, or some other allocation method based on the organization's cost allocation plan.
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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Sheet 5: Other funding

Other funding estimation
OMB Number: 0584-NEW Expiration Date: MM/DD/20YY
Organization:
Respondent:
Source of funding	Internal or external?	Amount of funding	Activity
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.