Form FNS 759 FNS 759 Food Stamp Nutrition Education EARS Reporting Form

Form Approved OMB No. 0584-XXXX

expires XX/XX/XXXX

Draft

Food Stamp Nutrition Education

EARS Reporting Form

OMB BURDEN STATEMENT:  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-XXXX.  The time to complete this information collection is estimated to average 54 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.  OMB #0584-XXXX expires XX/XX/XXXX.

State: ________________________ Federal Fiscal Year: ______________

Number of Implementing Agencies*: ____________________________

Name of Each Implementing Agency*

* An implementing agency is defined as an organization that has a contract/formal agreement with the State Food Stamp Program Agency to develop and deliver nutrition education activities in the state. Attach additional pages if necessary.

DIRECT EDUCATION:

Items #1-6 ask for information about participants and activities associated with direct food stamp nutrition education. Direct Education is defined as interventions where a participant is actively engaged in the learning process with an educator and/or interactive media. Direct education provides an opportunity to obtain information about individual participants. For an activity to qualify as direct education, information on the number of individuals, Food Stamp Program participation status, age, gender, and race/ethnicity must be collected.

Example 1: An implementing agency conducts a series of nutrition sessions designed to increase fruit and vegetable intake. The educators collect enrollment data including name, age, race, ethnic group, Food Stamp participation and gender.

Example 2: The implementing agency provides nutrition education via kiosks at several locations. Participant using the kiosks provides identifying information including their Food Stamp status, ethnicity, age and gender by entering this data or by using codes that can be linked to this information by the implementing agency.

Situations that would not count as “direct education” include cases where an individual obtains nutrition education or materials or listens to a session but no demographic information is captured about the individual. This would count as indirect education.

Direct Education: FSNE Participants and Contacts

1a. Direct Education: FSNE PARTICIPANTS by Age and Food Stamp Program Status

Reporting an unduplicated count of direct education participants means providing the number of different individuals who receive any FSNE direct education. Each individual counts as one participant, regardless of the number of times he or she has participated in direct education activities. You are encouraged to provide actual unduplicated counts but if you are unable, you should estimate the number of individuals served.

• For Question 1a, indicate below if you are providing actual unduplicated counts or an estimate of FSNE direct education participants.

___ Actual Counts of Participants (unduplicated)

___ Estimated Counts of Participants

		A	B	C	D	E
		Less than 5 Years	5-17 Years Grades K-12	18-59 Years	60 Years or More	All Ages Combined
1	Number of Food Stamp Recipients in FSNE
2	Number of All Other Participants in FNSE
3	Total Number of FSNE Participants

If you reported an estimate in Question 1a, please describe in 100 words or less the methods used to estimate the number of participants.

1b. Direct Education: FSNE CONTACTS by Age and Food Stamp Program Status

A “FSNE contact” is defined as an interaction in which a FNSE participant participates in a direct education activity. Each FSNE participant may have one or more FSNE contacts.

• For Question 1b, indicate below if you are providing actual counts or an estimate of FSNE direct education contacts.

___ Actual Counts of Contacts

___ Estimated Counts of Contacts

		A	B	C	D	E
		Less than 5 Years	5-17 Years Grades K-12	18-59 Years	60 Years or More	All Ages Combined
1	Contacts with Food Stamp Recipients in FSNE
2	Contacts with All Other Persons in FNSE
3	Total Contacts with FSNE Participants

If you reported an estimate in Question 1b, please describe in 100 words or less the methods used to estimate the number of contacts.

Instructions for Question 1a and 1b

• Row 1: Enter the total number of participants (1a) and contacts (1b) who are Food Stamp recipients by each age range and for all ages combined (Row 1; Columns A-E).

• Row 2: Enter the total participants (1a) and contacts (1b) for all other (non- food stamp) persons by each age range and for all ages combined (Row 2; Columns A-E). This includes persons who are eligible non-participants with respect to the Food Stamp Program combined with persons who are not eligible for the Food Stamp Program.

• Row 3: Enter the total participants (1a) and contacts (1b) for FSNE by age category (Row 3; Columns A-E). Each number in Row 3 should equal the sum of Rows 1 and 2 in that column.

Special Circumstances

○ If necessary, determine food stamp status among children (columns A and B)

who receive FSNE services in school and child care settings by multiplying the number of children participating in FSNE at each school or child care facility by the percent of students enrolled in the FREE school lunch program.

Example: An elementary school program has 100 children participating in FSNE and the school’s free lunch participation rate is 60%. In the “5-17 Years (grade K-12)” column, report 60 students under “Number of Food Stamp Participants in FSNE” and 40 students under “Number of All Other Participants in FSNE” for a total of 100 students.

○ Teen-age FSNE participants should be counted by their age for Question 1 even if they are parents.

Example: If the teen parent is 16 years old, they should be counted under Column B, 5-17 Years (Grades K-12). If the teen is 19 years old, they should be counted under Column C 18-59 Years.

2a. Direct Education: FSNE PARTICIPANTS by Gender

• For Question 2a, indicate below if you are providing an unduplicated count or an estimate of FSNE direct education participants.

___ Actual Counts of Participants (unduplicated)

___ Estimated Counts of Participants

		A	B
		Female	Male
1	Number of FSNE Participants

If you reported an estimate in Question 2a, please describe in 25 words or less the methods used to estimate the number of participants.

2b. Direct Education: FSNE CONTACTS by Gender

• For Question 2b, indicate below if you are providing actual counts or an estimate of FSNE direct education contacts.

___ Actual Counts of Contacts

___ Estimated Counts of Contacts

		A	B
		Female	Male
1	Number of FSNE Contacts

If you reported an estimate in Question 2b, please describe in 25 words or less the methods used to estimate the number of contacts.

Instructions for Question 2a and b

Enter the DIRECT EDUCATION participants (2a) and contacts (2b) by gender in Row 1; Columns A and B of Table 2a and 2b. The total of A and B in Table 2a should equal the total number of FSNE participants in Question 1a, Row 3, Column E. The total of A and B in Table 2b should equal the total number of FSNE contacts in Question 1b, Row 3, Column E.

3. Direct Education: Race and Ethnicity

• For Question 3, indicate below if you are providing actual unduplicated counts or an estimate of FSNE direct education participants.

___ Actual Counts of Participants (unduplicated)

___ Estimated Counts of Participants

		A	B	C
		Number of Hispanic or Latino FSNE Participants by Race	Number of Non-Hispanic/Latino FSNE Participants by Race	Total by Race
Individuals Reporting ONLY ONE RACE	1. American Indian or Alaska Native
	2. Asian
	3. Black or African American
	4. Native Hawaiian or Other Pacific Islander
	5. White
Individuals Reporting MULTIPLE RACES	6. American Indian or Alaska Native and White
	7. Asian and White
	8. Black or African American and White
	9. American Indian or Alaska Native and Black or African American
	10. All Others Reporting More than One Race
	11. TOTAL by ethnicity

Instructions for Question 3

• For purposes of this form, “Hispanic or Latino” is an ethnic group, not a race.

• Column A: Report the number of Hispanic or Latino FSNE participants for each racial category listed in Rows1-11. Specifically, in Rows 1-5, report the number of FSNE participants who are of Hispanic or Latino ethnicity and report only one race. In Rows 6-10, report the number of FSNE participants who are of Hispanic or Latino ethnicity and report two or more races. Use Row 10 for all FSNE participants who are of Hispanic or Latino ethnicity and describe themselves with a racial combination not included in Rows 6-9. For Row 11, enter the sum of Rows 1-10 under Column A.

• Column B: Report the number of FSNE participants who are not of Hispanic or Latino ethnicity for each racial category listed in Rows 1-10. Specifically, in Rows 1-5, report the number of FSNE participants who are not of Hispanic or Latino ethnicity and report only one race. In Rows 6-10, report the number of FSNE participants who are not of Hispanic or Latino ethnicity and report two or more races. Use Row 10 for all FSNE participants who are not Hispanic or Latino ethnicity and describe themselves with a racial combination not included in Rows 6-9. In Row 11, enter the sum of Rows 1-10 under Column B.

• Column C: Add the number of FSNE participants reported in Column A and Column B for each row. For Column C, Row 11, add the numbers reported in Column C.

Example 1: A FSNE participant who reports they are Hispanic and Black is counted in Column A, Row 3.

Example 2: A FSNE participant who reports being White, Asian, and Black but not Hispanic is counted in Column B, Row 10.

4. Direct Education: Number of FSNE Delivery Sites by Type of Setting

Type of Setting	Number of Different Sites/ Locations	Type of Setting	Number of Different Sites/Locations
Adult Education & Job Training Sites		Libraries
Adult Rehabilitation Centers		Churches
Worksites		Public/Community Health Centers
Community Centers		Public Schools
Elderly Service Centers		Head Start Programs
Emergency Food Assistance Sites		Other Youth Education Sites (includes Parks and Recreation)
Extension Offices		Shelters
Farmers Markets		WIC Programs
Food Stamp Offices		Other (please specify):
Food Stores		Other (please specify):
Public Housing		Other (please specify):
Individual Homes		Other (please specify):

Instructions for Question 4

For each type of DIRECT EDUCATION setting used, enter the number of different sites/locations used within the State. Record each site only ONCE on this form.

Example 1: FSNE is provided to residents of a shelter that is located in a local church. Record this site under “Church”.

Example 2: FSNE is provided to participants in Head Start which is operating in the local elementary school which also has FSNE activities with the elementary school students. Record this site only once under “Public School”.

• If you provide interactive multimedia education, please report locations where kiosks/computers are available.

Example 3: FSNE is provided through interactive multimedia via kiosks in 15 food stores and 10 worksites that have no other FSNE activities. These kiosks should be added to the numbers of sites reported under the food stores and worksite categories in Question 4.

5. Direct Education Programming Format

		A	B	C
	Format	Number delivered	Time range per session (in minutes)	% delivered by interactive multimedia
1	Single session
2	Series – 2 to 4 sessions
3	Series – 5 to 9 sessions
4	Series – 10 or more sessions

Instructions for Question 5

• For Rows 1-4, Column A, enter the number of single sessions, the number of 2-4 session series, the number of 5-9 session series, and the number of series with 10 or more sessions delivered.

• For Rows 1-4, Column B, enter the time range per session in minutes.

• For Rows 1-4, Column C, enter the percent of Column A delivered by interactive multimedia lessons/modules.
  

Example 1: A state reports that 40 single sessions were delivered ranging in time from 45-60 minutes and that 10% were delivered by interactive multimedia. Row 1 of the form would show:

		A	B	C
	Format	Number delivered	Time range per session (in minutes)	% delivered by interactive multimedia
1	Single Session	40	45-60 minutes	10%

6. Primary Content of Direct Education

CODE:

CODE:

CODE:

CODE:

INSTRUCTIONS for Question 6

• Identify up to four educational topic areas of emphasis from the list below. These four topic areas should reflect those areas given most emphasis (e.g. taught most frequently) in your State. Record only one code per box. DO NOT REPORT Food Stamp Program OUTREACH IN THIS TABLE.

A. FAT FREE & LOW FAT MILK OR EQUIV (& ALTERNATE CALCIUM SOURCES)

2. FATS AND OILS

3. FIBER-RICH FOODS

4. FOOD SHOPPING/PREPARATION

5. FRUITS & VEGETABLES

6. LEAN MEAT AND BEANS

7. LIMIT ADDED SUGARS OR CALORIC SWEETNERS

8. MYPYRAMID – HEALTHY EATING PLAN

9. PHYSICAL ACTIVITY

10. PROMOTE HEALTHY WEIGHT

11. SODIUM & POTASSIUM

12. WHOLE GRAINS

13. FOOD SAFETY

14. OTHER (specify): ______________________(possible for electronic form)

15. OTHER (specify): ______________________

16. OTHER (specify): ______________________

17. OTHER (specify): ______________________

SOCIAL MARKETING INITIATIVES:

Item #7 asks for information about FSNE social marketing initiatives. Social Marketing is defined as a consumer-focused, research-based process to plan, implement and evaluate interventions that are designed to influence the voluntary behavior of a large number of people in the target audience (adapted from Alan Andreasen 1995 and Social Marketing Division of Society for Nutrition Education).

For an activity to qualify as a social marketing campaign, the initiative being reported must have included all of the following steps:

 

• Identified a specific segment of the food stamp/low income population to target.

• Identified the specific nutrition needs of the target audience, associated target behavior(s), and the target audience’s reasons for and against changing behavior.

• Interacted with the target audience to see if the message, materials, and delivery channel are understood and meaningful (would lead to behavior change).

States that conduct social marketing campaigns that include both direct and indirect education activities may elect to report these under these categories. However, if direct and indirect education activities are reported in the “direct education” section or the “indirect education” section, they should not be reported in the social marketing section because that would result in a duplicate count.

6. Description of ALL Social Marketing Campaigns

Attach an additional form to record data, if there are more than five campaigns.

A. Name of Campaign	B. Current Year of Campaign	C. Major Campaign Activities for Current Year Use Codes	D. Priority Population(s) Use Codes	E. Estimated Number. of FSP Recipients Reached	F. Estimated Number of Other Low Income Persons Reached	G. Total Estimated Reach (Low-Income, FSP Recipients AND All Others
1
2
3
4
5

Instructions for Question 7

For each social marketing campaign being planned, under development or operating:

• Column A: Enter the name of all FNS approved social marketing campaigns.

• Column B:. Enter the current campaign year for this annual reporting cycle. Be sure to include planning and development phases.

Example: If this is the third year of a five year campaign, record 3 in Column B.

• Column C: Enter one or more of the following codes that describe major phases of campaign activities:

• P=Planning (includes market and formative research),

• D=Developing (includes campaign/materials design and consumer testing),

• I =Implementing

• E=Tracking and Evaluation

• Column D: Enter all of the appropriate codes describing the priority population (target audience) that this campaign reached during this fiscal year:

○ Ethnicity: F=Hispanic or Latino

G= Not-Hispanic or Latino

○ Race: A= American Indian or Native Alaska

B= Asian

C= Black or African American

D= Native Hawaiian or Other Pacific Islander

E= White

○ Gender: H=Female

I = Male

○ Age: J = All ages

K= Less than 5 years of age

L= 5 to 17 years of age

M=18 to 59 years of age

N= 60 years of age or older

For Columns E, F and G, enter the number of people reached, as estimated from demographic or marketing data or other sources.

• Column E: Enter the estimated number of Food Stamp Program recipients reached this reporting year through this campaign

• Column F: Enter the estimated number of low-income persons (EXCLUDING Food Stamp recipients) reached through this campaign this reporting year.

• Column G: Enter the total estimated number of people (low-income, Food Stamp recipients AND all others) reached this reporting year.

Example 1: The radio station that broadcasts social marketing nutrition messages has provided demographic statistics to the implementing partner showing the income range of their listening audience. The data show that roughly 20% of the audience or 400 people would not qualify for Food Stamps. The estimated count of 400 people should be counted under column G in Item 7 of the form.

Example 2: Nutrition education is conducted at a local grocery store in a low-income neighborhood and 200 people attend. Census track data is examined and shows that 55% of the population served by the store has income below 130% of the poverty level and 30% has income between 130% and 185% of the poverty level with the remaining 15% having income over 185% of the poverty level. In Column E, 110 (55% of 200 participants) should be included, 60 should be included in Column F (30% of 200) and 200 should be reported in Column G.

7. Continued-Description of ALL Social Marketing Campaigns

	H. Primary Intervention Levels Use Codes	I. Key Messages Use Codes	J. Primary Intervention Channels Use Codes	K. Total Expenditure for Social Marketing Campaign for Reporting Year	L Total Federal FSNE Expenditure for Reporting Year
1				$
2				$
3				$
4				$
5				$

Instructions for Question 7

• Column H: Enter one or more codes describing each campaign’s level(s) of intervention:

○ A=Individual

○ B=Interpersonal (groups)

○ C=Institution/Organization

○ D=Community

○ E=All Levels

○ F=Other – please specify

• Column I: Enter up to three codes for each campaign’s priority education topics/messages. Use the codes listed in the Instructions for Item # 6.

• Column J: Enter all of the codes corresponding to the intervention channels used in each campaign:

○ A=Nutrition Education Radio Public Service Announcement (PSA)

○ B=Nutrition Education TV Public Service Announcement (PSA)

○ C=Nutrition Education articles

○ D=Billboards, bus wraps, or other signage

○ E=Participation in community events/fairs

○ F=Sponsor community events/fairs

○ G=Fact sheets/pamphlets/newsletters

○ H=Posters

○ I=Calendars

○ J=Promotional materials w/nutrition messages (pens, pencils, wallet reference cards, magnets, cups, etc)

○ K=Website

○ L=Electronic (email) materials/info distribution

○ M=Videos/CD-Rom

○ N=Retail/point-of-purchase activities

○ O=Other – please specify

• Column K: Enter the total expenditure (include all State and Federal FSNE and any other sources of funds) for the campaign this reporting year.

• Column L: Enter the Federal FSNE expenditures for the campaign this reporting year.

INDIRECT EDUCATION:

Item #8 asks for information about food stamp indirect education. Indirect Education is defined as the distribution of information and resources, including any mass communications, public events and materials distribution that DO NOT meet the definitions of Direct Education or Social Marketing Campaigns. Mass communication, public events and material distribution efforts that don’t meet the definition of social marketing should be reported here.

8a. Types of Materials Distributed

	Check if applicable
Fact sheets/ pamphlets/newsletters
Posters
Calendars
Promotional Materials w/nutrition messages (pens/pencils/wallet reference cards/magnets/cups/etc)
Website
Electronic (Email) materials/info distribution
Videos/CD Rom
Other

Instructions for Question 8a

Check all methods/materials used for indirect education.

8b. Estimated Size of Audiences Reached through Communication and Events

	Estimated No. of target population reached	Source of Data
Nutrition Education Radio PSAs
Nutrition Education TV PSAs
Nutrition Education Articles
Billboard, Bus or Van Wraps, or Other Signage
Community Events/Fairs -- in which Participated
Community Events/Fairs -- Only Sponsored
Other

Instructions for Question 8b

For each type of communication channel and event enter the estimated number of individuals in the target population(s) reached and the code of the source of the data used to tabulate the estimate.

1 = commercial market data on audience size

2 = survey of target audience

3 = visual estimate

4= other

9. Expenditures by Sources of Funding (See Instructions)

	Expenditures for Reporting Year
l. Public Cash Contributions -- State and Local Tax Revenue only	$
2. Public and Private Cash Contributions -- other than State and Local Tax Revenue	$
3. Sum of Lines 1 & 2	$
4. Public In-Kind Contributions (non-cash)	$
5. Private Cash Contributions to State Food Stamp Agency only	$
6. Indian Tribal Organization Contributions	$
7. Sum of Lines 4, 5 & 6	$
8. Federal Reimbursement	$
9. TOTAL FSNE EXPENDITURES: Sum of Lines 3, 7 & 8	$

Instructions for Question 9

All dollar amounts recorded in item #9 should reflect actual expenditures NOT those initially budgeted.

• Line1: Enter the dollar value of expenditures paid only with State and local tax revenue designated specifically for FSNE activities.

• Line 2: Enter the dollar value of expenditures paid with public and private cash contributions. These are contributions that are received by state implementing agencies or their subcontractors other than State and local tax revenues designated specifically for FSNE activities. These are not from State and local tax revenues.

• Line 3: Enter the sum of lines 1 and 2 in line 3.

• Line 4: Enter the dollar value of expenditures paid with public in-kind (non-cash) contributions. These contributions are defined as goods or services provided by a state or local agency for which no cash funds are transferred and no out-of-pocket cost is incurred by the contributing agency. Typically, in-kind contributions are the value of goods or services provided by volunteers.

• Line 5: Enter the dollar value of expenditures paid with private cash contributions made to the State Food Stamp Office/Agency These contributions are funds provided by non-governmental groups. They may include cash provided to the State or outlays made directly by a non-governmental organization to cover approved FSNE costs.

• Line 6: If applicable, enter the dollar value of expenditures paid with Indian Tribal Organization (ITO) contributions. Although technically ITO contributions are Federal funds, for the purposes of FSNE reimbursement, they are considered state match.

• Line 7: Enter the sum of lines 4, 5 and 6 in line 7. This may be less than 50% of the Total FSNE Expenditures in line 9 when there is an ITO contribution because FNS reimburses allowable activities conducted on Indian reservations at the 75% rate.

• Line 8: Enter the total amount of the federal reimbursement for FSNE; this is the total amount chargeable to FNS. It may be greater than 50% of total outlays when there is an ITO contribution because FNS reimburses for allowable activities conducted on Indian reservations at the 75% rate.

• Line 9: Enter the sum of lines 3, 7 and 8 to record Total (allowable) FSNE Expenditures. This total should equal Line 3 in Question 10, Expenditures by Category of Spending.
  
  

10. Expenditures by Category of Spending (See Instructions below)

Cost breakouts for item #10 may be the actual allocation or estimated.

1. Total Expenditures for FSNE Program Delivery	$
2. Total Expenditures for Administrative Costs	$
3. TOTAL FSNE Expenditures (State and Federal)	$

Data provided in this table are (check one): ____ actual or ____estimated based on FTE allocation.

Instructions for Question 10

Costs reported in this table may be calculated based on: 1) the actual expenditures associated with

each component described above; or, 2) be estimated based on multiplying the percentage of

total FTE time spent on nutrition education versus administration to any cost component that is not

tracked separately as a delivery or administrative expense.

Example: 45% of FTEs are for administrative functions.  Apply this to the total expenditures and you can estimate your Total Expenditures for Administrative Costs, line 2.

Line 1: Count all of the following as Nutrition Education Program Delivery Expenditures:

• Dollar value of salaries and benefits associated with staff time spent providing approved and allowable FSNE activities.

• Cost of all food demonstration supplies.

• Cost of purchasing and/or developing educational materials (literature/materials/audiovisuals).

• Cost of developing and implementing media campaigns.

• Dollar value of the pro-rated costs of space used to deliver FSNE.

• Cost of any FSNE evaluation efforts.

• Cost of traveling to deliver FSNE services.

• Cost of training for nutrition education providers.

• Indirect costs (must be proportionate to time spent to delivery of FSNE)

• Other overhead charges (space, HR services, etc).

Line 2: Count all of the following as FSN Administrative Expenditures:

• Dollar value of salaries and benefits associated with staff time spent on FSNE administration not on nutrition education. (example: State FSP/IA/Project staff, support staff).

• Cost of training to performing administrative functions like record keeping, accounting, etc.

• Cost of reporting.

• Cost of equipment and office supplies.

• Operating Costs.

• Indirect Costs for those administrative staff not covered above.

• Other overhead charges associated with administrative expenses (space, HR services, etc).

Line 3: Sum of lines 1 and 2. This total should equal the total reported in Line 9 of Question 9, Expenditure by Sources of Funding.

FNS-759 (8-07) Previous Editions Obsolete. Electronic Form Designed in Word 2003

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