Food Stamp Nutrition Connection Resource Sharing Form (Private)

Resource Submission
Submitter Name
Submitter Email

Resource Information
Title

Description

Please provide a short description of the materials you are submitting

Please add author’s name if multiple add coma between

Author(s)

Please leave blank if organization is not applicable

Organization

Please add the name of the contact person for this material

Contact name

What is the funding source for the development of this material

Funding source

How can people get this material?
Not publicly available, email contact person for more information
Available for free online
Order hard copies or electronic copies
Document Upload
Upload the document(s) you’d like us to review. Please upload only if NOT available online.
Upload

Choose File

Files must be less than 1000 MB. File types accepted: txt, pdf, docx, pptx, xls, xlxs.
List the online link(s) or web site(s) for this material
Add another item

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Choose File

Upload
Files must be less than 1000 MB. File types accepted: png, gif, jpg.

Ordering Information
Contact name for ordering
Address
Contact email for ordering

Please add email address of contact person for this material

Phone
Ordering web site link
Publication number
Is this material free?

Yes

No

Ordering notes

Publication Information
2014

Year

Please list the date of the most recent publication or edition
Has this material been used by a SNAP-Ed Program?
Which State Territory

Which Region

Yes

No

None
Alabama
Alaska
Arizona

None

Was this material created to be used in an education setting?

Yes

No

Educational Material Information
How will full text be submitted to SNAP-Ed Connection for review?
I attached a PDF document above.
I entered a web site link above. The website has a link to the full text document.
I will mail the material.
Other
Submitting a document for review does not mean it will be publicly available on our web site. You must indicate
above that the document is allowed to be publicly available on the SNAP-Ed Connection web site. This is
necessary for all resources with nutrition education content. Please select one.

Material Format
Activity

Book

Game

Handbook / Manual

Poster

Presentation

Other Format

Bulletin Board

Cookbook / Recipes

Curriculum / Lessons

Icebreaker / Opener

Kit

Social Marketing Materials

Newsletter

Video

Fact Sheets
Other

Web site

Please provide details about the format here

Target Audience
Adults

Preschool Children

Pregnant / Breast-feeding Women
African Americans

Elementary Children

Teens

Hispanic / Latino Americans

Native Americans / American Eskimo

Older Adults

Parents

Asian Americans / Pacific Islanders
Middle School

Other

Available Languages
Cambodian

Chinese

Lao or Laoation

Creole

Native American

English
Russian

French
Spanish

Other language
Is this resource specific to the area, state, or region in which it was developed?
Yes, it is only pertinent to the location in which it was developed.
Yes, but it could be modified for other locations.
No, it could be used anywhere.
Which Dietary Guidelines is this resource compatible with?
2005 Dietary Guidelines
2010 Dietary Guidelines
Food Guide Pyramid
MyPlate
MyPyramid
None

Hmong
Vietnamese

Korean

How are evaluation activities involved in this resource?
A validated evaluation tool was used to create this resource?
Impact Evaluation
None
Other evaluation activities
Pilot Study
Process evaluation
The Material contains participant survey / questionnaires.
This material were studied and results were published in a peer-review journals.
This material uses an evaluation framework.
Are recipes provided in the resources?

Yes

Are Nutrition Facts Panels included for the recipes?
Educational Materials Notes

no
Yes

no

Please add any additional notes you feel are important about this educational material.
If you were able to answer “other” to any of the questions within the Educational Materials
Section, please use this area to provide more details.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0518-0031. The time required to complete
this information will vary based upon one’s relationship to the resource being submitted. It is estimated to take 10 minutes to complete the entire
survey. This includes time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. If you need help with this form, please contact us.