State, Local or Tribal Government

OMB Control No: 0584-XXXX

Expiration Date: XX/XX/20XX

Appendix I. List of Requested Administrative Data Elements

OMB No. 0584-[NEW]

Assessing SNAP Participants’ Fitness for Work

Project Officer: Eric Sean Williams

Office of Policy Support

SNAP Research and Analysis Division

Food and Nutrition Service

U.S. Department of Agriculture

1320 Braddock Place

Alexandria, VA 22314

703.305.2640

eric.williams@fns.usda.gov

List of Requested Administrative Data Elements

Administrative Data Element

Individual-Level Data

Individual identifier

SNAP unit identifier

Case affiliation (head of household, spouse, child, etc.)

Gender

Date of birth

Race/ethnicity

Disability indicator

Social Security income (amount or receipt indicator)

Supplemental Security Income (amount or receipt indicator)

Applicant veteran status

Earned income

Employment status

Limited English proficiency status

ABAWD status

Highest education level

Current work registration status

Indicator for mandatory or voluntary E&T participant

Current reason for work registration exemption/good cause determination (if applicable)

Past work registration statuses (if ever different from current)

Past reasons for work registration exemption/good cause determination (if ever different from current)

Dates of each work registration exemption/good cause determination

Most current SNAP unit data

Homeless status

Medical expenses

Medical deduction

Gross income

SNAP benefit amount

Application data for each SNAP unit

Initial application

Method of application (in-person, online)

Mode of eligibility interview (in-person, phone)

Date of eligibility determination

County of SNAP office that made eligibility determination

Zip code of SNAP office that made eligibility determination

Street address of SNAP office that made eligibility determination

Most recent recertification application (if applicable)

Method of application (in-person, online)

Mode of eligibility interview (in-person, phone)

Date of eligibility determination

County of SNAP office that made eligibility determination

Zip code of SNAP office that made eligibility determination

Street address of SNAP office that made eligibility determination

This information is being collected to assist the Food and Nutrition Service in understanding how States assess physical or mental limitations when screening for exemptions from work requirements or determining good cause. This is a voluntary collection and FNS will use the information to determine needs for technical assistance. This collection does not request any 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-[xxxx]. The time required to complete this information collection is estimated to average [12 or 24] 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. 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 22306 ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

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