Appendix A:

Optional Report and Plan Templates

**Appendix A. Template 1. Section A: State Nutrition Education Final
Report Summary**

**[(7 CFR 272.2 (i))OMB No. 0584-0083 Expiration 10/31/2010]{.mark}**

#### Section A. Final Report Summary for Projects and Social Marketing-provide the following data for each project and social marketing campaign that took place during the previous year. See page 7 -9 for instructions. 

+----------+------+-----+------+------+----------+-----+-----+------+
| *        |      |     |      |      |          |     |     |      |
| *Section |      |     |      |      |          |     |     |      |
| A. State |      |     |      |      |          |     |     |      |
| Summary  |      |     |      |      |          |     |     |      |
| of       |      |     |      |      |          |     |     |      |
| [Projec  |      |     |      |      |          |     |     |      |
| ts]{.und |      |     |      |      |          |     |     |      |
| erline}. |      |     |      |      |          |     |     |      |
| FY       |      |     |      |      |          |     |     |      |
| \_\_\_\_ |      |     |      |      |          |     |     |      |
| \_\_\_** |      |     |      |      |          |     |     |      |
|          |      |     |      |      |          |     |     |      |
| **A      |      |     |      |      |          |     |     |      |
| project  |      |     |      |      |          |     |     |      |
| is a     |      |     |      |      |          |     |     |      |
| discrete |      |     |      |      |          |     |     |      |
| unit of  |      |     |      |      |          |     |     |      |
| n        |      |     |      |      |          |     |     |      |
| utrition |      |     |      |      |          |     |     |      |
| e        |      |     |      |      |          |     |     |      |
| ducation |      |     |      |      |          |     |     |      |
| inte     |      |     |      |      |          |     |     |      |
| rvention |      |     |      |      |          |     |     |      |
| at the   |      |     |      |      |          |     |     |      |
| local    |      |     |      |      |          |     |     |      |
| level.** |      |     |      |      |          |     |     |      |
+----------+------+-----+------+------+----------+-----+-----+------+
| *        | **   |     | **Au |      | **M      | **  |     | **   |
| *Project | Deli |     | dien |      | ethods** | Con |     | Eval |
| Name**   | very |     | ce** |      |          | ten |     | uati |
|          | Loc  |     |      |      |          | t** |     | on** |
|          | atio |     |      |      |          |     |     |      |
|          | ns** |     |      |      |          |     |     |      |
+----------+------+-----+------+------+----------+-----+-----+------+
|          | **Ge | *   | **   | **T  | **Fr     | **  | **  | **   |
|          | ogra | *De | Targ | otal | equency, | Key | Key | Type |
|          | phic | liv | eted | No.  | Duration | M   | M   | and  |
|          | Area | ery | Au   | of   | and Type | ess | eas | Stat |
|          | (S   | S   | dien | Part | of       | age | ure | us** |
|          | tate | ite | ce** | icip | Edu      | s** | s** |      |
|          | wide | s** |      | ants | cational |     |     |      |
|          | or   |     |      | (es  | M        |     |     |      |
|          | coun | *   |      | tima | ethods** |     |     |      |
|          | ties | *(t |      | ted, |          |     |     |      |
|          | re   | ype |      | undu |          |     |     |      |
|          | ache | and |      | plic |          |     |     |      |
|          | d)** | num |      | ated |          |     |     |      |
|          |      | ber |      | coun |          |     |     |      |
|          |      | )** |      | t)** |          |     |     |      |
+----------+------+-----+------+------+----------+-----+-----+------+
| *(E      | *Co  | *15 | *Mot | *    | *6       | *Be | *\# | *P   |
| xample)* | unty | Sc  | hers | 300* | 3        | a   | of  | roce |
|          | A,*  | hoo | of   |      | 0-minute | r   | att | ss-c |
| *FSNE    |      | ls* | el   |      | group    | ole | end | ompl |
| Parent   | *Co  |     | emen |      | classes, | mod | ees | eted |
| Project* | unty |     | tary |      | 6 mailed | el: | in  | 9/30 |
|          | B*   |     | sc   |      | news     | eat | e   | /2\_ |
|          |      |     | hool |      | letters* | bre | ach | \_   |
|          |      |     | c    |      |          | akf | cla | \_*  |
|          |      |     | hild |      |          | ast | ss* |      |
|          |      |     | ren* |      |          | w   |     |      |
|          |      |     |      |      |          | ith |     |      |
|          |      |     |      |      |          | kid |     |      |
|          |      |     |      |      |          | s.* |     |      |
+----------+------+-----+------+------+----------+-----+-----+------+
| 1\.      |      |     |      |      |          |     |     |      |
+----------+------+-----+------+------+----------+-----+-----+------+
| 2\.      |      |     |      |      |          |     |     |      |
+----------+------+-----+------+------+----------+-----+-----+------+
| 3\.      |      |     |      |      |          |     |     |      |
+----------+------+-----+------+------+----------+-----+-----+------+
| Based on |      |     |      |      |          |     |     |      |
| th       |      |     |      |      |          |     |     |      |
| e above, |      |     |      |      |          |     |     |      |
| briefly  |      |     |      |      |          |     |     |      |
| discuss  |      |     |      |      |          |     |     |      |
| the      |      |     |      |      |          |     |     |      |
| outcomes |      |     |      |      |          |     |     |      |
| and      |      |     |      |      |          |     |     |      |
| effec    |      |     |      |      |          |     |     |      |
| tiveness |      |     |      |      |          |     |     |      |
| of the   |      |     |      |      |          |     |     |      |
| projects |      |     |      |      |          |     |     |      |
| and how  |      |     |      |      |          |     |     |      |
| the      |      |     |      |      |          |     |     |      |
| program  |      |     |      |      |          |     |     |      |
| can be   |      |     |      |      |          |     |     |      |
| improved |      |     |      |      |          |     |     |      |
| in the   |      |     |      |      |          |     |     |      |
| upcoming |      |     |      |      |          |     |     |      |
| FY.      |      |     |      |      |          |     |     |      |
+----------+------+-----+------+------+----------+-----+-----+------+

\*For evaluation type, indicate Formative, Process, Impact, Outcome or
None.

**Appendix A. Template 1. Section A: State Nutrition Education Final
Report Summary (cont.)**

**[(7 CFR 272.2 (i)) OMB No. 0584-0083 Expiration 10/31/2010]{.mark}**

+-------+-------+------+------+------+-----------+-----+-----+------+
| **Se  |       |      |      |      |           |     |     |      |
| ction |       |      |      |      |           |     |     |      |
| A.    |       |      |      |      |           |     |     |      |
| State |       |      |      |      |           |     |     |      |
| Su    |       |      |      |      |           |     |     |      |
| mmary |       |      |      |      |           |     |     |      |
| of    |       |      |      |      |           |     |     |      |
| [S    |       |      |      |      |           |     |     |      |
| ocial |       |      |      |      |           |     |     |      |
| Mark  |       |      |      |      |           |     |     |      |
| eting |       |      |      |      |           |     |     |      |
| Cam   |       |      |      |      |           |     |     |      |
| paign |       |      |      |      |           |     |     |      |
| s]{.u |       |      |      |      |           |     |     |      |
| nderl |       |      |      |      |           |     |     |      |
| ine}. |       |      |      |      |           |     |     |      |
| FY    |       |      |      |      |           |     |     |      |
| \     |       |      |      |      |           |     |     |      |
| _\_\_ |       |      |      |      |           |     |     |      |
| \_\_\ |       |      |      |      |           |     |     |      |
| _\_** |       |      |      |      |           |     |     |      |
|       |       |      |      |      |           |     |     |      |
| **S   |       |      |      |      |           |     |     |      |
| ocial |       |      |      |      |           |     |     |      |
| Mark  |       |      |      |      |           |     |     |      |
| eting |       |      |      |      |           |     |     |      |
| is    |       |      |      |      |           |     |     |      |
| de    |       |      |      |      |           |     |     |      |
| fined |       |      |      |      |           |     |     |      |
| as a  |       |      |      |      |           |     |     |      |
| di    |       |      |      |      |           |     |     |      |
| scipl |       |      |      |      |           |     |     |      |
| ined, |       |      |      |      |           |     |     |      |
| co    |       |      |      |      |           |     |     |      |
| nsume |       |      |      |      |           |     |     |      |
| r-foc |       |      |      |      |           |     |     |      |
| used, |       |      |      |      |           |     |     |      |
| rese  |       |      |      |      |           |     |     |      |
| arch- |       |      |      |      |           |     |     |      |
| based |       |      |      |      |           |     |     |      |
| pr    |       |      |      |      |           |     |     |      |
| ocess |       |      |      |      |           |     |     |      |
| to    |       |      |      |      |           |     |     |      |
| plan, |       |      |      |      |           |     |     |      |
| dev   |       |      |      |      |           |     |     |      |
| elop, |       |      |      |      |           |     |     |      |
| impl  |       |      |      |      |           |     |     |      |
| ement |       |      |      |      |           |     |     |      |
| and   |       |      |      |      |           |     |     |      |
| eva   |       |      |      |      |           |     |     |      |
| luate |       |      |      |      |           |     |     |      |
| inte  |       |      |      |      |           |     |     |      |
| rvent |       |      |      |      |           |     |     |      |
| ions, |       |      |      |      |           |     |     |      |
| pro   |       |      |      |      |           |     |     |      |
| grams |       |      |      |      |           |     |     |      |
| and   |       |      |      |      |           |     |     |      |
| mul   |       |      |      |      |           |     |     |      |
| tiple |       |      |      |      |           |     |     |      |
| cha   |       |      |      |      |           |     |     |      |
| nnels |       |      |      |      |           |     |     |      |
| of    |       |      |      |      |           |     |     |      |
| comm  |       |      |      |      |           |     |     |      |
| unica |       |      |      |      |           |     |     |      |
| tions |       |      |      |      |           |     |     |      |
| des   |       |      |      |      |           |     |     |      |
| igned |       |      |      |      |           |     |     |      |
| to    |       |      |      |      |           |     |     |      |
| infl  |       |      |      |      |           |     |     |      |
| uence |       |      |      |      |           |     |     |      |
| the   |       |      |      |      |           |     |     |      |
| volu  |       |      |      |      |           |     |     |      |
| ntary |       |      |      |      |           |     |     |      |
| beh   |       |      |      |      |           |     |     |      |
| avior |       |      |      |      |           |     |     |      |
| or a  |       |      |      |      |           |     |     |      |
| large |       |      |      |      |           |     |     |      |
| n     |       |      |      |      |           |     |     |      |
| umber |       |      |      |      |           |     |     |      |
| of    |       |      |      |      |           |     |     |      |
| p     |       |      |      |      |           |     |     |      |
| eople |       |      |      |      |           |     |     |      |
| in    |       |      |      |      |           |     |     |      |
| the   |       |      |      |      |           |     |     |      |
| t     |       |      |      |      |           |     |     |      |
| arget |       |      |      |      |           |     |     |      |
| audi  |       |      |      |      |           |     |     |      |
| ence. |       |      |      |      |           |     |     |      |
| (Ad   |       |      |      |      |           |     |     |      |
| apted |       |      |      |      |           |     |     |      |
| from  |       |      |      |      |           |     |     |      |
| Alan  |       |      |      |      |           |     |     |      |
| Andr  |       |      |      |      |           |     |     |      |
| easen |       |      |      |      |           |     |     |      |
| 1995  |       |      |      |      |           |     |     |      |
| and   |       |      |      |      |           |     |     |      |
| S     |       |      |      |      |           |     |     |      |
| ocial |       |      |      |      |           |     |     |      |
| Mark  |       |      |      |      |           |     |     |      |
| eting |       |      |      |      |           |     |     |      |
| Div   |       |      |      |      |           |     |     |      |
| ision |       |      |      |      |           |     |     |      |
| of    |       |      |      |      |           |     |     |      |
| So    |       |      |      |      |           |     |     |      |
| ciety |       |      |      |      |           |     |     |      |
| for   |       |      |      |      |           |     |     |      |
| Nutr  |       |      |      |      |           |     |     |      |
| ition |       |      |      |      |           |     |     |      |
| Edu   |       |      |      |      |           |     |     |      |
| catio |       |      |      |      |           |     |     |      |
| n.)** |       |      |      |      |           |     |     |      |
+-------+-------+------+------+------+-----------+-----+-----+------+
| ##    | #     |      | ###  |      | ###       | ### |     | #    |
| Title | # Loc |      | Audi |      | # Methods | # C |     | # Ev |
|       | ation |      | ence |      |           | ont |     | alua |
|       |       |      |      |      |           | ent |     | tion |
+-------+-------+------+------+------+-----------+-----+-----+------+
| *     | **    | **Le | **   | **T  | **Primary | **  | **  | # ** |
| *Name | Geogr | ngth | Targ | otal | Act       | Key | Key | Type |
| of    | aphic | of   | eted | No.  | ivities** | Me  | P   | \*** |
| Campa | A     | Ca   | Au   | of   |           | s-s | erf |      |
| ign** | rea** | mpai | dien | Per  | **        | age | or- | *    |
|       |       | gn** | ce** | sons | (campaign | s** | ma  | *and |
|       | **    |      |      | R    | materials |     | nce | Stat |
|       | (Stat | **(m |      | each | design,   |     | M   | us** |
|       | ewide | onth |      | ed** | radio     |     | eas |      |
|       | or    | s)** |      |      | PSAs, bus |     | ure |      |
|       | cou   |      |      | **(  | wraps,    |     | s** |      |
|       | nties |      |      | esti | point of  |     |     |      |
|       | reach |      |      | mate | sale      |     |     |      |
|       | ed)** |      |      | d)** | adv       |     |     |      |
|       |       |      |      |      | ertising, |     |     |      |
|       |       |      |      |      | etc.)**   |     |     |      |
+-------+-------+------+------+------+-----------+-----+-----+------+
| #     | *Any  | *12  | *A   | *5,  | *         | *   | *   | *[O  |
| ####  | town* | mon  | dult | 000* | Materials | Eat | Inc | utco |
| *[(Ex |       | ths* | fem  |      | dev       | m   | rea | me-] |
| ample |       |      | ales |      | elopment, | ore | sed | {.ma |
| )]{.m |       |      | in   |      | transit   | fru | pu  | rk}c |
| ark}* |       |      | FSP  |      | ads,      | its | rch | ompl |
|       |       |      | hou  |      | community | and | ase | eted |
| *FSNE |       |      | seho |      | events*   | veg | of  | 3/22 |
| Fruit |       |      | lds* |      |           | gie | fr  | /2\_ |
| and   |       |      |      |      |           | s.* | uit | \_   |
| Vege  |       |      |      |      |           |     | and | \_*  |
| table |       |      |      |      |           |     | veg |      |
| Camp  |       |      |      |      |           |     | gie |      |
| aign* |       |      |      |      |           |     | s.* |      |
+-------+-------+------+------+------+-----------+-----+-----+------+
| 1\.   |       |      |      |      |           |     |     |      |
+-------+-------+------+------+------+-----------+-----+-----+------+
| 2\.   |       |      |      |      |           |     |     |      |
+-------+-------+------+------+------+-----------+-----+-----+------+
| Based |       |      |      |      |           |     |     |      |
| on    |       |      |      |      |           |     |     |      |
| the a |       |      |      |      |           |     |     |      |
| bove, |       |      |      |      |           |     |     |      |
| br    |       |      |      |      |           |     |     |      |
| iefly |       |      |      |      |           |     |     |      |
| di    |       |      |      |      |           |     |     |      |
| scuss |       |      |      |      |           |     |     |      |
| the   |       |      |      |      |           |     |     |      |
| out   |       |      |      |      |           |     |     |      |
| comes |       |      |      |      |           |     |     |      |
| and   |       |      |      |      |           |     |     |      |
| eff   |       |      |      |      |           |     |     |      |
| ectiv |       |      |      |      |           |     |     |      |
| eness |       |      |      |      |           |     |     |      |
| of    |       |      |      |      |           |     |     |      |
| the   |       |      |      |      |           |     |     |      |
| camp  |       |      |      |      |           |     |     |      |
| aigns |       |      |      |      |           |     |     |      |
| and   |       |      |      |      |           |     |     |      |
| how   |       |      |      |      |           |     |     |      |
| the   |       |      |      |      |           |     |     |      |
| pr    |       |      |      |      |           |     |     |      |
| ogram |       |      |      |      |           |     |     |      |
| can   |       |      |      |      |           |     |     |      |
| be    |       |      |      |      |           |     |     |      |
| imp   |       |      |      |      |           |     |     |      |
| roved |       |      |      |      |           |     |     |      |
| in    |       |      |      |      |           |     |     |      |
| the   |       |      |      |      |           |     |     |      |
| upc   |       |      |      |      |           |     |     |      |
| oming |       |      |      |      |           |     |     |      |
| FY.   |       |      |      |      |           |     |     |      |
+-------+-------+------+------+------+-----------+-----+-----+------+

\*For evaluation type, indicate Formative, Process, Impact, Outcome or
None.

#### Appendix A. Template 1. Section B: State Nutrition Education Final Report Summary FY [\_\_\_\_]{.underline} [(7 CFR 272.2 (i)) OMB No. 0584-0083 Expiration 10/31/2010]{.mark}

#### Section B. Final Report Summary for Impact Evaluations. Provide the information requested below for each impact evaluation at \$400,000 or greater that was completed during the previous year. See page 7-8 for instructions. 

**1. Name of Project or Social Marketing Campaign**

*If multiple projects or campaigns were part of a single impact
evaluation, please list them all.*

**2. Key Evaluation Impact(s)**

*Identify each impact being assessed by the evaluations. For example are
FSNE participants more likely than non-participants to report they
intend to increase their fruit and vegetable intake? Or do a greater
proportion of FSNE participants choose low-fat (1% or fat-free) milk in
the school cafeteria compared to non-participants?*

**3. Evaluation participants**.

*Describe the population being evaluated and its size. For example, all
(1200) kindergarten students at public schools in one school district.*

#### Appendix A. Template 1. Section B: State Nutrition Education Final Report Summary FY\_\_\_\_\_\_

####  (continued)

**4. Assignment to intervention and control or comparison conditions**

> **a**. **Describe the unit of assignment to intervention and control
> groups.**
>
> *For example, an intervention focused on kindergarten students may
> assign school districts, individual schools, classrooms, or individual
> student to intervention and control groups.*
>
> **b. Describe how assignment to intervention and control groups was
> carried out.**
>
> *Be explicit about whether or not assignment was random. For example,
> ten kindergarten classrooms were randomly assigned to intervention and
> control groups.*
>
> **c. Describe how many units and individuals were in the intervention
> and control groups at the start of the intervention.**

#### Appendix A. Template 1. Section B: State Nutrition Education Final Report Summary FY \_\_\_\_\_ (continued)

**5. Impact Measure(s)**

*For each evaluation impact, describe the measure(s) used. Descriptions
should indicate if the focus is on knowledge, skills, attitudes,
intention to act, behavior or something else. Each measure should also
be characterized in terms of its nutritional focus, e.g. low fat food
preparation, number of whole grain servings consumed, ability to
accurately read food labels. Finally indicate if impact data were
collected through observation, self-report, or another method.*

> **a. Describe the points at which data were collected from
> intervention and control group participants.**
>
> *For example, these points may include pre-test or baseline, midway
> through the intervention, post-test as intervention ends or follow-up
> some weeks or months after the intervention ends.*

**6. Results**

*Compare intervention and control groups at each measurement point, by
individual measure. Report the number of intervention and the number of
control group participants measured at each point. Describe any tests of
statistical significance and the results.*

**7. Reference**

*Provide a contact for additional details and a reference to any other
report of the evaluation.*

**Appendix A. Template 2: FY \_\_\_\_\_\_Nutrition Education Plan
Proposed Projects**

**Section A. Identifying and Understanding the Target Audience**

**[(7 CFR (272.2 (e)) OMB No. 0584-0083 Expiration 10/31/2010]{.mark}**

Refer to pages 9-14 for instructions.

**[Needs Assessment Methodology & Findings]{.smallcaps}**

> **[Needs Assessment Methodology]{.underline}**
>
> *Describe and justify your methodology for assessing the needs of Food
> Stamp Program eligibles in your State.*

1.  Existing Information (source, content, time frame):

2.  New Information Collection (source and content):

> **[Needs Assessment Findings]{.underline}**

1.  **Demographic Characteristics of Food Stamp Program Eligibles in
    *\[Your State\] ***

> *If information is available, discuss geographic location,
> race/ethnicity, age, gender, family composition, education, and
> primary language**.** Reference the source(s) of any data described.*

**Appendix A. Template 2: FY \_\_\_\_\_Nutrition Education Plan Proposed
Projects (continued)**

2.  **Nutrition-Related Behavioral And Lifestyle Characteristics Of Food
    Stamp Program Eligibles In** *\[Your State\]*

> *If information is available, discuss implications of dietary and food
> purchasing habits and where and how food stamp eligibles eat, redeem
> food stamp benefits, live, learn, work, and play in your State. Cite
> sources of information.*

3.  **Other Nutrition-Related Programs Serving Low-Income Persons In**
    *\[Your State\]*

> *Discuss the availability of other nutrition-related programs,
> services, and social marketing campaigns (i.e., EFNEP, Child Nutrition
> services, etc).*

4.  **Areas Of** *\[Your State\]* **Where Food Stamp Program Eligibles
    Are Underserved Or Have Not Had Access To FSNE Previously**

5.  **[Implications of Your Needs Assessment And How These Findings Were
    Applied To This Current Year's FSNE Plan]{.mark}**

[]{.mark}

**Appendix A. Template 2: FY \_\_\_\_\_ Nutrition Education Plan
Proposed Projects (continued)**

**Section B: State FSNE Goals, Objectives, Projects, Campaigns,
Evaluation, and Collaboration [(7 CFR (272.2 (e)) OMB No. 0584-0083
Expiration 10/31/2010]{.mark}**

Refer to pages 14-20 for instructions.

1.  **[State Level Goals & Objectives]{.smallcaps}**

*Based on your needs assessment and the current availability of other
nutrition education services, identify your State's goals and objectives
for FSNE. Make sure your objectives are specific, measurable,
appropriate, realistic, and time specific.*

a.  **State Level Goals**

b.  **State Level Objectives**

**Appendix A. Template 2: FY \_\_\_\_\_\_Nutrition Education Plan
Proposed Projects (continued) [(7 CFR (272.2 (d) (2) (ii)) OMB No.
0584-0083 Expiration 10/31/2010]{.mark}**

2.  **[Description of Projects/Interventions For Each Project the
    following information should be provided:]{.smallcaps}**

**Project Title:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

a.  **Related State Objectives.**

> *Specify the objectives that the project/intervention supports.*

b.  **Audience.**

> *Specify the audience category as explained in Section A: Identifying
> and Understanding the Target Audience and other relevant
> characteristics of the proposed audience (e.g., age, gender, etc.).*

c.  **Focus on FSP Eligibles.**

> *Describe how the project will focus education on FSP eligibles.*

d.  **Project Description.**

> *Note how you will implement the project, giving particular attention
> to: how and where it will be delivered, its duration, the projected
> number of participants, the frequency of contacts (number of classes,
> mailings, billboards, etc.), and key educational messages.*

e.  **Summary of Research.**

> *Provide a [brief]{.underline} summary of existing research supporting
> the feasibility and effectiveness of your nutrition education
> methods.*

f.  **Modification of Project Methods/Strategies.**

> *Provide justification for adapting or changing an identified
> intervention/project method or strategy. Compared to previous delivery
> and/or intervention described in cited research*

g.  **Use of Existing Educational Materials.**

> *Give the title, author and description of existing educational
> materials that will be used in the delivery of the
> project/intervention. Specify the language(s) in which the materials
> will be used including English. Indicate whether the materials will be
> purchased and justify the need and cost.*

h.  **Development of New Educational Materials.**

> *Identify any new materials that you plan to produce or purchase and
> justify the need and cost.*

i.  **Key Performance Measures/Indicators***.*

> *List the key measures/indicators of implementation or performance
> that you will capture or collect. [An example of an implementation
> measure is the number of PSAs delivered in each media market during
> the intervention. One associated performance indicator might be the
> percent of people in a media market who report hearing the
> message.]{.mark}*

**Appendix A. Template 2: FY\_\_\_\_\_\_Nutrition Education Plan
Proposed Projects (continued)**

3.  **[Evaluation Plans]{.smallcaps}**

> *Describe any evaluation planned. For each evaluation, please
> indicate:*

*•[the name(s) of each project(s) that will be a part of this
evaluation]{.mark};*

*•the type of evaluation as primarily a formative, process, outcome or
impact assessment;*

*•the questions(s) that will be addressed and;*

-   *the approach to conducting the evaluation, including scope, design,
    measures and data collection;*

```{=html}
<!-- -->
```
-   *plans for using the results*

> *•if the project has been evaluated previously, note the most recent
> year in which the evaluation was done.*

4.  **[Coordination Efforts]{.smallcaps}**

> *Describe efforts to coordinate, complement and [collaborate]{.mark}
> with other programs in order to deliver consistent behavior-focused
> nutrition messages [and more comprehensive interventions]{.mark}.*
> *Describe your involvement with the State Nutrition Action Plan (SNAP)
> initiative in your State. Outline any tasks in the SNAP process that
> FSNE will lead or conduct during the FY. Attach written agreements as
> specified on page 20.*

#### Appendix A. Template 3: Nutrition Education Plan Staffing 

#### [(7 CFR (272.2 (d) (2) (i)) OMB No. 0584-0083 Expiration 10/31/2010]{.mark}

#### Section C. Staffing

> See page 20-21 for detailed instructions on completing this template.
> Provide the following summary by Food Stamp Nutrition Education (FSNE)
> project for all paid staff in the budget. Provide the Full Time
> Equivalents (FTE), describe staff responsibilities as they relate to
> FSNE and note the funding amounts that will be paid by State and/or
> Federal funds.

+----------------+-----------+--------+--------+---+------+------+---+------+
| ##             |           |        |        |   |      |      |   |      |
| Project Name:  |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
| **1.Position   | **2.      | **3.   |        | * |      |      |   |      |
| Title\***      | FTEs\*\*  | Descr  |        | * |      |      |   |      |
|                | charged   | iption |        | 4 |      |      |   |      |
|                | to FSNE** | of Job |        | . |      |      |   |      |
|                |           | Du     |        | T |      |      |   |      |
|                |           | ties** |        | o |      |      |   |      |
|                |           |        |        | t |      |      |   |      |
|                |           |        |        | a |      |      |   |      |
|                |           |        |        | l |      |      |   |      |
|                |           |        |        | F |      |      |   |      |
|                |           |        |        | S |      |      |   |      |
|                |           |        |        | N |      |      |   |      |
|                |           |        |        | E |      |      |   |      |
|                |           |        |        | S |      |      |   |      |
|                |           |        |        | a |      |      |   |      |
|                |           |        |        | l |      |      |   |      |
|                |           |        |        | a |      |      |   |      |
|                |           |        |        | r |      |      |   |      |
|                |           |        |        | y |      |      |   |      |
|                |           |        |        | , |      |      |   |      |
|                |           |        |        | B |      |      |   |      |
|                |           |        |        | e |      |      |   |      |
|                |           |        |        | n |      |      |   |      |
|                |           |        |        | e |      |      |   |      |
|                |           |        |        | f |      |      |   |      |
|                |           |        |        | i |      |      |   |      |
|                |           |        |        | t |      |      |   |      |
|                |           |        |        | s |      |      |   |      |
|                |           |        |        | a |      |      |   |      |
|                |           |        |        | n |      |      |   |      |
|                |           |        |        | d |      |      |   |      |
|                |           |        |        | W |      |      |   |      |
|                |           |        |        | a |      |      |   |      |
|                |           |        |        | g |      |      |   |      |
|                |           |        |        | e |      |      |   |      |
|                |           |        |        | s |      |      |   |      |
|                |           |        |        | * |      |      |   |      |
|                |           |        |        | * |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
| \*Attach       | \         | Perc   | Perc   | # |      | Fed  | T |      |
| statement of   | *\*Attach | entage | entage |   |      | eral | o |      |
| work listing   | d         | of     | of     | S |      | Dol  | t |      |
| FSNE-related   | efinition | FSNE   | FSNE   | t |      | lars | a |      |
| job duties for | of FTE    | Time   | Time   | a |      |      | l |      |
| each position. | and basis | spent  | spent  | t |      |      | ( |      |
|                | for       | on     | on     | e |      |      | S |      |
|                | calc      | Manag  | Direct | / |      |      | t |      |
|                | ulations. | ement/ | FSNE   | O |      |      | a |      |
|                |           | Ad     | De     | t |      |      | t |      |
|                |           | minist | livery | h |      |      | e |      |
|                |           | rative |        | e |      |      | / |      |
|                |           |        |        | r |      |      | o |      |
|                |           | Duties |        |   |      |      | t |      |
|                |           |        |        | D |      |      | h |      |
|                |           |        |        | o |      |      | e |      |
|                |           |        |        | l |      |      | r |      |
|                |           |        |        | l |      |      |   |      |
|                |           |        |        | a |      |      | + |      |
|                |           |        |        | r |      |      | F |      |
|                |           |        |        | s |      |      | e |      |
|                |           |        |        |   |      |      | d |      |
|                |           |        |        |   |      |      | e |      |
|                |           |        |        |   |      |      | r |      |
|                |           |        |        |   |      |      | a |      |
|                |           |        |        |   |      |      | l |      |
|                |           |        |        |   |      |      | ) |      |
|                |           |        |        |   |      |      |   |      |
|                |           |        |        |   |      |      | D |      |
|                |           |        |        |   |      |      | o |      |
|                |           |        |        |   |      |      | l |      |
|                |           |        |        |   |      |      | l |      |
|                |           |        |        |   |      |      | a |      |
|                |           |        |        |   |      |      | r |      |
|                |           |        |        |   |      |      | s |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
|                |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+
| **Totals**     |           |        |        |   |      |      |   |      |
+----------------+-----------+--------+--------+---+------+------+---+------+

**Appendix A. Template 4: Nutrition Education Plan Budget Summary for
Sub-Grantees**

#### Section D. Budget Summary [OMB No. 0584-0083 Expiration 10/31/2010]{.mark}

See pages 21-22 for additional instructions on completing this template.
Refer to Appendix C for additional information on allowable costs.

1\. Contracts/Grants/Agreements for nutrition education services

*[Provide this information for each contract, grant, or
agreement.]{.underline}*

a)  **Name of sub grantee**

b)  **Total Funding (Federal and non-Federal) for contract, grant, or
    agreement**

c)  **Federal funding requested**

d)  **State and other non-Federal funding provided and source in terms
    of cash and in-kind sources**

e)  **Description of services and/or products**

f)  **Cost of specific services and/or products**

[2. Project Costs]{.smallcaps}

> *For each sub-grantee, provide the State and Federal cost for each
> planned nutrition project. Provide a detailed breakdown that includes,
> at a minimum, the information contained on the following table.*

**Appendix A. Template 4: Nutrition Education Plan Budget Summary
(continued)**

**2. BUDGET INFORMATION BY PROJECT**

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 28%" />
<col style="width: 10%" />
<col style="width: 11%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2" rowspan="2"><p> </p>
<p> </p>
<p><strong>Expenses*</strong></p></td>
<td colspan="2"><strong>(a) Non-Federal Public Funds</strong></td>
<td><strong>(b) Non-Federal Non-Public Funds</strong></td>
<td colspan="2"><strong>(c) Total Non-Federal Funds (a+b)</strong></td>
<td colspan="2"><strong>(d) Federal Funds</strong></td>
<td><strong>Total Funds (c+d)</strong></td>
</tr>
<tr class="even">
<td><strong>Cash</strong></td>
<td><strong>In-kind Donations</strong></td>
<td colspan="2"><strong>Cash</strong></td>
<td><strong> </strong></td>
<td><strong> </strong></td>
<td colspan="2"> </td>
</tr>
<tr class="odd">
<td>1.</td>
<td>Salary/Benefits</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>2.</td>
<td>Contracts/Grants/Agreements**</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>3.</td>
<td>Non-Capital Equipment/Supplies</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>4.</td>
<td>Materials</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>5.</td>
<td>Travel</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>6.</td>
<td>Administrative</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>7.</td>
<td>Building/Space</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>8.</td>
<td>Maintenance</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>9.</td>
<td>Equipment &amp; Other Capital Expenditures</td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>10.</td>
<td><strong>Total Direct Costs</strong></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>11.</td>
<td>Indirect Cost***</td>
<td> </td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><strong>12.</strong></td>
<td><strong>Total Costs</strong></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>*Provide narrative describing all
expenses.</strong></td>
</tr>
<tr class="even">
<td colspan="10"><strong>**Attach copies of interagency agreements to
support line 2.</strong></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>***Provide assurance that the indirect cost
rate is an approved rate (see Appendix C, Section A.2).</strong></td>
</tr>
</tbody>
</table>

**Sub-grantee Name (if applicable):**

**Project Name:**

**Appendix A. Template 4: Nutrition Education Plan Budget Summary
(continued)**

**[3. Travel]{.smallcaps}** [(7CFR 277 (OMB Circular A-87)) OMB No.
0584-0083 Expiration 10/31/2010]{.mark}

> *Travel expenditures are a variable cost. In order to be considered
> for funding, the request should provide a direct and clear link to
> providing quality nutrition education for food stamp eligibles.
> Provide the following information for all travel included in your FSNE
> budget:*

3.  **In-State Travel**

    i.  **Travel Purpose**

        -   **[How attendance will benefit FSNE program goals and
            objectives]{.mark}**

        -   **Justification of need for travel**

        -   **Travel Destination (city, town or county or indicate local
            travel)**

        -   **Number of Staff Traveling**

        -   **Cost of Travel for this Purpose**

    ```{=html}
    <!-- -->
    ```
    i.  **Total In-State Travel Cost**

4.  **Out-of-State Travel**

    i.  **Travel Purpose and/or Name of Conference**

        -   **[How attendance will benefit FSNE program goals and
            objectives]{.mark}**

        -   **Justification of need for travel**

        -   **Travel Destination (city and state)**

        -   **Number of Staff Traveling**

        -   **Cost of Travel for this Purpose**

    ii. **Total Out-of-State Travel Cost**

**Note: Total Travel Cost (In- and Out-of-State) per project to be
entered as line 5 of budget summary (Template 4).**

**Appendix A. Template 5: Nutrition Education Plan Assurances**

**[(7 CFR (272.2 (d) (2) (iii)) and OMB No. 0584-0083 Expiration
10/31/2010]{.mark}**

####  Section F. 

  ------------------------------------------------------------------------------------------------------------
  **To assure compliance with policies described in this                                
  guidance, the Food Stamp Nutrition Education plan shall                               
  include the following assurances. Mark your response to the                           
  right.**                                                                              
  ------------------------------------------------------------- ----------------------- ----------------------
                                                                **[Yes]{.smallcaps}**   **[No]{.smallcaps}**

  1\. The State food stamp agency is accountable for the                                
  content of the State nutrition education plan and provides                            
  oversight to any sub-grantees. The State food stamp agency is                         
  fiscally responsible for nutrition education activities                               
  funded with Food Stamp Program funds and is liable for                                
  repayment of unallowable costs.                                                       

  2\. Efforts have been made to [target]{.underline} FSNE to                            
  FSP participants and eligibles.                                                       

  3\. In cases where Food Stamp Nutrition Education projects                            
  may inadvertently benefit persons that are ineligible for the                         
  Food Stamp Program because it is not practical or possible to                         
  meet the exclusivity requirement, the State has submitted                             
  approved waivers for each project. To be approved, the waiver                         
  request(s) shall [(7CFR 272.3)]{.mark} clearly demonstrates                           
  how the proposed project provides a good means of reaching                            
  food stamp eligibles and documents that at least 50 percent                           
  of those reached will have gross incomes at or below 185                              
  percent of the poverty thresholds or guidelines.                                      

  4\. Only expanded or additional coverage of those activities                          
  funded under the Expanded Food and Nutrition Education                                
  Program (EFNEP) are claimed under the FSNE grant. Approved                            
  activities are those designed to expand the State\'s current                          
  EFNEP coverage in order to serve additional food stamp                                
  eligibles or to provide additional education services to                              
  EFNEP clients who are eligible for the Food Stamp Program.                            
  [Activities]{.mark} funded under the EFNEP grant [are not                             
  included]{.mark} in the budget for FSNE.                                              

  5\. Cash or in-kind donations from other non-Federal sources                          
  to Food Stamp Nutrition Education have not been claimed or                            
  used as a match or reimbursement under any other Federal                              
  program                                                                               

  6\. Costs incurred by other State and/or local agencies for                           
  goods and services for Food Stamp Nutrition Education and                             
  which are then donated to the food stamp State agency make up                         
  the public in-kind contributions that are included in the                             
  State share of costs that are eligible for Federal                                    
  reimbursement. They may not used as a match under any other                           
  Federally funded project.                                                             

  7\. Documentation of State costs, payments, and donations for                         
  approved Food Stamp Nutrition Education activities are                                
  maintained by the State and will be available for USDA review                         
  and audit.                                                                            
  ------------------------------------------------------------------------------------------------------------

  ------------------------------------------------------------------------------------------------------------
  **To assure compliance with policies described in this                                
  guidance, the Food Stamp Nutrition Education plan shall                               
  include the following assurances. Mark your response to the                           
  right.**                                                                              
  ------------------------------------------------------------- ----------------------- ----------------------
                                                                **[Yes]{.smallcaps}**   **[No]{.smallcaps}**

  8\. Contracts are procured through competitive bid procedures                         
  governed by State procurement regulations.                                            

  9\. Program activities are conducted in compliance with all                           
  applicable Federal laws, rules, regulations including Civil                           
  Rights and OMB circulars governing cost issues.                                       

  10\. Program activities do not supplant existing nutrition                            
  education programs, and where operating in conjunction with                           
  existing programs, enhance and supplement them.                                       

  11\. Program activities are reasonable and necessary to                               
  accomplish Food Stamp Nutrition Education objectives and                              
  goals.                                                                                

  12\. All materials developed or printed with Food Stamp                               
  Nutrition Education funds include the appropriate USDA                                
  non-discrimination statement, credit to the Food Stamp                                
  Program as a funding source, and a brief message about how                            
  the Food Stamp Program can help provide a healthy diet and                            
  how to apply for benefits.                                                            

  13\. Messages of nutrition education are consistent with the                          
  Dietary Guidelines for Americans and stress the importance of                         
  variety, balance, and moderation, and do not disparage any                            
  specific food, beverage or commodity.                                                 
  ------------------------------------------------------------------------------------------------------------

**Appendix A: Template 6: Waiver Request Outline [(7CFR 272.3]{.mark})
Operating Guidelines, Forms, Waivers [OMB No. 0584-0083 Exp.
10/31/2010]{.mark}**

Refer to pages 53-55 for additional instructions regarding waiver
requests.

**1. Waiver serial number:**

> *Enter the waiver number if one was assigned in previous
> correspondence. The waiver serial number should be used in all
> correspondence regarding the waiver.*

**2. Type of request:**

> *Enter "initial" if the State agency is requesting the waiver for the
> first time or "extension" if the waiver has been approved previously.
> Enter "modification" if the State agency is requesting a change to a
> previously approved waiver. Enter "reconsideration" if the State
> agency is requesting that the denial of a previous request be
> reexamined.*

**3. Primary regulation citation:**

> *Identify the specific section of 7CFR for which the waiver is
> requested. Contact the regional office if there is any question
> regarding the citation.*
>
> *For exclusivity waivers the citation is 7CFR 272.2(d) (2) (iii).*
>
> *For cash donation waivers the primary citation is: 7 CFR 277.4(c)*

**4. Secondary regulation citation:**

> *Some proposals will require a cross-reference to another section of
> the regulations. For example, a waiver to count income in the month it
> is intended to cover, rather than the month of receipt, may relate to
> both 7 CFR 273.10 and 7 CFR 273.21. However, if the proposal requires
> waivers of two unrelated regulatory provisions (for example, to extend
> certification periods and also substitute a telephone interview for a
> face-to-face interview), two separate waiver requests and two primary
> regulation citations are needed.*
>
> *There is no secondary citation for exclusivity waivers.*
>
> *The secondary citation for private cash donation waivers is: 7 CFR
> 277.4(d).*

**5. State:**

**6. Region:**

**7. Regulatory requirements:**

> *Describe the requirement that is to be waived. For example, 7 CFR
> 273.21(c) requires the State agency to have a toll-free number or
> accept collect calls.*

**Appendix A: Template 6: Waiver Request Outline (continued)**

**8. Proposed alternative procedures:**

*Describe in detail the procedures the State agency plans to follow in
lieu of the regulatory requirement. For exclusivity waivers describe how
Food Stamp Nutrition Education will be delivered to FSP eligibles in a
way that may also inadvertently benefit persons that are ineligible for
the FSP. Provide the location of the project (e.g., school, congregate
meal site, etc.) and describe the* *audience that will receive FSNE.
Indicate the projected number of people the intervention will reach,
estimated number of total contacts and the number or percentage of total
contacts that will be with FSP eligibles. The request shall also
indicate how the project will offer an educational message about the
FSP, its benefits, and how to apply.*

**9. Justification for request:**

> *Explain the purpose of the waiver and how it meets the approval
> criteria of the regulations.* *For exclusivity waivers, States shall
> document that:*

-   *It is not possible to provide FSNE exclusively to FSP eligibles
    without inadvertently reaching other audiences because it is not
    possible or practical to identify FSP eligibility or to specifically
    provide FSP eligibles with nutrition education without reaching
    others.*

-   *The project provides an efficient and effective means of reaching
    FSP eligibles.*

-   *At least 50 percent of the population that will receive FSNE has
    gross household incomes that are at or below 185 percent of the
    poverty guidelines or thresholds or the setting is a high volume FSP
    authorized retail grocer with average monthly FSP redemptions of
    \$50,000 or more over a 12-month period. Reference data sources.*

**10. Anticipated impact on households and State agency operations:**

> *Describe the effect the waiver is expected to have on households in
> terms of quality or timeliness of service, any administrative or
> Program savings, and any adverse effect on households or the State
> agency if the waiver is not granted.*

**Appendix A: Template 6: Waiver Request Outline (continued)**

**11. Caseload information, including percent, characteristics, and
quality control error rate for affected portion:**

> *Provide detailed information regarding the percent of the total
> caseload which would be affected by the waiver, whether the households
> are prospectively or retrospectively budgeted, monthly reporters or
> change reporters, elderly or disabled, and other relevant information.
> Provide the latest quality control information available for the type
> of household affected. For example: "Pure SSI households constitute 15
> percent of the caseload and have an error rate of 7 percent."*

**12. Anticipated implementation date and time period for which waiver
is needed:**

> *Indicate the State agency's time frame for putting the waiver into
> effect and the period for which the waiver is requested.*

**13. Proposed quality control review procedures:**

> *Describe the effect the waiver is expected to have on quality control
> review procedures. If applicable, provide detailed review procedures
> to be used in lieu of procedures in the FNS Handbook 310.*

**14. Signature and title of requesting official:**

> *Type the requesting official's name and title and leave sufficient
> space for the stamped signature. The date will be date-stamped on line
> 15.*

**15. Date of request:**

*Date stamp with the date the request is signed.*

**Appendix A. Template 7: Nutrition Education Plan Signatures**

# **Section G: Signatures [(7CFR 272.2) OMB No. 0584-0083 Expiration 10/31/2010]{.mark}**

**Food Stamp Program**

**Annual Plan for Nutrition Education**

**for**

State AGENCY:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

FY \_\_\_\_\_\_\_\_

**Certified By:**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> STATE FOOD STAMP AGENCY NUTRITION DATE

COORDINATOR or

> STATE FOOD STAMP AGENCY DIRECTOR

**Certified By:**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

STATE FOOD STAMP AGENCY FISCAL REVIEWER DATE

**Appendix A. Template 8: Sample Time and Effort Documentation**

Refer to Appendix C, Section A.10 for instructions on time and effort
documentation.

[**OMB No. 0584-0083 Expiration 10/31/2010**]{.mark}

**Time and Effort Documentation for hours worked specifically on**

**Food Stamp Nutrition Education**

**Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Location\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Title/Position\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | #  |             |     | Mo |             |
| Mo |             |     | ## |             |     | nt |             |
| nt |             |     | #  |             |     | h: |             |
| h: |             |     | Mo |             |     |    |             |
| ** |             |     | nt |             |     |    |             |
|    |             |     | h: |             |     |    |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  | **Hours     |     | *  | **Hours     |     | *  | **Hours     |
| *D | Worked**    |     | *D | Worked**    |     | *D | Worked**    |
| ay |             |     | ay |             |     | ay |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *1 |             |     | *1 |             |     | *1 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *2 |             |     | *2 |             |     | *2 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *3 |             |     | *3 |             |     | *3 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *4 |             |     | *4 |             |     | *4 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *5 |             |     | *5 |             |     | *5 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *6 |             |     | *6 |             |     | *6 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *7 |             |     | *7 |             |     | *7 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *8 |             |     | *8 |             |     | *8 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| *  |             |     | *  |             |     | *  |             |
| *9 |             |     | *9 |             |     | *9 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 10 |             |     | 10 |             |     | 10 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 11 |             |     | 11 |             |     | 11 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 12 |             |     | 12 |             |     | 12 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 13 |             |     | 13 |             |     | 13 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 14 |             |     | 14 |             |     | 14 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 15 |             |     | 15 |             |     | 15 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 16 |             |     | 16 |             |     | 16 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 17 |             |     | 17 |             |     | 17 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 18 |             |     | 18 |             |     | 18 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 19 |             |     | 19 |             |     | 19 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 20 |             |     | 20 |             |     | 20 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 21 |             |     | 21 |             |     | 21 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 22 |             |     | 22 |             |     | 22 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 23 |             |     | 23 |             |     | 23 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 24 |             |     | 24 |             |     | 24 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 25 |             |     | 25 |             |     | 25 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 26 |             |     | 26 |             |     | 26 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 27 |             |     | 27 |             |     | 27 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 28 |             |     | 28 |             |     | 28 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 29 |             |     | 29 |             |     | 29 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 30 |             |     | 30 |             |     | 30 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+
| ** |             |     | ** |             |     | ** |             |
| 31 |             |     | 31 |             |     | 31 |             |
| ** |             |     | ** |             |     | ** |             |
+----+-------------+-----+----+-------------+-----+----+-------------+