Double Up Michigan Grocery Stores: QUARTERLY DESCRIPTIVE REPORT

Attention DOUBLE UP partners: This report collects descriptive information of grocery stores operating GusNIP-funded SNAP Incentive (SI) programs. INSTRUCTIONS: ---> All sites (i.e., firms) must submit a quarterly report. ---> If your site did not operate Double Up during a specific reporting period, you must still submit a report indicating the program did not operate. ---> Quarterly reports will only be accepted using this online form. ---> Use one form per quarter. Multiple reporting periods may not be combined into the same form. REPORTING SCHEDULE: --> January, February, and March reports are DUE APRIL 8. --> April, May, and June reports are DUE JULY 8. --> July, August and September reports are DUE OCTOBER 8. --> October, November, and December reports are DUE JANUARY 8.

QUARTERLY DESCRIPTIVE REPORT

Site Name (i.e., firm)*

Select your site from the list below. *Double check for accuracy.*

Select

If your firm name was not included in the drop-down list above, enter it here.*

Year*

Select the year for this reporting period.

2019

2020

2021

2022

Reporting Period*

Select the reporting period for this report.

Jan 1 - Mar 31

Apr 1 - Jun 30

Jul 1 - Sept 30

Oct 1 - Dec 31

Months Program Operated (Jan-Mar)*

During this reporting period, which month(s) was the Double Up program operational at this site? Select all that apply. If program did not operate, select "Did Not Operate."

Select

Months Program Operated (Apr-Jun)*

During this reporting period, which month(s) was the Double Up program operational at this site? Select all that apply. If program did not operate, select "Did Not Operate."

Select

Months Program Operated (Jul-Sept)*

During this reporting period, which month(s) was the Double Up program operational at this site? Select all that apply. If program did not operate, select "Did Not Operate."

Select

Months Program Operated (Oct-Dec)*

During this reporting period, which month(s) was the Double Up program operational at this site? Select all that apply. If program did not operate, select "Did Not Operate."

Select

Why did the program not operate?*

Select all that apply.

Select

Other Reason Program Not Operational*

If "Other" please specify.

ABOUT THIS SITE

If program was operational, questions about the location and hours of operation of your SNAP/Double Up incentive program will appear below.

Firm Type*

Select type of firm from the list below.

Brick and Mortar

Brick and Mortar*

Select category option from the list below.

Select

Farm Direct*

Select

Street Address*

In the fields below, provide the address of the PHYSICAL location for your firm for this reporting period. Enter the number and street here. (e.g., 123 Apple Lane)

City*

State*

Zip*

DOUBLE UP

If program was operational, questions about your SNAP/Double Up incentive program will appear below.

How is the SNAP/Double Up incentive ISSUED to participants/customers at this site?*

How and where is Double Up ISSUED or provided to each customer at this site. Choose from the options below. COUPON A SNAP customer purchases fruits and vegetables using their EBT card. The EBT card swipe activates the SNAP match and the Double Up amount shows up on the bottom of the receipt (e.g., like a coupon) to be used for future FV purchases. DIGITAL INCENTIVE DOLLARS ON DOUBLE UP CARD A SNAP customer purchases fruits and vegetables using their EBT card. The EBT card swipe activates the SNAP match and the cashier loads matching digital incentive dollars onto the Double Up card to be used for future purchases YES CARD A SNAP customer purchases fruits and vegetables using their EBT card. The EBT card swipe activates the SNAP match and the cashier then loads the matching digital incentive onto the Yes card to be used for future purchases. AUTOMATIC 50% OFF SNAP customers use their EBT card to purchase groceries and automatically receive 50% off their eligible FV purchases.

Select or enter value

How is the SNAP/Double Up incentive REDEEMED by participants/customers at this site?*

How and where is Double Up redeemed by customers at this site. Choose from the options below. AUTOMATIC 50% OFF SNAP customers use their EBT card to purchase eligible produce and automatically receive 50% off their eligible FV purchases. COUPONS SNAP customers redeem coupons at check-out for eligible FV purchases. CASHIER SWIPES DOUBLE UP CARD USING APP OR POS SNAP customers use their Double Up Card to purchase eligible produce at grocery check-out. The cashier uses a tablet or POS system to swipe Double Up card to complete Double Up transactions. YES CARD SNAP customers use their Yes Card at check-out for eligible FV purchases

Select or enter value

Financial Instrument for Double Up Incentives*

In what form are SNAP incentives provided to customers at this site?

Select

Other Financial Instrument*

If "Other" please specify here.

SNAP Purchases/Products Eligible to Trigger SNAP Incentive*

What are the allowable SNAP purchases that trigger (Double Up) incentives at this site? (i.e., What can a customer purchase with their EBT card to earn Double Up?) Select all that apply.

Select

Other SNAP Purchases/Products Eligible to Trigger SNAP Incentive*

If "Other" please specify here.

Fruit and Vegetable Products Eligible for Incentives*

What fruit and vegetable products are eligible for Double Up incentives at this site? (e.g., What can a customer purchase with their Double Up?) Select all that apply.

Select

Other F&V Products Eligible*

If "Other" please specify here.

Incentive-level Ratio*

Select the ratio for SNAP dollars to SNAP incentive (Double Up) for this site during this reporting period. If this site has more than one, select all that apply. *Double check for accuracy.* Example: For every $1 spent on SNAP, customer will earn $1 in Double Up incentive, up to $20, daily. In this scenario, the RATIO is 1:1.

Select or enter value

Other Incentive-level Ratio*

If "Other" please specify here.

Incentive-level Cap (Max)*

What is your maximum Double Up incentive amount based on the frequency you entered above? Enter number only. (e.g., 5, 10, 25, etc.) If this site does not have cap, enter "no cap." Example: For every $1 spent on SNAP, customer will earn $1 in incentive, up to $20, daily. In this scenario, the CAP is 20.

ADDITIONAL PROGRAMS

If program was operational, questions related to additional programs operating at this site will appear below.

Nutrition Assistance Benefits Programs*

During this reporting period, did this site accept any other nutrition assistance benefits? Select all that apply. Descriptions: • WIC = Special Supplemental Nutrition Program for Women, Infants, and Children • FMNP = Farmers Market Nutrition Program (one time vouchers for WIC recipients to use on farm fresh produce) • FDPIR = Food Distribution Program on Indian Reservations • CSFP = Commodity Supplemental Food Program

Select

Other Nutrition Assistance Programs*

If "Other" please specify here.

Nutrition Education Activities*

During this reporting period, did this site offer nutrition education activities for incentive participants? This could have been done independently or collaboration with a community partner. Select all that apply.

Select

Other Nutrition Education Activities*

If "Other" please specify here.

Auxiliary Services*

Did this site offer any auxiliary services for Double Up incentive participants during this reporting period? Select all that apply.

Select or enter value

Other Auxiliary Services*

If "Other" please specify here.

POINT OF SALE SYSTEM INFORMATION

Which POS system are you currently using?*

Select or enter value

If Other, please list POS system*

System version of POS system OR other details

Who services your POS system?*

Select or enter value

If Other, please list service vendor or dealer*

Plans to upgrade POS in 6-12 months*

Select or enter value

If so, which system are you considering?*

CONTACT INFORMATION

Contact Name*

Enter your first and last name.

Contact Email*

Enter your email address. *Double check for accuracy.*

Contact Phone Number*

Enter your phone number. *Double check for accuracy.* (e.g., 555-555-5555)

Questions/Comments

Please include any questions or clarifications you have related to this report. NOTE: If submitting a corrected report, enter "This is a corrected report. Delete previous report for [firm] [reporting period]."

FINAL STEPS BEFORE SUBMITTING

1. Review the information you provided above and check for accuracy. Make corrections if needed. 2. Click the box below titled “Send me a copy of my responses.” 3. Type your email address in the box that appears. Double check to ensure you entered it correctly. (After submitting your report, a copy of your responses will be sent automatically to the email you provide. Save for your records.) 4. Click the blue "Submit" button to send in your report.

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