Snap Ed Alternative Methodology Site Change Form B - California
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2SNAP-Ed Alternative Methodology
Site Change Form B
Form B. Request to Use an Alternative Site Methodology: Single Event
On-going Services
(1) County Jurisdiction:
(2) Name of LIA initiating site change:
CWD
AAA
CCC
LHD
UCCE
(Check one only.)
(4) Contact Phone Number:
(3) Contact Name and E-mail:
(6) Consensus on Site Change(s)
(5) Name of all SNAP-Ed LIA Partners within County Jurisdiction:
Reached and Approved by
N/A
[Check only if there are no other SNAP-Ed LIA Partners within County Jurisdiction]
SNAP-Ed Partners
(Required)
1.
Yes
2.
Yes
3.
Yes
4.
Yes
5.
Yes
(7) Specify site(s) location and address:
Site 1:
Site 2:
(8) Alternative Methodology Used:
(Please specify the methodology # used based on the
USDA/WRO Targeting Methodologies
Summary
Document)
Site 1: Methodology #:___
Site 2: Methodology #:___
(9) Describe and justify the Alternative Methodology
(Provide documentation on a separate attachment if needed as part of the justification. Please indicate if separate attachment provided.)
Site 1:
Site 2:
(10) SNAP-Ed Site List (i.e., Targeting Summary Update Spreadsheet) Completed and Attached
(Required)
(11) Additional Information
:
(if applicable, may attach a separate sheet)
(12) FOR SIA ONLY:
SIA has verified all forms and attachments and Provided TA to the LIA. Yes
(Required)
FOR CDSS SITE CHANGE COORDINATOR ONLY:
Date received by CDSS: ______
_
Date Completed by
CDSS: ______
_
Alternative Methodology Approved by USDA/WRO: Yes
No
N/A
Additional information needed: Yes
No
Information Needed: ________________________________________________________
If additional information needed, Date requested: ________
Note:
January 15 and April 15, 2016, are the deadlines to submit all Alternative Methodology site
change requests for FFY 16 to CDSS.
Revised 12/9/2015
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