This is (basically) the same system that Crescent City Farmers Market (CCFM) in New Orleans has used to gather data from incentive users (incentiv-ers?) since they began doing them some years back. They call their incentive Market Match.
As one of the staff who was responsible for doing it when it began and was part of the discussion about it, I really liked it. It is on a pad that is pulled off to have the person fill out and then each slip is added to the clipboard (or put in a container) to be entered into spreadsheets at a later time. The darker grey is filled out by the market staff person after the other part is completed by the shopper. What I know is that the system was designed with both the shopper and the market staff needs in minds, which as we all know is important and yet not always done. I’d like them to be numbered chronologically so as to know that none were lost. Maybe they are numbered, I’ll check to see.
Sorry for the wrinkles- it ended up in my market bag under the citrus. I’ll get some more pics of their system-including a better version of this and maybe the other collection forms if they will allow me to continue to peek over their shoulder.