Sponsor/FDCH Burden

APPENDIX B

OBSERVATION FORM

CACFP FAMILY DAYCARE HOME OBSERVATION FORM

Observer MPRID#:_______________________

Sponsor ID#:______________ FDCH ID#:___________________

1. Total enrollment from sponsor records: (fill in prior to visit) |__|__|

|__|__| Infants (under 1 year)

|__|__| Preschool children (1-5 years)

|__|__| School-age children (6+ years)

2. Does the enrollment form have a place for parents to record the meals or snacks their children will need while they are in day care? □YES □NO

Visit #1:

3. Check day of visit: □Monday □Tuesday □Wednesday □Thursday □Friday

4. DATE: | | | / | | | / | 2 | 0 | 0 | |

MONTH DAY YEAR

5. Was FDCH operating on day of visit:? □YES  GO TO Q6

□NO

5a. Is FDCH still operating: □YES

□NO  GO TO Q6

5b. Why was FDCH not operating on date of visit?

________________________________________________________

6. Time observer arrived: |__|__|:|__|__| am/pm

7. Accompanied by sponsor: □YES □NO

8. IF AVAILABLE, COLLECT COPIES/PROVIDE FEDEX SUPPLIES FOR THE FOLLOWING:

1. Menu for the current week

2. Daily Participation or Meal Counts forms for April-week of observation

3. Sign in/Sign out sheets for target week and week of observation

4. Enrollment forms for new children participating in meal program

9. Record the attendance at time of arrival:

Total number of infants and children: |__|__|

10. ASK NAMES AND AGES OF CHILDREN PRESENT

Name	Age (Check one)			(Check one)
	Infant	Preschool	School Age	Provider’s Child	Other	Not in Program

11. Check name(s) of eating occasion observed	□ Breakfast □ Lunch □ Supper □Snack	□ Breakfast □ Lunch □ Supper □ Snack
NOTE: If more than 5 children present, use the CACFP Meal Count Tally Sheet to count the number of meals served.
11a. Total number infants served at each eating occasion.	|__|__|	|__|__|
11b. Total number preschool children served at each eating occasion	|__|__|	|__|__|
11c. Total number school age children served at each eating occasion	|__|__|	|__|__|
11d. ASK SPONSOR: Was this meal/snack reimbursable for each age group of children? SPONSOR NOT PRESENT = NA	Check all that apply □ Infants □ Preschool □ School □ Not reimbursable □ NA	Check all that apply □ Infants □ Preschool □ School □ Not reimbursable □ NA

Sign-in/Sign-out sheets

12. Check the sign-in/sign-out procedure used at the FDCH.

Sign-in/sign-out sheet completed by parents/guardians □ 1

Attendance form completed by provider □ 2 GO TO Q16

No sign-in or attendance procedure observed □ 3 GO TO Q16

No sign-in/sign-out procedure used □ 4 GO TO Q16

OTHER PARENT SIGN-IN PROCEDURE (SPECIFY): □ 5 GO TO Q16

___________________________________________________

13. Did the parents/guardians record the times of arrival and departure on the sign in/sign out sheet?

YES, THE TIME OF ARRIVAL ONLY □ 1

YES, THE TIME OF DEPARTURE ONLY □ 2

YES, BOTH ARRIVAL AND DEPARTURE TIMES □ 3

NO, ARRIVAL AND DEPARTURE TIMES NOT REQUIRED □ 4

OTHER (SPECIFY): □ 5

_____________________________________________

14. Did the FDCH provider remind the parents/guardians to sign in or sign out?

YES □ 1

NO □ 0

NOT OBSERVED □ n

15. Use sign-in/sign-out (SISO) sheets for the target week and week of observation to complete the following grid. ASK PROVIDER FOR COPIES OF SISO SHEETS AND FILL OUT AFTER VISIT. 1) Record the dates for each day of the target week and the week of observation including the day of observation. 2) Record the children’s first names in alphabetic order. 3) Using the SISO sheets, record the daily arrival and departure times for each child. If the child is noted as absent, record “ABS” for that day. If no information is provided/required for either an arrival or departure time, record NA.

Child’s First Name	TARGET WEEK ___/___ to ___/___					WEEK OF OBSERVATION
	Monday ____/____	Tuesday ____/____	Wednesday ____/____	Thursday ____/____	Friday ____/____	Monday ____/____	Tuesday ____/____	Wednesday ____/____	Thursday ____/____	Friday ____/____
	Arrival /Departure	Arrival /Departure	Arrival /Departure	Arrival /Departure	Arrival /Departure	Arrival /Departure	Arrival /Departure	Arrival /Departure	Arrival /Departure	Arrival /Departure
(Pre-printed)

Other observations:

16. Was a Daily Participation or meal counts form completed while children were eating or being served, after each meal, at the end of the day, or was this not observed?

WHILE CHILDREN EATING/ BEING SERVED □ 1

AFTER EACH MEAL/SNACK □ 2

AT THE END OF THE DAY □ 3

NOT OBSERVED □ n  GO TO Q18

17. Who completed the information on the daily participation or meal counts form?

OWNER/ MANAGER OF FDCH □ 1

ASSISTANT/HELPER □ 2

VOLUNTEER/ PARENT □ 3

OTHER (SPECIFY) □ 4

_____________________________

18. Record the attendance at time of observer’s departure:

Total number of infants and children: |__|__|

19. ASK AGES OF CHILDREN STILL PRESENT

	Provider’s Children	Other Children	Children not in program
Infants (under 1 year)	|__|__|	|__|__|	|__|__|
Preschool (1-5 years)	|__|__|	|__|__|	|__|__|
School age (6+ years)	|__|__|	|__|__|	|__|__|

20. Time of departure: _________________am/pm

INTERVIEWER: COMPLETE THE FOLLOWING QUESTIONS AFTER LEAVING THE FDCH AT THE END OF THE FIRST VISIT.

21. Did it seem that FDCH provider was informed in advance of your visit?

YES □ 1

NO □ 0

Arrivals/Departures

22. What was the pattern of arrivals of children during your first observation period?

ALL THERE AT TIME OF MY ARRIVAL □ 1

MOST THERE AT TIME OF MY ARRIVAL □ 2

ARRIVED INTERMITTENTLY DURING THE OBSERVATION □ 3

23. What was the pattern of departure of children during your first observation period?

NONE LEFT DURING MY VISIT □ 1

ONLY A FEW LEFT DURING MY VISIT □ 2

LEFT INTERMITTENTLY DURING MY VISIT □ 3

INTERVIEWER: IF NO SECOND VISIT IS PLANNED OR PERMITTED, CONTINUE TO END, PAGE 8.

Visit #2:

24. Time observer arrived: |__|__|:|__|__| am/pm

□ No second visit: NA GO TO END

25. Accompanied by sponsor: □YES □NO

26. Record the attendance at time of arrival:

Total number of infants and children: |__|__|

27. ASK AGES OF CHILDREN PRESENT

Name	Age (Check one)			(Check one)
	Infant	Preschool	School Age	Provider’s Child	Other	Not in Program

28. Check name(s) of eating occasion observed	□ Breakfast □ Lunch □ Supper □Snack	□ Breakfast □ Lunch □ Supper □ Snack
NOTE: If more than 5 children present, use the CACFP Meal Count Tally Sheet to count the number of meals served.
28a. Total number infants served at each eating occasion.	|__|__|	|__|__|
28b. Total number preschool children served at each eating occasion	|__|__|	|__|__|
28c. Total number school age children served at each eating occasion	|__|__|	|__|__|
28d. ASK SPONSOR: Was this meal/snack reimbursable for each age group of children? SPONSOR NOT PRESENT = NA	Check all that apply □ Infants □ Preschool □ School □ Not reimbursable □ NA	Check all that apply □ Infants □ Preschool □ School □ Not reimbursable □ NA

29. Record the attendance at time of observer’s departure:

Total number of infants and children: |__|__|

30. ASK AGES OF CHILDREN STILL PRESENT

	Provider’s Children	Other Children	Children not in program
Infants (under 1 year)	|__|__|	|__|__|	|__|__|
Preschool (1-5 years)	|__|__|	|__|__|	|__|__|
School age (6+ years)	|__|__|	|__|__|	|__|__|

31. Time of departure: _________________am/pm

Arrivals/Departures

32. What was the pattern of arrivals of children during your second observation period?

ALL THERE AT TIME OF MY ARRIVAL □ 1

MOST THERE AT TIME OF MY ARRIVAL □ 2

ARRIVED INTERMITTENTLY DURING THE OBSERVATION □ 3

NO SECOND OBSERVATION PERIOD □ n

33. What was the pattern of departure of children during your second observation period?

NONE LEFT DURING MY VISIT □ 1

ONLY A FEW LEFT DURING MY VISIT □ 2

LEFT INTERMITTENTLY DURING MY VISIT □ 3

NO SECOND OBSERVATION PERIOD □ n

END. What is the status of the FDCH provider interview?

COMPLETED DURING VISIT □ 1

SCHEDULED TO COMPLETE BY PHONE □ 2

PROVIDER REFUSED □ 3