FNS-779 HealthierUS School Challenge Application for Gold or Gol

Food and Nutrition Service (FNS)

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Application Cover Sheet

Application for: _______ Gold Award ______ Gold Award of Distinction*

* To receive the Gold Award of Distinction a school must meet a stricter sodium requirement for competitive foods or meet a stricter physical education/activity requirement.

PRINT OR TYPE ALL INFORMATION

School Name
School District
School Address
Grades in School
Contact Person’s Name and Title
Contact Person’s Phone Number & Email
Date Submitted to State Agency

FOR OFFICE USE ONLY

State

Approved by State Child Nutrition Director: ____________________________________________

Signature Date

Regional Office

FNS Region _________ Reviewed by: _______________________________________________

Approved by Child Nutrition Director: _________________________________________________

Signature Date

FNS Headquarters (HQ)

Application received HQ_____________ Reviewed by _________________

Decision/Date_____________________ Award period _________________

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Application Check-off Sheet

Please include the following information in your Application:

_____ Cover Sheet (pg 1)

_____ Check-off Sheet (pg 2)

_____ Application Form (pg 3)

_____ The monthly menus for reimbursable school lunches served in your school.

(Menus must reflect four consecutive weeks, where each week has at least three days and the total number of days over the 4-week menu is 16 days or more.  For example: 3 days week 1; 3 days week 2; 5 days week 3; 5 days week 4 = 16 days)

_____ 4-week Lunch Menu Worksheets (pg 4-7)

_____ Production records for the 4-week Lunch Menus

_____ Documentation including recipes, food product ingredient statements, and/or Nutrition

Facts Labels to verify that the criteria have been met for the following:

• Whole-grain products

• A la carte, snack bar, and vended items sold anytime, anywhere on the school campus

_____ Nutrition Education Worksheet (pg 8)

_____ Physical Education/Activity Worksheet (pg 9)

_____ Competitive Foods Worksheet (pg 10-11)

_____ School Policies and Practices Checklist (pg 11)

_____ Review Committee Verification Form (pg 12)

_____ Copy of the School Wellness Policy and Team Nutrition Verification

Place all materials in a 3-ring binder.

Multiple schools applying in one District that use the same menu and the same foods, may submit one 4-week lunch menu, one set of menu worksheets, and one set of recipes, food product ingredient statements, and/or Nutrition Facts Labels. However, each school must have their own cover sheet, application form, review committee verification form, food production records, competitive foods worksheet that includes a la carte information and vended items (unless they are the same throughout the district), nutrition education and physical education/activity worksheets, as well as school policies and practices checklist and wellness policy (unless it is a district policy).

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Application for Gold or Gold Award of Distinction

Criteria	Yes	No
1. Are you a Team Nutrition School? (Include print out of Team Nutrition verification from Team Nutrition website: http://teamnutrition.usda.gov/schoolsdb/srchpage.asp)
2. Have all of your corrective actions from the most recent School Meals Initiative (SMI) review been completed?
Are all of lunches submitted reimbursable lunches?
4. Do your reimbursable lunches meet or exceed the criteria in the worksheets? (Include forms on pages 4-7 and documentation for menus served.)
5. Is nutrition education provided to students in multiple grades and does it meet or exceed the criteria in the worksheet? (Include worksheet on page 8.)
6. Is the opportunity for physical education/activity provided to students, that meets or exceeds the criteria in the worksheet? (Include worksheet on page 9.)
7. What is your student Average Daily Participation (ADP) for reimbursable lunches? List ADP: _________ Month: ________ (Must be 70% of enrollment or higher.)
8. Does your school serve/sell a la carte foods or have foods or beverages available in vending machines or a school store any time throughout the school day (including meal periods) and any place throughout the school campus? If yes, do these foods and beverages meet the competitive foods criteria listed in the worksheet? (Include worksheet on pages 10-11, Nutrition Facts Labels and/or recipes.)
9. Does your school meet the School Policies and Practices criteria listed on page 11 of this application? (Include worksheet on page 11.)

The State Agency and FNS reserve the right to verify all information on the application and reject applications that are incomplete or otherwise fail to provide factual information.

Lunch Menu Worksheet – GOLD or GOLD Award of Distinction

Dates Week 1 Menu was served: ___________________________________

Week 1
Menu Planning Approach Used: ____Traditional ____Enhanced ____NSMP
LUNCH MENU CRITERIA	FOOD ITEM	PORTION SIZE	ADDITIONAL INFORMATION
Vegetables: Offer a different vegetable every day of the week (at least ¼ cup serving size). Note that various preparations of the same vegetable are considered the same, i.e. mashed potatoes and tater tots are both potatoes.	M T W T F	M T W T F
Dark green or orange vegetables: Offer dark green or orange vegetables on 3 or more days per week. (Of the 3, at least 2 must be different. All must be at least ¼ cup serving size)	1 2 3	1 2 3
Cooked dry beans or peas (legumes): Offer at least once a week (at least ¼ cup serving size).	1	1
Fruits: Offer a different fruit every day of the week (at least ¼ cup serving size). Note that various preparations of the same fruit are considered the same, i.e. fresh apples and applesauce are both apples.	M T W T F	M T W T F
Fresh fruit: Offer fresh fruit at least 2 days a week (at least ¼ cup serving size).	1 2	1 2
Whole grain foods: Offer at least 1 serving of whole grain food every day, and may not be the same one each day.	M T W T F	In oz or grams: M T W T F
Does your menu only offer low-fat (1% or less) and fat-free (skim) milk, flavored or unflavored, each day?			YES NO
How many side items can a student take each day (excluding milk) for a reimbursable meal? ­
Do students have the opportunity to select each of the food items listed that meet the HealthierUS criteria?			YES NO

Lunch Menu Worksheet – GOLD or GOLD Award of Distinction

Dates Week 2 Menu was served: ___________________________________

Week 2
Menu Planning Approach Used: ____Traditional ____Enhanced ____NSMP
LUNCH MENU CRITERIA	FOOD ITEM	PORTION SIZE	ADDITIONAL INFORMATION
Vegetables: Offer a different vegetable every day of the week (at least ¼ cup serving size). Note that various preparations of the same vegetable are considered the same, i.e. mashed potatoes and tater tots are both potatoes.	M T W T F	M T W T F
Dark green or orange vegetables: Offer dark green or orange vegetables on 3 or more days per week. (Of the 3, at least 2 must be different. All must be at least ¼ cup serving size)	1 2 3	1 2 3
Cooked dry beans or peas (legumes): Offer at least once a week (at least ¼ cup servings).	1	1
Fruits: Offer a different fruit every day of the week (at least ¼ cup servings). Note that various preparations of the same fruit are considered the same, i.e. fresh apples and applesauce are both apples.	M T W T F	M T W T F
Fresh fruit: Offer fresh fruit at least 2 days a week (at least ¼ cup serving size).	1 2	1 2
Whole grain foods: Offer at least 1 serving of whole grain food every day, and may not be the same one each day.	M T W T F	In oz or grams: M T W T F
Does your menu only offer low-fat (1% or less) and fat-free (skim) milk, flavored or unflavored, each day?			YES NO
How many side items can a student take each day (excluding milk) for a reimbursable meal? ­
Do students have the opportunity to select each of the food items listed that meet the HealthierUS criteria?			YES NO

Lunch Menu Worksheet – GOLD or GOLD Award of Distinction

Dates Week 3 Menu was served: ___________________________________

Week 3
Menu Planning Approach Used: ____Traditional ____Enhanced ____NSMP
LUNCH MENU CRITERIA	FOOD ITEM	PORTION SIZE	ADDITIONAL INFORMATION
Vegetables: Offer a different vegetable every day of the week (at least ¼ cup serving size). Note that various preparations of the same vegetable are considered the same, i.e. mashed potatoes and tater tots are both potatoes.	M T W T F	M T W T F
Dark green or orange vegetables: Offer dark green or orange vegetables on 3 or more days per week. (Of the 3, at least 2 must be different. All must be at least ¼ cup serving size)	1 2 3	1 2 3
Cooked dry beans or peas (legumes): Offer at least once a week (at least ¼ cup serving size).	1	1
Fruits: Offer a different fruit every day of the week (at least ¼ cup serving size). Note that various preparations of the same fruit are considered the same, i.e. fresh apples and applesauce are both apples.	M T W T F	M T W T F
Fresh fruit: Offer fresh fruit at least 2 days a week (at least ¼ cup serving size).	1 2	1 2
Whole grain foods: Offer at least 1 serving of whole grain food every day, and may not be the same one each day.	M T W T F	In oz or grams: M T W T F
Does your menu only offer low-fat (1% or less) and fat-free (skim) milk, flavored or unflavored, each day?			YES NO
How many side items can a student take each day (excluding milk) for a reimbursable meal? ­
Do students have the opportunity to select each of the food items listed that meet the HealthierUS criteria?			YES NO

Lunch Menu Worksheet – GOLD or GOLD Award of Distinction

Dates Week 4 Menu was served: ___________________________________

Week 4
Menu Planning Approach Used: ____Traditional ____Enhanced ____NSMP
LUNCH MENU CRITERIA	FOOD ITEM	PORTION SIZE	ADDITIONAL INFORMATION
Vegetables: Offer a different vegetable every day of the week (at least ¼ cup serving size). Note that various preparations of the same vegetable are considered the same, i.e. mashed potatoes and tater tots are both potatoes.	M T W T F	M T W T F
Dark green or orange vegetables: Offer dark green or orange vegetables on 3 or more days per week. (Of the 3, at least 2 must be different. All must be at least ¼ cup serving size)	1 2 3	1 2 3
Cooked dry beans or peas (legumes): Offer at least once a week (at least ¼ cup serving size).	1 2	1 2
Fruits: Offer a different fruit every day of the week (at least ¼ cup servings). Note that various preparations of the same fruit are considered the same, i.e. fresh apples and applesauce are both apples.	M T W T F	M T W T F
Fresh fruit: Offer fresh fruit at least 2 days a week (at least ¼ cup serving size).	1 2	1 2
Whole grain foods: Offer at least 1 serving of whole grain food every day, and may not be the same one each day.	M T W T F	In oz or grams: M T W T F
Does your menu only offer low-fat (1% or less) and fat-free (skim) milk, flavored or unflavored, each day?			YES NO
How many side items can a student take each day (excluding milk) for a reimbursable meal? ­
Do students have the opportunity to select each of the food items listed that meet the HealthierUS criteria?			YES NO

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Nutrition Education Worksheet

Grades in which nutrition education is provided (circle all that apply) K 1 2 3 4 5 6 7 8

Is nutrition education provided in at least half of the grades? _____ Yes _____ No

Briefly describe how nutrition education is provided to students in multiple grades and:

• Is part of a structured and systematic unit of instruction such as MyPyramid lessons from Team Nutrition (explain below)

• Involves multiple channels of communication, including the classroom, cafeteria, and home/parents (explain below)

Grades	Description of Nutrition Education Efforts

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Physical Education/Activity Worksheet

Grades in which physical education classes are provided (circle all that apply): K 1 2 3 4 5 6 7 8

Does your school provide physical education classes to all full-day students throughout the school year? _____ Yes _____ No Gold: A minimum average of 90 minutes physical education per week. Gold Award of Distinction: A minimum average of 150 minutes physical education per week.
Grades	List the average number of minutes/week that physical education is provided throughout the school year for each grade circled above.	Describe any additional daily physical activity opportunities provided to students (such as recess). Indicate time allotted for any routine activities.

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Competitive Foods Worksheet

Does your school sell/serve a la carte foods or beverages anytime during the school day (including meal periods) and throughout your school campus in competition with reimbursable meals? (Including vending machines or a school store.) ____ Yes ____ No

If YES, attach the list of foods and beverages sold as competitive foods, complete the following table and provide food product ingredient labels, Nutrition Facts Labels and/or recipes for each item.

Exempt from competitive foods criteria: Second servings of entrees on the reimbursable lunch menu for the day.

Criteria		Meets	Doesn’t Meet
Total Fat	Calories from total fat must be at or below 35% per serving. Excludes nuts, seeds, nut butters, and reduced fat cheese.
Trans Fat	“Trans-fat free” or less than .5 g trans fat per serving.
Saturated Fat	Calories from saturated fat must be below 10% per serving. Excludes reduced fat cheese.
Sugar	Total sugar per serving must be at or below 35% by weight (includes naturally occurring and added sugars). Excludes fruits, vegetables and milk.
Sodium	Gold: Must be at or below 480 mg per side dish/non-entrée serving Must be at or below 600 mg per main dish/entrée serving
	Gold Award of Distinction: Must be at or below 200 mg per side dish/non-entrée serving Must be at or below 480 mg per main dish/entrée serving
Portion Size/Calories	Must not exceed the serving size of the food served in the school lunch program. For other items, the package or container must not exceed 200 calories.
Milk	Must be low-fat (1% or less) and/or fat-free (skim), flavored or unflavored, milk meeting State and local standards for pasteurized milk and/or USDA approved alternative dairy beverages.
Milk serving size	Must be limited to maximum of 8 fluid ounces.
Other Approved Beverages	100% full strength fruit and vegetable juices with no sweeteners (nutritive or non-nutritive). Water: non-flavored, no sweeteners (nutritive or non-nutritive), non-carbonated, non-caffeinated.
Juice serving size	Must be limited to maximum of 6 fluid ounces.

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

School Policies and Practices Checklist

School Policies and Practices		Yes	No
Fundraising	Are primarily non-food items sold through school fundraising activities? Do food items that are sold during the school day meet the guidelines for competitive foods?
Physical Activity	Does your school demonstrate a commitment to neither deny nor require physical activity as a means of punishment? (For example, students who misbehave are not denied recess.)
Nutrition	Does your school demonstrate a commitment to prohibit the use of food as a reward? (For example, teachers do not offer candy as a reward to students for good behavior, or for the completion of an assignment.)
Wellness Policy	Does your school have an approved Wellness Policy included in this application?

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Review Committee Verification Form

Please read the following statement and sign below if you agree:

We have reviewed this application, and we agree that our school meals are healthy and appealing to our students. We attest to the accuracy of the information provided, including the criteria for school practices and policies specified on page 11 of this application. We agree to maintain the nutrition excellence and physical education/activity standards and procedures indicated in this application for the duration of our certification as Gold or Gold Award of Distinction awardees. Furthermore, we agree to cooperate with USDA and other organizations, upon request, to publicize our efforts.

Foodservice Manager’s Name Signature Date

Team Nutrition Leader’s Name Signature Date

School Food Authority’s Name Signature Date

Representative of the School’s Parent Organization Signature Date

Physical Education/Health Teacher Name Signature Date

Principal’s Name Signature Date

Thank you for applying for the HealthierUS School Challenge.

For more information, visit the Team Nutrition Website: www.teamnutrition.usda.gov

Please submit your completed application and documentation to your

State Child Nutrition Agency.

Public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524).  Do not return the completed form to this address.

12

School Name_____________________ Gold/Gold Award of Distinction Application