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Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
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
School Name
FNS-779 (12-08) Previous Editions are Obsolete
SBU
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
1
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
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).
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
2
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
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?
3. 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.
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
3
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
Lunch Menu Worksheet - GOLD or GOLD Award of Distinction
Dates Week 1 Menu was served:
Week 1
Menu Planning Approach Used:
Traditional
LUNCH MENU CRITERIA
Enhanced
PORTION
SIZE
FOOD ITEM
M
M
T
T
W
W
T
T
F
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
1
1
2
2
3
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
M
M
T
T
W
W
T
T
F
F
1
1
2
2
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.
must be different. All must be at least ¼
cup serving size)
cup serving size). Note that various
preparations of the same fruit are
considered the same, i.e. fresh apples
and applesauce are both apples.
Fresh fruit: Offer fresh fruit at
least 2 days a week (at least ¼ cup
serving size).
Whole grain foods: Offer at
least 1 serving of whole grain
food every day, and may not be
the same one each day.
NSMP
COMMENTS
(OPTIONAL)
In oz or grams:
M
M
T
T
W
W
T
T
F
F
Does your menu only offer low-fat (1% or less) and fat-free (skim) milk,
flavored or unflavored, each day?
Yes
No
Yes
No
Students should have the opportunity to select a reimbursable meal that meets all of
the HealthierUS School Challenge menu criteria. If your school menu offers multiple
side choices, how many of them (excluding milk) can a child take each day for a
reimbursable meal?
Does this week's menu meet the HUSSC menu criteria?
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
4
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
Lunch Menu Worksheet - GOLD or GOLD Award of Distinction
Dates Week 2 Menu was served:
Week 2
Menu Planning Approach Used:
Traditional
LUNCH MENU CRITERIA
Enhanced
PORTION
SIZE
FOOD ITEM
M
M
T
T
W
W
T
T
F
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
1
1
2
2
3
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
M
M
T
T
W
W
T
T
F
F
1
1
2
2
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.
must be different. All must be at least ¼
cup serving size)
cup serving size). Note that various
preparations of the same fruit are
considered the same, i.e. fresh apples
and applesauce are both apples.
Fresh fruit: Offer fresh fruit at
least 2 days a week (at least ¼ cup
serving size).
Whole grain foods: Offer at
least 1 serving of whole grain
food every day, and may not be
the same one each day.
NSMP
COMMENTS
(OPTIONAL)
In oz or grams:
M
M
T
T
W
W
T
T
F
F
Does your menu only offer low-fat (1% or less) and fat-free (skim) milk,
flavored or unflavored, each day?
Yes
No
Yes
No
Students should have the opportunity to select a reimbursable meal that meets all of
the HealthierUS School Challenge menu criteria. If your school menu offers multiple
side choices, how many of them (excluding milk) can a child take each day for a
reimbursable meal?
Does this week's menu meet the HUSSC menu criteria?
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
5
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
Lunch Menu Worksheet - GOLD or GOLD Award of Distinction
Dates Week 3 Menu was served:
Week 3
Menu Planning Approach Used:
Traditional
LUNCH MENU CRITERIA
Enhanced
PORTION
SIZE
FOOD ITEM
M
M
T
T
W
W
T
T
F
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
1
1
2
2
3
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
M
M
T
T
W
W
T
T
F
F
1
1
2
2
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.
must be different. All must be at least ¼
cup serving size)
cup serving size). Note that various
preparations of the same fruit are
considered the same, i.e. fresh apples
and applesauce are both apples.
Fresh fruit: Offer fresh fruit at
least 2 days a week (at least ¼ cup
serving size).
Whole grain foods: Offer at
least 1 serving of whole grain
food every day, and may not be
the same one each day.
NSMP
COMMENTS
(OPTIONAL)
In oz or grams:
M
M
T
T
W
W
T
T
F
F
Does your menu only offer low-fat (1% or less) and fat-free (skim) milk,
flavored or unflavored, each day?
Yes
No
Yes
No
Students should have the opportunity to select a reimbursable meal that meets all of
the HealthierUS School Challenge menu criteria. If your school menu offers multiple
side choices, how many of them (excluding milk) can a child take each day for a
reimbursable meal?
Does this week's menu meet the HUSSC menu criteria?
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
6
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
Lunch Menu Worksheet - GOLD or GOLD Award of Distinction
Dates Week 4 Menu was served:
Week 4
Menu Planning Approach Used:
Traditional
LUNCH MENU CRITERIA
Enhanced
PORTION
SIZE
FOOD ITEM
M
M
T
T
W
W
T
T
F
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
1
1
2
2
3
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
M
M
T
T
W
W
T
T
F
F
1
1
2
2
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.
must be different. All must be at least ¼
cup serving size)
cup serving size). Note that various
preparations of the same fruit are
considered the same, i.e. fresh apples
and applesauce are both apples.
Fresh fruit: Offer fresh fruit at
least 2 days a week (at least ¼ cup
serving size).
Whole grain foods: Offer at
least 1 serving of whole grain
food every day, and may not be
the same one each day.
NSMP
COMMENTS
(OPTIONAL)
In oz or grams:
M
M
T
T
W
W
T
T
F
F
Does your menu only offer low-fat (1% or less) and fat-free (skim) milk,
flavored or unflavored, each day?
Yes
No
Yes
No
Students should have the opportunity to select a reimbursable meal that meets all of
the HealthierUS School Challenge menu criteria. If your school menu offers multiple
side choices, how many of them (excluding milk) can a child take each day for a
reimbursable meal?
Does this week's menu meet the HUSSC menu criteria?
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
7
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
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
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Description of Nutrition Education Efforts
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
8
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
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.
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Describe any additional daily physical activity opportunities
provided to students (such as recess). Indicate time allotted for
any routine activities.
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
9
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
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
Yes
No
school store.)
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
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
Doesn't
Meet
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.
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
10
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
School Policies and Practices Checklist
School Policies and Practices
Yes
Fundraising
1. Are primarily non-food items sold through school fundraising
activities?
2. 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?
School Name
FNS-779 (12-08) Previous Editions are Obsolete
No
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
11
Form Approved OMB No.: 0584-0524
Expiration Date: XX/XX/XXXX
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.
School Name
FNS-779 (12-08) Previous Editions are Obsolete
Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version
12
| File Type | application/pdf |
| Author | ITD |
| File Modified | 2010-02-18 |
| File Created | 2009-01-08 |