FNS 779 Gold/Gold Award of Distinction Application

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Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

Food and Nutrition Service (FNS)
HealthierUS School Challenge Application
General Information
Tips for Completing Application:
Submit the application 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).
Provide details in a Cover Letter, if you use the Alternative Menu Planning Approach.

School Name
FNS-779 (04-10) Previous Editions are Obsolete

Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version

Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

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
(list)
Contact Person's
Name and Title
Contact Person's
Phone Number &
Email
Date Submitted to
State Agency
FOR OFFICE USE ONLY
Approved by State Child Nutrition Director:

State
Signature

Reviewed by:

Date

Phone:
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 (04-10) 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: 04/30/2013

HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Table of Contents

Page Number
Cover Sheet .............................................................................................................................................. 1
Table of Contents ..................................................................................................................................... 2
Application for Gold Award/Gold Award of Distinction .............................................................................. 3
Week 1 Lunch Menu Worksheet ............................................................................................................... 4
Week 2 Lunch Menu Worksheet ............................................................................................................... 5
Week 3 Lunch Menu Worksheet ............................................................................................................... 6
Week 4 Lunch Menu Worksheet ............................................................................................................... 7
Nutrition Education Worksheet .................................................................................................................. 8
Physical Education/Activity Worksheet-Elementary Schools .....................................................................9
Physical Education/Activity Worksheet-Middle and High Schools .............................................................9a
Competitive Foods Worksheet ...................................................................................................................10
School Policies and Practices Checklist ....................................................................................................11
Review Committee Verification Form ........................................................................................................ 12
Application Check-Off Sheet ..................................................................................................................... 13

School Name
FNS-779 (04-10) Previous Editions are Obsolete

Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version

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Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

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. If applicable, have all of your corrective actions from the most recent School Meals
Initiative (SMI) review been completed?
3. Are all lunches submitted in this application reimbursable?
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. Does your school meet the criteria for the award it is seeking?
Elementary and Middle School ADP criteria: 70% Gold and Gold Award of Distinction
High School ADP criteria: 65% Gold and Gold Award of Distinction
List ADP:
Month/Year:
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 printouts
from the HUSSC Competitive Foods Online Calculator and product ingredient labels, Nutrition
Facts Label and/or recipes for each item.)
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 (04-10) Previous Editions are Obsolete

Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version

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Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

Lunch Menu Worksheet

GOLDS Award

GOLD Award of Distinction

Dates Week 1 Menu was served:
Week 1
Menu Planning Approach Used:
No Modifications
Traditional:
No Modifications
Enhanced:

Modifications (please explain)
Modifications (please explain)

NSMP
Assisted NSMP
Alternative Menu Planning Approach (describe in an application cover letter)
LUNCH MENU CRITERIA

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.

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

Does this week's menu meet the HUSSC menu criteria?

Yes

No

School Name
FNS-779 (04-10) 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: 04/30/2013

Lunch Menu Worksheet

GOLDS Award

GOLD Award of Distinction

Dates Week 2 Menu was served:
Week 2
Menu Planning Approach Used:
No Modifications
Traditional:
No Modifications
Enhanced:

Modifications (please explain)
Modifications (please explain)

NSMP
Assisted NSMP
Alternative Menu Planning Approach (describe in an application cover letter)
LUNCH MENU CRITERIA

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.

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

Does this week's menu meet the HUSSC menu criteria?

Yes

No

School Name
FNS-779 (04-10) 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: 04/30/2013

Lunch Menu Worksheet

GOLDS Award

GOLD Award of Distinction

Dates Week 3 Menu was served:
Week 3
Menu Planning Approach Used:
No Modifications
Traditional:
No Modifications
Enhanced:

Modifications (please explain)
Modifications (please explain)

NSMP
Assisted NSMP
Alternative Menu Planning Approach (describe in an application cover letter)
LUNCH MENU CRITERIA

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.

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

Does this week's menu meet the HUSSC menu criteria?

Yes

No

School Name
FNS-779 (04-10) 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: 04/30/2013

Lunch Menu Worksheet

GOLDS Award

GOLD Award of Distinction

Dates Week 4 Menu was served:
Week 4
Menu Planning Approach Used:
No Modifications
Traditional:
No Modifications
Enhanced:

Modifications (please explain)
Modifications (please explain)

NSMP
Assisted NSMP
Alternative Menu Planning Approach (describe in an application cover letter)
LUNCH MENU CRITERIA

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.

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

Does this week's menu meet the HUSSC menu criteria?

Yes

No

School Name
FNS-779 (04-10) 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: 04/30/2013

HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Nutrition Education Worksheet
K

1

Grades in which nutrition education is provided:
2
3
4
5
6
7
8
9
10
11

12

Elementary Schools:
Yes
No
Is nutrition education provided in at least half of the grades?
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)
Middle and High Schools:
Briefly describe how nutrition education is offered to:
• Middle school students in at least one grade level as part of year round instruction.
• High school students in at least two courses required for graduation.
Involves multiple channels of communication.
Grades

School Name
FNS-779 (04-10) Previous Editions are Obsolete

Description of Nutrition Education Efforts

Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version

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Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Physical Education/Activity Worksheet - Elementary Schools
Grades in which nutrition education is provided:
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

Both Gold Awards: 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 (04-10) 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

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Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Physical Education/Activity Worksheet - Middle and High Schools
Grades in which nutrition education is provided:
5
6
7
8
9
10
11
12

Briefly describe below how your school offers structures physical education classes to at least
two grades and provides students in all grades opportunities to participate in physical activity
(intramural/interscholastic sports or activity clubs) and actively promotes participation in
physical activities to all students throughout the school year. If possible, list the number of
minutes per week that physical education is provided throughout the school year for each
grade checked above.

Grades

School Name
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Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version

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Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Competitive Foods Worksheet
Are any foods or beverages outside the NSLP sold at your school anytime during the school day? This includes in
the cafeteria (a la carte or extra sales) or any other place (vending machines or school stores, etc.).
Yes
No
If YES, go to the online HUSSC Competitive Foods Calculator (http://healthlymeals.nal.usda.gov/hmrs/
HUSSC/calulator.html) to determine if the food and beverages sold as competitive foods meet the HUSSC
criteria. Print out results from the Calculator and include with product ingredient labels, Nutrition Facts
Labels and/or recipes for each item in the application.
If this is a school-made product, please submit recipe with the application.
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 (04-10) Previous Editions are Obsolete

Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version

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Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

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?

Meal Service

Do Students have the opportunity to select a reimbursement meal
that meets all of the HUSSC menu criteria? If so, please describe
in detail. For Example, include: your meal service structure
[number of entrees and side dishes, how students have the
opportunity to select HUSSC items on serving line(s), etc.] and
how Offer vs Serve is implemented, if applicable.

School Name
FNS-779 (04-10) 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: 04/30/2013

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/Address

Signature

Date

Team Nutrition Leader's Name

Signature

Date

School Food Authority Director's Name/Address

Signature

Date

Representative of the School's Parent Organization

Signature

Date

Physical Education/Health Teacher Name

Signature

Date

Principal's Name/Address

Signature

Date

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 Service,
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 (04-10) Previous Editions are Obsolete

Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version

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Form Approved OMB No.: 0584-0524
Expiration Date: 04/30/2013

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)
Table of Contents (n/a)
Application for Gold Award/Gold Award of Distinction (pg 3)
Week 1 Lunch Menu Worksheet (pg 4)
Week 2 Lunch Menu Worksheet (pg 5)
Week 3 Lunch Menu Worksheet (pg 6)
Week 4 Lunch Menu Worksheet (pg 7)
Nutrition Education Worksheet (pg 8)
Physical Education/Activity Worksheet (pg 9/9a)
Competitive Foods Worksheet (pg 10)
School Policies and Practices Checklist (pg 11)
Review Committee Verification Form (pg 12)
Check-off Sheet (pg 13)
Please submit the following additional documentation:
Copy of the School Wellness Policy and Team Nutrition Verification
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)
Production records for the 4 weeks
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 anythime, anywhere on the school campus.
Thank you for applying for the HealthierUS School Challenge.
For more information, visit the Team Nutrition Website: www.teamnutrition.usda.gov

School Name
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Gold/Gold Award of Distinction Application
Electronic Form Version Designed in Adobe 8.1 version

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