Hussc 2012

19

Food and Nutrition Service (FNS)

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

General Information

Public reporting burden for this collection of information is estimated to average 2 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.

Tips for Completing Application:

• You can submit your application two ways:

  • Submit the application and supporting documentation in a 3-ring binder, or

  • Submit the application and supporting documentation electronically to [email protected]

• Multiple schools applying in one District that use the same menu and the same foods, can provide:

  • one set of menus

  • one set of recipes

  • food product ingredient statements, and/or

  • Nutrition Facts Labels.

However, each school must have their own Application Cover Sheet, application form, SBP/NSLP 6-cent certification Menu Worksheet, 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, Local School Wellness Policy Worksheet, a copy of each school’s wellness policy (unless it is a district wellness policy), and Other Criteria for Excellence Checklist.

*Not required for Bronze level.

Food and Nutrition Service (FNS)

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Application Cover Sheet

Application for: _______Bronze Award ______Silver Award

* The school name on the Award Certificate will be typed exactly as written in the School Name* section below.  Please ensure that the entire name with any appropriate punctuation is clearly indicated.  Award Certificates will not be re-printed due to an incorrect or illegible school name.

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

State Agency

State Child Nutrition Director Approval: __________________________________________

Signature Date

Reviewed by: ___________________________ Phone: ­­­­­­­­­­­­­­­­­­­­­_______________________________

Email of the State Child Nutrition Director: ________________________________________________

Regional Office

FNS Region: _________ Reviewed by: ____________________________________________­

Child Nutrition Director Approval: _______________________________________________

Signature Date

FNS Headquarters (HQ)

Application received HQ: _____________ Reviewed by: _____________­­__

Decision/Date: ______________ Award period: _______________

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Table of Contents

Page Number

Cover Sheet 1

Table of Contents 2

General Criteria Worksheet 3

Menu Offerings 4

Nutrition Education Worksheet 8

Physical Education Worksheet-Elementary Schools 9

Physical Education Worksheet-Middle and High Schools 10

Physical Activity Worksheet 11

Competitive Foods Worksheet 12

School Wellness Policy Worksheet 13

Other Criteria for Excellence Checklist 14

Review Committee Verification Form 17

Application Check-Off Sheet 19

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Application for Bronze or Silver Award

General Criteria Worksheet	Yes	No
1. Are you a Team Nutrition School? ( check our Team Nutrition directory at: http://teamnutrition.usda.gov/schoolsdb/srchpage.asp)
Have all corrective actions from your school’s most recent State review of your school meals program been completed?
Is your school currently meeting school meal pattern requirements for the National School Lunch Program and School Breakfast program as specified in 7 CFR 210 and 220?
Is your School Food Authority certified to receive the additional six cent performance-based reimbursement (Healthy Hunger-Free Kids Act 2011)?
Do all students have the opportunity to select reimbursable meals that meet HUSSC criteria during the week? If so, please describe your meal service structure [number of entrees and side dishes, how students have to opportunity to select HUSSC items on serving line(s), etc.] and how Offer vs Serve is implemented, if applicable: _____________________________________________________ ______________________________________________________
Does your school meet the Average Daily Participation (ADP) criteria for breakfast and lunch? No ADP requirement for Bronze. Breakfast: Elementary and Middle School ADP: 20% Silver High School ADP: 15% Silver Lunch: Elementary and Middle School ADP: 60% Silver High School ADP: 45% Silver List ADP for Breakfast calculated based on attendance: ______ Month/Year: ______ List ADP calculated for Lunch based on attendance: ______ Month/Year: ________

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.

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Breakfast and Lunch Menu Offerings

To document menus served, please submit:

• Copy of school breakfast and lunch menus for two-week period.

• Copies of completed SBP/NSLP 6-cent certification Menu Worksheet for the two-week period specified below.

• Breakfast and lunch production records showing actual daily meal count (students and adults); menu items (used to meet meal pattern requirements), planned portion size (by age/grade); quantity prepared for each menu item, a la carte items sold (if applicable), and leftovers. Documentation required for whole grain-rich offerings: For each whole grain-rich offering listed below, submit one or more of the following:

  • An ingredients label that lists whole grain as the first ingredient by weight.

  • A copy of food label showing the amount of whole grain in grams provided for appropriate serving size.

  • A customized product specification sheet.

  • A recipe that includes the ingredients and ingredient amounts by weight and volume.

For additional information and examples of acceptable whole grain-rich documentation, please refer to the Whole Grain-Rich Resource (http://teamnutrition.usda.gov/healthierUS/index.html)

Provide the dates of the two-week period for which you are providing menus and other supporting materials. The two-week period must be two full weeks with no missing days due to school closing for holidays, teacher workdays, weather, etc. The two-week period used for breakfast and lunch should be the same.

List the dates of your menus here (month/day/year format):

Example: Week 1: 3/3/2013-3/7/2013

Week 1:____________________________________________________

Week 2:____________________________________________________

In addition, complete the following information about breakfast and lunch menu offerings.

Whole Grain-Rich Criteria

Breakfast

Bronze/Silver: 50% of grains offered weekly are whole grain-rich.

Lunch

Bronze/Silver: Two-thirds of the grains offered over a week must be whole grain-rich.

Whole Grain-Rich Variety:

At least three different types of whole grain-rich foods offered during the week.

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Whole Grain-Rich Offerings

Specify the whole grain-rich offerings (should be consistent with names of grains on menu and reflected in the 6-cent Certification Menu Worksheet) offered during the two-week period. For example, specify the food item, such as whole wheat bread, brown rice, quinoa, etc.

Week 1
Breakfast	Lunch

Whole Grain-Rich Offerings (continued)

Week 2
Breakfast	Lunch

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Fruit

Please complete the charts below to demonstrate the menu has met the Breakfast and Lunch fruit criteria.

Fruit - Breakfast – Week 1

Criteria	Food Item Amount
Fruit Variety: Offer at least 3 different fruits* each week (at least ½ cup each**). Note that various preparations of the same fruit (or vegetable) are considered the same, e.g., apple slices, apple sauce, and apple juice are all forms of apple.	M T W T F
Fresh fruit:*** Offer freshfruit* at least 1 day a week (at least ½ cup each).	1

*Vegetables from the dark-green, red/orange, beans and peas (legumes) and “other vegetable” sub-groups may be substituted for fruits to meet the HUSSC fruit variety criteria for breakfast. The substitution must be consistent with meal pattern requirements as defined in §210.10(c)(2)(iii).

**One quarter-cup of dried fruit counts as ½ cup of fruit; 1 cup of leafy greens counts as ½ cup of vegetables. Juice may be counted toward the HUSSC fruit variety criteria for breakfast only once per week. Juice must be 100% full strength.

***If unable to obtain adequate fresh fruit to meet the requirement, applicant can work with FNS to determine suitable alternative. Justification will be required.

Fruit - Breakfast – Week 2

Criteria	Food Item Amount
Fruit Variety: Offer at least 3 different fruits* and each week (at least ½ cup each**). Note that various preparations of the same fruit (or vegetable) are considered the same, e.g., apple slices, apple sauce, and apple juice are all forms of apple.	M T W T F
Fresh fruit:*** Offer freshfruit* at least 1 day a week (at least ½ cup each).	1

*Vegetables from the dark-green, red/orange, beans and peas (legumes) and “other vegetable” sub-groups may be substituted for fruits to meet the HUSSC fruit variety criteria for breakfast. The substitution must be consistent with meal pattern requirements as defined in §210.10(c)(2)(iii).

**One quarter-cup of dried fruit counts as ½ cup of fruit; 1 cup of leafy greens counts as ½ cup of vegetables. Juice may be counted toward the HUSSC fruit variety criteria for breakfast only once per week. Juice must be 100% full strength.

***If unable to obtain adequate fresh fruit to meet the requirement, applicant can work with FNS to determine suitable alternative. Justification will be required.

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Fruit – Lunch – Week 1

Criteria	Food Item Amount
Fruits: Offer a different fruit every day of the week (at least ½ cup each*). 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
Fresh fruit:** Bronze: Offer fresh fruit at least 1 day a week (at least ½ cup each*) Silver: Offer fresh fruit at least 2 days a week (at least ½ cup each*)	1 2

*One quarter-cup of dried fruit counts as ½ cup of fruit.

**If unable to obtain adequate fresh fruit to meet the requirement, applicant can work with FNS to determine suitable alternative. Justification will be required.

Fruit – Lunch – Week 2

Criteria	Food Item Amount
Fruits: Offer a different fruit every day of the week (at least ½ cup each). 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
Fresh fruit:** Bronze: Offer fresh fruit at least 1 day a week (at least ½ cup each*) Silver: Offer fresh fruit at least 2 days a week (at least ½ cup each*)	1 2

*One quarter-cup of dried fruit counts as ½ cup of fruit.

**If unable to obtain adequate fresh fruit to meet the requirement, applicant can work with FNS to determine suitable alternative. Justification will be required.

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Nutrition Education Worksheet

• Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition Award from the Alliance for a Healthier Generation in lieu of completing this section. Your HSP award must be dated within a year of your HUSSC application.

Elementary Schools:

Is Nutrition Education provided to all students in all grades? _____ Yes _____ No

Briefly describe below how nutrition education is provided to all students and:

• Is part of structured and systematic unit of instruction, such as Team Nutrition curricula and lessons.

• Utilizes multiple channels of communication, including the classroom, cafeteria, and home/parents.

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	Description of Nutrition Education Efforts

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Physical Education Worksheet – Elementary Schools

• Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition Award from the Alliance for a Healthier Generation in lieu of completing this section. Your HSP award must be dated within a year of your HUSSC application.

Physical Education
Does your school offer physical education (PE) classes to all full-day students throughout the school year? _____ Yes _____ No Bronze/Silver: Do the physical education (PE) classes for all grades cover a minimum average of 45 minutes* per week throughout the school year? _____ Yes _____ No *Up to 20 minutes (Bronze/Silver) and 45 minutes (Gold/Gold Award of Distinction) of the PE requirement may be met by providing structured physical activity planned by a certified PE teacher and implemented by a classroom teacher or school administrator. All students must participate in the physical activities, which must be at least moderate-intensity and in increments of at least 10 minutes.
Physical Education Details
Grades	List the average number of minutes/week that physical education is provided throughout the school year for the grade specified.	Description of Physical Education Offered

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Physical Education Worksheet – Middle and High Schools

• Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition Award from the Alliance for a Healthier Generation in lieu of completing this section. Your HSP award must be dated within a year of your HUSSC application.

Middle School: Briefly describe below how your school offers structured physical education classes to at least two grades.

High School: Briefly describe below how your school offers structured physical education classes in at least two courses.

Physical Education Details
Grades	Description of Physical Education Offered

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Physical Activity Worksheet

• Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition Award from the Alliance for a Healthier Generation in lieu of completing this section. Your HSP award must be dated within a year of your HUSSC application.

Physical Activity
Elementary Schools: Describe any additional daily physical activity opportunities provided to students (such as recess). Indicate time allotted for any routine activities. Middle and High Schools: Describe how school 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.
Physical Activity Details
Grades	Describe Physical Activity Provided

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Competitive Foods Worksheet

Does your school sell/serve a la carte or extra foods or beverages during meal periods in the food service area(s), including vending machines or a school store, in competition with school meals?

____ Yes ____ No

If YES, go to the online HUSSC Competitive Foods Calculator (http://healthymeals.nal.usda.gov/hsmrs/HUSSC/calculator.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.

For school-made products, please submit the recipes with the application.

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

The calculator formulas are at http://teamnutrition.usda.gov/HealthierUS/index.html

Fundraising

Do food items that are sold on campus (including food sold through school fundraising) during the school day meet the guidelines for competitive foods? If no, please briefly explain in the space provided below.

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HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

School Wellness Policy Worksheet

Provide a copy of the school’s local wellness policy with the HUSSC application. If following a district wellness policy, provide that copy.

List three ways your school is working to meet local wellness policy goals, for example, creating specifications for vending machine foods to ensure they meet nutritional criteria, including local wellness policy goals in your school improvement plan, school wellness committee meets every other month, etc.

1.

2.

3.

Describe how parents, students, school administration and staff, and the community are involved in the implementation of the local wellness policy at your school.

If your school has implemented wellness practices that are stricter than what is stated in your school district’s local wellness policy, please explain (e.g., your school does not sell competitive foods).

Briefly describe how your school demonstrates a commitment to neither deny nor require physical activity as a means of punishment? (For example, students who misbehave are not denied recess.)

Briefly describe how school demonstrates 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.)

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Other Criteria for Excellence Checklist

Select from any option and submit supporting documentation with the application:

Bronze: Must select at least 2 of the 20 options.

Silver: Must select at least 4 of the 20 options.

Program Outreach Excellence	√
School implements innovative practices to increase SBP participation, such as Breakfast in the Classroom. Provide a brief description and (if available) photo.
School operates an afterschool program that participates in the Afterschool Snack Program or at-risk afterschool meals component of the Child and Adult Care Food Program (CACFP). Provide a brief description.
If percentage of free- or reduced-students is 50% or more, Summer Food Service Program is available. Provide a brief description.
Physical Activity Excellence	√
School sponsors a non-competitive afterschool physical activity program. Provide a brief description.
School actively supports and promotes walking or bicycling to and from school. Provide a brief description.
School offers at least 20 minutes of recess daily before lunch. Provide a brief description.
Nutrition Education Excellence	√
School uses grade appropriate Team Nutrition curricula and lessons to teach nutrition education. Provide a brief description including the name of the Team Nutrition materials used.
School has partnered with a chef in the Chefs Move to Schools Program. Provide a brief description, including the name of the Chef.
School Food Service Excellence	√
School Food Service Manager is a certified food handler (local or national certification). Provide a copy of certification.
School has a Farm to School initiative. Provide a brief description.
Smarter Lunchroom techniques are used to encourage fruit consumption: Fruit is displayed in 2 locations, one of which is near the cash register, on all lunch lines. Attractive displays, signage, and staff encouragement are used to draw attention to the fruit and encourage children to select them. Provide a brief description and photos.
Smarter Lunchroom techniques are used to encourage vegetable consumption: Students are given the opportunity to provide input into vegetable offerings and to identify creative/descriptive names for the offerings. Creative/descriptive names are displayed with vegetables on the lunch line as well as on a poster or menu board outside the school cafeteria. If menu does not highlight this, a brief description or photos should be provided; photos can be digital and printed on copy paper.
When offered, dark-green, red and orange vegetables and dry beans and peas are displayed first or most prominently among vegetable side dishes on the lunch line. Provide a brief description or photos; photos can be digital and printed on copy paper.
Smarter Lunchroom techniques are used to encourage consumption of dry beans and peas: Entrees that include dry beans or peas are displayed first or most prominently on the lunch line amongst other entrée items on at least 2 days within the 2-week menu cycle submitted. Dry bean and pea entrée items are given creative/descriptive names with student input. Provide a brief description and photos; photos can be digital and printed on copy paper.
Grab-and-go reimbursable meal options include dark-green, red and orange vegetables, and/or dry beans and peas at least one day per week. If menu does not highlight this, a brief description should be provided
Excellence in School and Community Involvement in Wellness Efforts	√
Provides annual training to before and afterschool program staff on physical activity and nutrition. Provide a brief description.
All school staff receive annual training on wellness policies and ways to promote nutrition and physical activity. Provide a brief description.
School partners with one or more community groups to promote wellness. Provide a brief description and include names of specific community groups.
Students have the opportunity to provide input on school food and physical activity options. Provide a brief description.
School informs public on amount of time allotted for lunch. Solicits input from students and community members on the amount of time that is adequate for lunch. Provide a brief description.

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Review Committee Verification Form

For individual school applications only

Please read the following statement and add your name and date 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 in this application. We agree to maintain the nutrition excellence, physical education/activity, and other criteria for excellence standards and procedures indicated in this application for the duration of our certification as Bronze or Silver awardees. Furthermore, we agree to cooperate with USDA and other organizations upon request to publicize our efforts.

Foodservice Manager’s Name/Address Email Address Date

Team Nutrition Leader’s Name Email Address Date

District Food Service Authority Name/Address Email Address Date

(Foodservice Director)

Representative of the School’s Parent Organization Email Address Date

Physical Education/Health Teacher’s Name Email Address Date

Principal’s Name/Address Email Address 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 2 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.

HealthierUS School Challenge

Recognizing Excellence in Nutrition and Physical Activity

Review Committee Verification Form

For simplified school district applications only

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 in this application. We agree maintain the nutrition excellence, physical education/activity, and other criteria for excellence standards and procedures indicated in this application for the duration of our certification as Bronze or Silver awardees. Furthermore, we agree to cooperate with USDA and other organizations upon request to publicize our efforts.

Superintendent Name Email Address Date

District Food Service Authority Name/Address Email Address Date

(Foodservice Director)

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 2 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.

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

_____ General Criteria Worksheet (pg 3)

_____ Menu Offerings (pg 4-7)

_____ Nutrition Education Worksheet (pg 8)

_____ Physical Education Worksheet (pg 9-10)

_____ Physical Activity Worksheet (pg 11)

_____ Competitive Foods Worksheet (pg 12)

_____ Local School Wellness Policy Worksheet (pg 13)

_____ Other Criteria for Excellence Checklist (pg 14-16)

_____ Review Committee Verification Form (pg 17-18)

_____ Check-off Sheet (pg 19)

Please submit the following additional documentation:

• Copy of the School Wellness Policy.

• Two week menu for reimbursable school breakfast and lunches served in your school (Menus must reflect two full consecutive weeks).

• Copies of completed SBP/NSLP 6-cent certification Menu Worksheets for the two-week period.

• Production records for lunch and breakfast for the 2 weeks (not required for Bronze level)

• Documentation including Nutrition Facts labels, recipes, food product ingredient statements, and/or product formulation statements to verify that the criteria have been met for the following: a la carte, snack bar, and vended items sold anytime, anywhere on the school campus.

• Documentation for whole grain-rich products including food production ingredient statements, Nutrition Facts labels, recipes, whole grain stamp/claim, and/or customized product specification sheets.

Thank you for applying for the HealthierUS School Challenge.

For more information, visit the Team Nutrition Website:

www.teamnutrition.usda.gov

Xx/xx/xxxx

School Name_____________________ Bronze Award/Silver Award Application