Business for- & not-for profit: Sponsors & Family Day Care,

APPENDIX F

Child and Adult Care Food Program (CACFP)

Improper Payment Meal
Claims Assessment

(OMB No.: 0584-NEW)

Project Officer: Fred S. Lesnett

Office: Office of Research and Analysis

Food and Nutrition Service

Room 1014

3101 Park Center Drive

Alexandria, VA 22302

Telephone: 703-605-0811

Fax: 703-305-2576

E-mail: [email protected]

A

CHILD AND ADULT FOOD CARE PROGRAM (CACFP) MEAL CLAIMS ASSESSMENT
ICF Macro

Attn: Erika Gordon, Project Director
11785 Beltsville Drive, Suite 300
Calverton, MD 20705
Tel: (800) 840-8248

Public reporting burden for this collection of information is estimated to average 30 minutes 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-xxxx*).  Do not return the completed form to this address.

ppendix F:
CACFP Provider Child Enrollment Data Abstraction Table

State ID:_________	Sponsor ID:________________	Provider ID:_______________
Sampled FDCH #________	Sponsor Name:______________	Provider Name: _____________________
Replacement FDCH? Y/N
Date of Abstraction:_____/____/________	Respondent: ___________________________________________		Reviewed by:________
Time: _____________ am/pm	Interviewer: ________________		HQAPVL:_______

CACFP Provider Child Enrollment Data Abstraction Table

TOTAL CHILD ENROLLMENT FROM SPONSOR RECORD:

APPROVED FDCH MEAL SERVICE:

Breakfast (B)

AM Snack (AS)

Lunch (L)

PM Snack (PS)

Supper (S)

Evening Snack (ES)

Total number of infants (11 months old or younger):

_________

□

□

□

□

□

□

Total number of preschool children (1–5 years):

_________

Total number of school-age children (6+):

_________

What is the child’s name? (First name, Middle Initial, Last Name)

_________________________________________________ (First Name, MI, Last Name)

Does your sponsor organization have a unique ID number for this child? What is it?

Provider Child ID: _________________________

What is the child’s date of birth?

_____/_____/_______ (MM/DD/YYYY)

When did he/she begin attending your day care home?

_____/_____/_______ (MM/DD/YYYY)

What are the child’s parent/parents/guardian’s name(s)? (First Name and Last Name)

Can you provide me with the parent(s)/guardian’s home address and telephone number(s)?

Parent #1: ____________________________________ Parent/Guardian’s Name (1)

Parent #2____________________________________ Parent/Guardian’s Name (2)

__________________________________ Street Address

___________________________________ Street Address

________________________________ City

_______________ State/ZIP Code

_______________________________ City

_______________ State/ZIP Code

___________________________ Primary Phone Number

______________________________ Alternative Phone Number

__________________________ Primary Phone Number

______________________________ Alternative Phone Number

Does CHILD #1 NAME have any siblings that are enrolled in your care?

Yes No

Number of siblings in care? ______________

What is the sibling’s name? (First name, Middle Initial, Last Name)

1. __________________________________________________________ (First Name, MI, Last Name)

What is the sibling’s name? (First, Middle Initial, Last Name)

2. __________________________________________________________ (First Name, MI, Last Name)

What is the sibling’s name? (First Name, Middle Initial, Last Name)

3. ____________________________________________________________ (First Name, MI, Last Name)

What days of the week does [CHILD #1 NAME] attend your day care?

What time does [CHILD #1 NAME] usually attend your day care for those days?

BEFORE-SCHOOL CARE

AFTER-SCHOOL CARE

Arrive (am/pm)

Leave (am/pm)

Arrive (am/pm)

Leave (am/pm)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

For which meals that you provide this child do you receive reimbursement for?

Breakfast

AM Snack

Lunch

PM Snack

Supper

EV Snack

□

□

□

□

□

□

Does child’s parent(s) provide any meals for him/her to eat while in your care?

NO

NOTES ON MEALS:

Formula

Breakfast

AM Snack

Lunch

PM Snack

Supper

EV Snack