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

APPENDIX D

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]

FDCH Onsite Observation Form

FDCH Onsite Observation Form

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

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 120 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.

CACFP MEAL CLAIMS ASSESSMENT

^{OMB #}

FDCH ONSITE OBSERVATION FORM

^{DATA COLLECTOR ID:_________________}

SPONSOR’S NAME:

____________________________________________________________________________________________

ICF MACRO SPONSOR ID:

________________

PROVIDER’S NAME:

____________________________________________________________________________________________

ICF MACRO PROVIDER ID:

________________

PROVIDER’S ADDRESS:

___________________________________________________________________________________________

CITY ____________________________________________________ ST ________ZIP ______________

TELEPHONE NUMBER:

________________________________________

CONFIRMED ONSITE?

Y/N

PROVIDER TIER:

T1 □ T2 □ TIER MIXED □

Additional Information:

____________________________________________________________________________________________________________

1. BACKGROUND INFORMATION

TOTAL CHILD ENROLLMENT FROM SPONSOR RECORD:

^{COMPLETED BY HQ STAFF:}

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+):

_________

DATES OF OBSERVATION:

_{________/_________/___________ ------________/________/____________}

_(MM/DD/YYYY)

Days of the Week for Scheduled Observation

(Select 2 days):

MON

□

TUES

□

WED

□

THU

□

FRI

□

FIRST DATE OF VISIT:

________/________/___________

_(MM/DD/YYYY)

Meal observation information

DATA COLLECTOR TIME OF ARRIVAL:

______|______:______|______

_AM/PM

Meal(S) To Be Observed on Day 1 (At least 2 must be selected):

Breakfast

(B)

□

AM Snack (AS)

□

Lunch

(L)

□

PM Snack (PS)

□

Supper
(S)

□

Evening Snack (ES)
□

IS FDCH OPERATING ON DAY OF VISIT?

 Yes  No

Meal(S) To Be Observed on Day 2 (At least 2 must be selected):

Breakfast

(B)

□

AM Snack (AS)

□

Lunch

(L)

□

PM Snack (PS)

□

Supper

(S)

□

Evening Snack (ES)
□

SPONSOR’S MONITOR?

 Yes  No

MONITOR’S TELEPHONE NUMBER :

__________________________________________________________________________

MONITOR PRESENT FOR ALL VISITS?

 Yes  No

IF NO, MONITOR PRESENT FOR:  DAY 1  OBS 1  OBS 2  DAY 2  OBS 3  OBS 4

FIRST OBSERVATION

DATE OF OBSERVATION: ________/________/________

OBSERVER ARVL. TIME: _____|_____:_____|______

_(AM/PM)

OBSERVER DPT. TIME: _____|_____:_____|______

_(AM/PM)

RECORD THE ATTENDANCE AT TIME OF ARRIVAL:

NUMBER OF CHILDREN PRESENT AT START OF MEAL SERVICE:

_______________ TOTAL

_______________ CACFP PARTICIPATING

_______________ CACFP NON-PARTICIPATING

NUMBER OF INFANTS PRESENT: ________________

B	AS	L	PS	S	ES
					

MEAL OBSERVED:

MEAL SERVICE TIME OBSERVED:

B	AS	L	PS	S	ES
					

SCHEDULED START TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

SCHEDULED END TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

OBSERVED START TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

OBSERVED END TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

Were children already eating when you arrived at the home? YES  NO

1. COLLECT CHILD ATTENDANCE AND MEAL SERVED

Child’s Name (Record First Name, Middle Initial, and Last Name):

Age and Age Group

Provider Child?

In CACFP?

Record the Observed Meal Served to the Child for the Observed Meal Service:

1

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

2

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

3

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

4

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

5

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

6

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

7

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

8

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

9

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

10

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

11

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L		S S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

12

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

13

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

14

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

2. CLOSE-OUT QUESTIONS ON CHILD ATTENDANCE

NUMBER OF CHILDREN
AT THE END OF THE MEAL SERVICE:

__________TOTAL

__________CACFP
PARTICIPATING

__________CACFP NON-PARTICIPATING

Were all children served at the same time for this eating occasion?

 YES

 NOChild(ren) arrived during meal service

 NOChild(ren) were napping/otherwise occupied during meal service

1. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

2. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

3. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

Name(s) and ages of child(ren) napping/otherwise occupied:

1. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

2. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

3. _____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

Total number of infants served during the meal service:

_______

Number of infants receiving formula provided by parent:

__________

Name(s) of infants receiving formula from parent:

1. ____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

_{HQ Review: __________}

Additional Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

SECOND OBSERVATION

DATE OF OBSERVATION: _______/________/_______

OBSERVER ARVL. TIME: _____|_____:_____|______

_(AM/PM)

OBSERVER DPT. TIME: _____|_____:_____|______

_(AM/PM)

RECORD THE ATTENDANCE AT TIME OF ARRIVAL:

NUMBER OF CHILDREN PRESENT AT START OF MEAL SERVICE:

_______________ TOTAL

_______________ CACFP PARTICIPATING

_______________ CACFP NON-PARTICIPATING

NUMBER OF INFANTS PRESENT: ________________

B	AS	L	PS	S	ES
					

MEAL OBSERVED:

MEAL SERVICE TIME OBSERVED:

B	AS	L	PS	S	ES
					

SCHEDULED START TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

SCHEDULED END TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

OBSERVED START TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

OBSERVED END TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

Were children already eating when you arrived at the home? YES  NO

1. COLLECT CHILD ATTENDANCE AND MEAL SERVED

Child’s Name (Record First, Middle Initial, and Last Name):

Age and Age Group

Provider’s Child?

In CACFP?

Record the Observed Meal Served to the Child for the Observed Meal Service:

1

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

2

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

3

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

4

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

5

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

6

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

7

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

8

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

9

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

10

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

11

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

12

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

13

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

14

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

2. CLOSE-OUT QUESTIONS ON CHILD ATTENDANCE

NUMBER OF CHILDREN
AT THE END OF THE MEAL SERVICE:

__________TOTAL

__________CACFP PARTICIPATING

__________CACFP NON-PARTICIPATING

Were all children served at the same time for this eating occasion?

 YES

 NOChild(ren) arrived during meal service

 NOChild(ren) were napping/otherwise occupied during meal service

1. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

2. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

3. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

Name(s) and ages of child(ren) napping/otherwise occupied:

1. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

2. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

3. _____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

Total number of infants served during the meal service:

_______

Number of infants receiving formula provided by parent:

__________

Name(s) of infants receiving formula from parent:

1. ____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

_{HQ Review: __________}

Additional Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

THIRD OBSERVATION

DATE OF OBSERVATION: _______/________/________

OBSERVER ARVL. TIME: _____|_____:_____|______

_(AM/PM)

OBSERVER DPT. TIME: _____|_____:_____|______

_(AM/PM)

RECORD THE ATTENDANCE AT TIME OF ARRIVAL:

NUMBER OF CHILDREN PRESENT AT START OF MEAL SERVICE:

_______________TOTAL

_______________CACFP PARTICIPATING

_______________CACFP NON-PARTICIPATING

NUMBER OF INFANTS PRESENT: ________________

B	AS	L	PS	S	ES
					

MEAL OBSERVED:

MEAL SERVICE TIME OBSERVED:

B	AS	L	PS	S	ES
					

SCHEDULED START TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

SCHEDULED END TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

OBSERVED START TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

OBSERVED END TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

Were children already eating when you arrived at the home? YES  NO

1. COLLECT CHILD ATTENDANCE AND MEAL SERVED

Child’s Name (Record First Name, Middle Initial, and Last Name):

Age and Age Group

Provider’s Child?

In CACFP?

Record the Observed Meal Served to the Child for the Observed Meal Service:

1

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

2

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

3

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

4

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

5

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

6

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

7

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

8

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

9

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

10

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

11

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

12

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

13

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

14

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

2. CLOSE-OUT QUESTIONS ON CHILD ATTENDANCE

NUMBER OF CHILDREN AT THE END OF THE MEAL SERVICE:

__________TOTAL

__________ CACFP PARTICIPATING

__________CACFP NON-PARTICIPATING

Were all children served at the same time for this eating occasion?

 YES

 NOChild(ren) arrived during meal service

 NOChild(ren) were napping/otherwise occupied during meal service

1. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

2. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

3. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

Name(s) and ages of child(ren) napping/otherwise occupied:

1. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

2. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

3. _____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

Total number of infants served during the meal service:

_______

Number of infants receiving formula provided by parent:

__________

Name(s) of infants receiving formula from parent:

1. ____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

_{HQ Review: __________}

Additional Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

FOURTH OBSERVATION

DATE OF OBSERVATION: _______/________/________

OBSERVER ARVL. TIME: _____|_____:_____|______

_(AM/PM)

OBSERVER DPT. TIME: _____|_____:_____|______

_(AM/PM)

RECORD THE ATTENDANCE AT TIME OF ARRIVAL:

NUMBER OF CHILDREN PRESENT AT START OF MEAL SERVICE:

_______________ TOTAL

_______________ CACFP PARTICIPATING

_______________ CACFP NON-PARTICIPATING

NUMBER OF INFANTS PRESENT: ________________

B	AS	L	PS	S	ES
					

MEAL OBSERVED:

MEAL SERVICE TIME OBSERVED:

B	AS	L	PS	S	ES
					

SCHEDULED START TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

SCHEDULED END TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

OBSERVED START TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

OBSERVED END TIME OF MEAL:

_____|_____:_____|______

_(AM/PM)

Were children already eating when you arrived at the home? YES  NO

1. COLLECT CHILD ATTENDANCE AND MEAL SERVED

Child’s Name (Record First, Middle Initial, and Last Name):

Age and Age Group

Provider’s Child?

In CACFP?

Record the Observed Meal Served to the Child for the Observed Meal Service:

1

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

2

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

3

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

4

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

5

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

6

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

7

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

8

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

9

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

10

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

11

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

12

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

13

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

14

_{(First Name)}

_(MI)

_{(Last Name)}

___________ Months/Years

□YES

□NO

□YES

□NO

B	AS	L	PS	S	ES
					

• Child consumed formula

• Child consumed food from home replacing meal

• Child was not served a meal

• Child arrived during meal service

INFANT

□

PRE-SCHOOL

□

SCHOOL AGE

□

2. CLOSE-OUT QUESTIONS ON CHILD ATTENDANCE

NUMBER OF CHILDREN AT THE END OF THE MEAL SERVICE:

__________TOTAL

__________ CACFP PARTICIPATING

__________CACFP NON-PARTICIPATING

Were all children served at the same time for this eating occasion?

 YES

 NOChild(ren) arrived during meal service

 NOChild(ren) were napping/otherwise occupied during meal service

1. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

2. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

3. Child’s arrival time : _________|_____:_____|_______

Was child served a meal? □YES, child was served same meal being served □YES, provider served a different meal □NO

Name(s) and ages of child(ren) napping/otherwise occupied:

1. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

2. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

3. ____________________________________________________________________ Age: ____________ CACFP Participating: □YES □NO

Total number of infants served during the meal service:

_______

Number of infants receiving formula provided by parent:

__________

Name(s) of infants receiving formula from parent:

1. ____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

_{HQ Review: __________}

Additional Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CACFP Meal Claiming OMB Package 0