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 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 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:_____________________________
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+):

_______

ENTER ICF INTERNATIONAL ID NUMBER:

________________________________________________

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 (If different from Parent #1)

__________________________________________________ City

______________ State/ZIP Code

_________________________________________________ City

________________ State/ZIP Code

___________________________________________ Primary Phone Number

_______________________________________ Alternative Phone Number

______________________________________________ Primary Phone Number

________________________________________ Alternative Phone Number

What days of the week does [CHILD’S NAME] attend your day care?

What time does [CHILD’S 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

HEADQUARTERS USE ONLY: REVIEW ENROLLMENT DATA AND DETERMINE IF CHILD HAS SIBLING WITHIN FDCH. IF SIBLINGS ARE ALSO ENROLLED, PROVIDE SIBLING(S) NAMES AND IDs BELOW:

Does CHILD have any siblings that are enrolled in this FDCH?

Yes

No

Number of siblings in care? _____

SIBLING NAME:

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

1. _____________________________ (ICF INTERNATIONAL ID)

SIBLING NAME:

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

2. _____________________________ (ICF INTERNATIONAL ID)

SIBLING NAME:

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

3. _____________________________ (ICF INTERNATIONAL ID)

SIBLING NAME:

4. ___________________________________________________ (First Name, MI, Last Name)

4. _____________________________ (ICF INTERNATIONAL ID)