State, Local & Tribal LEA Schools

CEO C_5 Certification Record Abstraction Form

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

LEA ID #:

LEA Name:

School ID::

School Name:

Community Eligibility Option Evaluation

Certification Record Abstraction Form

INTERVIEWER NOTE: Introduce yourself to the respondent. Remind them of the reason for your visit (refer to advance letter if needed). Review informed consent paragraph from the advance letter; and give them a copy of this letter.

Location of Records:  LEA  School  Both Data Collector Name: Date:

Notes:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 10 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.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Food and Nutrition Service, Office of Research and Analysis, 3101 Park Center Drive, Alexandria, Virginia 22302.

Prepared for:

U.S. Department of Agriculture

Food and Nutrition Service

Office of Research and Analysis

Prepared by:

Abt Associates Inc.

Procedure for Approved/Identified Students:

1. Consult Pre-visit LEA Foodservice Director Questionnaire for contact and location of certification records.

2. If the sample was selected in advance, obtain list of Approved/Identified students sorted by Student ID or student name and locate the corresponding applications or source documents from the LEA foodservice director. If the sample was not selected in advance, select the sample first, then locate the corresponding applications or source documents from the LEA foodservice director.

3. From the list, record the first sampled Application Number (if applicable) in column B, Student ID in column C, Free/Reduced Price status in column D, Certification Type in column E, and Source Document type in column F. If there are two source document types, record second type in column G.

4. Refer to corresponding source document for given Student ID

5. If the source document information was recorded using the Application Data Form, check "App Data Form" in column H. If the source document was copied using a photocopier, check "Photocopied" in column H. If the application is unclear, make a photocopy and do no use the Application Data Form.

6. Check if name, DOB/Grade, and school on source document matches the list and indicate in columns I, J and K. If name or DOB/Grade is not on both list and source document, check "n/a."

7. Repeat steps 2-6 for subsequent approved/identified students.

Approved/Identified Students
A	B	C	D: Free/RP		E: Type of Certification					F: Source Document 1						G: Source Document 2						H: Application documentation			I	J	K
Abt ID	Application number	LEA Student ID	Free	Reduced Price	Application Not Found	Electronic Application	Paper Application	Direct Certification	Other List	Application	District Form	Direct Certification List	Direct Certification Query	Eligibility Report	Other	Application	District Form	Direct Certification List	Direct Certification Query	Eligibility Report	Other	Application Data Form	Photocopied	Not Available	Name Matched	DOB/Grade matched	School matched
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a

Other source document A: _________________________________ Other source document B: _________________________________ Other source document C: _________________________________

Procedure for Denied students (Only in non_COMEL schools):

1 Consult Pre-visit LEA Foodservice Director Questionnaire for contact and location of certification records.

2 Obtain list of Denied students sorted by Student ID or Student Name and obtain the corresponding applications or source documents.

3 From the list, record the first sampled Application Number (if applicable) in column B, LEA Student ID in column C, skip column D for Free/Reduced Price (RP) status, proceed to fill in Certification Type in column E, and Source Document type in column F. If there are two source document types, record second type in column G. If the source document is Other, check the box for Other and list source in the boxes at the end of the table

4 Refer to corresponding source document for given Student ID

5 If the source document information was recorded using the Application Data Form, check "Application Data Form" in column H. If the source document was copied using a photocopier, check "Photocopied" in column H. If the application is unclear, complete the Application Data Form, note what is unclear on the form, make a photocopy and check off both boxes.

6 Check if name, DOB/Grade, and school on source document matches the list and indicate in columns I, J and K. If name or DOB/Grade is not on both list and source document, check "n/a."

7 Repeat steps 2-6 for subsequent Denied students.

Denied Students
A	B	C	D: Free/RP		E: Type of Certification					F: Source Document 1						G: Source Document 2						H: Application documentation			I	J	K
Abt ID	Application number	LEA Student ID	Free	Reduced Price	Application Not Found	Electronic Application	Paper Application	Direct Certification	Other List	Application	District Form	Direct Certification List	Direct Certification Query	Eligibility Report	Other	Application	District Form	Direct Certification List	Direct Certification Query	Eligibility Report	Other	Application Data Form	Photocopied	Not Available	Name Matched	DOB/Grade matched	School matched
			NOT APPICABLE					NOT APPICABLE				NOT APPICABLE						NOT APPICABLE							 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
			NOT APPICABLE					NOT APPICABLE				NOT APPICABLE						NOT APPICABLE							 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
			NOT APPICABLE					NOT APPICABLE				NOT APPICABLE						NOT APPICABLE							 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a
																									 Yes  No  n/a	 DOB  Grade  No  n/a	 Yes  No  n/a

Other source document A: _________________________________ Other source document B: _________________________________ Other source document C: _________________________________

Certification Record Abstraction Form 1