State, Local & Tribal LEA Schools

Community Eligibility Option Evaluation

CEO C_15 Menu Survey

State, Local & Tribal LEA Schools

OMB: 0584-0570

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CEO C_15 Menu Survey

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX



Community Eligibility Option Evaluation







Menu Survey







Attach School ID Label















If you have questions or need assistance, please call
Abt’s toll-free number: 855-759-5752











The Community Eligibility Option Evaluation is being conducted for the:



Food and Nutrition Service

US Department of Agriculture

3101 Park Center Drive

Alexandria, Virginia 22301



By:



Abt Associates Inc.

55 Wheeler Street

Cambridge, Massachusetts 02138


Information provided in this survey will be kept private, to the extent provided by law. No data will be attributed to specific survey respondents. De-identified data from this study will be provided to the Food and Nutrition Service of the U.S Department of Agriculture, and aggregate measures of subgroups of Local Education Agencies (LEAs) may also be provided. Responses to the study will in no way affect your agency’s receipt of funds from USDA’s school meals program. As you may know, the Healthy-Free Kids Act of 2010 (PL 111-296, Section 305) requires cooperation with program research and evaluation by agencies and contractors participating in programs authorized under the Act and the Child Nutrition Act of 1966.

If you have any questions or concerns about your rights as a study participant, call Teresa Doksum. She is the Institutional Review Board Administrator at Abt Associates. Her phone number is 877-520-6835 (toll-free).

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 35 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.

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation


Daily Meal Counts Form—CEO Schools




School Name: _____________________________ Date (1st day of Target Week):__________


Instructions: In the boxes for Reimbursable Lunches and Reimbursable Breakfasts, please write in the number of USDA reimbursable meals served in your school each day of the target week. Do not include meals for which you do not claim reimbursement, for example, second lunches sold to students on an a la carte basis.




Number of Reimbursable Lunches Served


Day of Week

Total

Monday


Tuesday


Wednesday


Thursday


Friday




Number of Reimbursable Breakfasts Served


Day of Week

Total

Monday


Tuesday


Wednesday


Thursday


Friday




OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation


Daily Meal Counts Form—Non-CEO Schools




School Name: _____________________________ Date (1st day of Target Week):__________


Instructions: In the boxes for Reimbursable Lunches and Reimbursable Breakfasts, please write in the number of USDA reimbursable meals served in your school each day of the target week. Please write the number of free meals, reduced-price meals, and full-price meals, as well as the total number of meals. Do not include meals for which you do not claim reimbursement, for example, second lunches sold to students on an a la carte basis.




Number of Reimbursable Lunches Served


Day of Week

Free

Reduced-Price

Full-Price

Total

Monday





Tuesday





Wednesday





Thursday





Friday







Number of Reimbursable Breakfasts Served


Day of Week

Free

Reduced-Price

Full-Price

Total

Monday





Tuesday





Wednesday





Thursday





Friday







OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Reimbursable Food Form: Breakfast

School Name: _____________________________________________ Day of the Week: □ Mon □ Tue □ Wed □ Thu □ Fri

A.

B.

C.

D.

E.

F.

G.

H.

Food Item

Portion Size

(include units)

Number of Servings Planned
(reimbursable only)

Manufacturer/Brand Name
and Product Code

(if applicable)

Food Description

When describing food, include information about type, form, flavor, and fat content

USDA Commodity?

Recipe?

ABT USE ONLY

MILK (Note: if more than one size is available, list in blank spaces)

White, 1%

fl oz.







White, fat-free/skim

fl oz.







Chocolate fat-free/skim

fl oz.







Flavored fat-free/skim

fl oz.



Specify flavor:




















FRUIT (Note: Prelisted entries should be used for fruit that is served as purchased. If anything is added before serving, list as separate item and complete RECIPE FORM)

Apple, fresh







Banana, fresh








Blueberries

cup



Fresh Frozen
Sweetened Unsweetened



Grapes, fresh








Orange, fresh







Peaches, canned

cup



Heavy syrup Light syrup Extra light syrup

Juice Water













































JUICES (Note: prelisted entries should be used only for 100% fruit and vegetable juice. List fruit drinks under “Other Menu Items” section.)

Orange juice

fl oz.



Vitamin C added Calcium added



Apple juice

fl oz.



Vitamin C added Calcium added





fl oz.



Vitamin C added Calcium added




fl oz.


Vitamin C added Calcium added




fl oz.



Vitamin C added Calcium added




fl oz.



Vitamin C added Calcium added




fl oz.



Vitamin C added Calcium added



COLD CEREALS

Cheerios – Plain

oz.







Cheerios – Honey Nut

oz.







Cinnamon Toast Crunch

oz.







Golden Grahams

oz.







Trix

oz.







Special K

oz.







Frosted Flakes

oz.







Lucky Charms

oz.








oz.








oz.








oz.








oz.








oz.








oz.








oz.








oz.







HOT CEREALS (Note: if prepared with fat and/or milk, complete RECIPE FORM)

Cream of Wheat

oz.



Instant Quick Reg



Grits

oz.



Instant Quick Reg


Oatmeal

oz.



Instant Quick Reg



oz.






oz.





OTHER BREADS AND GRAINS OFFERED SEPARATELY

Bagel

oz.



Type: Whole grain




Biscuit

oz.



Type: Whole grain



Doughnut

oz.



Type: Icing/glaze No icing/glaze




English muffin

oz.



Type: Whole grain
Margarine Butter



Granola/cereal bar

oz.


Specify type(s):




Muffin

oz.



Specify type(s):



Pancake

oz.



Weight of each:


Roll, cinnamon

oz.



Icing No icing



Toast

oz.



Type: Whole grain
Margarine Butter



Toaster pastry

oz.



Icing No icing




Waffle/waffle sticks




Weight of each/stick: oz.


























MEAT AND MEAT ALTERNATES OFFERED SEPARATELY

Bacon

slices



Pork Turkey




Eggs




Boiled Fried Scrambled

If prepared with fat and/or milk, complete RECIPE FORM


Ham

oz.



Pork Turkey



Sausage

oz.



Pork Turkey Beef




Yogurt

oz.



Specify flavors:
Regular Low fat Fat free
Low-cal sweetener




























COMBINATION BREAD/MEAT ITEMS

Entrée bar

Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM


Breakfast burrito

oz.



Specify fillings:



Cheese sandwich, toasted

1 sandwich



Bagel English muffin

White bread Whole wheat bread



Egg sandwich

1 sandwich



Cheese Sausage □Ham

Bacon Other:

Bagel English muffin

White bread Whole wheat bread



French toast







French toast sticks

ea.



Weight of each stick: oz.




Pancake/sausage on a stick

oz.



Weight of each stick: oz.




Breakfast pizza

oz.



Specify toppings:















COMBINATION BREAD/MEAT ITEMS (continued)

























CONDIMENTS (Include size if single-serve item)

Self-Serve Bar

Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM


Butter








Cream cheese




Reg Low fat Fat-free




Gravy




Reg Low fat Fat-free



Jelly








Ketchup








Margarine








Salsa






Syrup




Reg Low sugar Sugar-free



























OTHER MENU ITEMS
































OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Reimbursable Food Form: Lunch

School Name: _____________________________________________ Day of the Week: □ Mon □ Tue □ Wed □ Thu □ Fri

A.

B.

C.

D.

E.

F.

G.

H.

Food Item

Portion Size

(include units)

Number of Servings Planned
(reimbursable only)

Manufacturer/ Brand Name
and Product Code

(if applicable)

Food Description

When describing food, include information about type, form, flavor, and fat content

USDA Commodity?

Recipe?

ABT USE ONLY

MILK (Note: if more than one size is available, list in blank spaces)

White, 1%

fl oz.







White, fat-free/skim

fl oz.







Chocolate fat-free/skim

fl oz.







Flavored fat-free/skim

fl oz.



Specify flavor:




















FRUIT (Note: Prelisted entries should be used for fruit that is served as packaged. If anything is added before serving, list as separate item and complete RECIPE FORM)

Apple, fresh







Banana, fresh








Grapes, fresh








Orange, fresh







Pears, fresh







Applesauce, canned

cup



Sweetened Unsweetened



Fruit cocktail, canned

cup



Heavy syrup Light syrup Extra light syrup
Juice Water



Peaches, canned

cup



Heavy syrup Light syrup Extra light syrup
Juice Water



Pears, canned

cup



Heavy syrup Light syrup Extra light syrup
Juice Water



Pineapple, canned

cup



Heavy syrup Light syrup Extra light syrup
Juice Water




FRUIT (continued)
















































JUICES (Note: prelisted entries should be used only for 100% fruit and vegetable juice. Fruit drinks are included in “Desserts, Drinks, and Snacks” section.)

Orange juice

fl oz.



Vitamin C added Calcium added



Apple juice

fl oz.



Vitamin C added Calcium added




Frozen juice cup / bar

fl oz.



Vitamin C added Calcium added





fl oz.


Vitamin C added Calcium added




fl oz.



Vitamin C added Calcium added




fl oz.



Vitamin C added Calcium added




fl oz.



Vitamin C added Calcium added



VEGETABLES

Beans, green

cup



Fresh Frozen Canned
Seasoning/fat added
Specify


Broccoli

cup



Fresh Frozen Canned
Seasoning/fat added
Specify



Carrots, cooked

cup



Fresh Frozen Canned
Seasoning/fat added
Specify


Corn, kernels

cup



Fresh Frozen Canned
Seasoning/fat added
Specify


Peas, green

cup



Fresh Frozen Canned
Seasoning/fat added
Specify


VEGETABLES (continued)

Potatoes, whipped or mashed

cup



From fresh
If prepared with fat and/or milk, use RECIPE FORM


French fries

oz.



Oven baked Deep fried



Tater tots or shapes

oz.



Oven baked Deep fried



Salad bar (non-entrée or small portion)

Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM




Salad, tossed

cup



List dressing as separate item or complete RECIPE FORM



Carrot sticks




If offered, list dip as separate item(s) or complete RECIPE FORM


Celery sticks





































ENTREES OTHER THAN SANDWICHES OR SELF-SERVE BARS (Exclude specialty lunches, such as those offered only to children with certain allergies or the inability to pay.)

Pizza, cheese

oz.



Thin crust Thick crust Stuffed crust
Whole grain crust



Pizza, French bread

oz.



Whole grain crust



Pizza, pepperoni

oz.



Thin crust Thick crust Stuffed crust
Whole grain crust



Pizza, sausage

oz.



Thin crust Thick crust Stuffed crust
Whole grain crust



Pizza, other specify

oz.



Thin crust Thick crust Stuffed crust
Whole grain crust



Pizza, other specify

oz.



Thin crust Thick crust Stuffed crust
Whole grain crust



Chicken patties (not sandwich)

oz.



Breaded
Oven baked Deep fried




ENTREES OTHER THAN SANDWICHES OR SELF-SERVE BARS (continued)

Chicken piece(s)
(specify part) _______________
(specify part) _______________




Breaded With skin
Oven baked Deep fried


Chicken nuggets

ea.



Oven baked Deep fried
Weight of each nugget: oz.




Turkey, slice

oz.






Ham, slice

oz.



Pork Turkey



Corndog

oz.



All beef Pork & beef
Chicken or turkey




Burrito

oz.



Specify fillings:



Taco




Hard shell Soft tortilla

Specify filling:



Spaghetti with meat sauce

cup






Chef’s salad

1 salad






Yogurt (as meat alternate)

oz.



Specify flavors:
Regular Low fat Fat free
Low-cal sweetener
































































SANDWICHES & BURGERS:

Describe contents of each sandwich in space at right.

For each sandwich type, complete a Recipe Form or record information for sandwich below including type and weight of bread; type and amount of filling; type and amount of any additions. Provide recipe if needed, such as for Tuna Salad. See Instruction Manual for examples.

Sandwich/deli bar

Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

(See Instruction Manual for examples.)




Hamburger

1 sandwich





Cheeseburger

1 sandwich






Hot dog

1 sandwich






Italian sub

1 sandwich






Chicken filet or breast (not breaded)

1 sandwich






Chicken patty (breaded)

1 sandwich






Rib, barbeque

1 sandwich





Turkey

1 sandwich






Tuna salad

1 sandwich






Cheese, grilled

1 sandwich






Ham and cheese

1 sandwich






Peanut butter (or almond, sesame, or sun butter) & jelly

1 sandwich


Do not record sandwich if not available to

ALL students.




1 sandwich







1 sandwich






1 sandwich







1 sandwich






SELF-SERVE ENTRÉE BARS

Entrée salad bar (or large portion)

Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM




Potato bar

Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM




Nacho/taco bar

Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM





Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM





Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM





Self-serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM




BREADS AND GRAINS OFFERED SEPARATELY

Biscuit

oz.



Type: Whole grain



Bread, plain

oz.



Type: Whole grain




Bread, buttered

oz.



Type: Whole grain
Margarine Butter




Breadstick

oz.



Type: Whole grain



Cornbread

oz.






Crackers

ea.



Type: Whole grain




Rice

cup



Type: Brown


Roll

oz.



Type: Whole grain



Pasta

cup



Type: Whole grain


Pretzels

oz.



Soft Hard Whole grain



Tortilla

oz.



Type: Whole grain


























DESSERTS, DRINKS, AND SNACKS OFFERED AS PART OF THE REIMBURSABLE MEAL

Brownie







Cake




Specify type:



Cookie

oz.



Specify type:



Fruit drink

fl oz.



Specify type:
Specify % juice content:




Gelatin, plain

cup







DESSERTS, DRINKS, AND SNACKS OFFERED AS PART OF THE REIMBURSABLE MEAL (continued)

Gelatin, with fruit

cup






Potato chips

oz.



Specify type:




Yogurt

oz.



Specify flavors:
Regular Low fat Fat free
Low-cal sweetener




Pudding

oz.



Flavor:



Ice cream / ice milk

fl oz.



Regular Low fat Fat free































SALAD DRESSINGS

French dressing




Regular Low fat Fat free



Italian dressing




Regular Low fat Fat free



Ranch dressing




Regular Low fat Fat free







Regular Low fat Fat free







Regular Low fat Fat free







Regular Low fat Fat free







Regular Low fat Fat free



OTHER CONDIMENTS (Include size of packet if single-serve. Write “Self -Serve” if students can choose the portion.)

Self-serve bar

Self-Serve


List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

(See Instruction Manual for examples.)




Barbeque sauce







Butter








Cream cheese




Regular Low fat Fat free




Gravy




Regular Low fat Fat free



Honey








Ketchup








Margarine








Mayonnaise




Regular Low fat Fat free




Mustard








Tartar sauce




Regular Low fat Fat free



OTHER CONDIMENTS (Continued)

Peppers, jalapeno








Pickles, relish








Pickles, slices








Ranch dip




Regular Low fat Fat free



Salsa






Sour cream




Regular Low fat Fat free
















OTHER MENU ITEMS



























































































OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Self-Serve and Made-to-Order Bar Form

Meal (Circle one): Breakfast Lunch


Name of Bar: ___________________________________ Day(s): 1 Mon 2 Tue 3 Wed 4 Thu 5 Fri


A.

B.

C.

D.

E.

F.

G.

Food Item

Portion size


(If pre-portioned,
include units)

Manufacturer/Brand Name & Product Code


(if applicable)

Include the following information:

Type, Form, Flavor, Fat content (See instruction manual for examples of each)


Food Description

USDA Commodity?

Recipe? *

ABT USE ONLY






























































*For each recipe, record recipe details on a Recipe Form

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX





Community Eligibility Option Evaluation



Recipe Forms





































The Community Eligibility Option Evaluation is being conducted for the:



Food and Nutrition Service

US Department of Agriculture

3101 Park Center Drive

Alexandria, Virginia 22301



By:



Abt Associates Inc.

55 Wheeler Street

Cambridge, Massachusetts 02138


Recipe Form (Side 1)


Recipe/Food name: ______________________________ Size of one serving (include units): ________________

Meal: 1 Breakfast 2 Lunch This recipe makes __________ servings



Day(s): 1 Mon 2 Tue 3 Wed 4 Thu 5 Fri Recipe Attached: (Please fill out Side 2)


A.

B.

C.

D.

E.

F.

G.

Ingredient Name

Amount in Recipe

(Include units)

Manufacturer/Brand Name and Product Code

Include the following information:

Type, Form, Flavor, Fat content (See instruction manual for examples of each)

Ingredient
Description

USDA Commodity?

Recipe?

ABT USE ONLY

































































































Recipe Form (Side 2)


Preparation Information

Please check () the boxes below to describe the procedures used in preparing this recipe.


1. If recipe was cooked, what cooking method did you use? (check all that apply)


1 Bake/roast

2 Oven heat

3 Microwave/warmer

4 Broil/grill

5 Pan fry/sauté 10 Floured 11 Battered

6 Deep fry 12 Floured 13 Battered

7 Boil

8 Steam

9 Other (Specify):

n Does not apply to recipe


2. If recipe contains meat or poultry, was amount measured raw or cooked?


Shape1 n Does not apply to recipe SKIP TO Q.4

1 Raw

2 Cooked


3. If recipe contains meat or poultry, did you . . .


check all that apply

Yes

No

Does not apply to recipe

Trim the visible fat?

1

0

n

Drain fat after cooking?

1

0

n

Remove skin before cooking?

1

0

n


4. If recipe contains noodles, rice, or vegetables, did you add salt to the cooking water?



Yes

No

Does not apply to recipe

Noodles/pasta or rice

1

0

n

Vegetables

1

0

n


5. If recipe contains canned vegetables or canned fruit, did you drain off all of the liquid?


1 Yes 0 No n Does not apply to recipe


Comments













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