Private Schools

NSLP/SBP Access, Participation, Eligibility, and Certification Study

rev062112 Attachment F.1-Student Sample Contact Info Formm

Private Schools

OMB: 0584-0530

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Attachment F.1- CERTIFIED AND DENIED APPLICANT SAMPLING FORMShape2



OMB Approval No.: 0584-0530

Approval Expires:


NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)


STUDENT SAMPLE CONTACT INFORMATION FORM FOR FREE\REDUCED-PRICE

AND DENIED APPLICANT SAMPLES













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 control number. The valid OMB control number for this collection is 0584-0530. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

Shape3


NATIONAL SCHOOL LUNCH AND SCHOOL BREAKFAST PROGRAM ACCESS,

PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)


STUDENT SAMPLE CONTACT INFORMATION FORM FOR FREE\REDUCED-PRICE

AND DENIED APPLICANT SAMPLES



SCHOOL DISTRICT ID NUMBER: | | | | | | | | | SCHOOL DISTRICT NAME:


SCHOOL ID NUMBER: | | | | | | | | | SCHOOL NAME:


DATE: | | | / | | | / | | |

MONTH DAY YEAR


I. FREE AND REDUCED-PRICE SAMPLE



SAMPLE RESULTS







A.

B.

C.

D.

E.

F.

G.

H.


Student

Number

Selection

Order

Selection

Type

(M or R)

Student Name

Grade

Parent’s Name

Mailing Address

Telephone

Number

1.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


2.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


3.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


4.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


5.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


6.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


7.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


8.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


9.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


10.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


11.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


12.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


13.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


14.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


15.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


16.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


17.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


18.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


19.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


20.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

Free Reduced Price


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR



II. DENIED APPLICANT SAMPLE



SAMPLE RESULTS







A.

B.

C.

D.

E.

F.

G.

H.


Student

Number

Selection

Order

Selection

Type

(M or R)

Student Name

Grade

Parent’s Name

Mailing Address

Telephone

Number

1.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

DENIED APPLICANT


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


2.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

DENIED APPLICANT


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


3.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

DENIED APPLICANT


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


4.




First:

Middle:

Last:


First:

Middle:

Last:

Street:

City:

State: Zip:


( )


_________


_________


I.


Application Number:



_______________________________

J.

Certification Status:

DENIED APPLICANT


K.

Application/Certification Dates:


Application Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR


Certification Date: | | | / | | | / | | | Date Not Available

MONTH DAY YEAR





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