Appendix G3
OTHER
FOOD SOURCES CHECKLIST
OTHER FOOD SOURCES CHECKLIST
Date: ______________________________ Observer Name: ____________________________________
School Name: _____________________________________________________________________________________
SFA ID: _______________ School ID: ____________________ Grades: ___________________
1. Please check the location of on-campus food sources available to students. Do not include vending machines.
Food Source |
Number in school or on school grounds |
Location of Alternative Food Source |
|||
In food service area |
Adjacent to food service area (within 20 feet) |
Elsewhere in school building |
Outside of school building |
||
a. À la carte food lines inside Food Service Area |
0□ None |
1□ |
|
|
|
b. School Store (NOTE: Sells items but does not prepare food) |
0□ None |
1□ |
2□ |
3□ |
4□ |
c. Snack Bar outside Food Service Area (NOTE: Include only snack bars that prepare some food to order.) |
0□ None |
|
2□ |
3□ |
4□ |
d. Food Cart outside Food Service Area |
0□ None |
|
2□ |
3□ |
4□ |
e. Other (Specify) ___________________________________
|
0□ None |
1□ |
2□ |
3□ |
4□ |
2. Please check the hours of operation for each food source available to students. Do not include vending machines.
Food Source |
Not Available to Students |
Hours of Operation (CHECK ALL THAT APPLY) |
||||||
Before Bkfst |
During Bkfst |
After Bkfst and Before Classes Start |
After Classes Start and Before Lunch |
During Lunch |
After Lunch and Before Classes End |
After Last Class |
||
a. À la carte food lines inside Food Service Area |
9□ |
1□ |
2□ |
3□ |
4□ |
5□ |
6□ |
7□ |
b. School Store (NOTE: Sells items but does not prepare food) |
9□ |
1□ |
2□ |
3□ |
4□ |
5□ |
6□ |
7□ |
c. Snack Bar outside Food Service Area (NOTE: Include only snack bars that prepare some food to order.) |
9□ |
1□ |
2□ |
3□ |
4□ |
5□ |
6□ |
7□ |
d. Food Cart outside Food Service Area |
9□ |
1□ |
2□ |
3□ |
4□ |
5□ |
6□ |
7□ |
e. Other (Specify) ________________________________
|
9□ |
1□ |
2□ |
3□ |
4□ |
5□ |
6□ |
7□ |
3. Place a check mark in the box corresponding to each food and/or beverage item sold at each Food Source.
Food Item |
Availability of Food Item in Other Food Sources |
||||
À la carte food lines |
School Store |
Snack Bar |
Food Cart |
Other (Specify ____________) |
|
A. Beverages |
|
|
|
|
|
Carbonated Sweetened Soft Drink |
1□ |
1□ |
1□ |
1□ |
1□ |
Carbonated Diet Soft Drink |
2□ |
2□ |
2□ |
2□ |
2□ |
Juice (100% juice) |
3□ |
3□ |
3□ |
3□ |
3□ |
Juice Drinks (Cranberry Drink, Fruit Blends, Hi-C, Lemonade, Punch) |
4□ |
4□ |
4□ |
4□ |
4□ |
Iced Tea (sweetened) |
5□ |
5□ |
5□ |
5□ |
5□ |
Iced Tea (unsweetened) |
6□ |
6□ |
6□ |
6□ |
6□ |
Water (Spring Water, Flavored Water, Sparkling Water, Mineral Water, Seltzer Water) |
7□ |
7□ |
7□ |
7□ |
7□ |
Water (Water with Juice) |
8□ |
8□ |
8□ |
8□ |
8□ |
Coffee |
9□ |
9□ |
9□ |
9□ |
9□ |
Tea (hot) |
10□ |
10□ |
10□ |
10□ |
10□ |
Hot Chocolate |
11□ |
11□ |
11□ |
11□ |
11□ |
Yogurt Drinks |
12□ |
12□ |
12□ |
12□ |
12□ |
Energy and Sports Drinks (Gatorade, Powerade, Red Bull) |
13□ |
13□ |
13□ |
13□ |
13□ |
Other (Specify ___________________________) |
14□ |
14□ |
14□ |
14□ |
14□ |
|
|
|
|
|
|
B. Dairy |
|
|
|
|
|
Whole Milk |
15□ |
15□ |
15□ |
15□ |
15□ |
Reduced Fat (2%) White Milk |
16□ |
16□ |
16□ |
16□ |
16□ |
Low Fat (1%) White Milk |
17□ |
17□ |
17□ |
17□ |
17□ |
Fat-Free White Milk |
18□ |
18□ |
18□ |
18□ |
18□ |
Fat-Free Flavored Milk |
19□ |
19□ |
19□ |
19□ |
19□ |
Yogurt |
20□ |
20□ |
20□ |
20□ |
20□ |
Cheese |
21□ |
21□ |
21□ |
21□ |
21□ |
Other (Specify ___________________________) |
22□ |
22□ |
22□ |
22□ |
22□ |
|
|
|
|
|
|
C. Baked Goods – Dessert |
|
|
|
|
|
Cake-Type (Brownies, Cupcakes, Twinkies) |
23□ |
23□ |
23□ |
23□ |
23□ |
Cake-Type (Low-Fat/Reduced-Fat Brownies, Cupcakes, Twinkies) |
24□ |
24□ |
24□ |
24□ |
24□ |
Cookies |
25□ |
25□ |
25□ |
25□ |
25□ |
Cookies (Low-Fat/Reduced Fat) |
26□ |
26□ |
26□ |
26□ |
26□ |
Pastries (Pies, Turnovers) |
27□ |
27□ |
27□ |
27□ |
27□ |
Other (Specify ___________________________) |
28□ |
28□ |
28□ |
28□ |
28□ |
|
|
|
|
|
|
D. Bread or Grain Products |
|
|
|
|
|
Regular Bread (Bread, Rolls, Bagels) |
29□ |
29□ |
29□ |
29□ |
29□ |
Whole Grain Bread (Bread, Rolls, Bagels) |
30□ |
30□ |
30□ |
30□ |
30□ |
Other Bread (Biscuits, Croissants, Hot Pretzels) |
31□ |
31□ |
31□ |
31□ |
31□ |
Muffins (Regular) |
32□ |
32□ |
32□ |
32□ |
32□ |
Muffins (Whole Grain) |
33□ |
33□ |
33□ |
33□ |
33□ |
Muffins (Low-Fat/Reduced-Fat) |
34□ |
34□ |
34□ |
34□ |
34□ |
Granola Bars |
35□ |
35□ |
35□ |
35□ |
35□ |
Granola Bars (Low-Fat/Reduced-Fat) |
36□ |
36□ |
36□ |
36□ |
36□ |
Pretzels (Regular, Sourdough) |
37□ |
37□ |
37□ |
37□ |
37□ |
Pretzels (Whole Grain) |
38□ |
38□ |
38□ |
38□ |
38□ |
Crackers/Cracker Sandwiches: Peanut Butter |
39□ |
39□ |
39□ |
39□ |
39□ |
Crackers/Cracker Sandwiches: Cheese |
40□ |
40□ |
40□ |
40□ |
40□ |
Cereal/Cereal Bars |
41□ |
41□ |
41□ |
41□ |
41□ |
Other (Specify ___________________________) |
42□ |
42□ |
42□ |
42□ |
42□ |
Food Item |
Availability of Food Item in Other Food Sources |
||||
À la carte food lines |
School Store |
Snack Bar |
Food Cart |
Other (Specify ____________) |
|
E. Frozen Desserts |
|
|
|
|
|
Frozen Non-Diary (Fruit Bars, Jello Pops, Popsicles) |
43□ |
43□ |
43□ |
43□ |
43□ |
Ice Cream (Bars, Cups, Fudgesicles, Sundaes) |
44□ |
44□ |
44□ |
44□ |
44□ |
Low-Fat Frozen Desserts (Frozen Yogurt, Ice Milk, Sherbet) |
45□ |
45□ |
45□ |
45□ |
45□ |
Milkshakes |
46□ |
46□ |
46□ |
46□ |
46□ |
Smoothies |
47□ |
47□ |
47□ |
47□ |
47□ |
|
|
|
|
|
|
F. Fruit and Vegetables |
|
|
|
|
|
48□ |
48□ |
48□ |
48□ |
48□ |
|
Fresh Fruit (whole, cut) |
49□ |
49□ |
49□ |
49□ |
49□ |
Fruit Salad (Fresh) |
50□ |
50□ |
50□ |
50□ |
50□ |
Fruit Salad (Canned in Water) |
51□ |
51□ |
51□ |
51□ |
51□ |
Fruit Salad (Canned in Light Syrup) |
52□ |
52□ |
52□ |
52□ |
52□ |
Dried Fruit |
53□ |
53□ |
53□ |
53□ |
53□ |
Other Fresh Fruit (Specify ___________________) |
54□ |
54□ |
54□ |
54□ |
54□ |
Vegetables, Side Salad |
55□ |
55□ |
55□ |
55□ |
55□ |
Vegetables, Raw |
56□ |
56□ |
56□ |
56□ |
56□ |
Other Fresh Vegetables (Specify ______________) |
57□ |
57□ |
57□ |
57□ |
57□ |
|
|
|
|
|
|
G. Snacks |
|
|
|
|
|
Chips (Corn, Potato, Tortilla) |
58□ |
58□ |
58□ |
58□ |
58□ |
Chips (Lower-Fat/Reduced-Fat Corn, Potato, Tortilla) |
59□ |
59□ |
59□ |
59□ |
59□ |
Puffed Cheese (Regular) |
60□ |
60□ |
60□ |
60□ |
60□ |
Puffed Cheese (Lower-Fat/Reduced-Fat) |
61□ |
61□ |
61□ |
61□ |
61□ |
Nuts and Seeds (Almonds, Peanuts, Sunflower Seeds, Trail Mix) |
62□ |
62□ |
62□ |
62□ |
62□ |
Fruit Snacks (Roll-Up, Gummies) |
63□ |
63□ |
63□ |
63□ |
63□ |
Popcorn |
64□ |
64□ |
64□ |
64□ |
64□ |
Meat Snacks (Jerky, Pork Rinds) |
65□ |
65□ |
65□ |
65□ |
65□ |
Candy with Chocolate |
66□ |
66□ |
66□ |
66□ |
66□ |
Candy without Chocolate |
67□ |
67□ |
67□ |
67□ |
67□ |
Energy Bars (Balance Bars, Luna Bars, Power Bars, etc) |
68□ |
68□ |
68□ |
68□ |
68□ |
Other (Specify ___________________________) |
69□ |
69□ |
69□ |
69□ |
69□ |
|
|
|
|
|
|
H. Prepared / Pre-Prepared Entrees and Food |
|
|
|
|
|
Hot Dogs |
70□ |
70□ |
70□ |
70□ |
70□ |
Hamburgers or Cheeseburgers |
71□ |
71□ |
71□ |
71□ |
71□ |
Veggie Burgers |
72□ |
72□ |
72□ |
72□ |
72□ |
Grilled Sandwiches |
73□ |
73□ |
73□ |
73□ |
73□ |
Cold Sandwiches |
74□ |
74□ |
74□ |
74□ |
74□ |
Burritos |
75□ |
75□ |
75□ |
75□ |
75□ |
Taco |
76□ |
76□ |
76□ |
76□ |
76□ |
Meal-Size Salad |
77□ |
77□ |
77□ |
77□ |
77□ |
Pizza (Slice) |
78□ |
78□ |
78□ |
78□ |
78□ |
Pizza (Bites) |
79□ |
79□ |
79□ |
79□ |
79□ |
Pasta |
80□ |
80□ |
80□ |
80□ |
80□ |
French Fries |
81□ |
81□ |
81□ |
81□ |
81□ |
Onion Rings |
82□ |
82□ |
82□ |
82□ |
82□ |
Mozzarella Sticks |
83□ |
83□ |
83□ |
83□ |
83□ |
Other (Specify ____________________________) |
84□ |
84□ |
84□ |
84□ |
84□ |
|
|
|
|
|
|
Food Item |
Availability of Food Item in Other Food Sources |
||||
À la carte food lines |
School Store |
Snack Bar |
Food Cart |
Other (Specify ____________) |
|
I. Other (Specify) |
|
|
|
|
|
___________________________________ |
85□ |
85□ |
85□ |
85□ |
85□ |
___________________________________ |
86□ |
86□ |
86□ |
86□ |
86□ |
___________________________________ |
87□ |
87□ |
87□ |
87□ |
87□ |
___________________________________ |
88□ |
88□ |
88□ |
88□ |
88□ |
___________________________________ |
89□ |
89□ |
89□ |
89□ |
89□ |
___________________________________ |
90□ |
90□ |
90□ |
90□ |
90□ |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Kim Standing |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |