Appendix G3 Other Food Sources Checklist

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
Canned or Cooked Fruit	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□