State and Local Governments

The Evaluation of Demonstrations of NSLP/SBP Direct Certification of Children Receiving Medicaid Benefits

Appendix A.1 (5-6-13)

State and Local Governments

OMB: 0584-0586

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Appendix A.1: Certification and Participation Data Request OMB #: 0584-xxxx

Expiration Date: xx/xx/20xx

Certification and Participation Data Request

A key component of the DC-M demonstration evaluation is to assess the impact of DC-M on certification and participation in the NSLP and SBP. To that end, we are asking each state to provide district-level data for each district included in the study (in either the demonstration or control group). Two types of data files are requested:

  1. Certification data: information on enrolled students by certification status and basis for certification as of the last operating day in October

  2. Participation data: monthly information on participation in the NSLP, SBP, Special Milk Program, and Afterschool Snack Program.

Certification Data

Certification data should be provided as of the last operating day in October in each of three years: 2011, 2012, and 2013. Table 1 lists the specific data elements that should be included in the certification data files.1 Most of these data elements are reported by districts to the state as part of the process for completing FNS Form 742.

Table 1. Data Elements Requested in Certification File

Data Element

Notes

Number of students enrolled

Total number of students enrolled in the district in schools or other facilities that operate the NSLP or SBP, excluding those schools participating in the Community Eligibility Option (CEO), Provision 2, or Provision 3 for lunch

Total number of students certified free



Number of students certified free:


- By application, based on income and household size


- By application, based on categorical eligibility


- By application, then later found on DC-M list

- By direct certification

We understand that this category may not be available for all districts. Please provide it for any districts for which it is available.



Number of students directly certified based on (if available):

We would like as much detail on the basis of direct certification as is available. If your data system does not include all of the categories listed here, please provide any that are available. If your data system includes other categories not listed here, please provide that information as well.

- Medicaid

- SNAP

- TANF

- FDPIR


- Other


- Both Medicaid and another program


- More than one other program


Number of students categorically eligible based on (if available):

If your data system does not include all of the categories listed here, please provide any that are available. If your data system includes other categories not listed here, please provide that information as well.

- Medicaid

- SNAP

- TANF


- FDPIR


- Other


Number of students certified reduced-price


Number of applications approved free


- Based on income and household size


- Based on categorical eligibility

Number of applications approved reduced-price


Average daily attendance in the district (if available)


School district name


Unique school district ID number


Note: Schools operating under the Community Eligibility Option (CEO) or Provision 2 or Provision 3 for lunch should not be included in these data.

Participation Data

Certification data should be provided for each operating month in school year (SY) 2011-12, 2012-13, and 2013-14. Table 2 lists the specific data elements that should be included in the monthly participation data files.2 Most of these data elements are reported by districts to the state as part of the process for completing FNS Form 10.

Table 2. Data Elements Requested in Monthly Participation Files

Data Element

Notes

Number of schools or other facilities participating in the NSLP

Exclude those schools or other facilities operating under the Community Eligibility Option (CEO), Provision 2, or Provision 3 for lunch.

Number of students enrolled in these facilities


Total number of reimbursable lunches served


Number of reimbursable lunches served, by reimbursement category:


- Free


- Reduced-price


- Paid


Average daily reimbursable lunches served


Number of NSLP operating days


Number of reimbursable lunches served that qualify state for additional payment


Number of reimbursable lunches served in districts certified for performance-based reimbursement


Number of schools or other facilities participating in the SBP

Include severe need. Exclude those participating in Provision 2 or Provision 3 for breakfast.

Number of students enrolled in these facilities


Number of severe need facilities


Number of students enrolled in severe need facilities


Total number of reimbursable breakfasts served

In all schools or other facilities, including severe need. (Exclude those participating in Provision 2 or Provision 3 for breakfast.)

Number of reimbursable breakfasts served, by reimbursement category:


- Free


- Reduced-price


- Paid


Number of severe need reimbursable breakfasts served

Severe need only. (Exclude those participating in Provision 2 or Provision 3 for breakfast.)

Number of severe need reimbursable breakfasts served, by reimbursement category:


- Free


- Reduced-price


- Paid


Average daily reimbursable breakfasts served


Number of SBP operating days


Number of schools or other facilities participating in the Special Milk Program (SMP)

If no schools or other facilities in a given district participate in the Special Milk Program, then this and related data elements will equal zero.

Number of facilities participating in the SMP,

by type:

- School


- Residential Child Care Institution


- Non-residential child care institution


- Summer camp


Number of students enrolled in each type of facility participating in the SMP (if available)


Total number of reimbursable milks served


Number of reimbursable milks served, by reimbursement category:


- Free


- Paid


Average daily milks served


Number of operating days for the SMP


Number of schools or other facilities participating in the NSLP Afterschool Snack Program (ASP)

If no schools or other facilities in a given district participate in the NSLP Afterschool Snack Program, then this and related data elements will equal zero.

Number of facilities participating in the ASP, by type:

- School


- Residential Child Care Institution


Number of students enrolled in each type of facility participating in the ASP (if available)


Number of students enrolled in afterschool programs in these facilities (if available)


Total number of reimbursable snacks served


Number of reimbursable snacks served, by reimbursement category:


- Free, in area-eligible sites


- Free, in all sites


- Reduced-price


- Paid


Average daily snacks served


Number of operating days for the ASP


School district name


Unique school district ID number


Note: Schools operating under the Community Eligibility Option (CEO) or Provision 2 or Provision 3 should not be included in these data.

Data Delivery Timeline

Table 3 provides the timeline for the data collection. The data files for SY 2011-2012 and the first few months of SY 2012-2013 should be provided as soon as possible. Data for the remaining months of SY 2012-2013 and for SY 2013-2014 should be provided as they become available.

Table 3: Timing of Data Collection

School Year

Data

Date By Which Data Should Be Delivered

SY 2011–2012

October 2011 Certification Data

December 2012

August 2011-June 2012 Participation Data

December 2012

SY 2012–2013

October 2012 Certification Data

December 2012

August-October 2012 Participation Data

December 2012

November 2012-June 2013 Participation Data

On an ongoing basis, with last file delivered July 12, 2013

SY 2013–2014

October 2013 Certification Data

November 29, 2013

August 2013-June 2014 Participation Data

On an ongoing basis, with last file delivered July 11, 2014





Data Delivery Methods

Mathematica can accept the requested data in any standard format, but we prefer Microsoft Excel or SAS file formats. Since these files will contain only aggregate data, with no personally identifiable information on individuals, they may be transmitted via email. However, we recommend encrypting the files before sending. If a state prefers, we will provide a secure FTP site for uploading the data files.

1 These data elements are similar to those listed in the first column of Table 4 of the MOU, but with additional detail and notes.

2 These data elements are similar to those listed in the second column of Table 4 of the MOU, but with additional detail and 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 control 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 240 minutes per response.

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