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pdfAPPENDIX H1. GROUP 2—BASIC MENU SURVEY
H1.1 - Instructions for Basic Menu Survey and Example Forms
H1.2 - Daily Meal Counts Form_Basic
H1.3 - Reimbursable Foods Form Breakfast_Basic
H1.4 - Reimbursable Foods Form Lunch_Basic
H1.5 - Recipe Form_Basic
H1.6 - Self-Serve and Made-to-Order Form_Basic
H1.7 - Afterschool Snack Form_Basic
H1.8 - Daily Reminder List_Basic
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Expiration Date: xx/xx/xxxx
School Nutrition and Meal Cost Study
Instructions for the
Menu Survey (Basic)
Sponsored by:
U.S. Department of Agriculture
Food and Nutrition Service
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
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INTRODUCTION TO THE MENU SURVEY
Thank you for participating in the School Nutrition and Meal Cost Study. Without your
help, and the help of school nutrition professionals like you across the country, this
important study could not be done.
As part of this study, you are being asked to complete a Menu Survey. The objective of
the Menu Survey is to obtain a complete and accurate description of the foods offered
and served by your school nutrition program, including foods offered in reimbursable
meals, sold a la carte, and in afterschool snacks (if reimbursed through the National
School Lunch Program). You will complete the survey forms during a specified time
period, referred to as the “target week.” The target week for your school is shown on the
front of the Menu Survey Folder.
The information you provide will be combined with information from many other schools
across the country and will be used to examine the food and nutrient content of school
meals and snacks.
This Instruction Manual describes the Menu Survey and provides easy-to-follow
instructions for completing the survey forms. Along with the manual is a set of sample
completed forms that may be useful when you are completing your own survey forms.
Be sure to look over the sample completed forms.
Below, we describe the forms included in the Menu Survey Folder. The rest of this
manual explains how to complete each form.
Daily Meal Counts Form
This one-page form (blue paper) is located behind the first tab inside the Menu Survey
Folder. This is a very simple form. All you have to do is write in the number of
reimbursable lunches and breakfasts you served each day of the target week. At the
bottom of the form, you will write in your non-reimbursable food sales each day of the
week, by venue (if applicable). Additional instructions are provided at the top of the
form.
Reimbursable Foods Forms
You will fill out these forms each day of the target week. They are located in colored
folders in the Menu Survey Folder labeled by day of the week (Monday forms, Tuesday
forms, etc.). There are separate forms for breakfast (yellow paper) and lunch (white
paper). You will use these forms to provide information about all foods and beverages
offered in reimbursable meals, including portion sizes, the number of portions prepared
and served, their contributions to the meal pattern food groups, and the food
descriptions needed for an accurate nutrient analysis. You will also check if any item
was a USDA Food or prepared from a recipe.
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Recipe Forms
A booklet of Recipe Forms (grey paper) is located behind the “Recipes” tab in the Menu
Survey Folder. The Recipe Forms are used to provide information for foods prepared
from two or more ingredients and certain other reimbursable menu items served during
the target week.
Self-Serve/Made-to-Order Bar Form
Behind the next tab in the Menu Survey Folder is another booklet of forms (lavender
paper) to be used for recording information about “Self-Serve Bars,” such as salad bars
and condiment bars, as well as made-to-order bars such as deli bars. If your school
offers self-serve or made-to-order bars, you will use a Self-Serve/Made-to-Order Bar
form to describe the foods offered on each bar.
A La Carte Foods Checklist
The A La Carte Foods Checklist is a multiple-page form (pink paper) that you will use to
identify all foods and beverages sold on an a la carte basis in your school. You only
need to fill out this form for ONE DAY during your target week. The day that has been
randomly selected to be your “a la carte checklist day” is shown on the front cover of the
Menu Survey Folder.
Afterschool Snack Form
If your school provides reimbursable snacks through the National School Lunch
Program for one or more afterschool programs, you will fill out the Afterschool Snack
Forms (green paper). One form will be completed for each day that afterschool snacks
are offered. These forms are similar to but much simpler than the Reimbursable Foods
Form.
Daily Reminder List
In each of the Monday through Friday folders we have also included the Daily Reminder
List (gold paper). This double-sided card provides tips for getting organized before the
target week and a summary of day-to-day activities for the target week. We suggest that
you also store or post this list in a convenient location so you can refer to it during the
target week.
School Nutrition Manager Survey
We have included a survey that asks about school’s foodservice operations and your
experiences implementing the new meals requirements. Please complete the survey
during your target week. You can choose to complete it on any day you would like.
The Rest of This Manual
The rest of this manual includes step-by-step instructions for completing each of the
Menu Survey forms. For each form, a completed “SAMPLE” is provided. Please take
the time to review the instructions and all of the sample completed forms before
beginning the Menu Survey.
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If You Need Assistance
We will be calling you before the start of the target week and again during the target
week to answer any questions you may have. If you have questions or need assistance
at any other time before, during, or after the target week, feel free to call our technical
assistance line at 1-xxx-xxx-xxxx. Thank you for your assistance with this important
study!
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General Guidelines for
Completing the Menu Survey
Getting Started
Please read this manual carefully. Be sure to review the sample completed forms that
are provided. Also, pay special attention to the Daily Reminder List. Keep this guide
handy during the target week and refer to it as you complete the survey forms.
Off-Site Kitchens
If your school receives prepared meals or any components of reimbursable meals from
another school, a central kitchen or commissary, or an outside vendor during the target
week, we ask that you obtain food descriptions, product information, and recipes for
these foods, as needed. You may wish to discuss strategies for this task with your
school food authority (SFA) director.
Filling Out Forms
Use pencil on all forms.
Write clearly and legibly (especially when recording numbers).
Write the name of your school and the date (if applicable) at the top of each form.
Double-check your work and review the Daily Reminder List at the end of each
day to be sure you have provided all the necessary information.
At the End of the Week
When you have completed all forms included in the Menu Survey, please double-check
your work to make sure you have provided all the necessary information. Please place
the completed forms in the empty plastic envelope at the back of the Menu Survey
Folder. Remember to also include your completed School Nutrition Manager Survey.
Return all completed survey materials to Mathematica in the pre-addressed
Federal Express envelope provided.
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Instructions for Completing the
Reimbursable Foods Forms
Purpose:
To describe foods and beverages that are offered as part of USDA
reimbursable lunches and breakfasts during the target week, and to
provide information on the number of portions of each item prepared and
served in reimbursable meals.
Location:
The Reimbursable Foods Forms are located in the five colored folders
labeled Monday-Friday, in the Menu Survey Folder. Separate forms are
provided for breakfast (yellow) and lunch (white).
Notes:
•
If your school offers reimbursable fruits and vegetables through the Fresh Fruit
and Vegetable Program during the target week, do NOT include these fruits and
vegetables on the Reimbursable Foods Form.
•
Be sure to look at the sample completed Reimbursable Foods Forms that
are provided. Looking at the sample forms as you read the instructions will
make it easier to understand what you need to do when filling out the forms.
How to Complete the Reimbursable Foods Form
Reimbursable Meal Counts
On the top right-hand corner of the form, you will see the Reimbursable Meal Counts
box. The questions in this box ask about the number of reimbursable meals (breakfast
or lunch) you planned to serve for the day and the number of reimbursable meals that
you actually served that day. Record the answers to both questions in the spaces
provided. Your production records may include this information. If not, you may need to
talk to your SFA director to obtain it.
Column A: Food Item
You will use this column to identify foods and beverages offered in reimbursable meals
each day. Most foods are already listed for you. Others you will need to write in. In
thinking about all the foods offered in your cafeteria each day and deciding which ones
to include on this form, keep the following in mind:
DO INCLUDE:
•
All foods and beverages offered in reimbursable meals (even if they may not
count toward USDA meal pattern requirements).
•
All condiments, salad dressings, optional toppings, desserts, and snack items.
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DO NOT INCLUDE:
•
Foods and beverages that are offered only a la carte or only to adults.
•
Foods and beverages that were planned for a given day, but not actually
prepared or served at your school because a substitution was made.
When foods are paired or offered together:
When a condiment/topping, bread/grain item or meat/meat alternate is paired with, or
offered only with another menu item, add a note in Column A to make this clear.
Examples:
For barbeque sauce that is offered only with chicken nuggets, add
a note…
Barbeque sauce w/ chicken nuggets
For crackers that are offered only with a Chef’s salad, add a note…
Crackers w/ Chef’s salad
For toast that is offered only with cereal, add a note…
Toast w/ cereal
For a cheese stick that is offered only with a peanut butter
sandwich, add a note…
Cheese stick w/ peanut butter sandwich
When writing in foods that are not already listed on the form:
•
Record foods in their appropriate food group sections whenever possible. Blank
lines are provided at the end of each section for your entries. A generous amount
of additional space is provided at the end of the form for recording items that do
not fit in the individual food group sections (for example, not enough blank lines for
additional fruits), as well as items that belong in a food group that is not listed on
the form.
•
Salad bars, condiment bars, and other food bars, whether self-serve or made-toorder, should be listed as single menu items. Salad bars (both side salad bars and
entrée salad bars) and other common theme bars are prelisted. Use separate lines
for any self-serve bars that are not prelisted.
•
If your school offers bag or box meals or fully preplated meals, write each type of
meal on a separate line. Complete a Recipe Form for each type of meal to identify
all of the foods and beverages included in the meal.
•
If foods are offered with optional components or ingredients, use separate lines to
list each component and make it clear that the main food and optional
components/ingredients go together, as shown below.
Example:
For a baked potato offered with optional toppings of cheese sauce
and/or broccoli, use separate lines for…
Baked potato
Cheese sauce, canned, low-fat
Broccoli, frozen, chopped
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Column B: Portion Size
For each item offered in reimbursable meals, write the size of one individual serving, as
offered to students.
•
Include both the amount, if not already printed on the form, and the unit of
measure. For example:
Food Item
Amount
Unit
Broccoli
¾
cup
Chicken patty
2.5
oz.
Tossed salad
½
cup
You may change the printed unit for any food if your school serves the item in a
different unit of measure.
•
Include the weight (oz.) of one portion whenever available, especially for
commercially prepared foods, such as burritos, chicken or fish nuggets, pizza,
doughnuts, or cookies.
•
For foods that are offered self-serve, write “self-serve” as the portion size.
•
If your school offers different portion sizes of the same food, for example to
students in different age-grade groups, you will need to list the food twice (on two
separate lines) and write in the different portion sizes.
Example:
If your school serves two age-grade groups (grades 6-8 and 9-12), there may
be different portion sizes for canned peaches. You would indicate this by
listing the food twice as shown below.
A.
B.
Portion Size
(Include
Units)
Food Item
Canned peaches
½ cup
Canned peaches
1 cup
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Column C: Number of Portions
Total Portions Prepared
For each menu item, enter the total number of portions prepared. Include portions that
are prepared for reimbursable meals at your school as well as portions that are
prepared to be sent off-site, served a la carte and to adults or others. For pre-packaged
foods and beverages, the total number of portions prepared refers to the number of
individual packages that are put out in the serving area. For example for cartons of
juice, write the number of cartons that are placed on the serving line before and
throughout the meal period.
Portions Sent Off-Site
If your school prepares food to be served at other schools or facilities, enter the total
number of portions for each item that is sent off-site. Include portions sent off-site on the
day they are sent – it doesn’t matter if they will be served on the same day or another
day. If your school does not prepare food to be served at other schools or facilities, you
do not need to complete this column.
Reimbursable Portions Served
For each menu item, enter the number of reimbursable portions served to students at
your school (excluding portions sold a la carte or to adults/others). Your production
records may include this information; if not, you may need to talk to your SFA director
about putting a procedure in place to record it for the target week. If a menu item is
prepared and available to students but none are served in reimbursable meals, be sure
to enter a zero in Column C.
Portions Served A La Carte or to Adults/Others
Also for each menu item, enter the number of portions that are served a la carte, to
adults, or to others who are not receiving meals through the NSLP or SBP. If no
portions are served a la carte or to adults, enter zero in this column.
Portions Left Over for Later Use
At the end of each meal, enter the number of portions that were not served on this day,
but were leftover and may be served on a different day. For instance, this may include
cartons of milk or juice to be used on the following day. Do not include leftover portions
that are thrown away. If no portions are left over and saved for later use, enter zero in
this column.
Portions Wasted
Also enter the number of portions that were not served and must be thrown out because
they cannot be used on a different day. For instance, this may include food prepared in
a large dish, such as macaroni and cheese. If no portions are wasted, enter zero in this
column.
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Example:
Note that for each of the following menu items, the number of portions entered in
the last five sub-columns (Sent Off-Site, Reimbursable Served, Served a La
Carte or to Adults/Others, Left Over, and Wasted) add up to the total number of
portions prepared (Total Prepared).
A.
B.
C.
Number of Portions
Onsite
Portion
Size
(Include
Units)
Total
Prepared
Sent
Offsite
Orange juice
8 fl oz
140
Macaroni and
cheese
1 cup
160
Food Item
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
0
83
15
42
0
20
110
14
0
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Column D: Meal Pattern Contributions
Fill in these columns with the contribution each menu item makes to the USDA meal
pattern food groups (“creditable amounts”). This information may be included in your
production records; if not, you may need to talk to your SFA director to obtain it. You
may be able to find meal pattern contributions in the Food Buying Guide for Child
Nutrition Programs, USDA Foods Fact Sheets or, for commercially prepared foods, on
CN labels.
•
For each menu item, enter the creditable amount of each meal pattern food
group contributed by one portion in cups or oz equivalents. In some cases the
meal pattern contribution will be the same as the portion size (recorded in
Column B), but this will not be true for all menu items or menu items that
contribute to more than one meal pattern food group.
•
You do not need to list the meal pattern contribution for milks or other food items
where the column is shaded in gray.
•
Note that many menu items will contribute to only one meal pattern food group
and few, if any, menu items will contribute to all meal pattern food groups.
•
If a menu item contributes to more than one meal pattern food group or
vegetable subgroup, be sure to enter the amount contributed to all applicable
meal pattern food groups in Column D.
•
When a menu item contains grains, enter the oz equivalent that it contributes in
the “Grains” column. Check the box in the “Whole Grain-Rich” column if the
menu item meets the whole grain-rich criteria (listed on page 13 of this
document).
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Example:
If your school offers a 2 cup portion of a chicken, broccoli and brown rice bowl,
you would list the contribution that one portion makes to the applicable meal
pattern food groups in Column D: 1/2 cup equivalent of dark green vegetables, 2
oz equivalents of meat/meat alternates, 1.5 oz equivalents of grains; and check
the box for whole grain-rich.
D.
Number of
Portions
Meal Pattern Contributions
Food Item
Chicken, broccoli and brown
rice bowl
•
2 cups
…
1/2
Other
Starchy
Legumes
…
Red/Orange
Portion Size
(Include Units)
Dark Green
Fruit (cups)
Vegetables (cups)
Whole Grain-Rich
C.
Grains (oz eq)
B.
Meat/Meat
Alternates (oz eq)
A.
2
1.5
X
Note that some fruits and vegetables do not credit on a volume as served basis
(for example, 1 cup of a food item does not always credit as 1 cup). Below are
some examples:
Dried fruit: credits as twice the volume as served, so 1/2 cup would credit as 1
cup of fruit
Raw leafy greens: credits as half the volume as served, so 2 cups would
credit as 1 cup of vegetable (dark green or other vegetables depending on the
type of leafy green)
Tomato paste: refer to manufacturing information or ask your SFA director for
crediting information
•
We have added shading to Column D to indicate the meal pattern food groups
that are not usually applicable to menu items within a given food group section. If
you write in a menu item that is not already listed on the form, be sure to enter
the contribution amount(s) to the appropriate meal pattern food group(s) in
Column D.
For self-serve or made-to-order bars:
•
List the meal pattern contribution for “1 serving” from the bar. This information
may be included in your production records; if not, you may need to talk to your
SFA director to obtain it.
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B.
C.
D.
Number
of
Portions
Meal Pattern Contributions
Side salad bar (non-entrée or
small portion)
1 serving
…
1/4
Other
1/2
Starchy
…
Legumes
(Include
Units)
Meat/Meat
Alternates (oz eq)
Food Item
Red/Orange
Portion Size
Dark Green
Fruit (cups)
Vegetables (cups)
Whole Grain-Rich
A.
Grains (oz eq)
Example:
If you offer a side salad bar, you would enter the amount that one serving
contributes to the meal pattern food groups. The side salad bar shown in the
example below provides ½ cup equivalent of dark green vegetables, ¼ cup
equivalent of red/orange vegetables, and ¼ cup equivalent of other vegetables.
The creditable amounts are listed under the appropriate vegetable subgroup
columns (in Column D).
1/4
For vegetables offered at breakfast:
There are currently no requirements for vegetable subgroups at breakfast.
However, if your school does offer vegetables as a separate menu item or as
part of a combination item at breakfast, be sure to record the meal pattern food
group amount in the vegetable column (in Column D).
Example:
If your school offers 1/2 cup of hash browns at breakfast, you would enter 1/2
cup under the vegetables column (in Column D).
Number of
Portions
Meal Pattern Contributions
Portion
Size
Food Item
(Include
Units)
…
Hash brown
1/2 cup
…
12
1/2
Whole GrainRich
D.
Grains (oz eq)
C.
Meat/Meat
Alternates (oz
eq)
B.
Vegetables
(cups)
A.
Fruit (cups)
•
Whole Grain-Rich Foods
Whole grain-rich foods must meet at least one of the following criteria:
•
•
•
Whole grains per serving must be ≥ 8 grams,
Product includes FDA’s whole grain health claim on its packaging, or
Product ingredient listing lists a whole grain first (HUSSC criteria).
Check the box in the “Whole Grain-Rich” column if the menu item meets the whole
grain-rich criteria.
If you are unsure whether a menu item is Whole Grain-Rich, you can…
•
Visit the following websites that describe the criteria for determining whether a
menu item is whole grain-rich:
http://www.fns.usda.gov/cnd/governance/Policy-Memos/2012/SP30-2012os.pdf
http://teamnutrition.usda.gov/Resources/jtf_grains.pdf
•
Include a package label for the product with your completed forms at the end of
the week.
Column E: Manufacturer/Brand Name and Product Code
This column is used to provide information on the manufacturer, brand name, and
product code of certain foods listed in Column A. We have shaded this column for prelisted foods that do not require manufacturer/brand name, or a product code.
•
For all other commercially prepared food products you serve, including entrees,
meat/meat alternates, and most bread/grain items (including biscuits, doughnuts,
breakfast pastries, and pancakes), please fill in the manufacturer/brand and
product code information in Column E.
•
Please do your best to record whatever manufacturer and/or brand information is
available (or at least how the food is described on the package label) for all
required foods listed above. Always include a product code, if available. The
product code is usually located on the label of the box in which commercially
prepared food products are delivered. An example is shown below.
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•
Below are additional examples of manufacturer and brand names, and products
codes, for some foods.
Food Item
(Column A)
Manufacturer/Brand Name
and Product Code (Column E)
Pizza, pepperoni
Super Donut
Pancake-on-a-stick
Schwan’s/Tony’s 78546
Super Bakery 6001
State Fair 70481
•
If your school purchases commercially prepared food products, including ones
that are lower in fat or sodium, you may wish to include package labels to tell us
more about the products. This will help ensure that the nutrient analysis is
accurate and reflects the types of foods used in your school meal program.
•
If you decide that you would like to give us package labels, you can put them in
the envelope with the completed forms at the end of the week.
Column F: Food Description
This column is used to describe foods so that an accurate nutrient analysis can be
done. For most of the pre-listed items, you will need to check a box or write in a
response. For example, for some foods you will be asked to check whether a food is
regular, low-fat or fat-free, or if it is breaded or has icing. For some foods you will be
asked to specify the type or variety of the food, such as the type of bread (100% whole
wheat, rye bread, etc.), or the flavor of milk or yogurt.
It is especially important to complete this column for commercially prepared products
and items that you add to the form. Please provide as complete a description of the item
as possible. Depending on the item, this may include information on:
type (100% whole wheat bread, rye bread, blueberry muffin, unbreaded chicken
patty, low-sodium green beans)
form (fresh, frozen or canned vegetable or fruit)
flavor (Strawberry milk, oatmeal cookie, vanilla yogurt)
fat content (low-fat yogurt, reduced-fat sour cream, fat-free salad dressing)
Column G: USDA Food?
For food items in Column A that are donated USDA Foods, place a check mark in the
box in Column G.
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Column H: Recipe?
For foods in Column A that require a recipe, place a check mark in the appropriate box
in Column H. Use these checkmarks to remind you to complete a Recipe Form or
provide a printed recipe.
We have shaded this column for pre-listed foods that do not require recipes. If the
column is not shaded, you may need a recipe, depending on the food. For example, for
purchased pizza that is served as is, a recipe is not needed. For pizza that is prepared
from scratch or is a modified version of a purchased product (for example, you added
your own toppings), a recipe is needed.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
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Instructions for Completing
Recipe Forms
Purpose:
To describe the types and amounts of ingredients used in preparing foods
made from scratch or made by combining two or more foods or
ingredients.
Location:
A booklet of Recipe Forms (grey) is located behind the “Recipes” tab in
the Menu Survey Folder. If you need more forms than are included in the
booklet, make copies of the form and file the completed extra forms inside
the Recipe Form booklet.
Notes:
•
A Recipe Form is needed for every item that is prepared from scratch or
prepared by combining two or more foods or ingredients. This includes all
sandwiches and foods prepared or cooked with added butter, margarine,
dressings, or other condiments.
•
Some foods may need more than one Recipe Form. For example, for a tuna
salad sandwich, you will need to use two Recipe Forms—one for the tuna salad
mixture and one for the assembled tuna salad sandwich. The same is true for a
brownie or cake with icing. See the sample completed Recipe Forms for an
example of a situation where two Recipe Forms are needed.
•
You may not have to fill out the Recipe Form if a printed copy of the recipe
is available. See the special instructions later in this section.
•
If the same recipe was prepared more than once during the target week,
you only need to fill out a Recipe Form once and be sure to check the boxes at
the top of the form to indicate which days of the week the recipe was served,
unless the recipe is prepared differently on other days of the week. If variations of
a recipe are used on different days, a separate Recipe Form is needed for each
variation.
•
Be sure to look at the sample completed Recipe Forms that are provided.
Looking at these forms as you read the instructions will make it easier to
understand what you need to do when filling out the form.
16
How to Complete the Recipe Form
Recipe/Food Name
Write the complete name of the recipe or food on the line provided in the upper right
hand corner of the form. Please be sure that the name is clear enough that we will be
able to match it up with the appropriate item on the Reimbursable Foods Form.
For recipes that are used in other recipe items, mention both recipes in the name. For
example, “Tuna salad for tuna sandwich.”
Meal
Check the meal or meals in which the recipe/food item was offered.
Day
Check the day or days of the target week on which the recipe/food was offered. Check
“all” if the item is offered every day.
Size of One Serving
Write the size of one individual serving, as offered to students. Include both the amount
and unit of measure (Examples: 1/4 cup, 8 fluid ounces, 1 sandwich).
Number of Servings Prepared
Please record the total number of individual servings prepared (recipe yield) in the
space provided. For some items, such as sandwiches, the Recipe Form describes the
ingredients or components of a single serving (Examples: 1 sandwich, 1 Chef’s salad).
Column A: Ingredient Name
List all foods and ingredients used to prepare the recipe/food. Remember to include all
items used in food preparation, including seasonings and salt, as well as oils, butter,
margarine, and other fats used in cooking.
Column B: Amount in Recipe
For each item listed in Column A, write the amount used in Column B. Be sure to
include information on both the amount and the unit of measure (Examples: 2 Tbsp, 6
oz, 5 cups, 7.5 gallons, 35 lbs)
Be sure to provide amount information on the form of the ingredient when it was
measured. For example, was pasta or rice measured cooked or uncooked? Was meat
measured raw or after cooking? Was the cheese sliced, cubed, shredded, or grated?
Column C: Manufacturer/Brand Name and Product Code
If the ingredient or food listed in Column A is a commercially prepared food, list the
manufacturer and/or brand name as well as the product code.
17
Column D: Ingredient Description
For each item listed in Column A, use this column to provide details about the food or
ingredient that will allow us to do an accurate nutrient analysis. Depending on the item,
this may include information on:
type (whole wheat flour, brown rice, ground turkey, low-sodium tomato sauce)
form (fresh, frozen or canned vegetables, fruits, or meats)
cooking status (cooked, uncooked, dry, raw)
fat content (part-skim cheese, 1% fat milk, fat-free mayonnaise)
whether whole grain-rich
See the sample completed forms for examples of ingredient descriptions.
Column E: USDA Food?
For ingredients in Column A that are donated USDA Foods, place a check mark in the
box in Column E.
Column F: Recipe?
For ingredients in Column A that require a recipe, place a check mark in the appropriate
box in Column F. Use these checkmarks to remind you to complete an additional
Recipe Form.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
If You Can Provide a Printed Copy of the Recipe…
Be sure to:
•
Staple or clip a copy of the printed recipe to a blank Recipe Form in the booklet,
and indicate on the Recipe Form the meal and days the recipe was used.
•
Mark the recipe, as needed, to show how the recipe was prepared in your school,
and make sure the name of the recipe matches the name used on the
Reimbursable Foods Form.
Make sure the recipe includes:
•
Yield information: size of the serving and number of servings prepared.
•
A complete description of all ingredients, including manufacturer and/or brand
and product code for commercially prepared food products.
•
An indication of any ingredients that are USDA Foods, for example, write “USDA”
beside the ingredient name.
18
Instructions for Completing Self-Serve/
Made-to-Order Bar Form
Purpose:
To describe the ingredients included on self-serve bars such as salad
bars, theme bars, and condiment bars, as well as made-to-order bars
such as deli bars.
Location:
A booklet of Self-Serve/Made-to-Order Bar Forms (lavender) is located
behind the “Self-Serve Bars” tab in the Menu Survey Folder.
Notes:
•
A separate Self-Serve/Made-to-Order Bar Forms must be completed for each
type of self-serve bar or made-to-order bar offered. If the same bar (with all the
same foods/ingredients) was offered more than once during the target
week, you only need to fill out one Self-Serve/Made-to-Order Bar Forms and
indicate the days on which the bar was offered. If the foods/ingredients offered
on the bar differ on other days of the week, a separate form is needed for each
day they are different.
•
Be sure to look at the sample completed Self-Serve/Made-to-Order Bar
Forms that are provided. Looking at these forms as you read the instructions
will make it easier to understand what you need to do when filling out the form.
How to Complete the Self-Serve/Made-to-Order Bar Forms
Name of Bar
Write the complete name of the self-serve/made-to-order bar on the line provided in the
upper right hand corner of the form. Please be sure that the name is clear enough that
we will be able to match it up with the same item on the Reimbursable Foods Form.
Meal
Check the meal or meals in which the bar was offered during the target week.
Day
Check the day or days of the target week on which the bar was offered. Check “all” if
the bar (with all the same ingredients) is offered every day.
Column A: Food Name
List all foods and ingredients offered on the bar. If you need additional lines, write the
name of the bar and “continued” on a blank Self-Serve/Made-to-Order Bar Forms and
list remaining foods/ingredients.
19
Column B: Portion Size (if pre-portioned)
For pre-portioned items only, describe the size of one portion. This includes items such
as baked potatoes, tortillas, packaged crackers, boxes of raisins, or packages of
sunflower seeds. It also includes items that might be portioned out by cafeteria servers,
such as pasta on a pasta bar, cold cuts on a deli bar, or meat and cheese items on a
salad bar.
Be sure to include information on both the amount and the unit of measure. See the
sample completed Self-Serve/Made-to-Order Bar Forms for examples.
Column C: Manufacturer/Brand Name and Product
For commercially prepared food products, please record the manufacturer and/or brand
name and a product code in Column C.
Column D: Food Description
For each item listed in Column A, use this column to provide details about the food or
ingredient that will allow us to do an accurate nutrient analysis. Depending on the item,
this may include information on:
type (100% whole grain bread, rye bread, graham cracker, cheddar cheese,
low-sodium green beans, deli turkey)
form (fresh, frozen or canned vegetables or fruit)
cooking status (cooked, uncooked, dry, raw)
fat content (low-fat yogurt, reduced-fat sour cream, fat-free salad dressing)
whether whole grain-rich
See the sample completed forms for examples of ingredient descriptions.
Column E: USDA Food?
For foods in Column A that are donated USDA Foods, place a check mark in the box in
Column E.
Column F: Recipe?
For foods in Column A that require a recipe, place a check mark in the appropriate box
in Column F. Use these checkmarks to remind you to complete a Recipe Form.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
20
Instructions for Completing the
A La Carte Foods Checklist
Purpose:
To identify foods and beverages your school offers on an a la carte basis
at lunch and breakfast.
Location:
The A La Carte Foods Checklist (pink paper) is located behind the
“A La Carte” tab in the Menu Survey Folder.
Notes:
•
Complete the A La Carte Foods Checklist on the one day specified on the front of
the Menu Survey Folder. Be sure to complete the checklist even if your school
does not offer items on an a la carte basis, or if you sell only milk.
•
Be sure to look at the sample completed A La Carte Foods Checklist that is
provided.
How to Complete the A La Carte Foods Checklist
1. Write the name of your school and the date on the first page of the form.
2. Answer Question 1. If your school does not offer any foods or beverages on an a
la carte basis, check “No.” You are done. If you check “Yes,” please answer
Questions 2 through 4 and go on to the next page.
3. Place a check mark in the box next to each food and beverage that was available
for a la carte purchase on the specified day. This includes items that are sold
only a la carte as well as components of a reimbursable meal that may be
purchased a la carte. There are separate check boxes for lunch and breakfast.
4. Do not include foods and beverages sold in vending machines, snack bars,
school stores, or food carts.
5. If a food or beverage is usually or sometimes available a la carte, but was not
available on the specified day, do not check the box.
6. If your school had a la carte foods or beverages available on your specified day
that are not included in the checklist, please write in the names of these foods
and beverages under the appropriate category. Extra lines are available on the
last page of the checklist, if necessary. Be sure to indicate whether each food or
beverage was offered at breakfast and/or lunch.
21
Instructions for Completing the
Afterschool Snack Form
Purpose:
To describe the foods and beverages offered in NSLP afterschool snacks
during the target week, and to provide information on the number of
individual snack items served and the total number of reimbursable
snacks served to students.
Location:
A booklet of Afterschool Snack Forms (green paper) is behind the
“Afterschool Snacks” tab in the Menu Survey Folder.
Notes:
•
If your school offers reimbursable fruits and vegetables through the Fresh
Fruit and Vegetable Program during the target week, do NOT include these
fruits and vegetables on the Afterschool Snack Form.
•
Be sure to look at the sample completed Afterschool Snack Form that is
provided. Looking at this sample as you read the instructions will make it
easier to understand what you need to do when filling out the form.
How to Complete the Afterschool Snack Form
On the front page of this booklet answer question 1 and indicate the days during the
target week that afterschool snacks were offered. Complete one Afterschool Snack
Form for each day snacks were offered.
This form is similar to the Reimbursable Foods Form. It includes columns for the food
item, portion size, number of reimbursable portions prepared/available and served, and
food description so that an accurate nutrient analysis can be done. Depending on how
your afterschool program operates, you may need assistance from afterschool program
staff to complete the columns for number of portions served.
Day
Check the day of the target week for which this form is being completed.
Number of Reimbursable Snacks Served
At the top of the form record the total number of reimbursable snacks served to students
that day.
22
Column A: Food Item
You will use this column to identify foods and beverages offered in reimbursable snacks
each day. Some foods are already listed for you. Others you will need to write in. In
thinking about all the foods offered in your snacks each day and deciding which to
include on this form, keep the following in mind:
DO INCLUDE:
•
All foods and beverages offered in reimbursable snacks (even if they may not
count toward USDA meal pattern requirements).
DO NOT INCLUDE:
•
Foods and beverages that are offered only to adults.
•
Foods and beverages that were planned for a given day, but not actually
prepared/available that day.
When writing in foods that are not already listed on the form:
•
Record foods in appropriate food group sections. Blank lines are provided at the
end of each section for your entries.
Column B: Portion Size
For each item offered in reimbursable afterschool snacks, write the size of one
individual serving, as offered to students. If the snack item is pre-packaged, list the
actual package size or weight, not “1 package.”
•
Include both the amount and the unit of measure:
Food Item
•
Amount
Unit
Banana, fresh
1
Medium
Orange juice
6
fl. oz
Granola bar
1
oz.
If a food or beverage is offered in more than one portion size (for different agegrade groups), list the food or beverage on separate lines and write in the
different portion sizes.
23
Example:
A.
B.
C.
Number of Reimbursable
Portions
Portion Size
(Include
Units)
Prepared/
Available
Served
Orange juice
6 fl.oz
50
25
Orange juice
8 fl.oz
50
50
Food Item
Column C: Number of Reimbursable Portions
Number of Reimbursable Portions Prepared/Available
For each snack item offered, write in the number of reimbursable portions
prepared/available. The number of reimbursable portions prepared should reflect the
actual number of servings available for students to select as part of a reimbursable
snack.
Number of Reimbursable Portions Served
Also for each snack item, enter the number of reimbursable portions or individual items
served to (or selected by) students as part of a reimbursable snack, excluding portions
served to adults. If a menu item is prepared and available to students but no portions
are served, be sure to enter a zero in this column.
You may need to ask the afterschool program staff for this information. You can also
give the afterschool program staff a copy of the Afterschool Snack Form and ask them
to complete this column.
Column D: Food Description
This column is used to describe foods so that an accurate nutrient analysis can be
done. For most of the pre-listed items, you will need to check a box or write in a
response. For example, for some foods you will be asked to check whether a food is
regular, low-fat or fat-free, or if it is whole grain-rich or reduced-fat. For some foods you
will be asked to specify the type or variety of the food, such as the type of crackers
(graham, wheat, saltines, etc.), or the flavor of milk or yogurt. Please provide as
complete a description of the item as possible. Depending on the item, this may include
information on:
Type (1% or 2% milk; white or whole wheat bread; 100% apple juice)
Form (fresh carrots, canned pineapple)
Flavor (chocolate milk, strawberry yogurt)
Fat or sugar content (low-fat yogurt, reduced-fat cookies; reduced-sugar jelly,
pears in light syrup)
24
OMB Clearance Number: 0584-xxxx
Expiration Date: xx/xx/xxxx
Daily Meal Counts Form (Basic)
School Name:
Date:
Instructions:
1. In the boxes for the Number of Reimbursable Lunches Served and Number of Reimbursable Breakfasts Served,
please record the number of free, reduced-price, and full-price 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.
2. Check if the number of reimbursable meals was much higher or lower than usual. If so, describe the reasons for this
difference in the space provided.
3. At the bottom of the page, please record the total value of your non-reimbursable food sales by venue (including all
student, adult, and other sales in venues supplied by foodservice only) for each day of the target week. If you do not
keep venue-specific records, you may simply enter the total sales into the last column.
Number of Reimbursable Lunches Served
Free
ReducedPrice
FullPrice
FOR OFFICE
USE ONLY
Please check if the number of reimbursable lunches
served this day was much higher or lower than usual.
Monday
Reason:_______________________________
Tuesday
Reason:_______________________________
Wednesday
Reason:_______________________________
Thursday
Reason:_______________________________
Friday
Reason:_______________________________
Number of Reimbursable Breakfasts Served
Free
ReducedPrice
FullPrice
FOR OFFICE
USE ONLY
Please check if the number of reimbursable
breakfasts served this day was much higher or lower
than usual.
Monday
Reason:_______________________________
Tuesday
Reason:_______________________________
Wednesday
Reason:_______________________________
Thursday
Reason:_______________________________
Friday
Reason:_______________________________
Total Non-Reimbursable Food Sales in Venues Supplied or Stocked by Foodservice
Serving Line
(A la Carte)
Snack Bar
Vending
Machine
Food Cart
School
Store
Other:
__________
Total
Monday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Tuesday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Wednesday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Thursday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Friday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Prepared by Mathematica Policy Research and Abt Associates.
Page 1
Reimbursable Meal Counts
How many reimbursable student breakfasts did you plan to serve at your
school this day?
SCHOOL NUTRITION AND MEAL COST STUDY
REIMBURSABLE FOODS FORM: BREAKFAST
How many reimbursable student breakfasts did you serve at your school
this day?
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
School Name:__________________________________________
Number of Portions
Meal Pattern Contributions
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
Wed
Thu
E.
F.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Fri
G.
H.
Recipe?
Sent
Off-Site
Tue
USDA Food?
Food Item
Total
Prepared
Whole Grain-Rich
D.
Onsite
Portion
Size
(Include
Units)
Mon
C.
Vegetables (cups)
B.
Day:
Fruit (cups)
A.
Date:______________________________
Grains (oz. eq.)
Expiration Date: XX/XX/20XX
Meat/Meat
Alternates (oz. eq.)
OMB Control # 0584-XXXX
MILK
White, fat-free/skim
fl oz.
White, 1%
fl oz.
White, 2%
fl oz.
White, whole
fl oz.
Chocolate, fat-free/skim
fl oz.
Chocolate, 1%
fl oz.
Chocolate, 2%
fl oz.
Other flavor
Specify: ____________________
fl oz.
Other flavor
Specify: ____________________
fl oz.
Other flavor
Specify: ____________________
fl oz.
fl oz.
fl oz.
fl oz.
Prepared by Mathematica Policy Research and Abt Associates.
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
REIMBURSABLE FOODS FORM: BREAKFAST
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
F.
G.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
H.
Recipe?
Onsite
E.
USDA Food?
Meal Pattern Contributions
Whole Grain-Rich
Number of Portions
Grains (oz. eq.)
D.
Meat/Meat
Alternates (oz. eq.)
C.
Vegetables (cups)
B.
Fruit (cups)
A.
Page 2
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, list as separate item and complete a RECIPE FORM.)
Apple, fresh
Applesauce, canned
cup
Sweetened
Unsweetened
Heavy syrup
Light syrup
Extra light syrup Juice
Apricots, canned
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Fruit cocktail, canned
cup
Grapes, fresh
cup
Water
Orange, fresh
Heavy syrup
Light syrup
Extra light syrup Juice
Water
cup
Pears, fresh
Heavy syrup
Light syrup
Extra light syrup Juice
Pears, canned
Water
Banana, fresh
Peaches, canned
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Pineapple, canned
cup
Raisins
oz.
Prepared by Mathematica Policy Research and Abt Associates.
Water
Water
REIMBURSABLE FOODS FORM: BREAKFAST
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
F.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
G.
H.
Recipe?
Onsite
E.
USDA Food?
Meal Pattern Contributions
Whole Grain-Rich
Number of Portions
Grains (oz. eq.)
D.
Meat/Meat
Alternates (oz. eq.)
C.
Vegetables (cups)
B.
Fruit (cups)
A.
Page 3
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and vegetable juice. List fruit drinks in the ‘Other Menu Items’ section.)
Apple juice
fl oz.
Vitamin C added Calcium added
Grape juice
fl oz.
Vitamin C added Calcium added
Orange juice
fl oz.
Vitamin C added Calcium added
fl oz.
BREADS AND GRAINS Please note in Column A if any items in this section were offered only with another bread or grain or with a particular meat/meat alternate or combination item (for example, Toast w/ cereal, or Biscuit w/ sausage).
COLD CEREALS
Apple Jacks
oz.
Cheerios, plain
oz.
Cheerios, Honey Nut
oz.
Cinnamon Toast Crunch
oz.
Cocoa Krispies
oz.
Cocoa Puffs
oz.
Froot Loops
oz.
Frosted Flakes
oz.
Frosted Mini Wheats
oz.
Golden Grahams
oz.
Kix
oz.
Lucky Charms
oz.
Raisin Bran
oz.
Rice Krispies
oz.
Special K
oz.
Trix
oz.
Prepared by Mathematica Policy Research and Abt Associates.
REIMBURSABLE FOODS FORM: BREAKFAST
Meal Pattern Contributions
F.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
G.
H.
Recipe?
E.
USDA Food?
Whole Grain-Rich
Number of Portions
Grains (oz. eq.)
D.
Meat/Meat
Alternates (oz. eq.)
C.
Vegetables (cups)
B.
Fruit (cups)
A.
Page 4
Cream of Wheat
cup
Instant
Quick
Reg
Grits
cup
Instant
Quick
Reg
Oatmeal
cup
Instant
Quick
Reg
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
HOT CEREALS (Note: If prepared with fat and/or milk, complete a RECIPE FORM)
OTHER BREADS AND GRAINS OFFERED SEPARATELY
Bagel
oz.
Biscuit
oz.
Danish or turnover
oz.
Fruit
Cheese
Doughnut
oz.
Icing/glaze
No Icing/glaze
English muffin, plain
oz.
English muffin, buttered
oz.
Margarine
Granola/cereal bar
oz.
Specify type: ___________________
Muffin
oz.
Specify type: ___________________
Pancake
oz.
Roll, cinnamon
oz.
Icing
Toast, plain
oz.
Specify type: ___________________
Specify type: ___________________
Toast, buttered
oz.
Toaster pastry
oz.
Prepared by Mathematica Policy Research and Abt Associates.
Specify type: ___________________
Margarine
Low-fat
Butter
No Icing
Butter
REIMBURSABLE FOODS FORM: BREAKFAST
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
F.
G.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
H.
Recipe?
Onsite
E.
USDA Food?
Meal Pattern Contributions
Whole Grain-Rich
Number of Portions
Grains (oz. eq.)
D.
Meat/Meat
Alternates (oz. eq.)
C.
Vegetables (cups)
B.
Fruit (cups)
A.
Page 5
MEATS AND MEAT ALTERNATES OFFERED SEPARATELY
Bacon
Pork
sl
Turkey
Eggs
cup
Scrambled Hard boiled
Fried
Ham
oz.
Pork
Peanut butter
oz.
Reduced-fat
Sausage
oz.
Beef or pork Chicken or turkey
Turkey
Reg Low-fat Fat-free Light
Yogurt
Specify flavors: _________________
oz.
COMBINATION ITEMS
Breakfast burrito
oz.
Eggs Cheese Beans
Potato Other:_______________
Cheese
Egg sandwich
1
sandwich
Cheese
Egg sandwich
1
sandwich
Sausage
Ham
Bacon
Other:____________
Specify bread type: ______________
Sausage
Ham
Bacon
Other:____________
Specify bread type: ______________
French toast
ea.
Weight of each stick:_________oz.
1
sandwich
Reduced-fat
Pancake on a stick
oz.
Beef or pork Chicken or turkey
Pizza
oz.
Reduced-fat
Specify toppings: _______________
French toast sticks
Grilled cheese
Prepared by Mathematica Policy Research and Abt Associates.
REIMBURSABLE FOODS FORM: BREAKFAST
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
F.
G.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
H.
Recipe?
Onsite
E.
USDA Food?
Meal Pattern Contributions
Whole Grain-Rich
Number of Portions
Grains (oz. eq.)
D.
Meat/Meat
Alternates (oz. eq.)
C.
Vegetables (cups)
B.
Fruit (cups)
A.
Page 6
CONDIMENTS
Self-serve condiments or fixins’
bar
Please list all ingredients on SELF-SERVE/ MADE-TO-ORDER
BAR FORM
1 serving
Butter
Reg Red. fat
Fat-free
Light
Cream cheese
Reg Red. fat
Fat-free
Low-fat
Gravy
Honey
Sugar-free
Jelly
Ketchup
Margarine
Salsa
Syrup
Prepared by Mathematica Policy Research and Abt Associates.
Low sodium
Sugar-free
REIMBURSABLE FOODS FORM: BREAKFAST
Meal Pattern Contributions
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
F.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
G.
H.
Recipe?
Food Item
Portion
Size
(Include
Units)
E.
USDA Food?
Onsite
Whole Grain-Rich
Number of Portions
Grains (oz. eq.)
D.
Meat/Meat
Alternates (oz. eq.)
C.
Vegetables (cups)
B.
Fruit (cups)
A.
Page 7
OTHER MENU ITEMS
Prepared by Mathematica Policy Research and Abt Associates.
Page 1
Reimbursable Meal Counts
SCHOOL NUTRITION AND MEAL COST STUDY
REIMBURSABLE FOODS FORM: LUNCH
How many reimbursable student lunches did you serve at your school
this day?
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
School Name:___________________________________________ Date:______________________________
Left Over for
Later Use
Wasted
Thu
E.
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Fri
G.
H.
Recipe?
Reimbursable
Served
Wed
USDA Food?
Sent
Off-Site
Whote GrainRich
Total
Prepared
Graims (oz. eq.)
Food Item
Dark Green
Fruit (cups)
Onsite
Served A La
Carte or to
Adults/Others
Tue
D.
Meal Pattern Contributions
Vegetables (cups)
Number of Portions
Portion Size
(Include
Units)
Mon
Meat/Meat
Alternates (oz. Eq.)
C.
Legumes
B.
Red/Orange
A.
Day:
Others
Expiration Date: XX/XX/20XX
Starchy
OMB Control # 0584-XXXX
How many reimbursable student lunches did you plan to serve at your
school this day?
MILK
White, fat-free/skim
fl oz.
White, 1%
fl oz.
White, 2%
fl oz.
White, whole
fl oz.
Chocolate, fat-free/skim
fl oz.
Chocolate, 1%
fl oz.
Chocolate, 2%
fl oz.
Other flavor
Specify: _____________________
fl oz.
Other flavor
Specify: _____________________
fl oz.
Other flavor
Specify: _____________________
fl oz.
fl oz.
fl oz.
fl oz.
Prepared by Mathematica Policy Research and Abt Associates.
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
REIMBURSABLE FOODS FORM: LUNCH
Left Over for
Later Use
Wasted
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
G.
H.
Recipe?
Reimbursable
Served
E.
USDA Food?
Sent
Off-Site
Whote GrainRich
Total
Prepared
Served A La
Carte or to
Adults/Others
Graims (oz. eq.)
Food Item
Portion Size
(Include
Units)
Meat/Meat
Alternates (oz. Eq.)
Onsite
Dark Green
Fruit (cups)
Number of Portions
Others
D.
Meal Pattern Contributions
Vegetables (cups)
Starchy
C.
Legumes
B.
Red/Orange
A.
Page 2
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, list as separate item and complete a RECIPE FORM.)
Apple, fresh
Applesauce, canned
Apricots, canned
cup
Sweetened
Unsweetened
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Banana, fresh
Fruit cocktail, canned
cup
Grapes, fresh
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Orange, fresh
Peaches, canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
cup
Pears, fresh
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Pineapple, canned
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Raisins
oz.
Pears, canned
Prepared by Mathematica Policy Research and Abt Associates.
REIMBURSABLE FOODS FORM: LUNCH
Left Over for
Later Use
Wasted
F.
G.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
H.
Recipe?
Reimbursable
Served
E.
USDA Food?
Sent
Off-Site
Whote GrainRich
Total
Prepared
Served A La
Carte or to
Adults/Others
Graims (oz. eq.)
Food Item
Portion Size
(Include
Units)
Meat/Meat
Alternates (oz. Eq.)
Onsite
Dark Green
Fruit (cups)
Number of Portions
Others
D.
Meal Pattern Contributions
Vegetables (cups)
Starchy
C.
Legumes
B.
Red/Orange
A.
Page 3
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and vegetable juice. Fruit drinks are included in ‘Desserts, Drinks, and Snacks’ section.)
Apple juice
fl oz.
Vitamin C added
Calcium added
Grape juice
fl oz.
Vitamin C added
Calcium added
Orange juice
fl oz.
Vitamin C added
Calcium added
Frozen juice cup/bar
fl oz.
Specify flavor: ______________
fl oz.
fl oz.
VEGETABLES (Note: If beans or peas are being counted as a meat alternate, enter them in the “Other Entrees and Meat/Meat Alternates” section.)
cup
Vegetarian
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_______________________
Broccoli, cooked
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
________________________
Broccoli, raw
cup
If offered, list dip as separate item(s) or complete a
RECIPE FORM
Carrots, cooked
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Carrots, raw
cup
If offered, list dip as separate item(s) or complete a
RECIPE FORM
Celery, raw
cup
If offered, list dip as separate item(s) or complete a
RECIPE FORM
Corn, kernels
cup
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Cucumber, raw
cup
Baked beans
Beans, green
Prepared by Mathematica Policy Research and Abt Associates.
With pork
If offered, list dip as separate item(s) or complete
RECIPE FORM
REIMBURSABLE FOODS FORM: LUNCH
French fries
cup
Lettuce and tomato
cup
Left Over for
Later Use
Wasted
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Oven-baked
G.
Deep-fried
H.
Recipe?
Reimbursable
Served
E.
USDA Food?
Sent
Off-Site
Whote GrainRich
Total
Prepared
Served A La
Carte or to
Adults/Others
Graims (oz. eq.)
Food Item
Portion Size
(Include
Units)
Meat/Meat
Alternates (oz. Eq.)
Onsite
Dark Green
Fruit (cups)
Number of Portions
Others
D.
Meal Pattern Contributions
Vegetables (cups)
Starchy
C.
Legumes
B.
Red/Orange
A.
Page 4
cup
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Peas, green
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Potatoes, whipped or mashed
cup
From fresh
cup
From dry Canned
Low sodium
Fat added, specify type:
_________________________
Sweet potatoes
cup
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Sweet potato fries or tots
cup
Oven-baked
Mixed vegetables
Refried beans
Side salad bar
(non-entrée or small portion)
1 serving
Salad, tossed
cup
Tater tots or shapes
cup
Prepared by Mathematica Policy Research and Abt Associates.
Deep-fried
Please list all ingredients on SELF-SERVE/
MADE-TO-ORDER BAR FORM
List dressing as separate item(s)
Oven-baked
Deep-fried
REIMBURSABLE FOODS FORM: LUNCH
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
G.
H.
Chicken filet or breast (not breaded)
1 sandwich
Chicken patty (breaded)
1 sandwich
Fish sandwich
1 sandwich
Grilled cheese
1 sandwich
Ham and cheese
1 sandwich
Hamburger
1 sandwich
Hot dog
1 sandwich
Italian sub
1 sandwich
Peanut butter & jelly
1 sandwich
Rib, barbeque
1 sandwich
Sloppy joe
1 sandwich
Turkey
1 sandwich
Tuna salad
1 sandwich
Veggie burger
1 sandwich
1 sandwich
1 sandwich
1 sandwich
1 sandwich
1 sandwich
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Others
1 sandwich
Food Item
Portion Size
(Include
Units)
Starchy
Cheeseburger
Onsite
Legumes
Recipe?
E.
USDA Food?
Dark Green
Fruit (cups)
Number of Portions
Whote GrainRich
D.
Meal Pattern Contributions
Vegetables (cups)
Graims (oz. eq.)
C.
Meat/Meat
Alternates (oz. Eq.)
B.
Red/Orange
A.
Page 5
SANDWICHES
Prepared by Mathematica Policy Research and Abt Associates.
Breaded
Beef or pork
Chicken or turkey
Beef Pork
Chicken or turkey
REIMBURSABLE FOODS FORM: LUNCH
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
G.
H.
Chicken Caesar salad
1 salad
1 salad
1 salad
1 salad
1 salad
1 salad
1 salad
1 salad
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Others
1 salad
Food Item
Portion Size
(Include
Units)
Starchy
Chef's salad
Onsite
Legumes
Recipe?
E.
USDA Food?
Dark Green
Fruit (cups)
Number of Portions
Whote GrainRich
D.
Meal Pattern Contributions
Vegetables (cups)
Graims (oz. eq.)
C.
Meat/Meat
Alternates (oz. Eq.)
B.
Red/Orange
A.
Page 6
ENTRÉE SALADS (Note: List all dressings as separate items)
SELF-SERVE/MADE-TO-ORDER ENTRÉE BARS
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
1 serving
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
1 serving
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
1 serving
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
1 serving
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
1 serving
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
1 serving
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
1 serving
Please list all ingredients on SELF-SERVE/MADETO-ORDER BAR FORM
Entrée salad bar
1 serving
Potato bar
1 serving
Nacho/taco bar
Sandwich/deli bar
Prepared by Mathematica Policy Research and Abt Associates.
REIMBURSABLE FOODS FORM: LUNCH
Left Over for
Later Use
Wasted
F.
G.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
H.
Recipe?
Reimbursable
Served
E.
USDA Food?
Sent
Off-Site
Whote GrainRich
Total
Prepared
Served A La
Carte or to
Adults/Others
Graims (oz. eq.)
Food Item
Portion Size
(Include
Units)
Meat/Meat
Alternates (oz. Eq.)
Onsite
Dark Green
Fruit (cups)
Number of Portions
Others
D.
Meal Pattern Contributions
Vegetables (cups)
Starchy
C.
Legumes
B.
Red/Orange
A.
Page 7
OTHER ENTREES AND MEAT/MEAT ALTERNATES Please note in Column A if any items in this section were offered only with a particular entrée or meat/meat alternate (for example, Cheese with peanut butter sandwich, or Yogurt with grilled cheese
sandwich).
Beans or peas
(Specify type) ____________________
cup
Burrito
oz.
Cheese (string cheese or cubes)
oz.
Cheese breadstick or pizza stick
oz.
From dry
Canned
Low sodium Fat added,
specify type: _______________
Bean
Chicken
Reduced-fat
Reduced-fat
Specify fillings:
________________________
Oven-baked Deep-fried
Weight of each
nugget:_____________oz.
Beef
Cheese
Chicken nuggets (breaded)
ea.
Chicken strips (not breaded)
oz.
Chicken patty (not sandwich)
oz.
Oven-baked
Deep-fried
Breaded
Oven-baked
With skin
Deep-fried
Beef or pork
Chicken or turkey
Oven-baked Deep-fried
Breaded
Weight of each
nugget/stick:__________oz.
Chicken piece(s)
(Specify part)__________________
Corndog
oz.
Fish sticks or nuggets
ea.
Macaroni and cheese
cup
Nachos
oz.
Peanut butter
oz.
Reduced-fat
Pizza, cheese
oz.
Reduced-fat
Pizza, pepperoni
oz.
Reduced-fat
Pizza, sausage
oz.
Reduced-fat
Pizza, vegetarian
oz.
Reduced-fat
Specify toppings:____________
Prepared by Mathematica Policy Research and Abt Associates.
REIMBURSABLE FOODS FORM: LUNCH
Left Over for
Later Use
Wasted
Pizza pocket
oz.
Stir fry with rice or noodles
cup
Spaghetti with sauce
cup
Taco
Yogurt
oz.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
G.
Food Description
Reduced-fat
Specify filling:_______________
H.
Recipe?
Reimbursable
Served
F.
USDA Food?
Sent
Off-Site
Whote GrainRich
Total
Prepared
Served A La
Carte or to
Adults/Others
E.
Graims (oz. eq.)
Food Item
Portion Size
(Include
Units)
Meat/Meat
Alternates (oz. Eq.)
Onsite
Dark Green
Fruit (cups)
Number of Portions
Others
D.
Meal Pattern Contributions
Vegetables (cups)
Starchy
C.
Legumes
B.
Red/Orange
A.
Page 8
Meat sauce
Marinara sauce
Hard shell Soft tortilla
Bean
Beef
Chicken
Cheese
Regular
Low-fat
Fat-free
Light
Specify flavors:______________
BREADS AND GRAINS OFFERED SEPARATELY Please note in Column A if any items in this section were offered only with a particular entrée or meat/meat alternate (for example, Crackers w/ Chef’s salad or Roll w/ chicken nuggets).
If all breads and grains were available with any entrée or meat/meat alternate, check here .
Biscuit
oz.
Reduced-fat
Bread, plain
oz.
Specify type:_______________
Bread, buttered
oz.
Specify type:_______________
Margarine
Butter
Breadstick
oz.
Specify type:_______________
Cornbread
oz.
Corn/tortilla chips
oz.
Crackers
ea.
Specify type:_______________
Rice
cup
White
Roll
oz.
Specify type:_______________
Pasta
cup
Pretzels
oz.
Prepared by Mathematica Policy Research and Abt Associates.
Brown
Wild
Soft
Salted
Hard
Unsalted
REIMBURSABLE FOODS FORM: LUNCH
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
G.
H.
Icing
Cake
Specify type: _______________
Specify type: _______________
Specify type: _______________
fl oz.
Specify type: _______________
Fruit turnover
oz.
Specify type: _______________
Gelatin
cup
With fruit
With whipped topping
Potato chips
oz.
Reduced-fat
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Others
Food Item
Portion Size
(Include
Units)
Starchy
Brownie
Onsite
Legumes
Recipe?
E.
USDA Food?
Dark Green
Fruit (cups)
Number of Portions
Whote GrainRich
D.
Meal Pattern Contributions
Vegetables (cups)
Graims (oz. eq.)
C.
Meat/Meat
Alternates (oz. Eq.)
B.
Red/Orange
A.
Page 9
DESSERTS, DRINKS, AND SNACKS OFFERED AS PART OF A REIMBURSABLE MEAL
Cookie
oz.
Fruit crisp or cobbler
Fruit drink (less than 100% juice)
Baked
SALAD DRESSINGS
Caesar dressing
Reg Light Red. calorie
Fat-free
French dressing
Reg Light Red. calorie
Fat-free
Honey mustard dressing
Reg Light Red. calorie
Fat-free
Italian dressing
Reg Light Red. calorie
Fat-free
Ranch dressing
Reg Light Red. calorie
Fat-free
Reg Light Red. calorie
Fat-free
Reg Light Red. calorie
Fat-free
Reg Light Red. calorie
Fat-free
Reg Light Red. calorie
Fat-free
Prepared by Mathematica Policy Research and Abt Associates.
REIMBURSABLE FOODS FORM: LUNCH
Left Over for
Later Use
Wasted
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
G.
H.
Recipe?
Reimbursable
Served
E.
USDA Food?
Sent
Off-Site
Whote GrainRich
Total
Prepared
Served A La
Carte or to
Adults/Others
Graims (oz. eq.)
Food Item
Portion Size
(Include
Units)
Meat/Meat
Alternates (oz. Eq.)
Onsite
Dark Green
Fruit (cups)
Number of Portions
Others
D.
Meal Pattern Contributions
Vegetables (cups)
Starchy
C.
Legumes
B.
Red/Orange
A.
Page 10
CONDIMENTS
Self-serve condiments or fixins’ bar
Please list all ingredients on SELF-SERVE/
MADE-TO-ORDER BAR FORM
1 serving
Barbeque sauce
Butter
Cream cheese
Reg Red. fat Low-fat
Fat-free
Gravy
Reg Red. fat Low-fat
Fat-free
Honey
Hot sauce
Jalapeno peppers
Sugar-free
Jelly
Ketchup
Margarine
Reg Red. fat Low-fat
Fat-free
Mayonnaise
Mustard
Pickles, slices
Reg Red. fat Low-fat
Fat-free
Ranch dip
Relish
Salsa
Low sodium
Sour cream
Reg Red. fat Low-fat
Fat-free
Syrup
Sugar-free
Tartar sauce
Reg Red. fat Low-fat
Fat-free
Prepared by Mathematica Policy Research and Abt Associates.
REIMBURSABLE FOODS FORM: LUNCH
Left Over for
Later Use
Wasted
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
G.
H.
Recipe?
Reimbursable
Served
E.
USDA Food?
Sent
Off-Site
Whote GrainRich
Total
Prepared
Served A La
Carte or to
Adults/Others
Graims (oz. eq.)
Food Item
Portion Size
(Include
Units)
Meat/Meat
Alternates (oz. Eq.)
Onsite
Dark Green
Fruit (cups)
Number of Portions
Others
D.
Meal Pattern Contributions
Vegetables (cups)
Starchy
C.
Legumes
B.
Red/Orange
A.
Page 11
OTHER MENU ITEMS
Prepared by Mathematica Policy Research and Abt Associates.
OMB Clearance Number: 0584-xxxx
Expiration Date: xx/xx/xxxx
Recipe Form (Basic)
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
1
Mon
6
All
2
2
Tue
Lunch
3
Wed
4
Thu
5
Fri
Size of One Serving (include units):
Number of Servings Prepared:
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
units)
Manufacturer/
Brand Name and Product Code
(If applicable)
Ingredient Description
Prepared by Mathematica Policy Research and Abt Associates.
E.
F.
Recipe?
Day:
Recipe/Food Name:
USDA Food?
School Name:
1 Breakfast
Meal:
OMB Clearance Number: 0584-xxxx
Expiration Date: xx/xx/xxxx
Self-Serve/Made-to-Order Bar Form (Basic)
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
1
Breakfast
2
Day:
Lunch
1
All
2
Mon
3
Tue
4
Wed
A.
B.
C.
D.
Food Name
Portion Size,
If Pre-portioned
(Include units)
Manufacturer/
Brand Name and Product
Code (if applicable)
Food Description
Prepared by Mathematica Policy Research and Abt Associates.
5
6
Thu
E.
Fri
F.
Recipe?
Meal:
Name of Bar:
USDA Food?
School Name:
OMB Clearance Number: 0584-xxxx
Expiration Date: xx/xx/xxxx
SCHOOL NUTRITION AND MEAL COST STUDY
Afterschool Snack Form Booklet
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name: _____________________________________________________
1. Please indicate the days that afterschool snacks were offered during the
target week:
Monday
Tuesday
Wednesday
Thursday
Friday
THIS PAGE LEFT INTENTIONALLY BLANK
OMB Clearance Number:
Expiration Date:
Afterschool Snack Form (Basic)
Day:
Mon
Tue
Wed
Thu
A.
Number of Reimbursable Snacks Served:
Fri
B.
C.
D.
Number of Reimbursable
Portions
Food Item
Portion Size
(Incl. Units)
Prepared/
Available
Served
Food Description
Milk
White
fl oz.
Fat-free/skim
1%
2%
Chocolate
fl oz.
Fat-free/skim
1%
2%
Other flavor, Specify: ____________________
fl oz.
Fat-free/skim
1%
2%
Other flavor, Specify: ____________________
fl oz.
Fat-free/skim
1%
2%
cup
Sweetened
Unsweetened
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Fruit
Apple, fresh
Applesauce, canned
Banana, fresh
Fruit cocktail, canned
Orange, fresh
Raisins
oz.
Juices
Apple juice
cup
Vit. C added Calcium added
Orange juice
cup
Vit. C added Calcium added
Grape juice
cup
Vit. C added Calcium added
Vegetables (if offered with a dip, list the dip as a separate item in the condiments section)
Carrots, raw
cup
Celery, raw
cup
Combination Items
Whole grain-rich
Peanut butter & jelly sandwich
Pizza
Sandwich
oz.
Whole grain-rich Reduced-fat
Specify toppings:_____________________
Whole grain-rich
Specify ingredients:___________________
A.
B.
C.
D.
Number of Reimbursable
Portions
Food Item
Portion Size
(Incl. Units)
Prepared/
Available
Served
Food Description
Meat and Meat Alternates
Cheese
oz.
Reduced-fat
Specify type:________________________
Trail mix
oz.
Specify ingredients:___________________
oz.
Regular Low-fat Fat-free
Light
Specify flavor(s):_____________________
Bagel
oz.
Whole grain-rich
Specify type:_______________________
Cereal
oz.
Whole grain-rich
Specify type:_______________________
Cookie
oz.
Whole grain-rich
Specify type:_______________________
Crackers
ea.
Whole grain-rich
Specify type:_______________________
Granola bar
oz.
Whole grain-rich
Specify type:_______________________
oz.
Whole grain-rich
Soft
Hard
Salted
Unsalted
Yogurt
Breads and Grains
Pretzels
Whole grain-rich
Whole grain-rich
Whole grain-rich
Whole grain-rich
Desserts and Other Items
Fruit snacks/fruit leather
Pudding
Specify flavor(s):____________________
Condiments
Ranch dip
Reg Light Red. calorie
Fat-free
Cream cheese
Reg Red. fat Light Fat-free
Ketchup
DAILY REMINDER LIST (Basic)
Before the Target Week:
•
Read the Instructions for the Menu Survey booklet carefully and be sure to
review all of the sample completed forms.
•
A technical assistant will contact you to ensure you have received your Menu
Survey Folder, to review the survey process and the forms to be completed,
and to answer any questions you may have.
•
Call the toll-free technical assistance line (xxx-xxx-xxxx) if you have any
questions or need additional help.
Each Day of the Target Week:
• Daily Meal Counts Form
Record the number of free, reduced-price, and full-price meals served for
lunch and for breakfast (if you serve breakfast), and record total daily nonreimbursable food sales by venue (for example, foods or beverages sold a la
carte from a serving line, vending machine, or snack bar).
• Reimbursable Foods Forms
Record the total number of reimbursable meals planned and served for the
day.
For every food and beverage offered in reimbursable meals, write in:
Food name, if not included in pre-listed foods
Portion size
Total portions prepared
Number of portions sent off-site (if applicable)
Number of reimbursable portions served
Number of portions served a la carte or to adults
Number of portions leftover for later use
Number of portions wasted
Meal pattern contributions for all foods except milk
Manufacturer/brand name and product code, where requested
Descriptive information needed for nutrient analysis
A check, if item is a USDA Food
OVER
A check, as needed, to indicate that a recipe has been provided.
• Recipe Forms
Fill out a Recipe Form for every food that is prepared from scratch or made by
combining two or more foods or ingredients. You may also provide printed
copies of the recipes, if available.
• Self-Serve/Made to Order Bar Forms
Fill out a Self-Serve/Made to Order Bar Form for each type of self-serve bar
or made-to-order bar offered. Be sure to record the number of reimbursable
portions prepared and taken from each bar on the Reimbursable Foods Form.
• Afterschool Snack Forms
Fill out the Afterschool Snack Forms if your school offers reimbursable snacks
through the National School Lunch Program.
On One Day During the Target Week:
• A La Carte Foods Checklist
Complete the A La Carte Foods Checklist on the one day of the target week
specified on the front of the Menu Survey Folder.
• School Nutrition Manager Survey
Complete this survey before the end of the week.
At the End of the Target Week:
•
Look over the contents of each folder for the five days of the Menu Survey to
be sure all forms are complete.
•
Check to be sure the Daily Meal Counts Form is complete and all of the
necessary Recipe Forms and Self-Serve/Made-to-Order Bar Forms have
been provided.
•
Make sure you have completed the A La Carte Foods Checklist and the
School Nutrition Manager Survey. If your school offers reimbursable snacks,
be sure the Afterschool Snacks Forms are complete.
•
Place all completed forms in the empty plastic envelope and return them to
Mathematica in the pre-addressed Federal Express envelope provided.
| File Type | application/pdf |
| Author | EZeidman |
| File Modified | 2014-04-04 |
| File Created | 2014-04-04 |