SNMCS State, Local & Tribal Governments

APPENDIX H2. Group 3—Expanded Menu Survey
H2.1 - Instructions for Expanded Menu Survey and Example Forms
H2.2 - Daily Meal Counts Form_Expanded
H2.3 - Reimbursable Foods Form Breakfast_Expanded
H2.4 - Reimbursable Foods Form Lunch_Expanded
H2.5 - Recipe Form_Expanded
H2.6 - Onsite Self-Serve and Made-to-Order Form_Expanded
H2.7 - Self-Serve and Made-to-Order Form_Expanded
H2.8 - CACFP Afterschool Snack and Supper Form_Expanded
H2.9 - NLSP Afterschool Snack Form_Expanded
H2.10 - Non-Reimbursable Foods Form_Expanded
H2.11 - Non-Reimbursable Foods Inventory Worksheet_Expanded
H2.12 - Daily Reminder List_Expanded

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OMB Clearance Number: 0584-xxxx
Expiration Date: xx/xx/xxxx

School Nutrition and Meal Cost Study

Instructions for the
Menu Survey (Expanded)

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
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 600 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection.

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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/suppers. 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.
NSLP Afterschool Snack Form
If your school provides reimbursable snacks through the National School Lunch
Program (NSLP) to one or more afterschool programs, you will fill out the NSLP
Afterschool Snack Form (green paper) to provide information about the items provided
in afterschool snacks each day. This includes much of the same information you will be
providing on the Reimbursable Foods Forms.
CACFP Afterschool Snack and Supper Form
If your school provides reimbursable snacks or suppers through the Child and Adult
Care Food Program (CACFP) to one or more afterschool programs, you will fill out the
CACFP Afterschool Snack and Supper Form (green paper) to provide information about
the items provided in afterschool snacks and/or suppers each day. This includes much
of the same information you will be providing on the Reimbursable Foods Forms.
Non-Reimbursable Foods Form
The Non-Reimbursable Foods Form (orange paper) will be used to record daily serving
information for foods that are served a la carte in the cafeteria or in other venues that
are supplied or stocked by foodservice, but are not part of a reimbursable meal or
reimbursable snack. Only non-reimbursable items that are prepared from recipes or
removed from their original packaging will be recorded on this form. Commercially
manufactured non-reimbursable items that are sold in their original packaging should be
recorded on the Non-Reimbursable Foods Inventory (see next item).

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Non-Reimbursable Foods Inventory
The Non-Reimbursable Foods Inventory (red paper) will be used to record daily
inventory information for foods that are served a la carte in the cafeteria or in other
venues that are supplied or stocked by foodservice, but are not part of a reimbursable
meal or reimbursable snack. Only commercially manufactured non-reimbursable items
that are sold in their original packaging will be recorded on this form. Non-reimbursable
items that are prepared from recipes or removed from their original packaging should be
recorded on the Non-Reimbursable Foods Form (see previous item).
Daily Reminder List
In each of the Monday through Friday folders we have also included the Daily Reminder
List (gold paper). This list 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.
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 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.

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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
NSLP Afterschool Snack Form
Purpose:

To describe the foods and beverages offered in NSLP reimbursable
afterschool snacks during the target week, and to provide information on
the number of individual snack items prepared and served, as well as the
total number of reimbursable snacks served to students.

Location:

A booklet of NSLP Afterschool Snack Forms (green paper) is behind the
“NSLP Afterschool Snacks” tab in the Menu Survey Folder.

Notes:
•

Only include afterschool snacks offered through the National School
Lunch Program (NSLP). If your school offers snacks and/or suppers through
the Child and Adult Care Food Program (CACFP), you will complete the
CACFP Afterschool Snack and Supper Forms.

•

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 NSLP Afterschool Snack Forms.

•

Be sure to look at the sample completed NSLP 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 NSLP Afterschool Snack Form
On the front page of this booklet answer question 1 by indicating the days during the
target week that NSLP afterschool snacks were offered. Complete one NSLP
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 sizes, the number of portions prepared and served, 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. 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 Onsite
At the top of the form record the total number of reimbursable snacks served to students
at your school 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 NSLP 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 NSLP 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 Portions
Onsite

Portion
Size
(Include
Units)

Sent
Off-Site

Reimbursable
Prepared/
Available

Reimbursable
Served

Orange juice

6 fl.oz.

0

50

25

Orange juice

8 fl.oz.

0

50

50

Food Item

Column C: Number of Portions
Sent Off-Site
For each snack item offered, enter the total number of portions, if any, that are sent offsite to be served at other schools or facilities.
Number of Reimbursable Portions Prepared/Available
For each snack item, write in the number of reimbursable portions prepared or
available to be served at your school. The number of reimbursable portions
prepared/available 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 NSLP Afterschool Snack Form and ask
them to complete this column.
Column D: 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, please fill in the
manufacturer/brand and product code information in Column D.

24

Column E: 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.
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 (1% milk; 100% whole wheat bread; blueberry muffin)
form (fresh, frozen or canned vegetable or fruit)
flavor (chocolate milk, strawberry yogurt)
fat content (low-fat yogurt, or fat-free salad dressing)

Column F: USDA Food?
For food items in Column A that are donated USDA Foods, place a check mark in the
box in Column F.
Column G: Recipe?
For foods in Column A that require a recipe, place a check mark in the appropriate box
in Column G. 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.

25

Instructions for Completing the
CACFP Afterschool Snack and Supper Form
Purpose:

To describe the foods and beverages offered in CACFP reimbursable
afterschool snacks and suppers during the target week, and to provide
information on the number of individual snack/supper items prepared and
served, as well as the total number of reimbursable snacks/suppers
served to students.

Location:

A booklet of CACFP Afterschool Snack and Supper Forms (green paper)
is behind the “CACFP Afterschool Snacks/Suppers” tab in the Menu
Survey Folder.

Notes:
•

Only include afterschool snacks and suppers offered through the Child
and Adult Care Food Program (CACFP). If your school offers snacks
through the National School Lunch Program (NSLP), you will complete the
NSLP Afterschool Snack Form.

•

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 CACFP Afterschool Snack and Supper Form.

•

Be sure to look at the sample completed CACFP Afterschool Snack and
Supper 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 CACFP Afterschool Snack and Supper Form
On the front page of this booklet answer question 1 by indicating the days during the
target week that CACFP afterschool snacks and/or suppers were offered. Complete one
CACFP Afterschool Snack and Supper Form for each day snacks and/or suppers were
offered.
This form is similar to the Reimbursable Foods Form. It includes columns for the food
item, portion sizes, the number of portions prepared and served, 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. 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.

26

Number of Reimbursable Snacks and/or Suppers Served Onsite
At the top of the form record the total number of CACFP reimbursable snacks and/or
suppers served to students at your school that day.
Column A: Food Item
You will use this column to identify foods and beverages offered in CACFP snacks
and/or suppers 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 CACFP reimbursable snacks and/or suppers
(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 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.

Column B: Portion Size
For each item offered in CACFP afterschool snacks or suppers, write the size of one
individual serving, as offered to students. If the snack/supper 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.
27

Example:
A.

B.

C.
Number of Portions
Onsite

Portion
Size
(Include
Units)

Sent
Off-Site

Reimbursable
Prepared/
Available

Reimbursable
Served

Orange juice

6 fl.oz

0

50

25

Orange juice

8 fl.oz

0

50

50

Food Item

Column C: Number of Portions
Sent Off-Site
For each snack/supper item offered, enter the total number of portions, if any, that are
sent off-site to be served at other schools or facilities.
Number of Reimbursable Portions Prepared/Available
For each snack/supper item offered, write in the number of reimbursable portions
prepared or available. The number of reimbursable portions prepared should reflect
the actual number of servings available for students at your school to select as part of a
CACFP snack or supper. If an item is prepared/available for both a snack and supper,
write the combined total.
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 CACFP snack or supper, 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. If an item is served during
both a snack and supper, write the combined total.
You may need to ask the afterschool program staff for this information. You can also
give the afterschool program staff a copy of the CACFP Afterschool Snack and Supper
Form and ask them to complete this column.

28

Column D: 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, please fill in the
manufacturer/brand and product code information in Column D.
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 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.
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 (1% milk; 100% whole wheat bread; blueberry muffin)
form (fresh, frozen or canned vegetable or fruit)
flavor (chocolate milk, strawberry yogurt)
fat content (low-fat yogurt, or 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.
Column G: Recipe?
For foods in Column A that require a recipe, place a check mark in the appropriate box
in Column G. 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.

29

Instructions for Completing the
Non-Reimbursable Foods Form
Purpose:

To describe non-reimbursable foods and beverages that are prepared
from a recipe or removed from their original packaging before serving, and
to provide information on the number of portions of each item served
during the target week.

Location:

The Non-Reimbursable Foods Form (orange paper) is located behind the
“Non-Reimbursable” tab in the Menu Survey Folder.

Notes:
•

You will use one Non-Reimbursable Foods Form for the whole week.

•

Include foods sold in the cafeteria but NOT offered as part of a reimbursable
meal or reimbursable snack AND foods sold in other venues that offer nonreimbursable foods only. Some examples of other venues are vending machines,
snack bars, school stores, and food carts.

•

Only include foods in venues that are supplied or stocked by foodservice and that
are prepared from recipes or removed from their original packaging. Items that
are commercially prepared and served in their original packaging will be recorded
on another form (Non-Reimbursable Foods Inventory.)

•

If your school serves ONLY non-reimbursable foods and beverages that are
commercially prepared and sold in their original packaging, you do not need to
complete this form.

•

Be sure to look at the sample completed Non-Reimbursable Foods 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 Non-Reimbursable Foods Form
Meal
At the top of the form, check the appropriate box or boxes to indicate whether the nonreimbursable recipe/food was offered during breakfast, lunch, and/or outside of meal
periods. Foods may be offered outside of meal periods, just one time or throughout the
day.
Where Offered
Non-reimbursable foods may be sold on cafeteria serving lines or in other venues, such
as vending machines, snack bars, school stores, or food carts or at another school or
facility (off-site). Indicate the venues where the non-reimbursable food items listed on
30

this form are offered, checking all boxes that apply. If your school sells nonreimbursable foods in a venue that is not listed, check “Other,” and write in the name of
the venue.
Column A: Food Name
Use this column to list non-reimbursable items that are prepared from recipes or that
are removed from their original packaging. Include foods sold in the cafeteria but NOT
offered as part of a reimbursable meal or reimbursable snack AND foods sold in other
venues that offer non-reimbursable foods only.
DO INCLUDE:
•

All non-reimbursable foods that are prepared from recipes (for example,
homemade baked goods, sandwiches, or smoothies).

•

Non-reimbursable foods that are removed from their original packaging (for
instance, a frozen pizza or burrito that is removed from the box and heated
before it is served).

DO NOT INCLUDE:
•

Non-reimbursable foods sold in venues that are not supplied or stocked by
foodservice.

•

Commercially prepared non-reimbursable items that are sold in their original
packaging. These items should only be recorded on the Non-Reimbursable
Foods Inventory (see next section).

Column B: Portion Size
For each non-reimbursable item, write the size of one individual serving, as offered.
Include both the amount and the unit of measure.
•

For items prepared from recipes, write the size of one individual serving (“1/2
cup” vanilla pudding) or simply the number of items offered (“1 sandwich,” “2
pieces,” or “1 each”).

•

For items that are packaged in bulk quantities, record the weight (oz.) of one
serving from the package, Child Nutrition (CN), or Nutrition Facts label.

•

If any items were packaged as individual portions—before the packaging was
removed—record the actual package size or weight, not “1 package.”

•

If a food or beverage item is offered in more than one portion size, you will need
to list the food twice (on separate lines) and write in both portion sizes for the
item.

31

Example:
A.

B.
Portion Size
(Include Units)
1 large cookie
3 small cookies
4.8 oz
2.5 oz

Food Name
Chocolate chip cookie, baked from recipe
Chocolate chip cookie, baked from recipe
Frozen individual pizza, heated
Bagel, cinnamon raisin
Column C: Recipe

If an item was prepared from a recipe, check the box in Column C. Use these
checkmarks to remind you to complete a Recipe Form or provide a printed recipe.
Remember that recipes are needed for all items that are made by combining two or
more foods or ingredients.
Column D: Manufacturer/Brand Name and Product Code
For commercially prepared foods that are not prepared from a recipe, please record the
manufacturer and/or brand name and a product code (if available) in Column D. Below
are examples of manufacturer/brand names and products codes for some foods.
Food Name
(Column A)

Manufacturer/Brand Name
and Product Code (Column D)

Pizza, pepperoni
Super Donut
Pancake-on-a-stick

Schwan’s/Tony’s 78546
Super Bakery 6001
State Fair 70481

Column E: Food Description
For each item listed in Column A, use this column to provide details about the type or
variety of the food. 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
See the sample completed form for examples of food descriptions.
Column F: Number of Portions
For each non-reimbursable food and beverage listed, record the number of portions
32

sent off-site, served onsite, leftover for later use, and wasted, each day of the target
week.
Sent Off-Site
For each item offered, enter the total number of portions, if any, that are sent off-site to
be served at other schools or facilities. 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.
Served Onsite
For each item offered, enter the number of non-reimbursable portions served onsite.
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
an item is offered but not served, be sure to enter zero.
Left Over for Later Use
Enter the number of non-reimbursable portions that were not served, but were saved to
be served on a different day. For instance, this may include cookies prepared from a
recipe that are wrapped in plastic wrap and may be offered the following day.
Wasted
Enter the number of non-reimbursable portions that were not served and must be
thrown out because they cannot be served on a different day. For instance, this may
include frozen pizza that has already been removed from its package and heated.
If there are no portions to enter in a column, enter zero.

33

Instructions for Completing the
Non-Reimbursable Foods Inventory
Purpose:

To describe and record inventory information for commercially prepared
non-reimbursable foods and beverages that are served in their original
packaging during the target week.

Location:

The Non-Reimbursable Foods Inventory (red paper) is located behind the
“Non-Reimbursable” tab in the Menu Survey Folder.

Notes:
•

You will use one Non-Reimbursable Foods Inventory for the whole week.

•

Include foods sold in the cafeteria but NOT offered as part of a reimbursable
meal or reimbursable snack AND foods sold in other venues that offer nonreimbursable foods only.

•

Only include foods sold in venues that are supplied or stocked by foodservice,
and that are commercially prepared and served in their original packaging.

•

Be sure to inventory foods and beverages that are non-perishable, refrigerated,
and frozen. Take into account all items in storage areas, plus items that are
already out for sale.

•

Be sure to look at the sample completed Non-Reimbursable Foods
Inventory 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 Non-Reimbursable Foods Inventory
Meal
Check the appropriate box or boxes to indicate whether the non-reimbursable food or
beverage was offered during breakfast, lunch, and/or outside of meal periods.
Delivery Day(s)
Check the boxes for all days when your school’s kitchen receives deliveries. If it is
different every week, check the box on each day that your kitchen receives deliveries
during the target week.
Where Offered
Non-reimbursable foods may be sold on cafeteria serving lines or in other venues, such
as vending machines, snack bars, school stores, or food carts or at another school or
facility (off-site). Indicate the venues where the non-reimbursable food items listed on
34

this form are offered, checking all boxes that apply. If your school sells nonreimbursable foods in a venue that is not listed, check “Other,” and write in the name of
the venue.
Column A: Food Name
Use this column to list commercially prepared non-reimbursable foods that are sold in
their original packaging and that are supplied or stocked by foodservice. Include foods
sold in the cafeteria but NOT offered as part of a reimbursable meal or reimbursable
snack AND foods sold in other venues that offer non-reimbursable foods only.
DO NOT INCLUDE:
•

Non-reimbursable foods sold in venues that are not supplied or stocked by
foodservice.

•

Non-reimbursable items that are prepared from recipes or that are removed from
their original packaging (for instance, a frozen pizza or burrito that is removed
from the box and heated before it is served). These items should only be
recorded on the Non-Reimbursable Foods Form (see previous section).

If a food item is available in different flavors AND the brand and package sizes are the
same, you can group the items and list them only once.
Example:
A 12 fl. oz. Tropicana 100% orange juice and 12 fl. oz. Tropicana 100%
grapefruit juice can be listed together as “100% juice” in Column A.
Column B: Individual Package Size
For each food (including groups of foods) listed, write the size of the package, which
represents one individual serving. The individual package size should include both the
amount and the unit of measure. If a food or beverage item is available in more than
one size, you will need to list the food twice (on separate lines) and write in both
package sizes for that item.
Column C: # Individual Packages in Bulk Case
Also for each food, write the number of individual packages received in a bulk case.
Example:
On the form below, two types of 100% juice are grouped together and recorded on the
same (first) line. However, items with different package sizes or different brands must
be written on separate lines:

35

C.
#
Individual
Packages
in Bulk
Case

Food Name
100% juice (orange, grapefruit)
100% juice, orange
100% juice, orange

B.
Individual
Package
Size

A.

12 fl. oz.
8 fl. oz.
12 fl.oz.

32
48
48

D.

Manufacturer/Brand
Name
Tropicana
Florida’s Natural
Florida’s Natural

Column D: Manufacturer/Brand Name
Please record the manufacturer and/or brand name, a product code (if available), and
any other information from the package that might be helpful in identifying the item in
Column D.
Column E: Starting Onsite Inventory
For each food, provide the starting inventory. Include the number of items in the stock
room, refrigerator, freezer, and other storage areas, plus the number of items already
put out for sale.
# Full Bulk Cases
Write the number of full bulk cases that are in the foodservice inventory at the start of
the week, after Monday deliveries have been received.
# Additional Individual Packages
Write the number of additional individual packages on hand that do not make up a full
bulk case. For example, there may be 8 48-carton bulk packages of orange juice, and
10 additional cartons left over from a bulk package that had already been opened.
Column F: Deliveries Received and Sent Off-Site
For each item or group of items, record the number of full bulk cases and/or fractions of
full cases (for example, 1/2 or 2 1/2 cases) that are received each day (Tuesday
through Friday) of the target week and added to the amounts on hand that you recorded
in Column E. If your school sends non-reimbursable items to another school or facility
during the week, write in the number of bulk containers sent off-site in the columns
provided.
Enter zeros on days when there are no deliveries or items sent off-site.
Column G: Ending Onsite Inventory
For each item or group of items, provide the ending inventory. Include the number of
items in the stock room, refrigerator, freezer, and other storage areas, plus the number

36

of items already put out for sale.
# Full Bulk Cases
Write the number of full bulk cases that remain in the foodservice inventory at the end of
the week, after all deliveries and sales.
# Additional Individual Packages
Similarly, write the number of additional individual packages on hand at the end of the
week.

Note: The Starting Onsite Inventory (Column E) + [Deliveries Received - Sent Off-Site (Column
F)] – Ending Onsite Inventory (Column G) should represent the number of bulk cases/containers
sold during the target week.

37

OMB Control # 0584-XXXX
Expiration Date: XX/XX/20XX

Daily Meal Counts Form (Expanded)
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 or stocked 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 Control # 0584-XXXX
Expiration Date: XX/XX/20XX

Recipe Form (Expanded)
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

3

Wed

Outside of Meal Periods
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:

Page 1

OMB Control # 0584-XXXX
Expiration Date: XX/XX/20XX

Onsite Self-Serve / Made-to-Order Bar Form (Expanded)

Mon

Tue
A.

Food Name

Wed

Thu

Fri

B.
Portion
Size
(If PrePortioned;
Include
Units)

Meal:

Breakfast

Lunch

C.
Production Information

Amount at
Beginning

Amount
Added

Amount
Left Over
for Later
Use

Name of Bar: ___________________________

Amount
Wasted

D.

E.

Manufacturer/
Brand Name and
Product Code
(If Applicable)

Food Description

F.

G.

Recipe?

Day:

Date: _______________________________

USDA Food?

School Name: ____________________________________

If more ingredients are present on the bar, please continue to next page.
Prepared by Mathematica Policy Research and Abt Associates.

Page 2

Portion
Size
(If PrePortioned;
Include
Units)

C.
Production Information

Amount at
Beginning

Prepared by Mathematica Policy Research and Abt Associates.

Amount
Added

Amount
Left Over

Amount
Wasted

D.

E.

Manufacturer/
Brand Name and
Product Code
(If Applicable)

Food Description

F.

G.

Recipe?

Food Name

B.

USDA Food?

A.

OMB Clearance Number: 0584-xxxx
Expiration Date: xx/xx/xxxx

Self-Serve/Made-to-Order Bar Form (Expanded)
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:

SCHOOL NUTRITION AND MEAL COST STUDY
CACFP Afterschool Snack and Supper Form Booklet (Expanded)
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 CACFP afterschool snacks and/or suppers were prepared
or served during the target week:
□ Monday
□ Tuesday
□ Wednesday
□ Thursday
□ Friday

THIS PAGE LEFT INTENTIONALLY BLANK

OMB Clearance Number:
Expiration Date:

CACFP Afterschool Snack and Supper Form (Expanded)

Tue

Wed

A.

Thu

Number of Reimbursable Snacks and/or Suppers Served Onsite: _________

Fri

B.

C.

D.

E.

F.

Manufacturer/Brand
Name and Product Code
(If Applicable)

Food Description

Number of Portions

Food Item

Portion
Size
(Incl.
Units)

Onsite
Sent
OffSite

Reimbursable
Prepared/
Available

Reimbursable
Served

G.
Recipe?

Mon

USDA Food?

Day:

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%

Fruit

Apple, fresh
Applesauce, canned

cup

Sweetened

Unsweetened

Banana, fresh

Fruit cocktail, canned

cup

Heavy syrup

Extra light syrup

Water

Light syrup

Juice

Orange, fresh
Raisins

oz.

Juices
Apple juice

cup

Vit. C added
Calcium added

Orange juice

cup

Vit. C added
Calcium added

cup

Vit. C added
Calcium added

Grape juice

C.

D.

E.

Manufacturer/Brand
Name and Product Code
(If Applicable)

Food Description

Number of Portions

Food Item

Portion
Size
(Incl.
Units)

Onsite
Sent
OffSite

Reimbursable
Prepared/
Available

Reimbursable
Served

F.

G.
Recipe?

B.

USDA Food?

A.

Vegetables (if offered with a dip or salad dressing, list as a separate item in the condiments section)
Carrots, raw

cup

Celery, raw

cup

Salad, tossed

cup

French fries

cup

Oven-baked

Deep-fried

Combination Items and Entrées
Burrito
Cheeseburger
Entrée salad

oz.

Bean

Chicken

Beef

Cheese

1 sandwich

1 salad

List dressing as a separate item in
the condiments section

Grilled cheese sandwich

1 sandwich

Hamburger

1 sandwich

cup

Whole grain-rich

Whole grain-rich
Reduced-fat
Specify toppings:________________

Whole grain-rich

Meat sauce
Marinara sauce

Hard shell
Soft tortilla

Bean

Beef

Chicken

Cheese

Macaroni and cheese
Peanut butter & jelly sandwich
Pizza
Sandwich
Spaghetti with sauce

Taco

1 sandwich

oz.
1 sandwich

cup

C.

D.

E.

Manufacturer/Brand
Name and Product Code
(If Applicable)

Food Description

Number of Portions

Food Item

Portion
Size
(Incl.
Units)

Onsite
Sent
OffSite

Reimbursable
Prepared/
Available

Reimbursable
Served

F.

G.
Recipe?

B.

USDA Food?

A.

Meat/Meat Alternates
Cheese

oz.

Reduced-fat
Specify type:___________________

Chicken nuggets (breaded)

ea.

Oven-baked

Deep-fried
Weight of each nugget: _________oz

Chicken strips (not breaded)

oz.

Peanut butter

oz.

Reduced-fat

oz.

Specify
ingredients:____________________

oz.

Regular
Low-fat
Fat-free

Light
Specify flavor(s):________________

Trail mix

Yogurt

Breads and Grains
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

Whole grain-rich

Whole grain-rich

Whole grain-rich

Whole grain-rich

Whole grain-rich

Pretzels

C.

D.

E.

Manufacturer/Brand
Name and Product Code
(If Applicable)

Food Description

Number of Portions

Food Item

Portion
Size
(Incl.
Units)

Onsite
Sent
OffSite

Reimbursable
Prepared/
Available

Reimbursable
Served

F.

G.
Recipe?

B.

USDA Food?

A.

Desserts

Fruit snacks/fruit leather
Pudding

Specify flavor(s):________________

Condiments
Ranch dip
Cream cheese

Reg
Red. fat
Low-fat

Fat-free

Reg
Red. fat
Low-fat

Fat-free

Ketchup

Mayonnaise
Mustard
Italian dressing
Ranch dressing

Reg
Red. fat
Low-fat

Fat-free

Reg
Light
Red. calorie

Fat-free

Reg
Light
Red. calorie

Fat-free

Other Menu Items

SCHOOL NUTRITION AND MEAL COST STUDY
NSLP Afterschool Snack Form Booklet (Expanded)
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 NSLP afterschool snacks were prepared or served during
the target week:
□ Monday
□ Tuesday
□ Wednesday
□ Thursday
□ Friday

THIS PAGE LEFT INTENTIONALLY BLANK

OMB Clearance Number:
Expiration Date:

NSLP Afterschool Snack Form (Expanded)

Tue

Wed

A.

Thu

Number of Reimbursable Snacks Served Onsite: _________

Fri

B.

C.

D.

E.

F.

Manufacturer/Brand
Name and Product Code
(If Applicable)

Food Description

Number of Portions

Food Item

Portion
Size
(Incl.
Units)

Onsite
Sent
OffSite

Reimbursable
Prepared/
Available

Reimbursable
Served

G.
Recipe?

Mon

USDA Food?

Day:

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%

Fruit

Apple, fresh
Applesauce, canned

cup

Sweetened

Unsweetened

Banana, fresh

Fruit cocktail, canned

cup

Heavy syrup

Extra light syrup

Water

Light syrup

Juice

Orange, fresh
Raisins

oz.

Juices
Apple juice

cup

Vit. C added
Calcium added

Orange juice

cup

Vit. C added
Calcium added

cup

Vit. C added
Calcium added

Grape juice

C.

D.

E.

Manufacturer/Brand
Name and Product Code
(If Applicable)

Food Description

Number of Portions

Food Item

Portion
Size
(Incl.
Units)

Onsite
Sent
OffSite

Reimbursable
Prepared/
Available

Reimbursable
Served

F.

G.
Recipe?

B.

USDA Food?

A.

Vegetables (if offered with a dip, list the dip as a separate item in the condiments section)
Carrots, raw

cup

Celery, raw

cup

Whole grain-rich

Whole grain-rich
Reduced-fat
Specify toppings:________________

Whole grain-rich

Combination Items and Entrées
Peanut butter & jelly sandwich
Pizza
Sandwich

1 sandwich

oz.
1 sandwich

Meat/Meat Alternates
Cheese

oz.

Reduced-fat
Specify type:___________________

Trail mix

oz.

Specify
ingredients:____________________

oz.

Regular
Low-fat
Fat-free

Light
Specify flavor(s):________________

Yogurt

C.

D.

E.

Manufacturer/Brand
Name and Product Code
(If Applicable)

Food Description

Number of Portions

Food Item

Portion
Size
(Incl.
Units)

Onsite
Sent
OffSite

Reimbursable
Prepared/
Available

Reimbursable
Served

F.

G.
Recipe?

B.

USDA Food?

A.

Breads and Grains
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

Whole grain-rich

Whole grain-rich

Whole grain-rich

Whole grain-rich

Pretzels

Desserts and Other Items

Fruit snacks/fruit leather
Pudding

Specify flavor(s):________________

Condiments
Ranch dip
Cream cheese
Ketchup

Reg
Red. fat
Low-fat

Fat-free

Reg
Red. fat
Low-fat

Fat-free

OMB Control # 0584-XXXX

Non-Reimbursable Foods Form (Expanded)

Expiration Date: XX/XX/20XX

NOTES:
For instructions on completing this form, please refer to Instructions for the Menu Survey.
Include ONLY non-reimbursable foods sold in venues supplied by foodservice that are prepared from recipes or removed from their original packaging.
Do not include items listed on the Non-Reimbursable Foods Inventory.

Prepared by Mathematica Policy Research and Abt Associates.

Tuesday

F.
Number of Portions
Wednesday

Wasted

Left Over for
Later Use

Served Onsite

Sent Off-Site

Friday

Wasted

Left Over for
Later Use

Thursday
Served Onsite

Sent Off-Site

Wasted

Left Over for
Later Use

Served Onsite

Food Description

Sent Off-Site

Recipe?

Food Name

Manufacturer/Brand Name
and Product Code
(If Applicable)

Other: _________________________

E.
Monday

Portion
size
(Include
Units)

Off-Site

Sent Off-Site

School Store

Wasted

D.

Food Cart

Left Over for
Later Use

C.

Vending Machine

Served Onsite

B

Snack bar

Outside of Meal Periods

Sent Off-Site

A.

Serving line lunch

Lunch

Wasted

Where Offered:
Serving line breakfast

Breakfast

Meal:

Left Over for
Later Use

School Name:______________________________________________________

Served Onsite

•
•
•

Food Name
Portion
size
(Include
Units)

Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Wasted

Left Over for
Later Use

Thursday
Served Onsite

Sent Off-Site

Wasted

Left Over for
Later Use

F.
Number of Portions
Wednesday
Served Onsite

Sent Off-Site

Wasted

Left Over for
Later Use

Tuesday
Served Onsite

E.

Sent Off-Site

Wasted

Left Over for
Later Use

Monday
Served Onsite

Sent Off-Site

Wasted

Left Over for
Later Use

D.

Served Onsite

C.

Sent Off-Site

B

Recipe?

A.
Page 2

Friday

OMB Control # 0584-XXXX
Expiration Date: XX/XX/20XX

Non-Reimbursable Foods Inventory (Expanded)
NOTES:
For instructions on completing this form, please refer to the Instructions for the Menu Survey.
Include ONLY non-reimbursable foods sold in venues supplied by foodservice that are commercially pre-packaged and served in their original packaging.
Do NOT include foods listed on the Non-Reimbursable Foods Form.
Be sure to inventory foods and beverages that are non-perishable, refrigerated, and frozen.

Prepared by Mathematica Policy Research and Abt Associates.

Tues

Wed

Thurs

Fri

Other: _________________

Deliveries
(Number and/or Fraction of Full Bulk Container)

Ending Onsite
Inventory

Thu

Fri

Sent
Off-Site

Wed

Received

Tue

# Additional
Individual
Packages

G.

# Full Bulk Cases

F.

Sent
Off-Site

E.
Starting Onsite
Inventory
(Including
Monday
Deliveries)

Off-Site

Mon

Received

Manufacturer/Brand Name

School Store

Sent
Off-Site

D.

Food Cart

Delivery Day(s):

Received

Vending Machine

Sent
Off-Site

C.

Snack bar

Received

Food Name

B.

# Individual Packages in
Bulk Case

A.

Serving line lunch

Individual Package Size
(Include Units)

Where Offered:
Serving line breakfast

Meal:
Breakfast
Lunch
Outside of Meal Periods

# Additional
Individual
Packages

School Name:_______________________________________________

# Full Bulk Cases

•
•
•
•

Food Name

B.
C.

# Individual Packages in
Bulk Case

A.

Individual Package Size
(Include Units)

Manufacturer/Brand Name
Thu
Fri
# Additional
Individual
Packages

# Full Bulk Cases

Sent
Off-Site

Received

Wed

Sent
Off-Site

Received

Tue

Sent
Off-Site

E.
Starting Onsite
Inventory
(Including
Monday
Deliveries)

Received

Sent
Off-Site

Received

# Additional
Individual
Packages

D.

# Full Bulk Cases

Page 2

F.
G.

Deliveries
(Number and/or Fraction of Full Bulk Container)
Ending Onsite
Inventory

DAILY REMINDER LIST (Expanded)
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

A check, as needed, to indicate that a recipe has been provided.
OVER

• 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.
• NSLP Afterschool Snack Forms
Fill out the NSLP Afterschool Snack Forms if your school provides
reimbursable snacks through the National School Lunch Program.
• CACFP Afterschool Snack and Supper Forms
Fill out the CACFP Afterschool Snack Forms if your school provides
reimbursable snacks and/or suppers through the Child and Adult Care Food
Program.
• Non-Reimbursable Foods Form
Fill out the Non-Reimbursable Foods Form for all non-reimbursable items that
are prepared from recipes or removed from their original packaging and are
served a la carte in the cafeteria or in other venues that are supplied or
stocked by foodservice, but are not part of a reimbursable meal or
reimbursable snack.
• Non-Reimbursable Foods Inventory
Fill out the Non-Reimbursable Foods Form for all non-reimbursable items that
are commercially manufactured non-reimbursable items sold in their original
packaging and are served a la carte in the cafeteria or in other venues that
are supplied or stocked by foodservice, but are not part of a reimbursable
meal or reimbursable snack.

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.