SNMCS State, Local & Tribal Governments

H3. GROUP 2, 3—FSM A LA CARTE FOODS CHECKLIST

(BASIC AND EXPANDED MENU SURVEY)

This page has been left blank for double-sided copying.

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OMB Clearance Number: 0584-xxxx

Expiration Date: xx/xx/xxxx

CHOOL NUTRITION AND MEAL COST STUDY

A La Carte Foods Checklist

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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 range from 480 to 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.

ovember 7, 2013

Please refer to the Instructions for the Menu Survey booklet for instructions on completing this form. Remember to include this form when you return the Menu Survey Folder with all completed survey materials.

SCHOOL NAME:

DATE COMPLETED: | | | / | | | / | | | | |

Month Day Year

1. Does your school sell food or beverages on an a la carte basis (including milk)?

1 □ Yes

0 □ No Thank you. You are done.

2. When does your school sell food or beverages on an a la carte basis?

1 □ During breakfast only

2 □ During lunch only Go to Q.4

3 □ During breakfast and lunch

3. Is milk the only item your school sells on an a la carte basis at breakfast?

1 □ Yes

0 □ No

4. Is milk the only item your school sells on an a la carte basis at lunch?

1 □ Yes

0 □ No

SCHOOL NUTRITION AND MEAL COST STUDY

A La Carte Foods Checklist

Food Item	Breakfast	Lunch
A. Milk
1. Whole white milk	1 □	1 □
2. Reduced fat (2%) white milk	2 □	2 □
3. Low-fat (1% or 0.5%) white milk	3 □	3 □
4. Fat-free/skim white milk	4 □	4 □
5. Reduced fat (2%) flavored milk	5 □	5 □
6. Low-fat (1% or 0.5%) flavored milk	6 □	6 □
7. Fat-free/skim flavored milk	7 □	7 □
8. Other milk beverages, including non-dairy milks (Specify)	8 □	8 □
a.	9 □	9 □
b.	10 □	10 □
If milk is the only item your school sells on an a la carte basis, you are done. If your school sells other items on an a la carte basis, please continue completing the checklist.
B. 100% Juice and Water
1. Juice (100% fruit or vegetable juice)	11 □	11 □
2. Bottled water (plain, flavored, or sparkling)	12 □	12 □
C. Beverages Other than Milk, 100% Juice, or Water
1. Diet carbonated soft drink (diet soda/pop)	13 □	13 □
2. Regular carbonated soft drink (regular soda/pop)	14 □	14 □
3. Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	15 □	15 □
4. Sports drinks (such as Gatorade or PowerAde)	16 □	16 □
5. Energy drinks (such as Red Bull or Monster Energy)	17 □	17 □
6. Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	18 □	18 □
7. Hot or cold coffee or tea	19 □	19 □
8. Other beverages (Specify)	20 □	20 □
a.	21 □	21 □
b.	22 □	22 □
D. Fruit
1. Dried fruit (such as raisins or apricots)	23 □	23 □
2. Canned fruit	24 □	24 □
3. Fresh fruit	25 □	25 □
E. Vegetables
cooked vegetables
1. Baked French fries (including tater tots)	26 □	26 □
2. Deep-fried French fries (including tater tots)	27 □	27 □
3. Potatoes (other than French fries/tater tots)	28 □	28 □
4. Corn	29 □	29 □
5. Carrots	30 □	30 □
6. Broccoli	31 □	31 □
7. Peas	32 □	32 □
8. Green beans	33 □	33 □
9. Mixed vegetables	34 □	34 □
10. Vegetable soup	35 □	35 □
11. Other cooked vegetables (Specify)	36 □	36 □
a.	37 □	37 □
b.	38 □	38 □
uncooked vegetables
12. Carrot sticks	39 □	39 □
13. Celery	40 □	40 □
14. Cucumbers	41 □	41 □
15. Salad bars	42 □	42 □
16. Tossed salads (side)	43 □	43 □
17. Prepared salads (such as potato salad, coleslaw, or three bean salad)	44 □	44 □
18. Other raw vegetables (Specify)	45 □	45 □
a.	46 □	46 □
b.	47 □	47 □
F. Bread/Grains
1. Regular bread, rolls, bagels, or tortillas	48 □	48 □
2. Whole grain-rich breads, rolls, bagels, or tortillas	49 □	49 □
3. Other bread items (such as biscuits, croissants, or hot pretzels)	50 □	50 □
4. Low-fat muffins	51 □	51 □
5. Regular muffins	52 □	52 □
6. Ready-to-eat breakfast cereal	53 □	53 □
7. Pancakes, waffles, or French toast	54 □	54 □
8. Rice, pasta, or cereal	55 □	55 □
9. Other bread/grains (Specify)	56 □	56 □
a.	57 □	57 □
b.	58 □	58 □
G. Meat/Meat Alternates
1. Breaded chicken/turkey (nuggets, patties, strips, parts)	59 □	59 □
2. Not breaded chicken/turkey (nuggets, patties, strips, parts)	60 □	60 □
3. Breaded beef/pork (nuggets, patties, strips)	61 □	61 □
4. Not breaded beef/pork (nuggets, patties, strips)	62 □	62 □
5. Sausage or bacon	63 □	63 □
6. Breaded fish (nuggets, patties, strips/sticks)	64 □	64 □
7. Not breaded fish (nuggets, patties, strips/sticks, fillets)	65 □	65 □
8. Eggs	66 □	66 □
9. Cheese	67 □	67 □
10. Fried or baked cheese or pizza sticks (for example, Bosco sticks)	68 □	68 □
11. Chili	69 □	69 □
12. Yogurt	70 □	70 □
13. Peanut butter	71 □	71 □
14. Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)	72 □	72 □
15. Other meat/meat alternates (Specify)	73 □	73 □
a.	74 □	74 □
b.	75 □	75 □
H. Entrees
sandwiches
1. Cheeseburger or hamburger	76 □	76 □
2. Hot dog or corn dog	77 □	77 □
3. Barbecue (including sloppy joes)	78 □	78 □
4. Peanut butter sandwich (including with jelly)	79 □	79 □
5. Cheese sandwich	80 □	80 □
6. Veggie burger	81 □	81 □
7. Chicken, egg, or tuna salad sandwich	82 □	82 □
8. Sandwich with breaded meat, poultry or fish	83 □	83 □
9. Sandwich with cold cuts (salami, bologna, or pepperoni)	84 □	84 □
10. Sandwich with plain (not breaded) meat, poultry or fish	85 □	85 □
11. Breakfast sandwich or breakfast burrito	86 □	86 □
12. Other sandwiches (Specify)	87 □	87 □
a.	88 □	88 □
b.	89 □	89 □
other entrees
13. Pizza without meat	90 □	90 □
14. Pizza with meat	91 □	91 □
15. Calzone or Hot Pocket	92 □	92 □
16. Burritos	93 □	93 □
17. Other Mexican foods (such as tacos, nachos, or quesadillas)	94 □	94 □
18. Chinese food	95 □	95 □
19. Lasagna	96 □	96 □
20. Spaghetti	97 □	97 □
21. Macaroni and cheese	98 □	98 □
22. Entrée salad (such as chef’s, cob, or chicken Caesar)	99 □	99 □
23 Soup with meat or beans (such as chicken, clam chowder, or minestrone)	100 □	100 □
24. Sausage and biscuits	101 □	101 □
25. Other entrees (Specify)	102 □	102 □
a.	103 □	103 □
b.	104 □	104 □
I. Baked Goods/Desserts
1. Low-fat/reduced-fat cakes, cupcakes, or brownies	105 □	105 □
2. Regular cakes, cupcakes, or brownies	106 □	106 □
3. Low-fat pies, turnovers, or toaster pastries	107 □	107 □
4. Regular pies, turnovers, or toaster pasties	108 □	108 □
5. Low-fat doughnuts or cinnamon rolls	109 □	109 □
6. Regular doughnuts or cinnamon rolls	110 □	110 □
7. Low-fat cookies	111 □	111 □
8. Regular cookies	112 □	112 □
9. Fruit crisp or cobbler	113 □	113 □
10. Other baked goods/desserts (Specify)	114 □	114 □
a.	115 □	115 □
b.	116 □	116 □
J. Frozen/Dairy Dessert
1. Frozen fruit bars or popsicles	117 □	117 □
2. Milkshakes, smoothies, or yogurt drinks	118 □	118 □
3. Low-fat/reduced-fat ice cream, frozen yogurt, or sherbet	119 □	119 □
4. Regular ice cream, frozen yogurt, or sherbet	120 □	120 □
5. Pudding	121 □	121 □
6. Other frozen/dairy dessert (Specify)	122 □	122 □
a.	123 □	123 □
b.	124 □	124 □
K. Snacks
1. Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	125 □	125 □
2. Regular chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	126 □	126 □
3. Hard pretzels	127 □	127 □
4. Popcorn	128 □	128 □
5. Cracker sandwiches with cheese or peanut butter	129 □	129 □
6. Other types of crackers (including animal crackers)	130 □	130 □
7. Low-fat/reduced-fat granola bars, cereal bars, or energy bars	131 □	131 □
8. Regular granola bars, cereal bars, or energy bars	132 □	132 □
9. Crispy rice bars or treats	133 □	133 □
10. Candy or gum	134 □	134 □
11. Fruit snacks (such as Fruit Roll-Ups or fruit leather)	135 □	135 □
12. Meat snacks (such as jerky or pork rinds)	136 □	136 □
13. Other snacks (Specify)	137 □	137 □
a.	138 □	138 □
b.	139 □	139 □
L. Other A La Carte Items (Specify)
Please list any food or beverage that is not listed in sections A-K of this checklist that the cafeteria offered a la carte on the day you complete this form.
a.	140 □	140 □
b.	141 □	141 □
c.	142 □	142 □
d.	143 □	143 □
e.	144 □	144 □