SNMCS State, Local & Tribal Governments

K3. GROUPS 2, 3—SCHOOL STAFF LIAISON OTHER SOURCES OF

FOODS AND BEVERAGES CHECKLIST

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S

OMB Clearance Number: 0584-xxxx

Expiration Date:

CHOOL NUTRITION AND MEAL COST STUDY

Other Sources of Foods/Beverages

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

Please return completed form by fax to (877) XXX-XXXX (Attn: SNMCS)

Your Name: Title:

Phone #: Date Form Completed:

School Name:

B esides vending machines and food sold in the cafeteria, does your school have any other sources of food or beverages available to students during the day, including before or after school?

 Yes Continue  No Thank you. You are done. Please fax form to number shown above.

Instructions: Please provide the following information for every source of foods/beverages your school has other than vending machines and the cafeteria. If there is more than one of a given food source (for example, if there are multiple food carts) you can check more than one location per column and check off all the foods and beverages that are available in any of those locations.

		School Store	Snack Bar/ Food Cart/Kiosk	Fundraiser	Other (Specify)
		Sells items in addition to foods/ beverages; does not prepare/heat food	Sells only foods/beverages	Bake sale, candy drive, special pizza day, etc.	______________
1 . Location Check the location(s) of each source
In cafeteria (including indoor and outdoor seating/eating area)		1 	NA	1 	NA
Outside but near (within 20 feet) cafeteria or seating/eating area		2 	2 	2 	2 
Elsewhere in school building(s)		3 	3 	3 	3 
Outside school building(s), but on school grounds (not in seating/eating area)		4 	4 	4 	4 
2 . Beverages Check items available from each source
Diet carbonated soft drink (diet soda/pop)		5 	5 	5 	5 
Regular carbonated soft drink (regular soda/pop)		6 	6 	6 	6 
Juice (100% fruit or vegetable juice)		7 	7 	7 	7 
Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)		8 	8 	8 	8 
Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)		9 	9 	9 	9 
Bottled water (plain, flavored, or sparkling)		10 	10 	10 	10 
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)		11 	11 	11 	11 
Whole or reduced fat (2%) flavored milk (such as chocolate)		12 	12 	12 	12 
Low-fat (1%) flavored milk (such as chocolate)		13 	13 	13 	13 
Fat-free/skim flavored milk (such as chocolate)		14 	14 	14 	14 
Whole or reduced fat (2%) white milk		15 	15 	15 	15 
Low-fat (1%) white milk		16 	16 	16 	16 
Fat-free/skim white milk		17 	17 	17 	17 
Other (Specify)		18 	18 	18 	18 
3 . Snacks Check items available from each source
Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	19 		19 	19 	19 
Regular chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	20 		20 	20 	20 
Pretzels	21 		21 	21 	21 
Popcorn	22 		22 	22 	22 
Cracker sandwiches with cheese or peanut butter	23 		23 	23 	23 
Other types of crackers (including animal crackers)	24 		24 	24 	24 
Low-fat/reduced-fat granola bars, cereal bars, or energy bars	25 		25 	25 	25 
Regular granola bars, cereal bars, or energy bars	26 		26 	26 	26 
Crispy rice bars or treats	27 		27 	27 	27 
Candy	28 		28 	28 	28 
Gum	29 		29 	29 	29 
Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)	30 		30 	30 	30 
Fruit snacks (such as Fruit Roll-Ups or fruit leather)	31 		31 	31 	31 
Meat snacks (such as jerky or pork rinds)	32 		32 	32 	32 
Other (Specify)
4 . Baked Goods Check items available from each source	33 		33 	33 	33 
Low-fat/reduced-fat cakes, cupcakes, or brownies	34 		34 	34 	34 
Regular cakes, cupcakes, or brownies	35 		35 	35 	35 
Low-fat pies, turnovers, or toaster pastries	36 		36 	36 	36 
Regular pies, turnovers, or toaster pastries	37 		37 	37 	37 
Doughnuts	38 		38 	38 	38 
Low-fat cookies	39 		39 	39 	39 
Regular cookies	40 		40 	40 	40 
Bread, rolls, bagels, or tortillas	41 		41 	41 	41 
Other (Specify)
5 . Other Foods Check items available from each source	42 		42 	42 	42 
Yogurt	43 		43 	43 	43 
Cheese	44 		44 	44 	44 
Frozen fruit bars or popsicles	45 		45 	45 	45 
Milkshakes, smoothies, or yogurt drinks	46 		46 	46 	46 
Low-fat/reduced-fat ice cream, frozen yogurt, or sherbet	47 		47 	47 	47 
Regular ice cream, frozen yogurt, or sherbet	48 		48 	48 	48 
Dried fruit (such as raisins or apricots)	49 		49 	49 	49 
Canned fruit	50 		50 	50 	50 
Fresh fruit	51 		51 	51 	51 
Vegetables	52 		52 	52 	52 
Other (Specify)	53 		53 	53 	53 