FFVP CFD Pilot - Local

Evaluation of the Canned, Frozen, or Dried Fruits and Vegetables Pilot Project in the FFVP

Appendix C3d. School – Level Reimbursable Fruit and Vegetable Form

					OMB Control No: 0584-XXXX
					Expiration date: XX/XX/XXXX
School – Level Reimbursable Fruit and Vegetable Form:			1 Breakfast	2 FFVP Snacks-AM	3 Lunch	4 FFVP Snacks-PM
Date: ____ /____/ ____	Record the Day	1 Mon	2 Tue	3 Wed	4 Thu	5 Fri
School ID.	Observer ID:		Observer Name:
School Name:			FSM Name:

A. Food Item	B. Served at This Meal or Snack	C. Portion Size (Include Units)	D. Food Description		E. Number of Reimbursable Portions Served
FRUIT
Apple			 Fresh  Canned  Dried
Applesauce, canned		cup	 Sweetened  Unsweetened
Apricots			 Fresh  Canned  Dried IF PACKED IN SYRUP, JUICE OR WATER:  Light syrup  Juice  Water
Banana			 Fresh  Dried
Blueberries		cup	 Fresh  Canned  Frozen  Dried
Cantaloupe, fresh	
Cranberries, dried / Craisins		cup
Grapes, fresh	
Honeydew melon, fresh	
Kiwis, fresh	
Nectarines, fresh	
Oranges, fresh	
Peaches			 Fresh  Canned  Frozen  Dried IF PACKED IN SYRUP, JUICE OR WATER:  Light syrup  Juice  Water
Pears			 Fresh  Canned  Frozen  Dried IF PACKED IN SYRUP, JUICE OR WATER:  Light syrup  Juice  Water
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
FRUITS, continued			LIST DRESSING AS SEPARATE ITEM(S) UNDER CONDIMENTS
Pineapple			 Fresh  Canned  Frozen  Dried IF PACKED IN SYRUP, JUICE OR WATER:  Light syrup  Juice  Water
Plums			 Fresh  Canned  Frozen  Dried IF PACKED IN SYRUP, JUICE OR WATER:  Light syrup  Juice  Water
Raisins	
Strawberries		cup	 Fresh  Canned  Frozen  Dried IF PACKED IN SYRUP, JUICE OR WATER:  Light syrup  Juice  Water
Tangerines, fresh	
Watermelon, fresh	
Mixed fruit		cup	 Fresh  Canned  Frozen IF PACKED IN SYRUP, JUICE OR WATER:  Light syrup  Juice  Water
Other (Specify):	
Other (Specify):	
Other (Specify):	
JUICES (Note: Include only full-strength (100%) fruit and vegetable juice. DO NOT include fruit drinks.)
Orange juice		fl oz.	 Vitamin C added  Calcium added
Apple juice		fl oz.	 Vitamin C added  Calcium added
Frozen juice cup/bar		fl oz.	 Vitamin C added  Calcium added
Other (Specify):		fl oz.	 Vitamin C added  Calcium added
Other (Specify):		fl oz.	 Vitamin C added  Calcium added
Other (Specify):		fl oz.	 Vitamin C added  Calcium added
VEGETABLES
Baked beans		cup	 Vegetarian  With pork
Beans, green			 Fresh/raw  Fresh/cooked  Canned  Frozen  Fat added, specify type____________________________________
Beans, other(specify):_____________________			 Fresh/raw  Fresh/cooked  Canned  Frozen  From dry  Fat added, specify type___________________________________
VEGETABLES, continued			LIST DRESSING AS SEPARATE ITEM(S) UNDER CONDIMENTS
Broccoli			 Fresh/raw  Fresh/cooked  Canned  Frozen  Fat added, specify type___________________________________
Carrots		cup	 Fresh/raw  Fresh/cooked  Frozen  Fat added, specify type___________________________________
Cauliflower			 Fresh/raw  Fresh/cooked  Frozen  Fat added, specify type___________________________________
Celery			 Fresh/raw  Fresh/cooked
Cucumber	
Corn		cup	 From Fresh  Canned  Frozen  Fat added, specify type___________________________________
Jicama			 Fresh /raw
Peas, green		cup	 Fresh  Canned  Frozen
Peppers, green			 Fresh/raw  Fresh/cooked  Frozen
Peppers, orange, red, or yellow			 Fresh/raw  Fresh/cooked  Frozen
Potatoes, whipped or mashed		cup	 From Fresh  Frozen  Dried  Fat added, specify type___________________________________
French fries		oz.	 From Fresh  Frozen  Oven-baked  Deep-fried
Tater tots or shapes		oz.	 Oven-baked  Deep-fried
Sweet potatoes			 From Fresh  Canned  Frozen  Fat added, specify type___________________________________  Oven-baked  Deep-fried
Tomatoes			 Fresh/raw  Fresh/cooked  Canned  Frozen
Mixed vegetables		cup	 From fresh  Canned  Frozen  From dry  Fat added, specify type___________________________________
Salad, tossed		cup
Other (Specify):	
Other (Specify):	
Other (Specify):	
SELF-SERVE BARS			LIST DRESSING AS SEPARATE ITEM(S) UNDER CONDIMENTS
Potato bar			List other vegetables offered:
Salad bar (side or small portion)			List fruits and vegetable offered:
Salad bar (entrée or large portion)			List meat/meat alternates, fruits, and vegetable offered:
Other (Specify):__________________________			List meat/meat alternates, fruits, and vegetable offered:
MILK
White, fat-free/skim		fl oz.
White, 1%		fl oz.
Chocolate, fat-free/skim		fl oz.
Other flavor (Specify): __________________		fl oz.	 Fat-free/skim  1%
Other (Specify): __________________		fl oz.	 Fat-free/skim  1%
Other (Specify): __________________		fl oz.	 Fat-free/skim  1%
SANDWICHES			PLEASE INCLUDE TYPE OF BREAD TYPE AND AMOUNT OF FILLING, AND ANY ADDED FAT OR SAUCE
		1 sandwich
		1 sandwich
		1 sandwich
		1 sandwich
		1 sandwich
ENTREE SALADS			PLEASE LIST TYPE AND AMOUNT OF MEAT/MEAT ALTERNATES, FRUIT AND VEGETABLES, AND OTHER MAIN INGREDIENTS. ALSO, LIST DRESSING AS SEPARATE ITEM(S) UNDER CONDIMENTS.
Chef's salad (entrée)		1 salad
		1 salad
		1 salad
OTHER ENTREES AND MEAT/MEAT ALTERNATES
			 Beef or pork  Breaded  Reduced-fat  Chicken or turkey  With skin  Fat added  Oven-baked  Deep-fried  Sauce (Specify):_______________
			 Beef or pork  Breaded  Reduced-fat  Chicken or turkey  With skin  Fat added  Oven-baked  Deep-fried  Sauce (Specify):_______________
			 Beef or pork  Breaded  Reduced-fat  Chicken or turkey  With skin  Fat added  Oven-baked  Deep-fried  Sauce (Specify):_______________
			 Beef or pork  Breaded  Reduced-fat  Chicken or turkey  With skin  Fat added  Oven-baked  Deep-fried  Sauce (Specify):_______________
			 Beef or pork  Breaded  Reduced-fat  Chicken or turkey  With skin  Fat added  Oven-baked  Deep-fried  Sauce (Specify):_______________
BREADS AND GRAINS OFFERED SEPARATELY
			Specify type:_______________________________  Whole grain -rich  Reduced-fat  Fat added (Specify):____________________________
			Specify type:________________________________  Whole grain -rich  Reduced-fat  Fat added (Specify):____________________________
			Specify type:________________________________  Whole grain -rich  Reduced-fat  Fat added (Specify):________________________
DESSERTS AND SNACKS OFFERED AS PART OF A REIMBURSABLE MEAL
			 Icing  With fruit  With whipped topping  Reduced-fat
			 Icing  With fruit  With whipped topping  Reduced-fat
			 Icing  With fruit  With whipped topping  Reduced-fat
			 Icing  With fruit  With whipped topping  Reduced-fat
DESSERTS AND SNACKS OFFERED AS PART OF A REIMBURSABLE MEAL, continued
			 Icing  With fruit  With whipped topping  Reduced-fat
			 Icing  With fruit  With whipped topping  Reduced-fat
CONDIMENTS AND SALAD DRESSINGS
			 Reg  Reduced fat  Low fat  Fat-free
			 Reg  Reduced fat  Low fat  Fat-free
			 Reg  Reduced fat  Low fat  Fat-free
			 Reg  Reduced fat  Low fat  Fat-free
			 Reg  Reduced fat  Low fat  Fat-free
			 Reg  Reduced fat  Low fat  Fat-free
			 Reg  Reduced fat  Low fat  Fat-free
			 Reg  Reduced fat  Low fat  Fat-free
BREAKFAST CEREAL
Name of cereal:________________________			 Cold  Hot-instant  Hot-quick  Hot-regular
Name of cereal:________________________			 Cold  Hot-instant  Hot-quick  Hot-regular
Name of cereal:________________________			 Cold  Hot-instant  Hot-quick  Hot-regular
Name of cereal:________________________			 Cold  Hot-instant  Hot-quick  Hot-regular
OTHER MENU ITEMS
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NOTES:

C.3d.7