FFVP CFD Pilot - Private

Evaluation of the Pilot Project for Canned, Frozen, or Dried (CFD) Fruits and Vegetables in the Fresh Fruit and Vegetable Program (FFVP)

FFVP-CFD_Appendix_C3d_School_ReimbursableFVFoodsForm.(2014-06-30)

FFVP CFD Pilot - Private

OMB: 0584-0598

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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







































NOTES:

C.3d.7

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AuthorSharon Clark
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