FFVP-CFD_Appendix_D2_Clsrm_Stud_Obs_Form_Snack

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Overview

Appendix.D2.Pg1
Appendix.D2.Pg2
Appendix.D2.Pg3
Appendix.D2.Pg4

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Sheet 1: Appendix.D2.Pg1

Evaluation of the Canned, Frozen, or Dried Fruits and Vegetables Pilot Project in the FFVP
Appendix D.2 CLASSROOM-STUDENT LEVEL FRESH FRUIT AND VEGETABLE OBSERVATION FORM FOR SNACK AND RECALL AND PLATE WASTE
				OMB Control No: 0584-XXXX
				Expiration date: XX/XX/XXXX
CLASSROOM AND STUDENT-LEVEL FRUIT AND VEGETABLE SNACKS OBSERVATION FORM
1.	Observer ID:
2.	Name of School:
3.	Classroom Number:		Classroom ID:
4.	Teacher Name:
5.	Grade:	□ 4th	□ 5th	□ 6th
6.	Students in this classroom had breakfast from		|__|__|:|__|__| AM to |__|__|:|__|__| AM
7.	Students in this classroom had lunch from		|__|__|:|__|__| AM / PM to |__|__|:|__|__| AM / PM
8.	Please mark all nutrition education activities and nutrition promotion material present in the classroom, in column A. Then for each type of activityor education materials present, please answer column B.
	A.	B.
	What types of nutrition education and promotion material are present? Mark all that apply	Are the activities or materials related to fruits and/or vegetables?
	□ Nutrition poster	□ Yes	□ No
	□ Nutrition display	□ Yes	□ No
	□ Other _______________	□ Yes	□ No
	□ None
	□ Not applicable
	Observer Notes:
	NOTE: This booklet contains three pages for each day.
	For each day, answer questions 1-9a on page 2.
	Record observations regarding Fruits and Vegetables on pages 3-4.
	On page 4, complete child-level observations each time snacks are served.

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Sheet 2: Appendix.D2.Pg2

Evaluation of the Canned, Frozen, or Dried Fruits and Vegetables Pilot Project in the FFVP
Appendix D.2 CLASSROOM-STUDENT LEVEL FRESH FRUIT AND VEGETABLE OBSERVATION FORM FOR SNACK AND RECALL AND PLATE WASTE
CLASSROOM AND STUDENT-LEVEL FRUIT AND VEGETABLE SNACKS OBSERVATION FORM
1	Today's Date	____/ ____/ ____	□ Mon. □ Tues. □ Wed. □ Thurs. □ Fri.
2	Were free fruit and vegetable snacks offered today? Please check one box for AM snack and another for PM snack			In the AM?		In the PM?
	If the answer is no, stop. If the answer to AM or PM is yes then go to question 3			£ Yes	£ No	£ Yes	£ No
3	Time(s) of day snacks offered in AM and / or PM			Offered at	___:___AM	Offered at	___:___PM
4	For each time free fruits and vegetables were offered, check all locations where fruits and vegetables were distributed to students in the sampled classroom.			£ Classroom		£ Classroom
				£ Kiosk		£ Kiosk
				£ Free vending machine		£ Free vending machine
				£ Cafeteria		£ Cafeteria
				£ In nurse or administrator office(s)		£ In nurse or administrator office(s)
				£ Other (Specify) _____________________		£ Other (Specify) _____________________
				£ Other (Specify) _____________________		£ Other (Specify) _____________________
5	For each time free fruits and vegetables were offered, check all locations where students in the sampled classroom ate the fruit and vegetable snacks.			£ Classroom		£ Classroom
				£ Cafeteria		£ Cafeteria
				£ Playground		£ Playground
				£ Other (Specify) ________________________		£ Other (Specify) ________________________
6	Were free FFVP fruit and vegetable snacks offered as part of a nutrition education activity today? Please check one box for AM snack and another for PM snack			£ Yes	£ No	£ Yes	£ No
7	Were staff providing nutrition education today?			£ Yes	£ No→ GO TO Q.8
7a	Was this activity related to fruits and/or vegetables?			£ Yes	£ No
8	Were staff encouraging students to consume nutritious food today?			£ Yes	£ No→ GO TO Q.9
8a	Was this related to fruits and/or vegetables?			£ Yes	£ No
9	Was there taste testing today?			£ Yes	£ No
9a	Was this activity related to fruits and/or vegetables?			£ Yes	£ No→ GO TO INSTRUCTIONS BELOW
	OBSERVER INSTRUCTIONS
	For AM observations In Column B, mark if served at this snack. In Column C, if applicable, check the form of the fruit or vegetable. In Column D record the number of portions that were provided to the class and then enter the number of portions left over after the students took the snacks or were served.
	For PM observations In Column B, mark if served at this snack. In Column C, if applicable, check the form of the fruit or vegetable. In Column E record the number of portions that were provided to the class and then enter the number of portions left over after the students took the snacks or were served.
	OBSERVER NOTES:

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Sheet 3: Appendix.D2.Pg3

Evaluation of the Canned, Frozen, or Dried Fruits and Vegetables Pilot Project in the FFVP
Appendix D.2 CLASSROOM-STUDENT LEVEL FRESH FRUIT AND VEGETABLE OBSERVATION FORM FOR SNACK AND RECALL AND PLATE WASTE
CLASSROOM AND STUDENT-LEVEL FRUIT AND VEGETABLE SNACKS OBSERVATION FORM
A.	B.	C.	D. AM SNACK			E. PM SNACK
			# of Portions Provided to Class	# of Portions Left Over		# of Portions Provided to Class	# of Portions Left Over
FOOD ITEM	Served at this Snack
FRUITS
Apples	£	£ Fresh £ Dried IF FRESH:
		£ Whole £ Cut -up
Applesauce, canned	£
Apricots	£	£ Fresh £ Dried £ Other________________ IF FRESH:
		£ Whole £ Cut -up
Bananas	£	£ Fresh £ Dried IF FRESH:
		£ Whole £ Cut -up
Blueberries	£	£ Fresh £ Dried £ Other________________
Cantaloupe, fresh	£
Cranberries / Craisins	£	£ Dried
Grapes, fresh	£
Honeydew melon, fresh	£
Kiwis, fresh	£	£ Whole £ Cut -up
Nectarines, fresh	£	£ Whole £ Cut -up
Oranges, fresh	£	£ Whole £ Cut -up
Peaches	£	£ Fresh £ Dried £ Other_________________________________
		IF FRESH £ Whole £ Cut -up
Pears	£	£ Fresh £ Dried £ Other_________________________________
		IF FRESH £ Whole £ Cut -up
Pineapple	£	£ Fresh £ Dried £ Other________________
Plums	£	£ Fresh £ Dried £ Other_________________________________
		IF FRESH £ Whole £ Cut -up
Raisins	£
Strawberries	£	£ Fresh £ Dried £ Other_________________________________
Tangerines, fresh	£	£ Whole £ Cut -up
Watermelon, fresh	£
Mixed fruit	£	£ Fresh £ Other________________
Other (Specify): ____________________	£	£ Fresh £ Dried £ Other_________________________________
		IF FRESH £ Whole £ Cut -up
Other (Specify): ____________________	£	£ Fresh £ Dried £ Other_________________________________
		IF FRESH £ Whole £ Cut -up
Other (Specify): ____________________	£	£ Fresh £ Dried £ Other_________________________________
		IF FRESH £ Whole £ Cut -up

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Sheet 4: Appendix.D2.Pg4

Evaluation of the Canned, Frozen, or Dried Fruits and Vegetables Pilot Project in the FFVP
Appendix D.2 CLASSROOM-STUDENT LEVEL FRESH FRUIT AND VEGETABLE OBSERVATION FORM FOR SNACK AND RECALL AND PLATE WASTE
CLASSROOM AND STUDENT-LEVEL FRUIT AND VEGETABLE SNACKS OBSERVATION FORM
A.	B.	C.	D. AM SNACK			E. PM SNACK
			# of Portions Provided to Class	# of Portions Left Over		# of Portions Provided to Class	# of Portions Left Over
FOOD ITEM	Served at this Snack
VEGETABLES
Beans, green	£	£ Fresh/raw £ Cooked
Beans, other(specify):_____________________		£ Fresh/raw £ Cooked
Broccoli	£	£ Fresh/raw £ Cooked
Carrots	£	£ Fresh/raw £ Cooked
Cauliflower	£	£ Fresh/raw £ Cooked
Celery, fresh/raw	£
Peas, green snap	£	£ Fresh/raw £ Cooked
Peppers, green	£	£ Fresh/raw £ Cooked
Peppers, orange, red, yellow	£	£ Fresh/raw £ Cooked
Tomatoes	£	£ Fresh/raw £ Cooked
Mixed vegetables	£	£ Fresh/raw £ Cooked
Other (Specify): ____________________	£	£ Fresh/raw £ Cooked
Other (Specify): ____________________	£	£ Fresh/raw £ Cooked
Other (Specify): ____________________	£	£ Fresh/raw £ Cooked
CONDIMENTS and OTHER ACCOMPANIMENTS Please list all condiments, dips, dressings, or sauces	£
	£
	£
	£
	£
CHILD-LEVEL OBSERVATION
Student 1 ID:______________ Identifying features or clothing : ____________________________ ____________________________ ____________________________	# portions served		|___|			|___|
	# portions added		|___|			|___|
	Percent of snack left over		 0%  25%  33%			 0%  25%  33%
			 50%  66%  75%			 50%  66%  75%
			 100%			 100%
	Did child take condiment?		 Yes	 No		 Yes	 No
	Did child consume condiment?		 Yes	 No		 Yes	 No
Student 2 ID:______________ Identifying features or clothing : ____________________________ ____________________________ ____________________________	# portions served		|___|			|___|
	# portions added		|___|			|___|
	Percent of snack left over		 0%  25%  33%			 0%  25%  33%
			 50%  66%  75%			 50%  66%  75%
			 100%			 100%
	Did child take condiment?		 Yes	 No		 Yes	 No
	Did child consume condiment?		 Yes	 No		 Yes	 No
Student 3 ID:______________ Identifying features or clothing : ____________________________ ____________________________ ____________________________	# portions served		|___|			|___|
	# portions added		|___|			|___|
	Percent of snack left over		 0%  25%  33%			 0%  25%  33%
			 50%  66%  75%			 50%  66%  75%
			 100%			 100%
	Did child take condiment?		 Yes	 No		 Yes	 No
	Did child consume condiment?		 Yes	 No		 Yes	 No
Student 4 ID:______________ Identifying features or clothing : ____________________________ ____________________________ ____________________________	# portions served		|___|			|___|
	# portions added		|___|			|___|
	Percent of snack left over		 0%  25%  33%			 0%  25%  33%
			 50%  66%  75%			 50%  66%  75%
			 100%			 100%
	Did child take condiment?		 Yes	 No		 Yes	 No
	Did child consume condiment?		 Yes	 No		 Yes	 No