FNS-66B Special Milk Program Site Data

U.S. Department of Agriculture Food and Nutrition Service
Form Approved OMB# 0584-0005
Expiration Date: xx/xx/20xx

SPECIAL MILK PROGRAM SITE DATA

According to the Paperwork Reduction Act of 1995, an agency may not coduct 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 0584-0005. The time required to complete this information collection is estimated to average 15
minutes (.25 hours) 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.

General
Sponsor Number

Site ID

Sponsor Name

1. Physical Address Of Institution

2. Type of Program

Name:

A. Day School

Contct Name:

B. Boarding School

Street Addr1:

C. RCCI

Street Addr2:

D. RCCI with day students

City:

E. Camps

State:

F. Child Care Institution

Zip:

G. Other

Tel:
County:
3. Pricing Status

4. Planned period of milk service for site (mm/dd/yyyy)

A. Pricing Program

A. Begin Date

B. Non-pricing program
B. End Date

C. Combination Pricing and Non-Pricing
5. Grade Levels and Ages
Grade levels (for schools)

From

To

Ages (RCCI's, Camps, Institutions)

From

To

6. Total Enrollment

7. Estimated average daily participation

8. Number of children eligible for free milk

9. Estimated number of half-pints served per child per day

10. Estimated number of half-pints served to adults per day

Form FNS-66B (2-00) Previous Edition Obsolete

U.S. Department of Agriculture Food and Nutrition Service
SPECIAL MILK PROGRAM SITE DATA

11. Milk Service Times
Begin Time End Time
First
Secon
Third
Notes

Last Modified By
Last Modified Date

Form FNS-66B (2-00) Previous Edition Obsolete

Form Approved OMB# 0584-0006