Businesses - Sponsors and Providers

D.3 Reference Portion Measurement Form

OMB Control No.: 0584-XXXX

OMB Approval Expiration Date: XX/XX/XXXX

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Reference Portion Measurement Form

Interviewer ID #: | | | | | | | | Date of observation: | | | / | | | / 2016 Month Day								Meal: (check one)
								0 £ Breakfast 1 £ Lunch 2 £ Dinner/Supper		3 £ Morning Snack 4 £ Afternoon Snack 5 £ Evening Snack
Use additional sheets as necessary to record all components of a meal or snack (including water)
Menu item or component: ____________________________________ Reference Portion : _________________________________________					Menu item or component: ____________________________________ Reference Portion : _________________________________________
Weights or volumes of samples:	#1		grams/fluid oz (circle one)		Weights or volumes of samples:	#1			grams/fluid oz (circle one)
	#2					#2
	#3					#3
	#4					#4
	#5					#5
Menu item or component: ____________________________________ Reference Portion: _________________________________________					Menu item or component: ____________________________________ Reference Portion: _________________________________________
Weights or volumes of samples:	#1		grams/fluid oz (circle one)		Weights or volumes of samples:	#1			grams/fluid oz (circle one)
	#2					#2
	#3					#3
	#4					#4
	#5					#5

Adapted from the Serving Size Measurement Form used in the Early Childhood and Childcare Study and the Family Childcare Homes Legislative Changes Study.

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 15 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.

Reference Portion Measurement Form, p. 1