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D.4b Meal Observation Form – Meals Brought from Home

OMB Control No.: 0584-XXXX

OMB Approval Expiration Date: XX/XX/XXXX

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Meal Observation Form – Meals Brought from Home

Interviewer ID #: | | | | | | | | Date of observation: | | | / | | | / 2016 Month Day	Meal from Home: (check one)		Meal START time: : £ am £ pm (check one) *Time at which 75% of children have been seated Meal END time: : £ am £ pm (check one) *Time at which 75% of children have left the table
	0 £ Breakfast 1 £ Lunch 2 £ Dinner/Supper	3 £ Morning Snack 4 £ Afternoon Snack 5 £ Evening Snack

Meal Component: (a complete and detailed description of each items should be included in the Food Diary after speaking to the parent)	Child 1 ID #: | | | | | | |			Child 2 ID #: | | | | | | |			Child 3 ID #: | | | | | | |
	Child 1 Description:			Child 2 Description:			Child 3 Description:
	Amount Served (cups, Tbsp, tsp, oz/g)	Additions/ Deletions (cups, Tbsp, tsp, oz/g)	Amount Remaining (Plate Waste) (cups, Tbsp, tsp, oz/g)	Amount Served (cups, Tbsp, tsp, oz/g)	Additions/ Deletions (cups, Tbsp, tsp, oz/g)	Amount Remaining (Plate Waste) (cups, Tbsp, tsp, oz/g)	Amount Served (cups, Tbsp, tsp, oz/g)	Additions/ Deletions (cups, Tbsp, tsp, oz/g)	Amount Remaining (Plate Waste) (cups, Tbsp, tsp, oz/g)

(+) Additions to the meal include: 2^nd portions, items taken from another child (–) Deletions include: items dropped or spilled, items given to another child

Meal Observation Form– Meals Brought from Home, pg. 2

These 2 questions pertain to only the 3 children being observed during this meal/snack

These 3 questions pertain to ALL children participating in this meal/snack

1. During this meal/snack did any staff member sit and eat a meal with the children? 0 £ No 1 £ Yes 2 £ Yes, beverages only For the 3 observed children, did you observe staff encouraging them to eat any of the following meal components? 2a. Child 1: 0 £ No 1 £ Yes, fruits 2 £ Yes, vegetables 3 £ Yes, breads/grains 4 £ Yes, meats/beans/nuts (proteins) 5 £ Yes, dairy 2b. Child 2: 0 £ No 1 £ Yes, fruits 2 £ Yes, vegetables 3 £ Yes, breads/grains 4 £ Yes, meats/beans/nuts (proteins) 5 £ Yes, dairy 2c. Child 3: 0 £ No 1 £ Yes, fruits 2 £ Yes, vegetables 3 £ Yes, breads/grains 4 £ Yes, meats/beans/nuts (proteins) 5 £ Yes, dairy

3. Were children seated at a table for the meal/snack? 0 £ No. If not, specify? _______________________________________ 1 £ Yes 4. During this meal, how many children in the classroom participated in the meal? _________________- 5. For this meal or snack, were any single food items brought in from home or elsewhere that were provided for the entire class? 0 £ No 1 £ Yes 5a. If yes, who brought in the food item(s)? 0 £ Teacher/other staff member 1 £ Parent/child 2 £ Other _________________________________________________ 5b. What foods/drinks were brought in? ____________________________ ____________________________________________________________ ____________________________________________________________

Meal Observation Decision Log

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Meal Observation Form, p. 1