FNS 779 Food and Nutrition Service (FNS) HealthierUS School Chal

ATTACHMENT A

OMB Control No.: 0584-0524

Food and Nutrition Service (FNS)
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
General Information
Public reporting burden for this collection of information is estimated to average 2 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. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service,
Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584 - 0524).
Do not return the completed form to this address.
Tips for Completing Application:
1. You can submit your application two ways:
a. Submit the application and supporting documentation in a 3-ring binder to your State Child
Nutrition Agency.
b. Submit the application and supporting documentation electronically to [email protected].
2. When more space is needed to accommodate for additional days of the week or to provide more
information, schools and residential child care institutions (RCCI’s) can attach additional pages as needed.
3. Multiple schools can apply under the same district application when all of the following apply:
a. The same nutrition education, physical education, and physical activities are provided or offered
(according to the grade level).
b. The same Smart Snacks foods and beverages were sold throughout the cafeteria and/or school
campus. Submit:
i. One Smart Snacks Worksheet with a listing of foods available and
ii. One set of supporting documentation.
c. Each individual school follows the district’s wellness policy.
In addition, each school must submit a Smarter Lunchroom Self-Assessment Score Card, an individual School
Wellness Policy Worksheet (if applicable) and complete the Other Criteria for Excellence Checklist, which are both
included in the online application. If a district finds that their schools have the same menu with corresponding foods
served, but has different nutrition education, physical education, physical activities, Smart Snacks, or wellness
policies, they can still apply as a district, but must make note of those items that differ among the schools and
submit additional documentation for those schools with the district application.
Each District should submit an Application Cover Sheet reflecting the name of the District with a completed District
School List form, Smart Snacks Worksheet that includes a la carte information and vended items (unless they are
the same throughout the district), Smarter Lunchroom Self-Assessment Score Card, Nutrition Education and
Physical Education/Activity Worksheets, School Wellness Policy Worksheet, a copy of each school’s wellness policy
(unless it is a district wellness policy), and Other Criteria for Excellence Checklist.
School Name:
FNS-779 (07-14) Previous Edition Obsolete

SBU
Page 1

Electronic Form Version Designed in Adobe 10.0 Version

ATTACHMENT A
Food and Nutrition Service (FNS)
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Application Cover Sheet
Application for:

Bronze

Silver

Gold Award

Gold Award of Distinction

*The school name on the Award Certificate will be typed exactly as written in the School Name section
below. Please ensure that the entire name with any appropriate punctuation is clearly indicated. Award Certificates
will not be reprinted due to an incorrect or illegible school name.
PRINT OR TYPE ALL INFORMATION
*School Name
School District
School Address
Grades in School
Contact Person’s
Name and Title
Contact Person’s
Phone Number & Email
Date Submitted to
State Agency
FOR OFFICE USE ONLY
State
State Child Nutrition Director Approval:

Signature

Date

Reviewed by:

Phone:

Reviewer’s Email:
Email of the State Child Nutrition Director:
Regional Office
FNS Region:
Child Nutrition Director Approval:

Reviewed by:
Signature

Date
FNS Headquarters (HQ)

Application received HQ:

Reviewed by:

Decision/Date:

Award period:

School Name:
Page 2

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Table of Contents
Cover Sheet
Table of Contents
General Criteria Worksheet
Smart Snacks Worksheet
Nutrition Education Worksheet
Physical Education Worksheet – Elementary Schools
Physical Education Worksheet – Middle and High Schools
Physical Activity Worksheet
School Wellness Policy Worksheet
Other Criteria for Excellence Checklist
Review Committee Verification Form
Application Check-off Sheet

School Name:
Page 3

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Application for HUSSC
General Criteria

Yes

Are you a Team Nutrition School? (Check our Team Nutrition directory at:
http://teamnutrition.usda.gov/schoolsdb/srchpage.asp). Print and enclose a copy of each
school(s) Team Nutrition enrollment form. If your school is not a Team Nutrition School,
complete the Online Enrollment Form and submit a copy with your HUSSC application.
Have all corrective actions from your school's most recent State review of your school
meals program been completed? If not, please contact your State Agency.
Is your school currently meeting school meal pattern requirements for the National School
Lunch Program and School Breakfast Program as specified in 7 CFR 210 and 220?
Is your School Food Authority certified to receive the additional six cent performancebased reimbursement (Healthy Hunger-Free Kids Act 2010)?
Is your school implementing Smarter Lunchroom techniques in six areas (Fruits,
Vegetables, Entrées, Milk, Sales of Reimbursable Meals, and School Synergies) as defined
on the Smarter Lunchrooms Self-Assessment Scorecard (). The number of techniques
from the scorecard that the school must implement is dependent upon the award level.
Documentation that the school is meeting this criteria shall include a copy of the
completed score card and a brief summary with 2-3 photos describing the school’s overall
Smarter Lunchroom effort.
- Bronze applicants must select at least 30 actions items.
- Silver/Gold applicants must select 50 action items.
- Gold Award of Distinction applicants must select 70 action items.
Does your school meet the Average Daily Participation (ADP) criteria for breakfast and
lunch?
Bronze – No ADP required.
Breakfast: Elementary and Middle School: Silver 20%, Gold and Gold Award of Distinction 35%
High School: Silver 15%, Gold and Gold Award of Distinction 25%
Lunch: Elementary and Middle School: Silver 60%, Gold and Gold Award of Distinction 75% High
School: Silver 45%, Gold and Gold Award of Distinction 65%
List ADP for Breakfast calculated based on attendance:
Month/Year:
List ADP for Lunch calculated based on attendance:
Month/Year:
The State Agency and FNS reserve the right to verify all information on the application and reject
applications that are incomplete or otherwise fail to provide factual information.
School Name:
Page 4

No

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Smart Snacks Worksheet
All Award Levels: Must meet Smart Snacks in School Nutrition Standards. All foods and beverages sold to students
during the school day* meet or exceed the USDA’s nutrition standards for all foods and beverages sold to students
(commonly called Smart Snacks in School). This includes a la carte, vending, school stores, snack or food carts and
any food-based fundraising (school follows fundraising exemptions and guidance set by their State agency, which
also must adhere to the federal Smart Snacks in School requirements).
Use the Smart Snacks Calculator to analyze foods and beverages sold to students during the school day
(http:healthymeals.nal.usda.gov/smartsnacks). Provide a copy of calculator results, along with product nutrition facts
labels and ingredient statements with the HUSSC application.
Additional Smart Snacks Criteria
Bronze and Silver
Meet Smart Snacks criteria as defined in 7 CFR Parts 210 and 220.
The school offers training on Smart Snacks criteria annually to all individuals who are involved in the sale of foods to
students on the school campus during the school day. Use the space provided below to briefly describe the training
that is offered.

The school does not advertise or market foods and beverages that do not meet Smart Snacks criteria to students
(e.g., signs and marketing materials promoting these foods are not visible to students on the school campus during
the school day). Documentation of meeting these criteria includes evidence of a written policy and/or writing
communication/training for school staff and parent organizations. Describe below how the school meets these
criteria and provide documentation with HUSSC application.

Gold
Meets criteria for Bronze/Silver and
The school only permits food-related fundraisers that meet USDA’s Smart Snacks standards, even if the State
allows exemptions. Provide a brief statement to explain how the school meets these criteria with a list of food-related
fundraisers and product labels and ingredient statements (if applicable).

School Name:
Page 5

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Smart Snacks Worksheet continued
If foods and beverages are sold to students on the school campus at events outside of the school day (e.g., sporting
events, after-school activities, award ceremonies), then water, fruits, and/or vegetables are also offered and
promoted as options. Documentation of meeting these criteria includes a written school policy and/or instructions for
those that sell foods to students on the school campus. Provide a brief statement below and a copy of this
documentation and/or instructions with the HUSSC application as evidence that the school is meeting the criteria.

Gold Award of Distinction
Meets Gold criteria and
The majority (greater than 50%) of school-sponsored fundraising events conducted outside of the school day
includes only non-food items or only foods and beverages that meet or exceed USDA’s Smart Snacks in School
nutrition standards. Documentation includes list of school-sponsored fundraisers during the past year and written
policy or guidance. Submit documentation with HUSSC application.

School Name:
Page 6

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Nutrition Education Worksheet
*Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition Award from the
Alliance for a Healthier Generation in lieu of completing this section.
Elementary Schools:
Is nutrition education provided to all full-day students in all grades?

Yes

No

Briefly describe how nutrition education is provided to students in all grades and:
• Is part of a structured and systematic unit of instruction.
• Incorporates Team Nutrition curricula and materials.
• Utilizes multiple channels of communication, including the classroom, cafeteria, and home/parents.
Middle Schools:
Briefly describe below how nutrition education is offered to:
• Bronze/Silver: Middle school students in at least one grade during the school year.
• Gold/Gold Award of Distinction: Middle school students in at least two grades during the school year.
• All award levels must incorporate the latest Dietary Guidelines and MyPlate and incorporate Team
Nutrition materials.
High Schools:
Briefly describe below how nutrition education is offered to:
• High school students in at least two courses required for graduation and nutrition education is part of a
structured and systematic unit of instruction with the two courses. List the courses below.
• Utilizes multiple channels of communication, including the classroom, cafeteria, and home/parents.
• Must be consistent with the Dietary Guidelines for Americans and MyPlate.
Grades

Description of Nutrition Education Efforts

School Name:
Page 7

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Physical Education Worksheet – Elementary Schools
*Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition Award from the
Alliance for a Healthier Generation in lieu of completing this section. *Let’s Move Active Schools (LMAS) Award
Recipients: Submit a copy of your LMAS Recognition Award in lieu of completing this section.
Does your school provide physical education classes to all full-day students throughout the school year?
Yes

No

Bronze/Silver: A minimum average of 45 minutes* physical education per week.
Gold Award: A minimum average of 90 minutes* physical education per week.
Gold Award of Distinction: A minimum average of 150 minutes* per week.
* Up to 20 minutes (Bronze/Silver) and up to 45 minutes (Gold/Gold Award of Distinction) of the PE
requirement may be met by providing structured physical activity planned by a certified PE teacher and
implemented by a classroom teacher or school administrator. All students must participate in the physical
activities, which must be at least moderate-intensity and in increments of at least 10 minutes. If utilizing
the structured physical activity option, you must provide a description below.

Grades

List the average number of
minutes/week that physical
education is provided
throughout the school year for
each grade circled above.

Description of Physical Education Offered

School Name:
Page 8

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Physical Education Worksheet – Middle and High Schools
*Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition Award from the
Alliance for a Healthier Generation in lieu of completing this section. *Let’s Move Active Schools (LMAS) Award
Recipients: Submit a copy of your LMAS Recognition Award in lieu of completing this section.
Middle School: Briefly describe below how your school offers structured physical education classes to at least two
grades.
High School: Briefly describe below how your school offers structured physical education classes in at least two
courses. List the courses below.
Grades

Description of Physical Education Offered

School Name:
Page 9

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Physical Activity Worksheet
*Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition Award from the
Alliance for a Healthier Generation in lieu of completing this section. *Let’s Move Active Schools (LMAS) Award
Recipients: Submit a copy of your LMAS Recognition Award in lieu of completing this section.
Elementary Schools: Describe the additional daily physical activity opportunities provided to students (such as
recess). Indicate time allotted for any routine activities. If the physical activity was used as “Structured Physical
Activity” for counting towards the PE requirement, it cannot be listed here also.
Middle and High Schools: Describe how school provides students in all grades opportunities to participate in
physical activity (intramural/interscholastic sports or activity clubs) and actively promotes participation in physical
activities to all students throughout the school year.
Grades

Describe Physical Activity Provided

School Name:
Page 10

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
School Wellness Policy Worksheet
Provide a copy of the school’s local wellness policy with the HUSSC application. If following a district wellness
policy, provide a copy.
List three ways your school is working to meet School/District Wellness policy goals. For example, completing and
reporting the results of the School Health Index Self-Assessment process (http://www.cdc.gov/healthyyouth/shi/index.htm),
including local wellness policy goals in your school improvement plan, school wellness committee meets every other
month, etc.
1.
2.
3.
Describe how parents, students, school administration and staff, and the community are involved in the
implementation of the School/District Wellness Policy at your school.

If your school has implemented wellness practices that are stricter than what is stated in your school district’s local
wellness policy, please explain.

Briefly describe how your school demonstrates a commitment to neither deny nor require physical activity as a
means of punishment. (For example, students who misbehave are not denied recess).

Briefly describe how school demonstrates a commitment to prohibit the use of food as a reward. (For example, food
is not used to reward students for good behavior or for the completion of an assignment).

School Name:
Page 11

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Other Criteria for Excellence Checklist
Select from any option and submit supporting documentation with the application:
Bronze: Must select at least two of the 14 options.
Silver: Must select at least four of the 14 options.
Gold: Must select at least six of the 14 options.
Gold Award of Distinction: Must select at least eight of the 14 options.

Program Outreach Excellence
School implements innovative practices to increase SBP participation, such as Breakfast in the Classroom, Grab
and Go options, or vended reimbursable breakfasts. Provide a brief description and (if available) photo*.
School operates an afterschool program that participates in the Afterschool Snack Program or at-risk afterschool
meals component of the Child and Adult Care Food Program (CACFP). Provide a brief description.
If percentage of free- or reduced-students is 50% or more, Summer Food Service Program is available. Provide a
brief description.
Implement the Community Eligibility Provision (CEP), if economically feasible. (For more information on CEP, select
this link http://www.fns.usda.gov/schoolmeals/community-eligibility-provision).
School Food Service Excellence
School Food Service Manager is a certified food handler (local or national certification). Provide a copy of
certification.
School Nutrition Program Director meets or exceeds the minimum education standards required by the Professional
Standards proposed rule requirements.
All school nutrition program directors, managers, and staff meet or exceed the annual continuing education/training
hours required by the Professional Standards proposed rule requirements.
School is implementing at least one aspect of the Farm to School initiative (schools may choose one or more):
-Local and/or regional products are incorporated in to the school meal program
-Messages about agriculture and nutrition are reinforced throughout the learning environment
-School hosts a school garden
-School hosts field trips to local farms
-School utilizes promotions or special events, such as tastings, that highlight the local/regional products.
School has joined the U.S. Food Waste Challenge to recognize efforts to reduce food waste.

School Name:
Page 12

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Other Criteria for Excellence Checklist continued
Excellence in School and Community Involvement in Wellness Efforts
Provide annual training to before and afterschool program staff on physical activity and nutrition. Provide a brief
description.
All school staff receives annual training on wellness policies and ways to promote nutrition and physical activity.
Provide a brief description.
School partners with one or more community groups or SNAP Education providers to promote wellness. Provide a
brief description and include names of specific community grows.
Students are engaged (via student advisory council, student wellness team, or similar student interest groups) in
wellness efforts and have the opportunity to provide input on school food, marketing of school meals, and physical
activity options. Input from students (when feasible) should be taken and put into action.
School informs public on amount of time allotted for eating lunch. Solicits inputs from students and community
members on the amount of time that is adequate for eating lunch. Provide a brief description.
The school offers an afterschool class, workshop, or club for students or families focused on healthy cooking
techniques. These types of events could take place weekly, monthly, quarterly, or seasonally.

School Name:
Page 13

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Review Committee Verification Form
For individual school applications only

Please read the following statement and add your name and date below if you agree:
We have reviewed this application, and we agree that our school meals are healthy and appealing to our
students. We attest to the accuracy of the information provided in this application. We agree to maintain the
nutrition excellence and physical education/activity standards and procedures indicated in this application
for the duration of our certification as a HUSSC awardees. Furthermore, we agree to cooperate with USDA
and other organizations, upon request, to publicize our efforts.

Foodservice Manager’s Name

Email Address

Date

Team Nutrition Leader’s Name

Email Address

Date

District Food Service Authority Name/Address

Email Address

Date

Representative of the School’s Parent Organization

Email Address

Date

Physical Education/Health Teacher Name

Email Address

Date

Principal’s Name

Email Address

Date

Please submit your completed application and documentation to your State Child Nutrition Agency.
Public reporting burden for this collection of information is estimated to average 2 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. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and
Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524).
Do not return the completed form to this address.

School Name:
Page 14

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Review Committee Verification Form

For simplified school district applications only
Please read the following statement and add your name and date below if you agree:
We have reviewed this application, and we agree that our school meals are healthy and appealing to our
students. We attest to the accuracy of the information provided in this application and attest that it applies
to all schools in the district unless otherwise noted. We agree to maintain the nutrition excellence and
physical education/activity standards and procedures indicated in this application for the duration of our
certification as a HUSSC awardees. Furthermore, we agree to cooperate with USDA and other
organizations, upon request, to publicize our efforts.

Superintendent Name

Email Address

Date

District Food Service Authority Name/Address

Email Address

Date

Representative of the District’s Parent Organization

Email Address

Date

Please submit your completed application and documentation to your State Child Nutrition Agency.
Public reporting burden for this collection of information is estimated to average 2 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. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and
Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524).
Do not return the completed form to this address.

School Name:
Page 15

ATTACHMENT A
HealthierUS School Challenge
Recognizing Excellence in Nutrition and Physical Activity
Application Check-off Sheet
Please include the following information in your Application:
Cover Sheet (pg 2)
Table of Contents (pg 3)
Application Form (pg 4)
Smart Snacks Worksheet (pg 5-6)
Nutrition Education Worksheet (pg 7)
Physical Education/Activity Worksheet (pg 8-10)
Wellness Policy Worksheet (pg 11)
Other Criteria for Excellence Checklist (pg 12-13)
Review Committee Verification Form (pg 14-15)
Copy of the School Wellness Policy and Team Nutrition Verification

Thank you for applying for the HealthierUS School Challenge.
For more information, visit the Team Nutrition Website:
www.teamnutrition.usda.gov

School Name:
Page 16