Profit/Non-profit Sponsors and Child Care Centers

APPENDIX C6. MEAL OBSERVATION FORM-FAMILY STYLE

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

ERRONEOUS PAYMENTS IN CHILD CARE CENTER STUDY (EPICCS)

MEAL OBSERVATION FORM – FAMILY STYLE

Summary

Field Data Collectors will use this form to document food production records and observations of meals served at the child care centers to CACFP eligible children. This form is used for meals served family style, with the children serving themselves or staff serving the children.

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 for the child care center director or manager to provide information concerning the center’s food production records and meal service is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the collection of information.

SECTION A: MEAL OBSERVATION SUMMARY

SPONSOR Name and ID: | | | |

CENTER Name and ID: | | | | | |

Date:	| | | / | | | / | | | | |				Time Observation Began: | | | / | | |				am
	MONTH	DAY	YEAR				hour	minute	pm

Data Collector Name & ID: | | |		Time Observation Ended: | | | / | | |			am
			hour	minute	pm

Meal Period: ____________________	Meal Type:	 Breakfast	 Lunch

SECTION B: SELECTION OF SERVING LOCATION AND/OR MEAL PERIOD

NOTE: Section B will only be completed if the center has multiple serving locations and/or meal periods. This information only needs to be recorded ONCE (in one booklet) per center.

The center may have more than one location for serving meals (e.g. in each classroom or separate rooms) and/or multiple meal periods in a single location or in each location. Observations must be conducted for each meal period. However, the serving location for each period must be randomly selected. Obtain and enter the information in the meal transaction sampling spreadsheet to obtain the instructions on which location to observe for each meal period. Document the information and results in the tables below.

Center Meal Serving Information

BREAKFAST				LUNCH
Serving Location	# of Periods	Approximate # of children		Serving Location	# of Periods	Approximate # of children
1				1
2				2
3				3
4				4

Results

Breakfast			Lunch
Period	Serving Location		Period	Serving Location
1			1
2			2
3			3
4			4

SECTION C: MEAL PRODUCTION RECORD – FAMILY STYLE

Record meal production information as provided by Center staff. The meal production record is for the entire center’s meals served on the observation day to children up to 5 years old.

Does the number served at the table include adults supervising the meals? ☐ Yes ☐ No

If yes, how many adults? _________________

Meal Pattern	Food Item	Serving Size	Total Amount Prepared	# Served
BREAKFAST – Must serve all 3 components
Fluid Milk
Vegetable/Fruit or Juice
Grains/Breads
Other Food: __________
Other Food: __________
LUNCH – Must serve all 5 components
Fluid Milk
Meat/Meat Alternate
Vegetable/Fruit
Vegetable/Fruit
Grains/Breads
Other Food: __________
Other Food: __________

SECTION D: MEAL OBSERVATION – FAMILY STYLE

Record breakfast meals that are served family style at each table and/or serving location. Please be sure to check the age group of children (as provided by Center director and/or classroom teacher) being served breakfast and if a supervising adult eats with children.

Table and/or Serving Location:	______________________________________
Number of Children Served by Age:	Ages 1-2: ________	Ages 3-5: ______
Does Supervising Adult Eat with Children?	☐ Yes	☐ No
Meal Pattern	Food Item Served	Serving Size Comment
BREAKFAST – Must serve all 3 components
Fluid Milk
Vegetable/Fruit or Juice
Grains/Breads
Other Food: __________
Other Food: __________

*The table will repeat for each breakfast meal observed at each table and/or serving location.

Record lunch meals that are served family style at each table and/or serving location. Please be sure to check the age group of children (as provided by Center director and/or classroom teacher) being served lunch and if a supervising adult eats with children.

Table and/or Serving Location:	______________________________________
Number of Children Served by Age:	Ages 1-2: ________	Ages 3-5: ______
Does Supervising Adult Eat with Children?	☐ Yes	☐ No
Meal Pattern	Food Item Served	Serving Size Comment
LUNCH – Must serve all 5 components
Fluid Milk
Meat/Meat Alternate
Vegetable/Fruit
Vegetable/Fruit
Grains/Breads
Other Food: __________
Other Food: __________

*The table will repeat for each lunch meal observed at each table and/or serving location.

SECTION E: MEAL OBSERVATION NOTES

1. Did you find any differences between food items served and those documented on food production record/menu?

2. Were any changes to the menu documented?

3. Were children encouraged to accept/eat the full required portion?

Additional Comments: Provide any additional comments regarding the meal observation. In addition, record any special meal circumstances observed (e.g., number of children that ate a different meal due to food allergy or any changes in food such as the use of a meat alternative, etc.).

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