Profit/Non-profit Sponsors and Child Care Centers

APPENDIX C12. (INDEPENDENT) CENTER MEAL CLAIM TO STATE FOR TARGET MONTH

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

ERRONEOUS PAYMENTS IN CHILD CARE CENTERS STUDY (EPICCS)

(INDEPENDENT) CENTER MEAL CLAIM TO STATE FOR TARGET MONTH

Summary

Field Data Collectors will collect this data from meal claim records from the independent center to the State agency. While onsite, the data will be abstracted and entered on computerized data entry forms. This data will be compared to eligibility status, attendance records, and meal count records during data analysis.

Data variables that can be pre-loaded into this instrument are: sampled child care center name, child care center study ID, and target month as well as meal count totals for the target month as entered on Form D2.

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 collection is 0584-XXXX. The time required for data managers from the sponsoring organizations to complete this information collection is estimated to average two hours per response. This time estimate includes the time to review instructions, search existing data resources, gather and maintain the data needed and complete and review the collection of information.

Center Name: Date of Data Collection: | | | / | | | / | | | | |

MONTH DAY YEAR

Center Study ID: | | | | | | | | | Target Month: | | |/ | | | | |

MONTH YEAR

1. (INDEPENDENT) CENTER MEAL CLAIM TO STATE AGENCY (TARGET MONTH)

A1. NUMBER OF OPERATING DAYS (during the target month)

Breakfast Lunch

| | | | | |

A2. BREAKFAST

Meal Claim Submitted by Independent Center to State Agency

Free: | | | |,| | | |

Reduced: | | | |,| | | |

Paid: | | | |,| | | |

Total: | | | |,| | | |

PROGRAMMING NOTE: DISPLAY CALCULATED, SUMMED COUNTS OF BREAKFASTS BY MEAL CATEGORY FROM FORM D2.

A3. LUNCH

Meal Claim Submitted by Independent Center to State Agency

Free: | | | |,| | | |

Reduced: | | | |,| | | |

Paid: | | | |,| | | |

Total: | | | |,| | | |

PROGRAMMING NOTE: DISPLAY CALCULATED, SUMMED COUNTS OF LUNCHES BY MEAL CATEGORY FROM FORM D2.

2. CENTER MEAL COUNT AND CLAIM COMPARISON

The number of meals an INDEPENDENT CENTER claims and reports to the STATE AGENCY may differ from what the INDEPENDENT CENTER reported on meal count records due to some form adjustment or error. Use the comments section to document any comments or notes that may explain any discrepancies.

B1. COMPARE BREAKFAST COUNTS AND CLAIMS. Compare the INDEPENDENT CENTER CLAIMS to State agency against the INDEPENDENT CENTER MEAL COUNT reported for the target month. If they differ, then check the INDEPENDENT CENTER records to see if there are any notes in the file indicating that the INDEPENDENT CENTER corrected the breakfast counts. Document your findings in the space provided below under “COMMENTS.”

1. DID YOU FIND A DISCREPANCY IN BREAKFAST MEAL COUNTS?

YES 1

NO 2 (GO TO B1d)

2. SELECT THE STATEMENTS BELOW THAT BEST DESCRIBE ANY DISCREPANCY FOUND BETWEEN BREAKFAST COUNTS IN THE INDEPENDENT CHILD CARE CENTER MEAL COUNTS AND NUMBERS CLAIMED TO THE STATE. (MARK ALL THAT APPLY)

MORE FREE BREAKFASTS CLAIMED 1

FEWER FREE BREAKFASTS CLAIMED 2

MORE REDUCED-PRICE BREAKFASTS CLAIMED 3

FEWER REDUCED-PRICE BREAKFASTSCLAIMED 4

MORE PAID BREAKFASTS CLAIMED 5

FEWER PAID BREAKFASTS CLAIMED 6

MORE TOTAL BREAKFASTS CLAIMED 7

FEWER TOTAL BREAKFASTS CLAIMED 8

OTHER, SPECIFY 9

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3. DESCRIBE DIFFERENCES IN THE BREAKFASTS CLAIMED FOR EACH ITEM MARKED ABOVE. THAT IS, HOW MANY MORE OR FEWER BREAKFASTS WERE CLAIMED?

4. DID THE INDEPENDENT CENTER MAKE NOTES INDICATING WHY CORRECTIONS WERE MADE?

YES........................................................................................ 1

NO.......................................................................................... 2 (GO TO B2)

5. SUMMARIZE THE INDEPENDENT CENTER’S NOTES ABOUT THE CORRECTIONS

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6. ARE THE INDEPENDENT CENTER’S NOTES CONSISTENT WITH YOUR FINDINGS?

YES........................................................................................ 1(GO TO B2)

NO.......................................................................................... 2

7. DESCRIBE DIFFERENCES BETWEEN YOUR FINDINGS AND THE CENTER’S NOTES.

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B2. COMPARE LUNCH COUNTS AND CLAIMS. Compare the INDEPENDENT CENTER CLAIMS to State agency against the INDEPENDENT CENTER MEAL COUNT for the target month. If they differ, then check the INDEPENDENT CENTER records to see if there are any notes in the file indicating that the INDEPENDENT CENTER corrected the lunch counts. Document your findings in the space provided below under “COMMENTS.”

1. DID YOU FIND A DISCREPANCY IN LUNCH MEAL COUNTS?

YES 1

NO 2 (GO TO B2d)

2. SELECT THE STATEMENTS BELOW THAT BEST DESCRIBE ANY DISCREPANCY FOUND BETWEEN LUNCH COUNTS IN THE INDEPENDENT CHILD CARE CENTER MEAL COUNTS AND THE NUMBER CLAIMED TO THE STATE. (MARK ALL THAT APPLY)

MORE FREE LUNCHES CLAIMED 1

FEWER FREE LUNCHES CLAIMED 2

MORE REDUCED-PRICE LUNCHES CLAIMED 3

FEWER REDUCED-PRICE LUNCHES CLAIMED 4

MORE PAID LUNCHES CLAIMED 5

FEWER PAID LUNCHES CLAIMED 6

MORE TOTAL LUNCHES CLAIMED 7

FEWER TOTAL LUNCHES CLAIMED 8

OTHER, SPECIFY 9

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3. DESCRIBE DIFFERENCES IN THE LUNCHES CLAIMED FOR EACH ITEM MARKED ABOVE. THAT IS, HOW MANY MORE OR FEWER MEALS WERE CLAIMED?

4. DID THE CENTER MAKE NOTES INDICATING WHY CORRECTIONS WERE MADE?

YES........................................................................................ 1

NO.......................................................................................... 2 (GO TO C)

5. SUMMARIZE THE INDEPENDENT CENTER’S NOTES ABOUT THE CORRECTIONS

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6. ARE THE INDEPENDENT CENTER’S NOTES CONSISTENT WITH YOUR FINDINGS?

YES........................................................................................ 1(GO TO C)

NO.......................................................................................... 2

7. DESCRIBE DIFFERENCES BETWEEN YOUR FINDINGS AND THE CENTER’S NOTES.

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3. SPECIAL NOTES / COMMENTS:

Provide any additional comments regarding (independent) center meal claims sent to the state for the target month.

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