Profit/Non-profit Sponsors and Child Care Centers

APPENDIX C17. MEAL COUNTS FOR OBSERVATION MONTH

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

ERRONEOUS PAYMENTS IN CHILD CARE CENTERS STUDY (EPICCS)

MEAL COUNTS FOR OBSERVATION MONTH

Summary

A request for an electronic data file will collect final meal counts data for the month that meal observations were completed at the center. This data will be used to make dollar estimates for erroneous payments due to meal claiming errors.

The request will be targeted to the center and will specify the month that the final meal counts are requested.

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 complete this information collection is estimated to average one hour 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.

Center Name: <INSERT NAME OF CENTER> Center Study ID: <INSERT CENTER ID>

Sponsor Name: <INSERT NAME OF SPONSOR> Sponsor ID: <INSERT SPONSOR STUDY ID>

________________________________________________________________________________________________

CENTER MEAL COUNTS FOR BREAKFAST AND LUNCH

The EPICCS data collector observed meal service during < INSERT MONTH YEAR>. Please record the final meal counts for each meal (breakfast or lunch) in the appropriate certification category. For days that the center was not operating, indicate NA. Record “Total” only if Child Care Center does not break out meal counts into certification status categories (free, reduced and paid).

A1. FINAL BREAKFAST COUNTS FOR < INSERT MONTH YEAR>

Check here if center does not serve breakfast: 

Day of Month	Free	Reduced	Paid	Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

A2. FINAL LUNCH COUNTS FOR < INSERT MONTH YEAR>

Check here if center does not serve breakfast: 

Day of Month	Free	Reduced	Paid	Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

SPECIAL NOTES / COMMENTS:

Provide any additional comments regarding center meal counts.

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