Consumer Research for Nutrition Educatoin and Promotion Activities (SLT)

Generic Clearance to Conduct Formative Research

Appendix A.7 FNS-779 HUSSCSL2014

Consumer Research for Nutrition Educatoin and Promotion Activities (SLT)

OMB: 0584-0524

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OMB APPROVED NO. 0584-0524
Expiration Date: XX/XX/XXXX

Food and Nutrition Service

HealthierUS School Challenge:
Smarter Lunchrooms

General Information
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 0584-0524. The time
required to complete this information collection 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.

The HealthierUS School Challenge:Smarter Lunchrooms (HUSSC: SL) is a voluntary certification
initiative recognizing those schools enrolled in Team Nutrition that have created healthier school
environments through promotion of smarter lunchrooms, nutrition, and physical activity. Schools
receiving a HUSSC award will commit to meeting the criteria throughout their 4-year certification
period. Recognized schools receive a plaque with a certificate signed by the Secretary of Agriculture,
a display banner, recognition on the Team Nutrition Website, and a monetary incentive.
After being awarded, schools should work with their school district’s financial management/budget
staff to verify their DUNS Number and District’s Tax ID (EIN) Number within the System for Awards
Management (SAM) https://www.sam.gov. Monetary incentives are awarded on a quarterly basis and
once the school is formally announced as an award winner, a banking information request form will be
sent for the school district to complete by the end of that quarter. Submit the complete and
accurate form to USDA/FNS Team Nutrition staff for information verification and payment processing
via electronic funds transfer to the award-winning school(s). Incorrect or inadequate information
and the failure to ensure the information contained in the SAM is correct and current will delay
the processing of the funds payment to your district, and may even result in the elimination of
your ability to receive the award funds.
Recognized as a Healthy Schools Program school in SY 2014-2015 or later.
Awardee should submit a copy of their HSP recognition certificate with their HUSSC: SL
application in lieu of completing application ONLY if they want to be automatically awarded at the
HUSSC: SL Bronze level.

School

HealthierUS School Challenge: SL Application 1

Food and Nutrition Service

HealthierUS School Challenge:
Smarter Lunchrooms

General Information Continued
Tips for Completing Application:
1. You can submit your application two ways:
n Submit the application and supporting documentation in a 3-ring binder to your State
Child Nutrition Agency.
n 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:
n The same nutrition education, physical education, and physical activities are provided
or offered (according to the grade level).
n The same Smart Snacks foods and beverages were sold throughout the cafeteria and/
or school campus. Submit:
a.) One Smart Snacks Worksheet with a listing of foods available and
b.) One set of supporting documentation.
n Each individual school follows the district’s wellness policy.
In addition, each school within the District must submit a Smarter Lunchroom Self-Assessment Score
Card, individual School Wellness Policy Worksheet (if applicable) and complete the Other Criteria for
Excellence Checklist, which are both included in the application. If a district finds that their schools
has different nutrition education, physical education, physical activities, competitive foods,
or wellness policies, they can still apply as a district, but must make note of those items that
differ among the schools on the application worksheets and submit additional documentation
for those schools with the district application.
Each District must submit an Application Cover Sheet reflecting the name of the District with a
completed District School List form.

School

HealthierUS School Challenge: SL Application 2

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Application Cover Sheet
Application for:

Bronze

Silver

Gold

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 re-printed due to an incorrect or illegible school name.

School Name

PRINT OR TYPE ALL INFORMATION

School District
School Address
Grades in School (list)
more Contact Person’s
info. Name and Title
Contact Person’s
Phone Number
& Email
Date Submitted to
State Agency

FOR OFFICE USE ONLY
State Agency

State Child Nutrition Director Approval:

Signature

Reviewed by:
Reviewer’s Email:
Email of the State Child Nutrition Director:

Date

Phone:

Regional Office
FNS Region:
Child Nutrition Director Approval:

Reviewed by:
Signature

Date

FNS Headquarters
Application received HQ:

Reviewed by:

Decision/Date:

Award period:

School

HealthierUS School Challenge: SL Application 3

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Table of Contents

Page Number

Cover Sheet

..............................................................................................

Table of Contents

.....................................................................................

General Criteria Worksheet
Smart Snacks Worksheet

.....................................................................
........................................................................

4
5
6-7

..............................................................

Physical Education Worksheet-Elementary Schools ............................

Physical Education Worksheet-Middle and High Schools ....................

Physical Activity Worksheet ....................................................................

School Wellness Policy Worksheet

Nutrition Education Worksheet

.......................................................

Other Criteria for Excellence Checklist
Review Committee Verification Form
Application Check-off Sheet

School

.................................................

13-15

....................................................

16-17

...................................................................

HealthierUS School Challenge: SL Application 4

FNS HealthierUS School Challenge:
Smarter Lunchrooms

General Criteria Worksheet

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
performance-based reimbursement (Healthy Hunger-Free Kids Act 2010)?
Is your school implementing Smarter Lunchroom techniques in six areas (Fruits,
Vegetables, Entrees, 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 action 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?
No ADP requirement for Bronze.
Breakfast: Elementary and Middle School ADP: 35% Gold and Gold Award of Distinction, 20% Silver
High School ADP: 25% Gold and Gold Award of Distinction, 15% Silver
Lunch: Elementary and Middle School ADP: 75% Gold and Gold Award of Distinction, 60% Silver
High School ADP: 65% Gold and Gold Award of Distinction, 45% Silver
Both the breakfast and the lunch ADPs should be reported for the same month.
List ADP for Breakfast calculated based on attendance: more info.
Month/Year:
List ADP calculated for Lunch based on attendance: more info.
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.

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Smart Snack Worksheet
All Award Levels: Must meet Smart Snack 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 store, 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 Snack Calculator to analyze foods and beverages sold to students during the
school day (http://healthymeals.nal.usda.gov/smartsnacks). Provide a copy of the calculator
results, along with the product nutrition facts labels and ingredient statement with the HUSSC:
SL application.
Additional Smart Snacks Criteria
Bronze and Silver
Meets Smart Snacks criteria as defined in 7 CFR Parts 210 and 220.
The school offers training on Smart Snacks criteria annually and 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 the
Smart Snacks criteria to students (e.g. signs and marketing materials promoting these
foods are not visible to the students on the school campus during the school day.)
Documentation of meeting these criteria includes evidence of a written policy and/or written
communication/training for school staff and parent organizations. Describe below how the
school meets these criteria and provide documentation with HUSSC: SL application.

School

HealthierUS School Challenge: SL Application 6

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Smart Snack Worksheet Continued
Gold
Meets criteria for Bronze and Silver and
The school only permits food-related fundraisers that meet USDA’s Smart Snack
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.)

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, fruit, and/or vegetables are also offered and promoted as options. Documentation
of meeting these criteria includes a written school policy and/or instruction 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: SL 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: SL application.
List attached and documentation included with application.

School

HealthierUS School Challenge: SL Application 7

FNS HealthierUS School Challenge:
Smarter Lunchrooms

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. Your HSP award must be dated within a year of your HUSSC: SL application.
Elementary Schools:
Is Nutrition Education provided to all full-day students in all grades?
Yes
No
more
info.
Briefly describe below how nutrition education is provided to all students and:
Is part of structured and systematic unit of instruction.
Incorporates Team Nutrition curricula and materials.
Middle and High Schools Gold and Gold Award of Distinction:
Briefly describe below how nutrition education is offered to:
Middle school students in at least two grades. Nutrition education offered must incorporate latest
Dietary Guidelines for Americans and MyPlate and Team Nutrition materials.
High school students in at least two courses required for graduation. List the courses below. Nutrition
education must be part of a structured and systematic unit of instruction within the two courses. Nutrition
education must be consistent with latest Dietary Guidelines for Americans and MyPlate.
Middle and High Schools Bronze and Silver:
Briefly describe below how nutrition education is offered to:
Middle school students offered in at least one grade. Nutrition education offered must incorporate latest
Dietary Guidelines for Americans and MyPlate and Team Nutrition materials.
High school students in at least two courses required for graduation. List the courses below. Nutrition
education must be part of a structured and systematic unit of instruction within the two courses. Nutrition
education must be consistent with latest Dietary Guidelines for Americans and MyPlate.
All grades and award levels should utilize multiple channels of communication, including classroom, cafeteria, and home/parents.
Describe below.

Grades

School

Description of Nutrition Education Efforts

Communication Channel Used

HealthierUS School Challenge: SL Application 8

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Physical Education Worksheet-Elementary Schools

Does your school provide physical education (PE) 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* physical education per week.

*Up to 45 minutes (Gold/Gold Award of Distinction,) *up to 20 minutes (Bronze/Silver,) 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.
Physical Education Details

Grades

School

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

Description of Physical Education Offered

HealthierUS School Challenge: SL Application 9

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Physical Education Worksheet-Middle and High Schools

School

Physical Education

Description of Physical Education Offered

HealthierUS School Challenge: SL Application 10

FNS HealthierUS School Challenge:
Smarter Lunchrooms

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.
Physical Activity
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.
Physical Activity Details
Grades

School

Describe Physical Activity Provided

HealthierUS School Challenge: SL Application 11

FNS HealthierUS School Challenge:
Smarter Lunchrooms

School Wellness Policy Worksheet
Provide a copy of the school’s local wellness policy with the HUSSC: SL
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,
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.
(For example your school does not sell competitive foods.)

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

HealthierUS School Challenge: SL Application 12

FNS HealthierUS School Challenge:
Smarter Lunchrooms

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, click on this link
http://www.fns.usda.gov/school-meals/community-eligibility-provision).

School

HealthierUS School Challenge: SL Application 13

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Other Criteria for Excellence Checklist Continued
Excellence in School and Community Involvement in Wellness Efforts

Provides 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
groups.

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. Provide a brief description.

School informs public on amount of time allotted for eating lunch. Solicits input 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. Provide a brief description.

School

HealthierUS School Challenge: SL Application 14

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Other Criteria for Excellence Checklist
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 final rule requirements.
Provide a brief description.

All school nutrition program directors, managers, and staff meet or exceed the
annual continuing education/training hours required by the Professional
Standards final rule requirements. Provide a brief description.

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 into 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.
Provide a brief description.

School has joined the U.S. Food Waste Challenge to recognize efforts to
reduce food waste. Provide a brief description.

School

HealthierUS School Challenge: SL Application 15

FNS HealthierUS School Challenge:
Smarter Lunchrooms

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, physical education/activity, and other criteria for excellence standards and procedures indicated in this application for the duration of our certification as HUSSC: SL
awardees. Furthermore, we agree to cooperate with USDA and other organizations upon request to
publicize our efforts.
Foodservice Manager’s Name/Address

Email Address

Date

Team Nutrition Leader’s Name

Email Address

Date

District Food Service Authority Name/Address
(Foodservice Director)

Email Address

Date

Representative of the School’s Parent Organization

Email Address

Date

Physical Education/Health Teacher’s Name

Email Address

Date

Principal’s Name/Address

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 Service, Office
of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed
form to this address.

School

HealthierUS School Challenge: SL Application 16

FNS HealthierUS School Challenge:
Smarter Lunchrooms

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, physical education/activity, and other criteria for excellence standards and procedures
indicated in this application for the duration of our certification as HUSSC: SL 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
(Foodservice Director)

Email Address

Date

Email Address

Date

Representative of the District’s Parent
Organization Name

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 Service, Office of
Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed form
to this address.

School

HealthierUS School Challenge: SL Application 17

FNS HealthierUS School Challenge:
Smarter Lunchrooms

Application Check-off Sheet
Please include the following information in your Application:
Application Cover Sheet (pg 3)
Table of Contents (pg 4)
General Criteria Worksheet (pg 5)
Smart Snacks Worksheet (pg 6-7)
Nutrition Education Worksheet (pg 8)
Physical Education Worksheets (pg 9-10)
Physical Activity Worksheet (pg 11)
School Wellness Policy Worksheet (pg 12)
Other Criteria for Excellence Checklist (pg 13-15)
Review Committee Verification Form (pg 16-17)
Check-off Sheet (pg 18)
Please submit the following additional documentation:
Copy of the School Wellness Policy (if school does not have its own and follows a District
Wellness Policy, please submit a copy).
Smart Snacks documentation including Alliance for a Healthier Generation Smart Snacks Calculator
results, along with product nutrition fact labels and ingredient statements or recipes to verify that the
Smart Snacks criteria have been met.
Completed Smarter Lunchrooms Scorecard and Documentation
School District Financial Manager

more Name:
info.
Email:

Phone Number:

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

HealthierUS School Challenge: SL Application 18

File Type	application/pdf
File Title	form.indd
File Modified	2016-05-17
File Created	2014-07-22