CACFP Characteristics - Businesses

OMB Control No.: 0584‐0601

Expiration Date: 04/30/2018

Exhibit 2: Family Day Care Home Sponsor Web Survey

FDCH Name: ______________ FDCH’s Sponsor ID Number: ________________

1. Did this provider submit a claim for meals served in October 2016?

YES ________ GO TO QUESTION 2

 NO ________ THANK YOU.

2. What was the tiering status of this FDCH?

Tier I _______

Tier II-Low   _______

Tier II-Mixed _______

Tier II-Hi _______

3. How many children were included on this FDCH’s October 2016 claim for reimbursement?

_________ Children included in October 2016 claim

4. Of the <number from Q.3> children on this FDCH’s October 2016 claim for reimbursement, how many were for meals claimed at the Tier I and Tier II rates?

_________ Children at Tier I rates

_________ Children at Tier II rates

THANK YOU.  

Frederic Glantz, President

Kokopelli Associates, LLC

Disclosure statement:

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 0584‐0601. The time required to complete this information collection is estimated to average 20 minutes 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.

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