CACFP Characteristics - Businesses

OMB Control No.: 0584‐0601

Expiration Date: 04/30/2018

Exhibit 4: Independent Child Care Center and Sponsored Child Care Center Web Survey

Center Name: ______________

Address: __________________________________________________________________

City _________________________ State ___________ Zip Code ________________

1. Did your center submit a claim for meals served in October 2016?

YES ________ GO TO QUESTION 2

  NO ________ THANK YOU.

2. What was your center’s total enrollment in October 2016?

_______ CHILDREN

 3. Of the <number from Q.2> children on this center’s October 2016 claim for reimbursement, how many were for meals reimbursed at the free, reduced-price, and paid rates?

Free   _______

Reduced-Price _______

Paid ________

Please check to make certain that these numbers add up to the total enrollment reported in Question 2.

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 15 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.