CACFP Characteristics - State Government

Exhibit 6: State Agency Web Survey

OMB Control No.: 0584‐0601

Expiration Date: 04/30/2018

Center Name: ______________

Address: __________________________________________________________________

City _________________________ State ___________ Zip Code ________________

Web questions:

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

YES ________ GO TO QUESTION 2

  NO ________ SKIP TO NEXT CENTER.

2. What was this center’s enrollment for the regular CACFP in October 2016?

_______ CHILDREN

 3. For how many of these children were 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.

SKIP TO NEXT CENTER

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 one hour per respondent, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.