State/Local: F - Certified and Denied Applicant Sampling

A ttachment F.2- CERTIFIED AND DENIED APPLICANT SAMPLING FORM

– NEWLY CERTIFIED

OMB Approval No.: 0584-0530

Approval Expires:

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

STUDENT SAMPLE CONTACT INFORMATION FORM FOR NEWLY APPROVED

FREE\REDUCED-PRICE SAMPLE

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0584-0530. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

NATIONAL SCHOOL LUNCH AND SCHOOL BREAKFAST PROGRAM ACCESS,

PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

STUDENT SAMPLE CONTACT INFORMATION FORM FOR NEWLY APPROVED

FREE\REDUCED-PRICE SAMPLE

SCHOOL DISTRICT ID NUMBER: | | | | | | | | | SCHOOL DISTRICT NAME:

SCHOOL ID NUMBER: | | | | | | | | | SCHOOL NAME:

DATE: | | | / | | | / | | |

MONTH DAY YEAR

I. NEWLY APPROVED FREE AND REDUCED-PRICE SAMPLE

SAMPLE RESULTS

A.

B.

C.

D.

E.

F.

G.

H.

Student Number

Selection Order

Selection Type (M or R)

Student Name

Grade

Parent’s Name

Mailing Address

Telephone Number

1.

First: Middle: Last:

First: Middle: Last:

Street: City: State: Zip:

Area Code: ( ) _________ _________

I. Application Number: _______________________________

J. Certification Status: Free Reduced Price

K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR

L. Did student enroll in this school after the beginning of the school year?  Yes  No

If Yes, did student transfer from within the district?  Yes  No

2.

First: Middle: Last:

First: Middle: Last:

Street: City: State: Zip:

Area Code: ( ) _________ _________

I. Application Number: _______________________________

J. Certification Status: Free Reduced Price

K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR

L. Did student enroll in this school after the beginning of the school year?  Yes  No

If Yes, did student transfer from within the district?  Yes  No

3.

First: Middle: Last:

First: Middle: Last:

Street: City: State: Zip:

Area Code: ( ) _________ _________

I. Application Number: _______________________________

J. Certification Status: Free Reduced Price

K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR

L. Did student enroll in this school after the beginning of the school year?  Yes  No

If Yes, did student transfer from within the district?  Yes  No

4.

First: Middle: Last:

First: Middle: Last:

Street: City: State: Zip:

Area Code: ( ) _________ _________

I. Application Number: _______________________________

J. Certification Status: Free Reduced Price

K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR

L. Did student enroll in this school after the beginning of the school year?  Yes  No

If Yes, did student transfer from within the district?  Yes  No

5.

First: Middle: Last:

First: Middle: Last:

Street: City: State: Zip:

Area Code: ( ) _________ _________

I. Application Number: _______________________________

J. Certification Status: Free Reduced Price

K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR

L. Did student enroll in this school after the beginning of the school year?  Yes  No

If Yes, did student transfer from within the district?  Yes  No

6.

First: Middle: Last:

First: Middle: Last:

Street: City: State: Zip:

Area Code: ( ) _________ _________

I. Application Number: _______________________________

J. Certification Status: Free Reduced Price

K. Application/Certification Dates: Application Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR Certification Date: | | | / | | | / | | |  Date Not Available MONTH DAY YEAR

L. Did student enroll in this school after the beginning of the school year?  Yes  No

If Yes, did student transfer from within the district?  Yes  No

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