State/Local: H - School Meal Count Verification Form

OMB Approval No.: 0584-0530

Approval Expires:

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

SCHOOL MEAL COUNT VERIFICATION FORM

FOR TARGET WEEK

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 20 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

SFA: | | | | | | | | |

School: | | | | | | | | |

Target Week Start and End Dates: | | | / | | | / | | | To | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

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

SCHOOL MEAL COUNT VERIFICATION FORM

FOR TARGET WEEK

A. Meal Counts for: Lunch |___| Breakfast |___| (USE ONE FORM PER EATING OCCASION)

FOR A PROVISION 2 OR 3 SCHOOL OPERATING IN A NON-BASE YEAR OR A CEO SCHOOL, ENTER TOTAL COUNTS ONLY.

MONDAY: | | | / | | | / | | | MONTH DAY YEAR	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 1:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 2:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 3:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 4:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |

MONDAY (continued)	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 5:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 6:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 7:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 8:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 9:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 10:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
DAILY TOTAL FOR ALL REGISTERS	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
IF NO MEAL SERVED OR NO DATA AVAILABLE THAT DAY, RECORD REASON	School holiday 1 Cafeteria closed 2 Interviewer unable to access daily data 3	Other (SPECIFY):

TUESDAY (continued)	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 1:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 2:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 3:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 4:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 5:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 6:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 7:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 8:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |

TUESDAY (continued)	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 9:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 10:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
DAILY TOTAL FOR ALL REGISTERS	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
IF NO MEAL SERVED OR NO DATA AVAILABLE THAT DAY, RECORD REASON	School holiday 1 Cafeteria closed 2 Interviewer unable to access daily data 3	Other (SPECIFY):

WEDNESDAY: | | | / | | | / | | | MONTH DAY YEAR
	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 1:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 2:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 3:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |

WEDNESDAY (continued)	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 4:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 5:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 6:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 7:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 8:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 9:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 10:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
DAILY TOTAL FOR ALL REGISTERS	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
IF NO MEAL SERVED OR NO DATA AVAILABLE THAT DAY, RECORD REASON	School holiday 1 Cafeteria closed 2 Interviewer unable to access daily data 3	Other (SPECIFY):

THURSDAY: | | | / | | | / | | | MONTH DAY YEAR	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 1:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 2:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 3:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 4:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 5:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 6:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 7:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 8:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |

THURSDAY (continued)	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 9:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 10:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
DAILY TOTAL FOR ALL REGISTERS	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
IF NO MEAL SERVED OR NO DATA AVAILABLE THAT DAY, RECORD REASON	School holiday 1 Cafeteria closed 2 Interviewer unable to access daily data 3	Other (SPECIFY):

FRIDAY: | | | / | | | / | | | MONTH DAY YEAR	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 1:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 2:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 3:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 4:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |

FRIDAY (continued)	SCHOOL RECORDED COUNTS	FIELD STAFF VERIFIED COUNTS
Register 5:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 6:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 7:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 8:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 9:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
Register 10:	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
DAILY TOTAL FOR ALL REGISTERS	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |	Free: | |,| | | | Reduced: | |,| | | | Paid (Full-Price): | |,| | | | Total: | |,| | | |
IF NO MEAL SERVED OR NO DATA AVAILABLE THAT DAY, RECORD REASON	School holiday 1 Cafeteria closed 2 Interviewer unable to access daily data 3	Other (SPECIFY):

B. STUDENT INFORMATION FOR SCHOOL

1. Total number of enrolled students: | | | |,| | | |

2. Average daily attendance: | | | |,| | | |

or | | | | %

IF SCHOOL IS PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR, SKIP TO SECTION C.

IF SCHOOL IS CEO SCHOOL, SKIP TO SECTION D.

3. Number of students approved for free meals: | | | |,| | | |

4. Number of students approved for reduced-price meals: | | | |,| | | |

C. PROVISION 2 OR 3 CLAIMING PERCENTAGES

COMPLETE ONLY FOR P2/3 SCHOOL IN NON-BASE YEAR

Lunch |___| Breakfast |___| (MUST MATCH EATING OCCASION CHECKED ON PAGE 1)

CLAIMING PERCENTAGES USED BY SCHOOL:

1. Free Meals | | | | PERCENT

2. Reduced-Price Meals | | | | PERCENT

3. Paid Meals | | | | PERCENT

BASE YEAR PERIOD USED:

BASE YEAR PERIOD USED:

Yearly Percentages 1

Monthly Percentages 2

Specify Month:

D. CEO SCHOOL CLAIMING PERCENTAGES

COMPLETE ONLY FOR CEO SCHOOL

Lunch |___| Breakfast |___| (MUST MATCH EATING OCCASION CHECKED ON PAGE 1)

CLAIMING PERCENTAGES USED BY SCHOOL:

1. Free Meals | | | | PERCENT

2. Paid Meals | | | | PERCENT

Prepared by Mathematica Policy Research Page 0