Private Schools: F - Certified and Denied Applicant Sampling

Third Access, Participation, Eligibility and Certification Study Series (APEC III)

rev062112 Attachment F.2-Newly Cert FRP

Private Schools: F - Certified and Denied Applicant Sampling

OMB: 0584-0530

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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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File Modified2012-06-27
File Created2012-01-19

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