State, Local, and Tribal Government - State Child Nutrition Agency, SFA, and Schools

APPENDIX B7. APPLICATION DATA ABSTRACTION FORM

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

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

APPLICATION DATA ABSTRACTION FORM

SUMMARY:

Field data collectors will complete the application data abstraction at the SFA in all three phases of school year 2017-2018 data collection. Application abstraction will be used to determine certification error due to administrative error and household reporting error. After sampling, the data collector will abstract key data elements from either the hard copy application or the electronic record for each sampled student and enter the data directly onto the web based data entry form on the laptop computer.

Using a MiFi internet connection on their computer, the data will be entered into the Application Data Abstraction Form and automatically saved and transmitted. In the event the internet connectivity is not available, the data will be entered on hardcopy and later entered into the web based data entry form.

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 0584-0530. The time required for the SFA Director to provide access to the SFA and/or school administrative records is estimated to average 1 hour per response during each data collection round, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the collection of information.

THIRD ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-III)

APPLICATION DATA ABSTRACTION FORM

Select all sources used to complete application data abstraction form

 Paper application  School or district post verification summary

 Web-based application  School or district Agency list

 School or district summary/activity page (screen shot)  Other:

A. STUDENT INFORMATION			IF NOT COMPLETING SECTIONS B, C, AND D, MARK REASON BELOW
STUDENT: (Last Name, First Name)	WESTAT STUDENT ID:		DIRECT CERTIFICATION STUDENT (W/ APP.)  DIRECT CERTIFICATION STUDENT (No APP.)  APPLICATION CANNOT BE FOUND  APPLICATION HAS NOT BEEN SUBMITTED  OTHER REASON (Specify) 
SFA NAME AND ID #:
SCHOOL NAME AND ID #:	GRADE:

B. HOUSEHOLD INFORMATION AND CERTIFICATION STATUS: Complete the information below using the most recent school meal application completed for school year 2017-2018 for the student named in Section A.

	Complete this column based on information from the section of the application completed by school/district staff.
1. APPLICATION DATE | | |/| | |/| | | MONTH DAY YEAR  Date Not Available	4. CERTIFICATION DATE | | |/| | |/| | | MONTH DAY YEAR  Date Not Available
2. BASIS FOR ELIGIBILITY  INCOME  CATEGORICAL CASE #:_____________________________  TANF  FDPIR  MEDICAID  SNAP  Not Specified  SCHIP  FOSTER CHILD  RUNAWAY  MIGRANT  HOMELESS  OBSERVED NEED  INSTITUTIONALIZED/RCCI  Comment (for Other Source C.E.) _______________________	5. CERTIFICATION STATUS  FREE  REDUCED-PRICE  DENIED
3. NUMBER OF STUDENTS COVERED BY APPLICATION | | |	6. SFA’S ASSESSMENT OF NUMBER OF PERSONS IN HOUSEHOLD | | |  Data Not Available
	7. SFA’S ASSESSMENT OF TOTAL INCOME $ | | |,| | | |  Weekly  Bi-weekly  Twice a month  Monthly  Annual  Other _________________  Data not available

C. INCOME RECORDED ON APPLICATION FORMS: List all household members recorded on the application, including all students covered by application. Record income data for all persons receiving income exactly as shown on the application. If the income section for a household member is left blank, enter LB (left blank) in the Earnings from Work column. Enter income denomination codes next to amounts under the “PER” column. W=Weekly; BW=Bi-weekly (every two weeks); TM=Twice a month (semi-monthly); M=Monthly; Y=Yearly; OTH=Other (indicate period on form). If the period is printed in the column heading or instructions, rather than filled in by the applicant, then add “-DP” after the period code. If the period is not available, and the SFA Director verbally provides this information, use the appropriate period code, then add "-DT”. Use the check box to indicate if income was provided from a secondary source (not from the original application). Use the check box to indicate if the SFA Director obtained any information from a phone call with the household. If there is anyone listed on the application that is not listed in the application’s income grid, list them in Section C, Column 1, enter $0 for their income and check “yes” in column 6.

 Income information provided from secondary source (not from the original application)

 Information was obtained by a phone call with the household (PROGRAMMER NOTE: allow data collector to specify which data point was collected via phone call)

1.		2.		3.		4.		5.		6.
LIST HOUSEHOLD MEMBERS		EARNINGS FROM WORK		WELFARE, CHILD SUPPORT, OR ALIMONY (NO SNAP)		PENSIONS, RETIREMENT, OR SOCIAL SECURITY		ALL OTHER INCOME		WAS PERSON ADDED TO THE INCOME GRID BY DATA COLLECTOR?
LAST NAME	FIRST NAME	AMOUNT	PER	AMOUNT	PER	AMOUNT	PER	AMOUNT	PER	 Yes  No
1.		$		$		$		$
2.		$		$		$		$
3.		$		$		$		$
4.		$		$		$		$
5.		$		$		$		$
6.		$		$		$		$
7.		$		$		$		$
8.		$		$		$		$
9.		$		$		$		$
10.		$		$		$		$

D. FORM COMPLETENESS

			Yes		No
	1. Was target child’s name listed?		1		0
	2. If basis for eligibility is income, was income recorded for at least one household member?		1		0	N/A
	3. If basis for eligibility is income, were the last four digits of the SSN of adult signer entered or an indication that signer does not have SSN?		1		0	N/A
	4. If basis for eligibility is TANF, SNAP, or FDPIR, was a case number recorded?		1		0	N/A
	5. Was the form signed by an adult household member?		1		0
E. DATA COLLECTOR SIGNATURE DATA COLLECTOR ID |___|___| - |___|___|___|___|___|				DATE: | | | / | | | / | | | MONTH DAY YEAR