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State, Local, and Tribal Government - State Child Nutrition Agency, SFA, and Schools
ICR 201705-0584-004 · OMB 0584-0530 · Object 73929901.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | State, Local, and Tribal Government - State Child Nutrition Agency, SFA, and Schools |
| Author | Megan Collins |
| Last Modified By | Writer |
| File Modified | 2017-01-25 |
| File Created | 2026-09-13 |
| Conversion State | complete |
Extracted Text
OMB Number: 0584-0530
Expiration Date: XX/XX/XXXX
Third Access, Participation, Eligibility and Certification Study Series (APEC III)
SFA REIMBURSEMENT CONSOLIDATION AND CLAIM VERIFICATION FORM—ALL SCHOOLS
SUMMARY:
The data collector will obtain and abstract meal count and claims data for the Target Month, which is the most recent calendar month in which meal count and claims data were submitted. In the rare instances in which the data for the Target Month is no longer available or accessible, the data collector will abstract data for the Target Week, which is the week prior to the data collection visit. In the even more rare instance in which the Target Week is not available, the data collector will collect the data for the Target Day, which is the day of the data collection visit.
Data will be entered into the SFA Reimbursement Consolidation and Claim Verification Form—All Schools on the computer, saved, and securely transmitted to the home office.
SFA meal claim data will be used to determine aggregation errors at the SFA level.
SFA Name: _______________________________________________________
SFA ID: |___|___|___|___|___|___|___|___|
Date Collected: | | | / | | | / | | |
MONTH DAY YEAR
___________________________________________________________________________________________________________
Select ONE (Target Month, Target Week, or Target Day):
Target Month: | | | / | | || | |
MONTH YEAR
Target Week: | | | / | | | / | | | TO | | | / | | | / | | |
MONTH DAY YEAR MONTH DAY YEAR
Target Day | | | / | | | / | | |
MONTH DAY YEAR
IF CEP SCHOOL, ENTER REPORTED MEALS FOR FREE, PAID AND TOTAL ONLY.
IF NUMBER OF SCHOOLS REPORTED EXCEEDS TEN (10), USE ADDITIONAL FORMS TO RECORD INFORMATION.
PART A. MEAL CLAIMS FOR EACH SCHOOL FOR TARGET MONTH (IF TARGET MONTH IS NOT AVAILABLE, ENTER TARGET WEEK OR TARGET DAY DATA)
Number of meals reported by the school to the SFA for School 1.
BREAKFASTS REPORTED
LUNCHES REPORTED
School 1 Name:
Free: | | | |,| | | |
Reduced: | | | |,| | | |
Paid: | | | |,| | | |
Total: | | | |,| | | |
Free: | | | |,| | | |
Reduced: | | | |,| | | |
Paid: | | | |,| | | |
Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 2.
BREAKFASTS REPORTED
LUNCHES REPORTED
School 2 Name:
Free: | | | |,| | | |
Reduced: | | | |,| | | |
Paid: | | | |,| | | |
Total: | | | |,| | | |
Free: | | | |,| | | |
Reduced: | | | |,| | | |
Paid: | | | |,| | | |
Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 3.
BREAKFASTS REPORTED
LUNCHES REPORTED
School 3 Name:
Free: | | | |,| | | |
Reduced: | | | |,| | | |
Paid: | | | |,| | | |
Total: | | | |,| | | |
Free: | | | |,| | | |
Reduced: | | | |,| | | |
Paid: | | | |,| | | |
Total: | | | |,| | | |
Number of meals reported by the school to the SFA for School 4.
BREAKFASTS REPORTED
LUNCHES REPORTED
School 4 Name:
Free: | | | |,| | | |
Reduced: | | | |,| | | |
Paid: | | | |,| | | |
Total: | | | |,| | | |
Free: | | | |,| | | |
Reduced: | | | |,| | | |
Paid: | | | |,| | | |
Total: | | | |,| | | |
*Add additional row for each additional school
PART B. SFA Consolidated Meal Claim – For All Schools in Target Month (IF TARGET MONTH IS NOT AVAILABLE, ENTER TARGET WEEK OR TARGET DAY DATA)
Enter number of meals SFA claimed for all schools.
BREAKFASTS
LUNCHES
Free: | |,| | | |,| | | |
Reduced: | |,| | | |,| | | |
Paid: | |,| | | |,| | | |
Total: | |,| | | |,| | | |
Free: | |,| | | |,| | | |
Reduced: | |,| | | |,| | | |
Paid: | |,| | | |,| | | |
Total: | |,| | | |,| | | |