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

APPENDIX C6. SCHOOL MEAL COUNT VERIFICATION FORM

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

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

SCHOOL MEAL COUNT VERIFICATION FORM

SUMMARY:

The data collector will obtain and abstract meal count and claims data from the cashier/school and the final meal counts and claims submitted to the SFA 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.

These will be compared to identify discrepancies. School meal count data will be used to determine aggregation errors at the school level.

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 School staff and/or Cafeteria Manager to provide access to the school meal count records is estimated to average 30 minutes 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.

SFA: | | | | | | | | |

School: | | | | | | | | |

Date: | | | / | | | / | | | Select One (Target Month, Target Week, or Target Day):

MONTH DAY YEAR  Target Month (Go to Section A)  Target Week (Go to Section B)

 Target Day (Go to Section C)

Supplemental Reporting Form Required  NO  YES (Also complete Section G)

A. TARGET MONTH

Specify the Target Month | | | / | | || | |

MONTH YEAR

A1. FOR PROVISION SCHOOLS OPERATING IN A NON-BASE YEAR OR A CEP SCHOOL, ENTER TOTAL COUNTS ONLY (LINE 4). FOR PROVISION SCHOOLS IN A BASE YEAR, ENTER ALL COUNTS.

1. BREAKFAST COUNT—MONTHLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—MONTHLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

IF SCHOOL ALSO KEEPS WEEKLY RECORDS, COMPLETE SECTION A2 – A6.

OTHERWISE, CONTINUE TO SECTION D: STUDENT INFORMATION.

A2. FIRST WEEK OF TARGET MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

A3. SECOND WEEK OF TARGET MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

A4. THIRD WEEK OF TARGET MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

A5. FOURTH WEEK OF TARGET MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

A6. FIFTH WEEK OF TARGET MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

B. TARGET WEEK (NOT INCLUDED IN TARGET MONTH)

Specify the Target Week: From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

C. TARGET DAY

Meal Counts for: Lunch |___| Breakfast |___| (REPEAT FOR EACH MEAL TYPE)

FOR PROVISION SCHOOLS OPERATING IN A BASE YEAR, ENTER ALL COUNTS. FOR PROVISION SCHOOLS IN A NON-BASE YEAR OR A CEP SCHOOL, ENTER TOTAL COUNTS ONLY.

 Check box if all data is electronic and leave the verified counts column blank.

DATE: | | | / | | | / | | | 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: | |,| | | |
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):

**Additional rows will be added if there are more than four registers.

D. STUDENT INFORMATION FOR SCHOOL

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

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

or | | | | %

3. Number of serving days: | | | |,| | | |

(Number of Serving Days in the Target Month or Target Week. For Target Day, enter 1.)

IF SCHOOL IS PROVISION SCHOOL IN A NON-BASE YEAR, SKIP TO SECTION E.

IF SCHOOL IS CEP SCHOOL, SKIP TO SECTION F.

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

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

E. PROVISION SCHOOL CLAIMING PERCENTAGES

COMPLETE ONLY FOR PROVISION SCHOOL IN NON-BASE YEAR

CLAIMING PERCENTAGES FOR BREAKFAST:

1. Free Meals | | | | %

2. Reduced-Price Meals | | | | %

3. Paid Meals | | | | %

4. Base Year Period Used:

Yearly Percentages 1

Monthly Percentages 2

Specify Month:

CLAIMING PERCENTAGES FOR LUNCH:

5. Free Meals | | | | %

6. Reduced-Price Meals | | | | %

7. Paid Meals | | | | %

8. Base Year Period Used:

Yearly Percentages 1

Monthly Percentages 2

Specify Month:

F. CEP SCHOOL CLAIMING PERCENTAGES

COMPLETE ONLY FOR CEP SCHOOL

CLAIMING PERCENTAGES FOR BREAKFAST:

1. Free Meals | | | | %

2. Paid Meals | | | | %

CLAIMING PERCENTAGES FOR LUNCH:

3. Free Meals | | | | %

4. Paid Meals | | | | %

G. SUPPLEMENTAL REPORTING FORM

COMPLETE THIS SECTION IF THE SCHOOL RECORDS MEAL COUNTS ONTO AN INTERMEDIARY ‘SUPPLEMENTAL’ FORM AND THEN TRANSFERS THE MEAL COUNTS FROM THE SUPPLEMENTAL FORM ONTO ANOTHER FORM THAT IS SUBMITTED TO THE SFA.

RECORD THE INFORMATION FROM THE INTERMEDIARY “SUPPLEMENTAL REPORTING FORM” IN THIS SECTION CORRESPONDING TO THE SAME PERIOD (TARGET MONTH, TARGET WEEK, OR TARGET DAY)

G1. TOTAL MEALS REPORTED

IF CEP SCHOOL:

• ENTER REPORTED MEALS FOR FREE, PAID, AND TOTAL ONLY

• ENTER CLAIMING PERCENTAGES FOR FREE AND PAID ONLY

• DON’T INDICATE BASE PERIOD USED.

TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | %
2. Reduced-Price:	| | |,| | | |,| | | | | | | | %
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
4. Total Breakfasts:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
TOTAL LUNCHES REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
5. Free:	| | |,| | | |,| | | | | | | | %
6. Reduced-Price:	| | |,| | | |,| | | | | | | | %
7. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
8. Total Lunches:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

IF DATA IS FOR TARGET MONTH AND SCHOOL ALSO KEEPS WEEKLY RECORDS, ALSO COMPLETE PARTS “G2-G6”
G2. FIRST WEEK OF TARGET MONTH
TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | %
2. Reduced-Price:	| | |,| | | |,| | | | | | | | %
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
4. Total Breakfasts:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
TOTAL LUNCHES REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
5. Free:	| | |,| | | |,| | | | | | | | %
6. Reduced-Price:	| | |,| | | |,| | | | | | | | %
7. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
8. Total Lunches:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

G3. SECOND WEEK OF TARGET MONTH
TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | %
2. Reduced-Price:	| | |,| | | |,| | | | | | | | %
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
4. Total Breakfasts:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
TOTAL LUNCHES REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
5. Free:	| | |,| | | |,| | | | | | | | %
6. Reduced-Price:	| | |,| | | |,| | | | | | | | %
7. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
8. Total Lunches:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

G4. THIRD WEEK OF TARGET MONTH
TOTAL BREAKFASTS REPORTED TO SFA			IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | %
2. Reduced-Price:	| | |,| | | |,| | | | | | | | %
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
4. Total Breakfasts:	| | |,| | | |,| | | |
			PROVISION SCHOOL BASE YEAR PERIOD USED:
			YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
TOTAL LUNCHES REPORTED TO SFA				IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
5. Free:		| | |,| | | |,| | | | | | | | %
6. Reduced-Price:		| | |,| | | |,| | | | | | | | %
7. Paid (Full Price):		| | |,| | | |,| | | | | | | | %
8. Total Lunches:		| | |,| | | |,| | | |
				PROVISION SCHOOL BASE YEAR PERIOD USED:
				YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

G5. FOURTH WEEK OF TARGET MONTH
TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | %
2. Reduced-Price:	| | |,| | | |,| | | | | | | | %
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
4. Total Breakfasts:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
TOTAL LUNCHES REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
5. Free:	| | |,| | | |,| | | | | | | | %
6. Reduced-Price:	| | |,| | | |,| | | | | | | | %
7. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
8. Total Lunches:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

G6. FIFTH WEEK OF PREVIOUS MONTH
TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | %
2. Reduced-Price:	| | |,| | | |,| | | | | | | | %
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
4. Total Breakfasts:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
TOTAL LUNCHES REPORTED TO SFA		IF PROVISION SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
5. Free:	| | |,| | | |,| | | | | | | | %
6. Reduced-Price:	| | |,| | | |,| | | | | | | | %
7. Paid (Full Price):	| | |,| | | |,| | | | | | | | %
8. Total Lunches:	| | |,| | | |,| | | |
		PROVISION SCHOOL BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

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