| Supporting Statement for OMB Clearance for the Study of Non-Response to the School Meals Application Verification Process - Appendix 18 - Verification Data Request Template | |||||||||||||||||||||||||||||||||||||||
| OMB Approval No.: 0584-XXXX Expiration Date: XX/XX/20XX |
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-XXXX. The time required to complete this information collection is estimated to average 3.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. | ||||||||||||||||||||||||||||||||||||||
| Household ID | Houshold size | Household monthly income | Number of students in household (enrolled at the time the verification sample was selected) | Name of student in household | School of student in the household | Grade level of student in household | Foster Child? (yes/no) | Student Still Enrolled? (yes/no) | District's initial determination of eligibility status (free, reduced-price, paid, not recorded) | Household certified for free meals by application based on categorical eligibility (yes/no) | Household certified for school meal benefits based on household income reported on the application (yes/no) | Application selected for cause (yes/no) | Result of verification process (no change, free to reduced-price, free to paid, reduced-price to free, reduced-price to paid, missing) | Reason for change in benefits (change in income eligibility, household income, change in SNAP/TANF/FDPIR participation, refusal to cooperate, no response, other (please specify), missing) | Application was directly verified (yes/no) | Parent/Guardian1 First Name | Parent/Guardian1 Last Name | Parent/Guardian1 Street Address, Line 1 | Parent/Guardian1 Street Address, Line 2 | Parent/Guardian1 City of Residence | Parent/Guardian1 State of Residence (2 letter code e.g. NJ, PA, TX, etc.) | Parent/Guardian1 Zip Code (5 digits) | Parent/Guardian1 Home Telephone Number (10 digits) | Parent/Guardian1 Cell Telephone Number (10 digits) | Parent/Guardian1 Work Telephone Number (10 digits + extension, if applicable) | Parent/Guardian1 Email Address | Parent/Guardian Language1 (English/Spanish/Other (please specify)) | Parent/Guardian2 First Name | Parent/Guardian2 Last Name | Parent/Guardian2 Street Address, Line 1 | Parent/Guardian2 Street Address, Line 2 | Parent/Guardian2 City of Residence | Parent/Guardian2 State of Residence | Parent/Guardian2 Zip Code (5 digits) | Parent/Guardian2 Home Telephone Number (10 digits) | Parent/Guardian2 Cell Telephone Number (10 digits) | Parent/Guardian2 Work Telephone Number (10 digits + extension, if applicable) | Parent/Guardian2 Email Address | Parent/Guardian Language2 (English/Spanish/Other (please specify)) |
| 1234 | 4 | $3,500 | 2 | Mary Jones | New York Public Elementary | 4 | no | yes | free | no | yes | no | no change | NA | yes | Marie | Jones | 123 Red Street | Apt 1 | New York | NY | 12345 | 505-020-2999 | 489-292-2920 | English | Charles | Jones | 123 Red Street | Apt 1 | NY | New York | 12345 | 505-020-2999 | 802-283-0298 | English | ||||
| 1234 | 4 | $3,500 | 2 | Mike Jones | New York Public Middle School | 6 | no | yes | free | no | yes | no | reduced-price | household income | no | Marie | Jones | 123 Red Street | Apt 1 | New York | NY | 12345 | 505-020-2999 | 489-292-2920 | English | Charles | Jones | 123 Red Street | Apt 1 | NY | New York | 12345 | 505-020-2999 | 802-283-0298 | English | ||||
| 1235 | 6 | $3,000 | 3 | Jane Smith | St. Louis Middle School | 5 | no | yes | reduced-priced | no | yes | no | free | change in income eligibility | no | Carol | Brady | 456 Green Road | St.Louis | MO | 12222 | 849-930-2020 | 829-289-9821 | [email protected] | Spanish | ||||||||||||||
| 1235 | 6 | $3,000 | 3 | Jerry Smith | St. Louis High School | 11 | no | yes | reduced-priced | no | yes | no | free | change in income eligibility | no | Carol | Smith | 456 Green Road | St.Louis | MO | 12222 | 849-930-2020 | 829-289-9821 | [email protected] | Spanish | ||||||||||||||
| 1235 | 6 | $3,000 | 3 | Joan Smith | St. Louis High School | 9 | no | yes | paid | no | yes | yes | no change | NA | no | Carol | Smith | 456 Green Road | St.Louis | MO | 12222 | 849-930-2020 | 829-289-9821 | [email protected] | Spanish | ||||||||||||||
| 1236 | 2 | $2,500 | 1 | Sarah Miller | Portland Elementary | 3 | yes | yes | free | yes | no | no | reduced-price | change in SNAP/TANF/FDPIR participation | no | David | Miller | 789 Organe Blvd | Portland | OR | 34332 | 992-020-2002 | 872-280-2992 | [email protected] | Other (Chinese) | ||||||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |