Respondents- Individuals/Households (Parents/Children/Teens)

OMB Control No: 0584-XXXX

Expiration Date: XX/XX/20XX

Appendix G7a. Caregiver Survey Web Screen Shot

SUMMER MEALS SURVEY

How many children ages 18 and younger are now living in your household?   Number of children ages 18 and under in your household   Please tell us about the age, gender, ethnicity, and race for all children ages 18 and younger that are living in your household. CHILD 1 Is this child a boy or a girl?
Boy   Girl How old is this child?    Years old Is this child Hispanic or Latino? Yes, Hispanic or Latino   No, not Hispanic or Latino

Public reporting burden for this collection of information is estimated to average 20 minutes 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.