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

OMB Control No: 0584-XXXX

Expiration Date: XX/XX/20XX

Appendix G8a. Child Participant Survey Web Screen Shot

SUMMER MEALS SURVEY

CAREGIVERS, PLEASE HELP YOUR CHILD COMPLETE THIS SURVEY THIS IS NOT A TEST WE WANT TO KNOW WHAT CHILDREN YOUR AGE THINK OF THE FOODS AT <SITE NAME> Are you a boy or a girl?
Boy   Girl How old are you?    Years old This summer, did you ever eat breakfast at <SITE NAME>? Yes   No

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.