State, Local and Tribal Agencies (Respondents)

OMB Control No: 0584-XXXX Expiration Date: XX/XX/20XX Expiration Date: 03/31/2019

Appendix D5. Site Operations Survey

Please answer the following questions about the following Summer Food Service Program (SFSP) or Seamless Summer Option (SSO) sites under your sponsorship:

[LIST SITES]

1. <SITE NAME>

<SITE NAME 1>

[ONLY ASK Q1 FOR SITES SAMPLED FROM 2017 LIST. FOR SITES SAMPLED FROM 2018 LIST, START WITH Q2]

Q1. Will <SITE NAME 1> participate in the Summer Food Service Program or Seamless Summer Option in Summer 2018?

• Yes

• No  GO TO SITE NAME 2

• Don’t know at this time, decision will be made by <DATE>  GO TO SITE NAME 2

Q2. Please provide the start and end dates for each session that this site offers the summer meals program.

Session 1: What is the start and the end date for offering the summer meal program at this site: [START AND END DATES WILL BE SELECTED ON A CALENDAR; END DATES WILL NOT BE ALLOWED TO PRECEDE START DATES.]

• START DATE 1: __/__/2018

• END DATE 1: __/__/2018

• Don’t know at this time, decision will be made by <DATE>  GO TO SITE NAME 2

Does this site session operate: [ONLY ONE BOX WILL BE ALLOWED TO BE CHECKED.]

• Every week from start date to end date

• Some weeks from start date to end date

[RESPONDENT WILL BE ABLE TO “ADD ANOTHER SESSION DATE” UNTIL UP TO FIVE SESSIONS HAVE BEEN ENTERED.]

Q3. Please verify and update the contact information for the site supervisor at <SITE NAME 1>. [INFORMATION WILL BE PRE-FILLED.]

NAME:

TITLE:

ADDRESS:

EMAIL:

PHONE NUMBER:

Q4.     Our records indicate that the name for the summer meals program at <address> is <SITE NAME>.  Is there a different name that households in the area use for this summer meals program?  

• Yes.  The summer meals program name that households in the area use is: _______________________

• No

• Unsure

Q5. Does the site supervisor at <SITE NAME 1> require study materials in Spanish?

• Yes

• No

Q6. Does <SITE NAME 1> serve a significant number of children whose parents primarily speak Spanish?

• Yes

• No

• Unsure

Q7. Please provide contact information for the person employed by your organization or the site organization who is responsible for planning menus for <SITE NAME 1>:

NAME:

TITLE:

ORGANIZATION:

EMAIL:

PHONE:

Q8. Does <SITE NAME 1> use cycle menus? A cycle menu is a menu that is different every day but repeats after a certain number of days or weeks.

• Yes  What is the length of the cycle for the menu?

1 week

2 weeks

3 weeks

4 weeks

Other (PLEASE SPECIFY):

• No

• Unsure

[REPEAT SURVEY QUESTIONS FOR ALL OF SPONSOR’S SELECTED SITES]

Thank you for completing this brief survey. We are looking forward to your partnership in the Summer Meals Study this summer.

Soon, we will email you a short informational recording about the study. The recording will provide you information about the study timeline, data collection activities, and participant recruitment efforts. If you have any questions about the study, please email us at [email protected] or call 1-800-XXX-XXXX.

Thank you very much for completing this brief survey. We look forward to working with you!

Public reporting burden for this collection of information is estimated to average 15 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.