State, Local and Tribal Agencies (Respondents)

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

Appendix F9. Site Menu Follow-Up Report

Instructions

Your list of foods and beverages served and their recipes provided most of the information we need. In the tables below, we list items for which we need additional details organized by the type of meal component the item provides.

The meal components include: Grains/Bread, Fruits/Vegetables, Meats/Meat Alternates, and Milk. If the menu item was a combined food (like a sandwich) or a mixed dish (like pizza), the table lists the ingredient followed by the menu item containing the ingredient. For example, if the menu item was a peanut butter and jelly sandwich, we may have questions about the bread in the sandwich. The table will list “Bread (peanut butter & jelly sandwich)” in the section on Grains/Bread, and “Peanut butter (peanut butter & jelly sandwich)” in the section on Meats/Meat Alternates (see Figure 1.)

Figure 1. Followup report questions for components of PB&J sandwich

The details needed vary for the type of food, and include:

• Brand name and product name

• Grains/Bread: The details needed vary by the Meal Pattern you use:

  • If using the SFSP meal pattern: Was the item whole grain, enriched, or (for cereals only) fortified?

  • If using the CACFP or NSLP meal pattern: Was the item whole grain-rich, enriched, or (for cereals only) fortified?

• Fruits & Vegetables: Were they:

  • Peeled?

  • Whole, sliced, diced, shredded?

  • Raw, canned/jarred, cooked or dried?

    • For canned/jarred fruit, was it packed in heavy syrup, light syrup, extra light syrup, juice, or water?

    • For cooked fruit or vegetable, was it made from

      • Fresh

      • Frozen

      • Canned/jarred

      • Dried

    • For cooked fruit or vegetable, how was it prepared?

      • Baked/roasted

      • Microwaved

      • Broiled/grilled

      • Pan-fried/sautéed

      • Deep fried

      • Boiled

      • Steamed

      • Other (specify

  • Fruit or vegetable juice: Was it 100% juice?

• Meats/meat alternatives:

  • For meats: Was the item regular or lean?

  • For cheese: Was the item regular, reduced-fat or fat-free?

• Milk: Was it

  • Plain or flavored?

  • Regular (whole), reduced-fat (2%), low-fat (1%), fat-free (skim)

The table on the following pages shows an example of the form. The type of information that will be pre-filled is shown in black. The responses that a sponsor provided are shown in blue. The table with your menu items and the details needed begins on page ___.

If you have any questions about this form, please contact the study team at XXX-XXX-XXXX or [email protected].

SAMPLE 1 – For sites using SFSP Meal Pattern

Sponsor Name: ____Sponsor ABC_________________ Meal pattern: ____SFSP____

Site: ______Site XYZ_______

Menu week: ___2___ Week start date: ___6/26/2018

GRAINS/BREAD
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	B	Mini pancakes	What kind was it? Blueberry whole wheat What was the brand name? Aunt Jemima Was it:  Whole grain  Enriched
W	L	Bread (Chicken sandwich)	What kind was it? White Sandwich What was the brand name? Nickel’s Was it:  Whole grain  Enriched
FRUIT/VEGETABLE
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	L	Vegetable	What kind was it? Baby carrots Was it peeled?  Yes  No What was the form?  Whole  Sliced  Diced  Shredded How was it prepared?  Raw  Cooked If cooked, was it from  Fresh  Frozen  Canned/jarred  Dried What was the brand name? What was the amount served? ½ cup
F	L	Fruit	What kind was it? Applesauce What was the form?  Whole  Sliced  Diced  Shredded How was it prepared?  Fresh  Frozen  Canned/jarred  Dried If canned/jarred, was it  Packed in water or unsweetened  Packed in juice  Packed in syrup or sweetened Was the syrup:  Heavy  Light  Extra light What was the brand name? Motts
MEAT/MEAT ALTERNATE
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	B	Cheese stix	What kind was it? Mozzarella cheese stick What was the brand name? Poly-O Was it:  Regular  Reduced fat  Fat free
	D	Peanut butter (PBJ Uncrustable)	Was it:  Regular  Reduced fat
MILK
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	B	Menu was missing milk	Was milk served?  Yes  No Plain or flavored?  Plain  Flavored Was it:  Regular (Whole or vitamin D)  Reduced-fat (2%)  Low-fat (1%)  Fat-free (skim)
ADDITIONAL INGREDIENTS: Did the following foods include ingredients not mentioned in the name of the food?
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	L	Pizza	What kind was it? Cheese pizza What was the brand name? No brand name Did it include meat?  Yes  No If yes, what kind of meat was it? Was the meat:  Regular  Lean
			Did it include any vegetables?  Yes  No If yes, what kind of vegetable was it? Was the vegetable peeled?  Yes  No What was the form of the vegetable?  Whole  Sliced  Diced  Shredded How was the vegetable prepared?  Raw  Cooked If cooked, was it from  Fresh  Frozen  Canned/jarred  Dried
T	B	Ham/Egg Scrambler	Did it include any vegetables?  Yes  No If yes, what kind of vegetable was it? Was the vegetable peeled?  Yes  No What was the form of the vegetable?  Whole  Sliced  Diced  Shredded How was the vegetable prepared?  Raw  Cooked If cooked, was it from  Fresh  Frozen  Canned/jarred  Dried

SAMPLE 2 – For sites using CACFP or NSLP Meal Pattern

Sponsor Name: ____Sponsor ABC_________________ Meal pattern: ____CACFP____

Site: ______Site XYZ_______

Menu week: ___2___ Week start date: ___6/26/2018

GRAINS
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	B	Mini pancakes	What kind was it? Blueberry whole wheat What was the brand name? Aunt Jemima Was it:  Whole grain-rich  Enriched
W	L	Bread (Chicken sandwich)	What kind was it? White Sandwich What was the brand name? Nickel’s Was it:  Whole grain-rich  Enriched
VEGETABLES
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	L	Vegetable	What kind was it? Baby carrots Was it peeled?  Yes  No What was the form?  Whole  Sliced  Diced  Shredded How was it prepared?  Raw  Cooked If cooked, was it from  Fresh  Frozen  Canned/jarred  Dried What was the brand name? What was the amount served? ½ cup
FRUITS
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
F	L	Fruit	What kind was it? Applesauce What was the form?  Whole  Sliced  Diced  Shredded How was it prepared?  Fresh  Frozen  Canned/jarred  Dried If canned/jarred, was it  Packed in water or unsweetened  Packed in juice  Packed in syrup or sweetened Was the syrup:  Heavy  Light  Extra light What was the brand name? Motts
MEAT/MEAT ALTERNATE
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	B	Cheese stix	What kind was it? Mozzarella cheese stick What was the brand name? Poly-O Was it:  Regular  Reduced fat  Fat free
	D	Peanut butter (PBJ Uncrustable)	Was it:  Regular  Reduced fat
FLUID MILK
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	B	Menu was missing milk	Was milk served?  Yes  No Plain or flavored?  Plain  Flavored Was it:  Regular (Whole or vitamin D)  Reduced fat (2%)  Lowfat (1%)  Fat free (skim)
ADDITIONAL INGREDIENTS: Did the following foods include ingredients not mentioned in the name of the food?
DAY	MEAL	MENU ITEM	ADDITIONAL DETAILS
M	L	Pizza	What kind was it? Cheese pizza What was the brand name? No brand name Did it include meat?  Yes  No If yes, what kind of meat was it? Was the meat:  Regular  Lean
			Did it include any vegetables?  Yes  No If yes, what kind of vegetable was it? Was the vegetable peeled?  Yes  No What was the form of the vegetable?  Whole  Sliced  Diced  Shredded How was the vegetable prepared?  Raw  Cooked If cooked, was it from  Fresh  Frozen  Canned/jarred  Dried
T	B	Ham/Egg Scrambler	Did it include any vegetables?  Yes  No If yes, what kind of vegetable was it? Was the vegetable peeled?  Yes  No What was the form of the vegetable?  Whole  Sliced  Diced  Shredded How was the vegetable prepared?  Raw  Cooked If cooked, was it from  Fresh  Frozen  Canned/jarred  Dried

Public reporting burden for this collection of information is estimated to average 30 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.