Form FNS-892 Team Nutrition CACFP Organizations

Appendix_11_Online FNS 892_Team Nutrition CACFP Organization

Create CACFP
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
OMB BURDEN STATEMENT: 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 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.

Organization Information
ORGANIZATION NAME
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
DUNS NUMBER
ORGANIZATION WEBPAGE URL (http://www.example.com)
Organization Types (Select the type of Organization)
Sponsoring Organization
Independent At-Risk Afterschool Care Center
Independent Child Care Center
Public or Private Nonprofit Emergency Shelter
Independent Adult Day Care Center

Number of Sites Under the Organization
AT-RISK AFTERSCHOOL CARE CENTERS
DAY CARE HOMES

ADULT DAY CARE CENTERS
EMERGENCY SHELTERS
CHILD CARE CENTERS
Age Groups (Select the age groups served by your sites)
0-11 Months
1-2 Years
3-5 Years
6-12 Year
13-18 Years
Over 18 Years (Adults)

Organization Point of Contacts
CACFP DIRECTOR NAME
CACFP DIRECTOR PHONE NUMBER
CACFP DIRECTOR EMAIL
NUTRITION EDUCATION/TRAINING CONTACT NAME
NUTRITION EDUCATION/TRAINING CONTACT NUMBER
NUTRITION EDUCATION/TRAINING CONTACT EMAIL

Nutrition and Wellness Activities your site(s) are
working On (If you have multiple sites, check if the
statement applies to at least one of your sites.)
Fruit and/or vegetable garden
N/A
Yes
No
Breastfeeding space to encourage mothers to breastfeed or pump breastmilk at your child care
site
N/A
Yes
No
Do/Does your site(s) offer at least 90 minutes of active play in an 8-hour period for children 6
years and older?
N/A
Yes
No
Offer supervised tummy time every day for infants in short periods when they are awake
N/A
Yes
No

Allow 60-90 minutes in an 8-hour period of physical activity to children 1-3 years old
N/A
Yes
No
Offer opportunities for physical activity throughout the day for adults
N/A
Yes
No
Limit screen time to no more than 1 hour per day of high-quality media viewed with an adult for
children over the age of 2 years
N/A
Yes
No
Have the participant's meals and/or snacks catered by an outside food vendor
N/A
Yes
No
Use family style meal service at meals and/or snacks
N/A
Yes
No
Develop or create original training materials for the CACFP, such as handouts, worksheets,
presentations, etc.
N/A
Yes
No
Develop or create original recipes or menus for the CACFP
N/A
Yes
No

Close Organization
Close Organization
SAVE AS