State CN Directors, State Agriculture Directors, and SFA Directors for Public Schools (SLT)

APPENDIX R

CENSUS PREPARATION WORKSHEET

FARM TO SCHOOL CENSUS PREPARATION WORKSHEET

This optional worksheet is designed to help you gather information you will be asked as part of the Census. It will assist you with being able to more quickly complete the survey. Please use this tool to gather information from schools, other departments, staff, or vendors before filling out the Census. The worksheet can be discarded after the Census is completed.

Census Question	Your response
Q7. How many schools in your SFA had salad bars during the 2017-2018 school year?
Q8. How many of the salad bars served local products?
Q22. During the 2017-2018 school year, what grades participated in farm to school activities? [You’ll check all that apply.]	Pre-K and younger K through 5th grade 6th grade to 8th grade 9th grade to 12th grade
Q24. How many of the schools participating in farm to school activities during the 2017-2018 school year served local food of any kind?
Q25. How many of the schools participating in farm to school activities during the 2017-2018 school year provided food, nutrition and agricultural education?
Q29. How many schools in your SFA had edible school gardens during the 2017-2018 school year?
Q35. Please list the top 5 specific LOCAL FOOD items your SFA purchased in 2017-2018, based on TOTAL DOLLARS spent. Please record each item and how much was spent on that local food item.	Food: Amount Spent: Food: Amount Spent: Food: Amount Spent: Food: Amount Spent: Food: Amount Spent:
Q37. How much money have you spent on food and local food during the 2017-2018 school year. Please give your best approximation and do not include the value of USDA Foods or USDA DoD Fresh. For the 2017-2018 school year, what were your SFA’s approximate total food costs (in dollars)?
Q38. For the 2017-2018 school year, about how much of your total food purchases (in dollars) were spent on LOCAL foods INCLUDING fluid milk?
Q39. For the 2017-2018 school year, about how much did you spend on local fluid milk ONLY (in dollars)?
Q40. For the 2017-2018 school year, what were your SFA’s approximate LOCAL food costs (in dollars) for USDA DoD Fresh ONLY? (Do not count USDA Foods)
Q41. For the 2017-2018 school year, what were your SFA’s approximate food costs (in dollars) for USDA DoD Fresh ONLY? (Do not count USDA Foods)
Q46a. Number of full time PAID staff dedicated to farm to school efforts in your SFA (Full time is defined as at least 40 hours in one week)
Q46b. Number of part time PAID staff who use some portion of their time for farm to school in your SFA (Part time is defined as less than 40 hours in one week; this does not include volunteers)

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 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. 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