State, Local, and Tribal Government (CN Agency Staff, State Medicaid Agency Staff, Other State Agency Staff, and School District Staff)

---

Overview

Activity Descriptions
Time Log
Salary information
ODC information
Indirect Cost information
Time Log - Optional Weekly Ver

---

Sheet 1: Activity Descriptions

APPENDIX C.3a. STATE COST DATA TRACKING LOGS		OMB #: 0584-0630 EXPIRATION DATE: 12/31/2020
State child nutrition agency activity	Most relevant for matching at:	Activity description
Start-up activities (For States participating in the previous DCM demonstration, these are activities involved in converting from the previous demonstration to DCM-F/RP. For States new to DCM, these are activities involved in adding DCM-F/RP to existing direct certification procedures.)
Negotiate data-sharing agreements	State and district levels	Draft MOU/MOA with Medicaid eligibility agency; edit and execute the agreements; develop specifications for the data needed from the Medicaid eligibility files.
Develop specifications for matching	State and district levels	Develop specifications for matching Medicaid data to student data. Decide the order in which to use match variables, what is considered an exact or a close match, formats for resulting files, and so on.
Enhance MIS or student database	State and district levels	Make enhancements to systems and databases to allow for entry of information related to DCM-F/RP.
Test match procedures	State level	Test automated (or manual) match procedures, refine, and retest.
Provide training and TA to districts	State and district levels	Provide training and technical assistance (for example, webinars) to districts on the DCM-F/RP process and respond to their questions.
Pre-implementation meetings and coordination	State and district levels	Hold internal pre-implementation staff meetings or conference calls with specialists and programmers, FNS, or the Medicaid eligibility agency to coordinate and discuss progress. Draft any necessary memos or status reports.
Other pre-implementation activities (describe in Notes column)	State and district levels	Other pre-implementation activities not described above; please specify.
Ongoing activities for DCM-F/RP (These are activities that occur on an ongoing basis, or each time a DCM-F/RP match is conducted.)
Extract student data	State and district levels	Extract relevant student data from State student database or files provided by school districts.
Receive/check Medicaid file	State and district levels	Receive and check file of Medicaid-eligible school-aged children from the State agency that collects the Medicaid data.
Conduct automated match	State level	Conduct automated match; separate among the full matches, near matches, and nonmatches.
Conduct manual match (if necessary)	State level	Conduct manual matching of cases not matched by the automated system (if State decides to do this).
Merge DCM-F/RP students with other DC students	State level	Merge students who qualify for DCM-F/RP with students who qualify through SNAP or TANF (or other public assistance); remove duplicates if needed.
Extract Medicaid file for each district	District level	Select subset of Medicaid file for each district's area—selection could be by district, county, city, or zip code, depending on how school districts are set up and what is most convenient.
Provide data file to districts	State and district levels	Provide data file to districts. These data will already be matched in States that conduct State-level matching. Otherwise, the file will include Medicaid participation data only.
Post-implementation meetings and coordination	State and district levels	Hold internal post-implementation staff meetings or conference calls with specialists and programmers, FNS, or the Medicaid eligibility agency to coordinate and discuss any ongoing issues. Draft any necessary memos or status reports.
Conduct USDA evaluation activities	State and district levels	Conduct activities related to the USDA DCM-F/RP evaluation. These include developing and executing MOUs with Mathematica, participating in interviews, discussing the evaluation with the evaluation team, and providing administrative data to the evaluation team.
Other post-implementation activities (describe in Notes column)	State and district levels	Other post-implementation activities not described above; please specify.
Note: In the time log on the next worksheet, please include only time incurred to implement DCM-F/RP that is in addition to time already associated with other forms of direct certification for school meals (such as direct certification through SNAP, TANF, or other programs).
Glossary of Terms:
DC = Directly certified;
DCM-F/RP = Demonstrations of Direct Certification with Medicaid for free and reduced-price meals;
MOU/MOA = memorandum of understanding (or agreement);
SNAP = Supplemental Nutrition Assistance Program;
TA = technical assistance;
TANF = Temporary Assistance for Needy Families;
USDA = U.S. Department of Agriculture.
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 0584-0630. The time required to complete this information collection is estimated to average 3 hours 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 Service, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0630). Do not return the completed form to this address.

---

Sheet 2: Time Log

APPENDIX C.3a. STATE COST DATA TRACKING LOGS					OMB #: 0584-0630 EXPIRATION DATE: 12/31/2020
DCM-F/RP
Time Tracking Log
[STATE NAME] Child Nutrition Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])
Name of agency/division:
Staffing position	Activity (select from list)	Total hours spent during month			Notes
		Month 1	Month 2	Month xx
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
	[select from list]
Note: In this time log, please include only time incurred to implement DCM-F/RP that is in addition to time already associated with other forms of direct certification for school meals (such as direct certification through SNAP, TANF, or other programs).

---

Sheet 3: Salary information

APPENDIX C.3a. STATE COST DATA TRACKING LOGS					OMB #: 0584-0630 EXPIRATION DATE: 12/31/2020
DCM-F/RP
Salary Worksheet
[STATE NAME] Child Nutrition Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])
Staffing position (include each staff position listed in time log)	Pay rate (dollars)	Basis paid (select from list)	Fringe benefit percentage /amount	Fringe benefits calculated as:	Notes
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]
		[select from list]		[select from list]

---

Sheet 4: ODC information

APPENDIX C.3a. STATE COST DATA TRACKING LOGS		OMB #: 0584-0630 EXPIRATION DATE: 12/31/2020
DCM-F/RP
Other Direct Costs (ODC) Worksheet
[STATE NAME] Child Nutrition Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])
Type of other direct cost (such as printing and mailing costs, charges for conference calls, or amounts paid to outside contractors for work on the project; please describe)	Amount during this data collection period (dollars)	Notes
Note: If totals by month are easier to report, please record them in the Notes column.

---

Sheet 5: Indirect Cost information

APPENDIX C.3a. STATE COST DATA TRACKING LOGS		OMB #: 0584-0630 EXPIRATION DATE: 12/31/2020
DCM-F/RP
Indirect Costs Worksheet
[STATE NAME] Child Nutrition Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])
Question	Response
1. Does your accounting system assign indirect costs to any of the direct labor and ODC costs listed above? (Yes or No)	CHECK ONE: ___YES ___NO
2. If yes, describe how applicable indirect costs are defined and measured. (Hypothetical example: Indirect costs include management, human resources, accounting, IT services, and building maintenance. They are charged at the rates of 12% of labor costs and 2% of ODCs.)
3. If yes, what were the total indirect costs associated with DCM-F/RP in [first month] - [last month]? (in dollars)
Thank you for completing this form. Your responses will help us understand the costs you incur and the various types of activities you perform when conducting direct certification. We understand that this task requires the investment of your time and greatly appreciate your participation. Although we have tried to make these forms both flexible and straightforward, we will appreciate any suggestions for improvements. Please contact your liaison with the study team or Josh Leftin ([email protected]) with any questions.

---

Sheet 6: Time Log - Optional Weekly Ver

APPENDIX C.3a. STATE COST DATA TRACKING LOGS

OMB #: 0584-0630 EXPIRATION DATE: 12/31/2020

DCM-F/RP

Time Tracking Log

[STATE NAME] Child Nutrition Agency Version ([FIRST MONTH] - [LAST MONTH] [YEAR])

Name of agency/division:

Staffing position

Activity (select from list)

Total hours spent during week

Notes

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 10

Week 11

Week 12

Week xx

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

[select from list]

Note: In this time log, please include only time incurred to implement DCM-F/RP that is in addition to time already associated with other forms of direct certification for school meals (such as direct certification through SNAP, TANF, or other programs).