CN Agency and SFA Directors, Business Managers, Superintendents, Menu Planners, School Nutrition Managers, School Liaisons, and Principals - SLT

D1. SCHOOL ROSTER DATA REQUEST (GROUP 2)

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SCHOOL NUTRITION AND MEAL COST STUDY-II

Conducted on behalf of the USDA

Phone: [TOLL FREE NUMBER]

Email: [EMAIL]@mathematica-mpr.com

SAMPLING DATA FILE

As part of the study we will need to collect lists of students in the following schools:

1. [SCHOOL1]	4. [SCHOOL4]
2. [SCHOOL2]	5. [SCHOOL5]
3. [SCHOOL3]	6. [SCHOOL6]

Lists should reflect your most current roster information and include all students enrolled in grades 1 through 12 at these schools.

Please provide the roster information listed on the following page for each student. For some fields we have provided recommended values in italics. Please provide the roster information in whatever format is easiest for you, but please provide documentation if you use different values. Please provide files in .xls, .csv, or .txt format.

Please provide this file within 2 weeks of receiving this form.

Once completed, please upload the data file and this form to our secure file transfer website:

[SECURE TRANSFER SITE ADDRESS AND UPLOAD INSTRUCTIONS]

• This is a secure site that will help protect the privacy of the data. If you have any questions about completing this data request, please contact [RECRUITER NAME] at Mathematica, or a member of the study team toll-free at [TOLL FREE NUMBER] or [EMAIL]@mathematica-mpr.com

***Please DO NOT email the data file***

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 1 hour 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. All information collected is authorized under the statutory exception at 20 U.S.C. 1232g(b)(1)(K) and will be kept private under the Privacy Act to the extent allowed by law. 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-xxxx). Do not return the completed form to this address.

SAMPLING DATA FILE: REQUESTED DATA ITEMS

Current Student-Level Roster Information

Please provide the roster information listed below for each student. This information will be used only to select students to invite to participate in the study. Students and their families will have the option not to participate in the study. No roster information will be retained on students who do not consent to participate in the study.

1. Student ID*

2. Student's School Name*

3. Student First Name*

4. Student Last Name*

5. Grade (1-12)*

6. Gender (M/F) (if available)

7. Race (if available)

8. Ethnicity (if available)

9. Date of Birth (if available)

10. Student Certification Status [Free, Reduced-Price, or Paid/Full-Price] (if available)

11. Student Language (English/Spanish/Other)

12. Student's Street Address, Line 1

13. Student's Street Address, Line 2

14. Student's City of Residence

15. Student's State of Residence

16. Student's Zip Code (5 digits)

17. Student Telephone Number (10 digits) (if available)

18. Student Email Address (if available)

19. Parent/Guardian1 First Name*

20. Parent/Guardian1 Last Name*

21. Parent/Guardian1 Street Address, Line 1*

22. Parent/Guardian1 Street Address, Line 2

23. Parent/Guardian1 City of Residence*

24. Parent/Guardian1 State of Residence*

25. Parent/Guardian1 Zip Code (5 digits)*

26. Parent/Guardian1 Home Telephone Number (10 digits)*

27. Parent/Guardian1 Cell Telephone Number (10 digits)

28. Parent/Guardian1 Email Address

29. Parent/Guardian Language1 (English/Spanish/Other)

30. Parent/Guardian2 First Name

31. Parent/Guardian2 Last Name

32. Parent/Guardian2 Street Address, Line 1

33. Parent/Guardian2 Street Address, Line 2

34. Parent/Guardian2 State of Residence

35. Parent/Guardian 2 City of Residence

36. Parent/Guardian2 Zip Code (5 digits)

37. Parent/Guardian2 Home Telephone Number (10 digits)

38. Parent/Guardian2 Cell Telephone Number (10 digits)

39. Parent/Guardian2 Email Address

40. Parent/Guardian Language2 (English/Spanish/Other)

* Denotes a required variable.